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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a pleasant ___ who presents as a transfer from
___ for a T1 compression fracture as well as a
right clavicle and ___ rib fractures. She initially had a
mechanical fall last night at her nursing home which she did not
tell anyone about. This AM her aids noticed swelling and pain of
her right shoulder. She presented to the ___ ED
where she underwent a CT Head, C-Spine, Chest, Abdomen and
Pelvis. In addition to multiple non-acute findings, the work-up
revealed the displaced right clavicle fracture, right first and
second rib fractures, and a T1 compression fracture of
indeterminate chronicity. She was transferred to ___ with
concern for the thoracic fracture. On exam here she was found to
be pleasant, hemodynamically appropriate, in minimal pain and
saturating well on room air. She had no neurological deficit or
tenderness over her T spine. Images were not sent with her or
electronically so they could not be reviewed.
Past Medical History:
PAST MEDICAL HISTORY:
HTN
HLD
Hypothyroidism
Rectal cancer
Iron-deficiency anemia
Dementia
PAST SURGICAL HISTORY:
Denies
Social History:
___
Family History:
Non-contributory
Physical Exam:
Afebrile, VSS
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
DRE: normal tone, no gross or occult blood
Ext: TTP at right clavicle, contusion of right upper back. RUE
in sling. No ___ edema, ___ warm and well perfused
Pertinent Results:
Right shoulder and clavicle X-ray (___):
IMPRESSION: Mildly displaced fracture involving the right mid
clavicle. Nondisplaced right first and second rib fractures.
CT T-spine ___:
IMPRESSION:
1. Study is limited secondary to diffuse osteopenia.
2. Age indeterminate T1 and T6 anterior compression deformities,
without
prevertebral soft tissue swelling. While findings may be
chronic in nature,
if concern for acute fracture, consider cyst thoracic spine MRI
for further
evaluation.
3. Ground-glass opacity in the right lower lobe is similar to 1
day ago and
may reflect inflammatory, infectious or neoplastic process.
4. Minimal interval progression of small right basilar
atelectasis versus
small effusion. If clinically indicated, consider dedicated
chest imaging for
further evaluation.
5. Multilevel degenerative changes as described, most pronounced
at T7-8,
where there is at least small vertebral canal stenosis.
6. Moderate hiatal hernia.
Medications on Admission:
Ensure Compact oral liquid 4oz BID
Citalopram 10 mg Daily
Colace 100 mg Daily
Donepezil 5 mg QHS
Levothyroxine 88 mcg Daily
Vitamin D3 1,000 unit Daily
Vitamin B-12 1,000 mcg/mL injection once a month
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Ciprofloxacin HCl 250 mg PO Q12H UTI Duration: 5 Days
Please continue until ___ for total 5 day course.
RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth twice a day
Disp #*7 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Senna 8.6 mg PO HS
5. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth q6 Disp
#*30 Tablet Refills:*0
6. Citalopram 10 mg PO DAILY
7. Donepezil 5 mg PO QHS
8. Levothyroxine Sodium 88 mcg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. R displaced clavicle
2. ___ rib fractures
3. T 1 compression fx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ year old woman s/p fall with rib fractures and T1 fracture of
questionable chronicity evaluate for acute cervical trauma.
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.8 s, 22.8 cm; CTDIvol = 32.4 mGy (Body) DLP = 738.1
mGy-cm.
Total DLP (Body) = 738 mGy-cm.
COMPARISON: Thoracic spine CT dated ___.
FINDINGS:
The visualized osseous structures are osteopenic. Severe multilevel
degenerative changes include minimal anterolisthesis of C2 on C3 and of C7 on
T1, likely degenerative in the absence of acute cervical spine fracture
(602b:43). Multilevel facet arthropathy, uncovertebral hypertrophy, and
posterior osteophyte formation cause moderate right greater than left neural
foraminal stenosis throughout the cervical spine, worst at C4-C5 where neural
foraminal stenosis is severe (02:53).
There is no acute cervical spine fracture. A comminuted mildly displaced
right clavicular fracture and minimally displaced posterior right first and
second rib fractures are better assessed on outside hospital chest CT ___:
29, 43, 53). Partial opacification of the left mastoid air cells is noted
without associated skullbase fracture.
IMPRESSION:
1. No acute fracture of the cervical spine.
2. Extensive multilevel degenerative changes including multilevel
anterolisthesis and severe C4-5 right sided neural foraminal stenosis. Please
note MRI of the cervical spine is more sensitive for the evaluation of
ligamentous injury.
3. Comminuted right medial third clavicular fracture and minimally displaced
right first and second rib fractures.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:39 ___, 2 minutes after
discovery of the findings.
Radiology Report
INDICATION: History: ___ with pain in right shoulder and clavicle
TECHNIQUE: Right shoulder, three views and right clavicle, two views
COMPARISON: None.
FINDINGS:
Oblique fracture involving the right mid clavicle is demonstrated with mild
medial and superior dislocation of the distal fracture fragment and
approximately 15 mm of overlap. No dislocation is seen. Mild degenerative
spurring is noted involving the right AC and glenohumeral joints. There are
no soft tissue calcifications. No concerning lytic or sclerotic osseous
abnormalities seen. Imaged right lung is grossly clear.
There appear to be a nondisplaced fractures involving the right first and
second ribs posteriorly.
IMPRESSION:
Mildly displaced fracture involving the right mid clavicle. Nondisplaced
right first and second rib fractures.
Radiology Report
EXAMINATION: CT T-SPINE W/O CONTRAST Q321 CT SPINE
INDICATION: ___ female status post trauma. Evaluate for T1
compression 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 7.3 s, 28.8 cm; CTDIvol = 30.9 mGy (Body) DLP = 890.7
mGy-cm.
Total DLP (Body) = 891 mGy-cm.
COMPARISON: ___ 0706 outside torso CT.
FINDINGS:
For the purposes of numbering, the highest rib-bearing vertebral body was
designate the T1 level.
There is mild anterolisthesis of C7 on T1. The visualized osseous structures
are osteopenic. There is mild anterior wedge deformity of T1 and T6. There
is no prevertebral soft tissue swelling. Within the limits of this noncontrast
study, there is no evidence of infection or neoplasm. There is multilevel
degenerate changes of the thoracic spine which include extensive loss of
intervertebral disc height, endplate sclerosis, vacuum disc phenomenon,
endplate subchondral cysts, facet joint arthropathy and disc osteophyte
complexes. At T7-8 there is partially calcified disc bulge resulting in at
least mild vertebral canal stenosis.
Ground-glass opacity in the right lower lobe is similar to prior examination.
There is been interval progression of right basilar atelectasis versus small
pleural effusion. A 2.6 cm hypodensity in the left kidney is consistent with
a simple renal cyst. There is moderate hiatal hernia. Atherosclerotic
vascular calcifications are noted.
IMPRESSION:
1. Study is limited secondary to diffuse osteopenia.
2. Age indeterminate T1 and T6 anterior compression deformities, without
prevertebral soft tissue swelling. While findings may be chronic in nature,
if concern for acute fracture, consider cyst thoracic spine MRI for further
evaluation.
3. Ground-glass opacity in the right lower lobe is similar to 1 day ago and
may reflect inflammatory, infectious or neoplastic process.
4. Minimal interval progression of small right basilar atelectasis versus
small effusion. If clinically indicated, consider dedicated chest imaging for
further evaluation.
5. Multilevel degenerative changes as described, most pronounced at T7-8,
where there is at least small vertebral canal stenosis.
6. Moderate hiatal hernia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: T-spine fracture
Diagnosed with Multiple fractures of ribs, right side, init for clos fx, Unspecified fall, initial encounter
temperature: 98.6
heartrate: 80.0
resprate: 18.0
o2sat: 97.0
sbp: 109.0
dbp: 74.0
level of pain: 0
level of acuity: 3.0 | The patient is an ___ who was transferred from ___
after a fall at her nursing home. She was found to have a T1
compression fracture as well as a right clavicle and ___ rib
fractures. At the outside hospital, she underwent a CT Head,
C-Spine, Chest, Abdomen and Pelvis. In addition to multiple
non-acute findings, the work-up revealed the displaced right
clavicle fracture, right first and second rib fractures, and a
T1 compression fracture of indeterminate chronicity. She was
transferred to ___ with concern for the thoracic vertebral
fracture. She was admitted to the trauma service for pain
management of her rib fractures, which was optimized during her
stay to allow for adequate respiratory effort in combination
with incentive spirometry. She was seen by the orthopedic team
for her clavicle fracture and her right arm was placed in a
sling. Additionally, she was seen by the neurosurgery team to
evaluate her T1 fracture, which was deemed chronic, and no
intervention was required. She was discharged home in stable
condition with her pain well controlled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Shellfish
Attending: ___
Chief Complaint:
Chest pain, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ old woman with a history of heart failure with preserved
LVEF (LVEF 46% ___, severe aortic stenosis s/p TAVR
(___)
c/b ___ cardiac arrest, coronary artery disease
status post CABG complicated by in-stent restenosis ___, status
post multiple PCIs with persistent stable angina, hypertension,
hyperlipidemia, diabetes, ___ stage kidney disease initiated on
___, anemia, and s/p recent DES to Cx and POBAs more
distally that was complicated by hypotension. Now coming in for
chest pain.
During her last admission with discharge ___ she underwent
PCI
on ___ with DES to Cx and POBAs more distally that was
complicated by periprocedural hypotension requiring CCU
admission
for IABP and dobutamine briefly. CCU course was complicated by
small left groin hematoma requiring 1U pRBC, which has since
resolved. Was planned for discharge on ___, but had chest pain
during HD with slowly uptrending troponins. She received heparin
for 24h, and we restarted her Imdur at 120mg PO daily which was
the uptitrated to 180mg PO daily as well as uptitrating
Metoprolol succinate to 100mg BID for another episode of chest
pain 48 hours later after a hemodialysis session.
She developed severe left-sided chest pressure before bed last
night at about 1am. It developed while she was lying in bed. It
was associated with shortness of breath. It does not radiate to
her back, arms, or jaw. This does feel like the pain she has
with
previous ischemic events however not as intense. She was given 3
nitros with only mid symptomatic improvement and subsequently
developed a headache. She denies nausea, vomiting, abdominal
pain, extremity tingling or numbness.
In the ED, initial vitals were:
Temp 98.5 HR 65 BP 140/71 RR18 SpO2 94% 2L NC
- Exam:
General: Appearing stated age
HEENT: NCAT, PEERL, MMM
Neck: Supple, trachea midline
Heart: RRR, no MRG. No peripheral edema.
Lungs: CTAB. No wheezes, rales, or rhonchi. Diminished breath
sounds bilateral bases
Abd: Soft, NTND.
GU: No CVA tenderness
MSK: No obvious limb deformities.
Derm: Skin warm and dry
Neuro: Awake, alert, moves all extremities.
Psych: Appropriate affect and behavior
- Labs:
'CBC/Diff' : WBC: 6.5. HGB: 9.3*.
'Chem 10' : Na: 133* . K: 6.1* Cl: 95*. CO2: 22. BUN: 33*.
Creat: 3.0*. Glucose: 92 Ca: 9.1. Mg: 1.6. PO4: 3.2.
___: %HbA1c: 6.0
'Cardiac Labs' CK-MB: 2. proBNP: GREATER TH (GREATER THAN
___ Troponin T: a) 0.23* b) 0.23*
- Imaging:
___: Chest X-Ray: CHEST (PA & LAT)
- ECG: LAD with PVC's resolved TWI in V3
- Consults:
Renal-Dialysis with plan to remove 1L
- Patient was given:
Epoetin Alfa 8000 UNIT
Heparin Dwell (1000 Units/mL) 1600 UNIT
Upon arrival to the floor, patient reports that she feels well
however is continuing to have chest pain over her left chest
that
is now very mild. She denies any dyspnea, fever, chills, N/V,
abd
pain, ___ edema or dysuria. ECG and cardiac markers were repeated
and noted to be largely unchanged.
Past Medical History:
1. CARDIAC RISK FACTORS
- Type 2 diabetes mellitus with nephropathy and retinopathy
- Hypertension
- Hyperlipidemia
2. CARDIAC HISTORY
- CABG ___
- TAVR ___
- Congestive heart failure, diastolic dysfunction (LVEF 46% TTE
___
- Cartotid stenosis s/p CEA
- TIA
3. OTHER PAST MEDICAL HISTORY
- ESRD ___ DM/HTN) on HD ___
- Chronic anemia likely secondary to chronic renal insufficiency
- Iron deficiency anemia
- Asthma (FVC 66%, FEV1 76%)
- Diverticulosis
- Gout
- Temporal arteritis
Social History:
___
Family History:
- Mother had MI in her ___
- Grandmother had diabetes
- Father passed away in an accident
Physical Exam:
ADMISSION EXAM:
24 HR Data (last updated ___ @ 1751) Temp: 98.6 (Tm 98.6),
BP: 150/85, HR: 79, RR: 20, O2 sat:
99%, O2 delivery: 1L NC
___: Weight: 88.62 (Standing Scale)
GEN: Alert, cooperative, no distress, appears stated age
HENT: NC/AT, MMM. Nares patent, no drainage or sinus
tenderness. No Teeth present and gums are normal.
EYES: PERRL, EOM intact, conjunctivae clear, no scleral
icterus.
NECK: No cervical lymphadenopathy. No JVD, no carotid bruit.
Neck supple, symmetrical, trachea midline.
LUNG: inspiratory crackles in bilateral bases L>R, good air
movement, no accessory muscle use
HEART: RRR, Normal S1/S2, ___ systolic murmur at LUSB, ___
systolic murmur at apex
BACK: Symmetric, no curvature. ROM normal. No CVA tenderness.
ABD: Soft, non-tender, non-distended; nl bowel sounds; no
rebound or guarding, no organomegaly
GU: Not examined
EXTRM: Extremities warm, no edema, no cyanosis, positive ___
pulses bilaterally
SKIN: Skin color and temperature, appropriate. No rashes or
lesions
NEUR: CN II-XII intact . Moving all extremities, strength,
sensation and reflexes equal and intact throughout.
PSYC: Mood and affect appropriate
DISCHARGE EXAM:
24 HR Data (last updated ___ @ 1457)
Temp: 99.0 (Tm 99.0), BP: 115/62 (115-130/62-82), HR: 73
(72-77),
RR: 18 (___), O2 sat: 96% (95-100), O2 delivery: 1L (1L-1.5
L),
Wt: 85.54 lb/38.8 kg (from 88 lbs on ___
Gen: lying comfortably in bed in NAD
HEENT: PERRL, EOMI, OP clear
CV: RRR, nl S1, S2, II/VI SEM, JVP flat
Chest: crackles resolved R base, decreased BS L base
Abd: + BS, soft, NT, ND
MSK: lower ext warm without edema
Skin: R tunneled HD catheter in place, c/d/I
Neuro: AOx3, CN II-XII intact, ___ strength all ext, sensation
grossly intact, gait not tested
Psych: pleasant, appropriate affect
Pertinent Results:
CBC:
___ 03:15AM BLOOD WBC-6.5 RBC-3.12* Hgb-9.3* Hct-30.2*
MCV-97 MCH-29.8 MCHC-30.8* RDW-18.4* RDWSD-65.0* Plt ___
___ 06:50AM BLOOD WBC-6.6 RBC-2.82* Hgb-8.5* Hct-27.7*
MCV-98 MCH-30.1 MCHC-30.7* RDW-18.6* RDWSD-66.8* Plt ___
CHEM:
___ 03:15AM BLOOD Glucose-92 UreaN-33* Creat-3.0* Na-133*
K-6.1* Cl-95* HCO3-22 AnGap-16
___ 06:50AM BLOOD Glucose-102* UreaN-10 Creat-1.9*# Na-136
K-3.9 Cl-96 HCO3-29 AnGap-11
___ 03:15AM BLOOD Calcium-9.1 Phos-3.2 Mg-1.6
___ 08:16AM BLOOD Calcium-8.9 Phos-2.3* Mg-2.2
___ 08:25AM BLOOD Calcium-8.9 Phos-1.8* Mg-1.9
___ 06:50AM BLOOD Calcium-9.0 Phos-2.2* Mg-1.7
CARDIAC ENZYMES:
___ 09:15AM BLOOD cTropnT-0.23*
___ 09:25PM BLOOD CK-MB-2 cTropnT-0.26*
___ 02:20PM BLOOD CK-MB-3 cTropnT-0.28*
___ 12:42PM BLOOD CK-MB-2 cTropnT-0.19*
___ 05:45PM BLOOD CK-MB-2 cTropnT-0.21*
IMAGING:
========
CXR (___):
Comparison to ___. Decreased lung volumes, stable
moderate left pleural effusion. Increasing right pleural
effusion. Signs of mild to moderate pulmonary edema now present.
Moderate cardiomegaly persists. Stable alignment of the sternal
wires, stable position of the hemodialysis catheter.
EKG ___ after nitro): NSR at 73 bpm, LAD, LVH, PR 214, QRS
108,
QTC 408, Q in III, TW flattening I/AVL, TWI V2-V3, significant
improvement in ST depressions in V2-V6 compared to early ___
EKG ___ w/chest pain): NSR at 83 bpm, LAD, LVH, PR 212, QRS
110, QTC 406, Q in III, TWI I/AVL with ST depressions II, V2-V6
with reciprocal STE AVR (ST depressions more prominent than
___
EKG (___): NSR at 63 bpm, borderline LAD, PR 190, QRS 108, QTC
427, Q in III, TW flattening inferior leads, TWI and ST
depressions V3-V6 (TWI/ST depressions more prominent compared to
___
CXR (___):
Mild decrease in extent of the pulmonary edema. Otherwise no
significant interval change.
TTE (___):
Mildly reduced left ventricular systolic function (EF 45%).
Mildly dilated right ventricle with moderate global hypokinesis.
Increased left ventricular filling pressure. Severe
inferolaterally directed mitral regurgitation. Mild tricuspid
regurgitation. Small inferolateral pericardial effusion.
Moderate pulmonary hypertension.
Compared with the prior TTE ___ , the severity of
tricuspid regurgitation has decreased. The right ventricle is
less dilated. The pericardial effusion has increased in size.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Calcitriol 0.25 mcg PO M, WED, FRI
5. Clopidogrel 75 mg PO DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH DAILY
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Levothyroxine Sodium 50 mcg PO ___
10. Levothyroxine Sodium 100 mcg PO SUN
11. Montelukast 10 mg PO DAILY
12. Nephrocaps 1 CAP PO DAILY
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. Pantoprazole 40 mg PO Q24H
15. Senna 17.2 mg PO BID
16. sevelamer CARBONATE 800 mg PO TID W/MEALS
17. Thiamine 100 mg PO DAILY
18. B complex with C#20-folic acid 1 mg oral DAILY
19. mometasone-formoterol 200-5 mcg/actuation inhalation BID
20. Metoprolol Succinate XL 100 mg PO BID
21. Isosorbide Mononitrate (Extended Release) 180 mg PO DAILY
22. Polyethylene Glycol 17 g PO DAILY
23. amLODIPine 2.5 mg PO DAILY
Discharge Medications:
1. Isosorbide Mononitrate (Extended Release) 240 mg PO DAILY
2. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN
3. amLODIPine 2.5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. B complex with C#20-folic acid 1 mg oral DAILY
7. Calcitriol 0.25 mcg PO M, WED, FRI
8. Clopidogrel 75 mg PO DAILY
9. Fluticasone Propionate 110mcg 2 PUFF IH DAILY
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. Levothyroxine Sodium 100 mcg PO SUN
13. Levothyroxine Sodium 50 mcg PO ___
14. Metoprolol Succinate XL 100 mg PO BID
15. mometasone-formoterol 200-5 mcg/actuation inhalation BID
16. Montelukast 10 mg PO DAILY
17. Nephrocaps 1 CAP PO DAILY
18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
19. Pantoprazole 40 mg PO Q24H
20. Polyethylene Glycol 17 g PO DAILY
21. Senna 17.2 mg PO BID
22. Thiamine 100 mg PO DAILY
23. HELD- sevelamer CARBONATE 800 mg PO TID W/MEALS This
medication was held. Do not restart sevelamer CARBONATE until a
doctor tells you because you have low phos
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Angina
Type 2 NSTEMI
CAD
HFpEF
Severe MR
___ stage renal disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with chest pain, oxygen requirement.// ? acute
cardiopulmonary process
TECHNIQUE: Chest AP and lateral
COMPARISON: Multiple prior chest radiographs, most recently ___.
FINDINGS:
A right sided central venous catheter terminates in the upper right atrium, as
before. Prosthetic valve, mediastinal surgical clips and sternotomy wires are
unchanged.
The lungs are moderately lax banded. Retrocardiac opacity may reflect
atelectasis, although it is difficult to exclude pneumonia. There is
pulmonary vascular congestion and mild interstitial edema. Small bilateral
pleural effusions are present. No pneumothorax. Cardiomegaly is unchanged.
IMPRESSION:
1. Cardiomegaly with small bilateral pleural effusions and mild pulmonary
edema.
2. Retrocardiac opacity may be related to atelectasis, although it is
difficult to exclude pneumonia if clinically appropriate.
Radiology Report
INDICATION: ___ year old woman with o2 req, hypotension// Evaluation for
pneumonia
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
Unchanged right central venous catheter terminating in the right atrium. The
patient has had prior median sternotomy and cardiac replacement. The size of
the cardiac silhouette is enlarged but unchanged. A retrocardiac opacity
likely reflects atelectasis and a small pleural effusion. A small right
pleural effusion is also unchanged. No pneumothorax. Mild pulmonary edema is
decreased since prior.
IMPRESSION:
Mild decrease in extent of the pulmonary edema. Otherwise no significant
interval change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with new cough, dyspnea, decreased right breath
sounds// Pneumonia? Pneumonia?
IMPRESSION:
Comparison to ___. Decreased lung volumes, stable moderate left
pleural effusion. Increasing right pleural effusion. Signs of mild to
moderate pulmonary edema now present. Moderate cardiomegaly persists. Stable
alignment of the sternal wires, stable position of the hemodialysis catheter.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified, Pleural effusion, not elsewhere classified
temperature: 98.5
heartrate: 65.0
resprate: 18.0
o2sat: 94.0
sbp: 140.0
dbp: 71.0
level of pain: 7
level of acuity: 2.0 | ___ with a PMH significant for HFpEF (LVEF 45% ___, severe
aortic stenosis s/p TAVR (___) c/b ___ cardiac
arrest, coronary artery disease status post CABG complicated by
in-stent restenosis ___, status post multiple PCIs with
persistent stable angina (last DES to LMCA-Cx ___, HTN,
HLD, DM, ESRD on HD ___ p/w angina, likely secondary to demand
ischemia in setting of unrevascularized coronary disease, course
c/b recurrent chest pain post HD and pulmonary edema.
# Angina:
# CAD s/p CABG:
# NSTEMI:
# HTN:
# Acute on chronic HFpEF:
# Severe MR/mild TR:
# Moderate pHTN:
# B/l pleural effusions with pulmonary edema:
Patient p/w chest pain with dynamic EKG changes (lateral TWI and
ST depressions) and stable cardiac enzyme elevation (peaked at
0.28), likely secondary to demand ischemia in setting of volume
overload and incompletely revascularized CAD. Low suspicion for
acute plaque rupture. TTE revealed stable mildly reduced
systolic function (EF 45%) and severe MR compared to ___. Ms.
___ was clear that she is not interested in further invasive
interventions for her severe CAD. She was seen by cardiology for
assistance with medical management of refractory angina, who
initially recommended discontinuation of amlodipine and
transition from home Toprol to carvedilol and uptitration of
home Imdur for angina. On that regimen, she developed mild,
asyptomatic hypotension after HD on ___ (with UF 1L) with SBPs
in the ___, resolved with gentle IVF replacement. Her BPs
improved, but unfortunately she had recurrence of angina post HD
___ (at which time only 500cc was
removed), with more extensive ST depressions in the
anterolateral leads and some improvement with SL nitro,
suggestive of persistent demand ischemia with HD-related fluid
shifts. In discussion with cardiology and renal, ranolazine was
thoughtcontraindicated and she was transitioned back to home
metoprolol and amlodipine with continuation of uptitrated Imdur.
She tolerated HD ___ (with 1L UF) on that regimen without
recurrence of chest pain, and is being discharged on Toprol
100mg BID, amlodipine 2.5mg daily, and Imdur 240mg daily, along
with her home ASA, plavix, and atorvastatin. Unfortunately,
additional
pharmacologic management of refractory angina is limited, and
fluid management will remain challenging given the need to
maintain euvolemia in setting of ESRD, acute on chronic HFpEF,
and severe MR while maximizing coronary/systemic perfusion. Dry
weight on discharge 85.54 lb/38.8 kg. ___ NP follow-up
scheduled for ___.
# SOB/cough:
# Asthma:
Ms. ___ developed mild SOB and cough on ___ prior to HD,
likely secondary to pulmonary edema/small b/l pleural effusions.
CXR showed no e/o PNA, and her symptoms improved with HD. She
was intermittently kept on 1L NC during her hospitalization for
comfort, with adequate oxygenation on RA (with goal SpO2 >92%).
Home albulterol, fluticasone, Advair (in place of home
mometasone-formoterol for formulary reasons), and montelukast
were continued. She will need to f/u with her outpatient
pulmonologist (Dr. ___ after discharge.
# ESRD:
# Hypophosphatemia:
Renal followed and she was maintained on HD ___. As above,
fluid management will remain challenging given the need to
maintain euvolemia in setting of ESRD, acute on chronic HFpEF,
and severe MR while maximizing coronary/systemic perfusion. Dry
weight on discharge 85.54 lb/38.8 kg. Continued home calcitriol
and nephrocaps. Home sevelamer was held on d/c for
hypophosphatemia per renal recommendations.
# Hyponatremia:
Likely secondary to ESRD and impaired ability to dilute urine.
Improved with HD.
# Normocytic anemia:
Likely due to ESRD. No evidence of active bleeding. Continued on
Epo with HD.
# Hypothyroidism:
Continued home levothyroxine.
# GERD:
Continued home PPI.
# DM:
Diet controlled. Was maintained on an ISS in-house.
# Contact: ___ (son) ___ (updated ___
# Code: DNR/DNI (confirmed; no ICU tx and no NIPPV or invasive
interventions)
TRANSITIONAL ISSUES:
=======================
[ ] f/u response to Imdur uptitration for chronic angina
[ ] ensure pulmonary f/u; missed appoint while hospitalized
[ ] repeat phos; may need to resume sevelamer
[ ] continue ESRD ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lipitor / Influenza Virus Vaccine
Attending: ___.
Chief Complaint:
Orthostatis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo F with hypothyroidism and HLD with no known CAD who awoke
___ with L leg cramp she's had previously and had gradual
onset of chest pressure while at rest. She had associated
presyncope without vertigo when getting out of bed, worsened
with warm shower but resolving over a few minutes. She had no
tachycardia, diaphoresis, radiation of pain, dyspnea, or
worsening with exertion and the chest pain did not recur all
day. She did have palpitations/irreg HR. This has never occurred
previously.
Per Dr. ___ the leg cramp "is something that she
gets periodically (about every 2 months) and was no different in
intensity, quality of discomfort, than usual".
In the ED intial vitals were:
Temp: 97.7 HR: 63 BP: 153/77 Resp: 18 O2Sat: 96 Normal
-Troponins negative x2
-Chest x-ray negative
-ETT and went 3.75 min on mod ___ and achieved ___ METs
with non-specific ST changes. Her BP dropped from 98/60-->90/60.
Overall, due to her limited exercise tolerance, the test is
non-diagnostic.
-During her ED obs course she was persistently orthostatic after
a large PO water challenge (1L free water = 125cc isotonic
crystalloid challenge) and 1L IVF.
Patient was given:
-1L NS in past 2hrs, none previously
-81mg ASA yesterday
Vitals on transfer:
Today 16:58 Sitting 68 161/79
Today 16:58 Standing 76 140/86 RR 17 98% r/a, afebrile
Today 16:58 Sitting 68 161/79
Past Medical History:
#DCIS ___: cured with lumpectomy
#Hyperlipidemia: Last LDL ___, not on tx
#Hypothyroidism: on levothyroxine
Social History:
___
Family History:
Father with first MI at age less than ___. Positive for CAD
Physical Exam:
ADMISSION EXAM:
97.7 HR: 63 BP: 153/77 Resp: 18 O2Sat: 96 Normal
General: Alert, oriented, no acute distress, pleasantly
conversing
HEENT: malar telangiectasias, conjunctival pallor, sclerae
anicteric, MMM, oropharynx clear
Neck: JVP < 8
Lungs: CTAB
CV: RRR, no m/r/g
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, no tremor, no pronator drift, motor ___
throughout, DTRs ___ at patellae, ___ at biceps/triceps, normal
FTN
DISCHARGE EXAM:
VS: 98.4 127/81 53 18 98%
General: Alert, oriented, no acute distress, pleasantly
conversing
HEENT: malar telangiectasias, conjunctival pallor, sclerae
anicteric, MMM, oropharynx clear
Neck: JVP < 8
Lungs: CTAB
CV: RRR, no m/r/g
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, no tremor, no pronator drift, motor ___
throughout, DTRs ___ at patellae, ___ at biceps/triceps, normal
FTN
Pertinent Results:
___ 03:15PM BLOOD WBC-6.3 RBC-4.86 Hgb-14.7 Hct-45.3 MCV-93
MCH-30.4 MCHC-32.6 RDW-13.2 Plt ___
___ 03:15PM BLOOD Neuts-61.4 ___ Monos-7.2 Eos-1.6
Baso-2.3*
___ 03:15PM BLOOD Glucose-95 UreaN-12 Creat-0.7 Na-140
K-5.3* Cl-103 HCO3-24 AnGap-18
___ 09:14PM BLOOD cTropnT-<0.01
___ 03:15PM BLOOD cTropnT-<0.01
___ 10:02AM BLOOD D-Dimer-265
___ 03:20PM BLOOD Lactate-1.4
___:
STUDY: Chest radiograph.
INDICATION: Chest pain and weakness. Rule out pneumonia.
TECHNIQUE: Two views were obtained.
COMPARISON: ___.
REPORT: There is pulmonary hyperinflation. Some generalized
increased lung markings are seen. Heart size is normal. No
acute cardiopulmonary finding is noted. Degenerative changes in
the spine and bony osteopenia are noted. Biapical calcification
is seen.
CONCLUSION: No acute findings.
----------
TOTAL EXERCISE TIME: 3.75 % MAX HRT RATE ACHIEVED: 64
SYMPTOMS: ATYPICAL
INTERPRETATION: This ___ yo woman was referred to the lab for
evaluation of chest pain and pre-syncope. The patient exercised
for 3.75 minutes on a Modified ___ protocol and was stopped
for a drop in systolic BP accompanied by fatigue, weakness, and
mild lightheadedness. The estimated peak MET capacity was 3
which represents a poor exercisetolerance for her age. The
patient denied any arm, neck, back, or chest discomfort however
she did note fatigue, shortness of breath, heaviness\weakness in
the lower extremities as well as mild to moderate
lightheadedness. These discomforts resolved by 3 minutes in
recovery. At peak exercise there was ~0.5 mm upsloping/scooping
ST segment depression in the inferolateral leads which returned
to baseline morphology by 6 minutes in recovery. The rhythm was
sinus with frequent isolated APBs and several atrial couplets.
Blunted HR response to exercise in the absence of beta blockade.
Progressive drop in systolic BP at a low workload.
IMPRESSION: Mild pre-syncopal symptoms associated with a drop in
SBP at a low workload. Non-specific EKG changes in the absence
of anginal
symptoms. Abnormal HR and BP response. Poor exercise tolerance.
------------
ECG: NSR, rate 58, nl axis and intervals. No ST or TW changes
consistent with ischemia.
ECG w/ R sided precordial leads also shows NSR w/ no ischemia.
PACs.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 88 mcg PO DAILY
2. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Levothyroxine Sodium 88 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Orthostatic hypotension
Atypical chest pain
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
STUDY: Chest radiograph.
INDICATION: Chest pain and weakness. Rule out pneumonia.
TECHNIQUE: Two views were obtained.
COMPARISON: ___.
REPORT:
There is pulmonary hyperinflation. Some generalized increased lung markings
are seen. Heart size is normal. No acute cardiopulmonary finding is noted.
Degenerative changes in the spine and bony osteopenia are noted.
Biapical calcification is seen.
CONCLUSION:
No acute findings.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: CHEST PAIN
Diagnosed with CHEST PAIN NOS
temperature: 97.7
heartrate: 63.0
resprate: 18.0
o2sat: 96.0
sbp: 153.0
dbp: 77.0
level of pain: 0
level of acuity: 2.0 | ___ yo F with hypothyroidism and HLD with no known CAD who awoke
___ gradual onset of chest pressure while at rest and came to
ED for evaluation. She was ruled out for ACS and PE and had
non-diagnostic ETT. She was found to have orthostatic
hypotension and was admitted.
#Orthostasis: She had prominent orthostatic hypotension with
relative bradycardia in the ED. This was concerning for some
sympatholytic process though the patient does not take AV nodal
blockers or sympatholytics, no did she look hypothyroid. She had
no neurologic findings associated with primary autonomic failure
or multiple system atrophy. She had normal bowel and bladder
function. She received a total of 2L IVF and her orthostasis
improved. She remained orthostatic despite fluid resuscitation.
EKGs showed normal sinus rhythm and sinus bradycardia with PACs.
She had no further CP or presyncope. She was asymptomatic and
wanted to discharge with outpatient cardiology follow up.
#Atypical Chest Pressure: Found to have non-ischemic EKG changes
in ED and negative troponins x2. She did not tolerate an ETT and
the findings were inconclusive. It was recommended by cardiology
that she get outpatient dobutamine TTE to risk stratify her. She
has mild HLD, +family CAD history, but is otherwise low risk.
#Hypothyroidism: She was treated with her home levothyroxine. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ranitidine / Celebrex
Attending: ___.
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old ___ speaking woman with a history of
recurrent UTIs who is presenting with two days of weakness,
report of foul smelling urine and one day of dyspnea. She lives
alone with care giver who is there for most of the day and has a
daughter nearby who was with her in the emergency room. I was
unable to reach her daughter ___, ___ overnight.
The remainder of this history was obtained from the patient with
the help of a ___ translator by phone.
She explains that she fell 10 days ago in the corridor of her
building and landed on her knees. No headstrike and no LOC. She
did not seek medical attention at that time. Her knees have been
hurting her since however. She has also been feeling more tired
than usual. According to her daughter she has not been getting
out of bed for the last two days. When I asked her why she said
that it was because it hurt to walk.
Of note her daughter reported that she had foul-smelling urine.
The patient herself denies any dysuria, urinary frequency, or
change in smell. She does confirm that she felt somewhat short
of breath earlier today however she states that this was mild
and resolved. Otherwise she has not felt much differently than
her baseline except for the knee pain.
She does note that she has not been eating and drinking much
over the last few days primarily because she has been in bed.
When asked she states that she does have some nausea but mostly
just after drinking water. When asked she said she does have
some mild pain with swallowing that she has noticed for the last
10 days or so (roughly since her fall). She does not otherwise
have a sore throat.
No chest pain, cough, abdominal pain, vomiting, diarrhea,
constipation, dysuria, change in urinary frequency, dizziness,
light-headedness, headache.
Of note she did have a UTI with a urine culture on ___ U
growing out E.coli resistant to trim/sulfa, amp, cipro, levoflox
which was treated with macrobid.
On the floor she is complaining of thirst but otherwise denying
any other current pain or symptoms. Her knee pain has resolved.
She is not short of breath.
Review of Systems:
(+) as per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
DEPRESSION
DYSPEPSIA
HYPERCHOLESTEROLEMIA
INSOMNIA
LEUKOCYTOSIS
OSTEOARTHRITIS
PALPITATIONS
S/P APPENDECTOMY
S/P COCCYX FRACTURE
S/P OS VITREOUS DETACHMENT
PERIPHERAL EDEMA
VITAMIN B12 DEFICIENCY
VISITING NURSE
H/O COLONIC POLYPS
H/O L SHOULDER PAIN
H/O SCIATICA
H/O VERTIGO
H/O ATRIAL FIBRILLATION
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.7 145/63 91 20 98/ra
General: elderly woman in NAD
HEENT: NCAT, dry MM, EOMI, limited oropharyngeal exam was WNL
Neck: no JVD appreciated
Lungs: diminished breath sounds anteriorly
CV: RRR no murmurs appreciated
Abdomen: soft, nontender in all quadrants, +bs
Ext: no significant edema, knees mildly swollen, no significant
effusions, on initial exam right knee was warm compared to left
however this resolved on re-examination
Neuro: CN2-12 grossly intact, moving all extremities
DISCHARGE PHYSICAL EXAM:
Vitals- 97.6 123/56 62 18 95/2L
General: elderly woman. Unkempt. AOx2.
HEENT: NCAT, MMM, EOMI
Neck: JVD<8cm
Lungs: Rales bilaterally R>L, extending halfway up. No wheezes,
rhonchi.
CV: regular rate, regular rhythm, no murmurs appreciated
Abdomen: soft, nontender in all quadrants, +bs
Ext: no significant edema, knees mildly swollen, no significant
effusions.
Neuro: CN2-12 grossly intact, strength is grossly intact.
Pertinent Results:
LABS:
On admission:
___ 06:57PM BLOOD WBC-29.0*# RBC-5.20 Hgb-15.3 Hct-49.1*
MCV-94 MCH-29.4 MCHC-31.2 RDW-13.7 Plt ___
___ 06:57PM BLOOD Neuts-49* Bands-0 ___ Monos-5 Eos-2
Baso-0 Atyps-2* ___ Myelos-0
___ 06:57PM BLOOD ___ PTT-29.2 ___
___ 09:20PM BLOOD Glucose-132* UreaN-37* Creat-1.1 Na-136
K-4.2 Cl-99 HCO3-30 AnGap-11
___ 07:08PM BLOOD Lactate-1.6
On discharge:
___ 08:15AM BLOOD WBC-22.4* RBC-4.71 Hgb-13.9 Hct-45.1
MCV-96 MCH-29.5 MCHC-30.9* RDW-13.8 Plt ___
___ 08:15AM BLOOD ___
___ 08:15AM BLOOD Glucose-103* UreaN-28* Creat-0.9 Na-143
K-4.2 Cl-102 HCO3-38* AnGap-7*
Miscellaneous:
___ 04:55PM BLOOD ESR-52*
___ 04:55PM BLOOD CRP-106.5*
___ 07:00AM BLOOD TSH-2.9
___ 06:30AM BLOOD CK-MB-14* MB Indx-4.7 cTropnT-0.06*
___ 04:55PM BLOOD CK-MB-9 cTropnT-0.08*
___ 10:15AM BLOOD CK-MB-7 cTropnT-0.07*
___ 06:13AM BLOOD CK-MB-8 cTropnT-0.07* proBNP-___*
___ 05:55PM BLOOD cTropnT-0.05*
MICRO:
___ blood cx x2
___ 7:10 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
___ 10:01 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
___ CT abd/pelvis:
IMPRESSION:
1. Focal cortical abnormality in the right kidney suggestive of
infection or infarction. This is age indeterminate but new since
___. Clinical correlation is recommended.
2. Indeterminate left adrenal nodule again seen but stable
compared to prior, likely representing an adenoma or
myelolipoma.
___ CXR:
FINDINGS: There are low lung volumes and bibasilar atelectasis.
There is persistent elevation of the right hemidiaphragm.
There is blunting of the left costophrenic angle, which could be
due to a small effusion. There are questionable subtle rib
deformities along the lateral fifth and sixth ribs of
indeterminate age, correlate with history of trauma. The
cardiac silhouette is not assessed but is likely top normal to
mildly enlarged. Mediastinal contours are unremarkable. No
overt pulmonary edema. Mild prominence of the pulmonary
vasculature is likely at least in part due to low lung volumes.
___ Knee xray:
IMPRESSION:
Severe degenerative changes of both knees involving
predominantly the medial compartment which appear stable,
allowing for differences in patient positioning from the
___ study.
___ CXR:
FINDINGS: Mild pulmonary vascular congestion is new. Right
middle and right lower lobe atelectasis has slightly worsened,
with persistent adjacent elevation of right hemidiaphragm.
Slight improvement in left retrocardiac opacity, likely due to
atelectasis. Small left pleural effusion is unchanged. No
visible pneumothorax
___
The left atrial volume is normal. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The estimated
cardiac index is normal (>=2.5L/min/m2). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Moderate mitral regurgitation with normal valve
morphology. Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Mild pulmonary artery hypertension.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
___ Non-contrast head CT:
(wet read)
Signficant brain atrophy. Some hypodensity possibly due to
small vessel ischemic disease. No evidence of old territorial
infarcts suggestive of embolic CVAs.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Metoprolol Succinate XL 100 mg PO DAILY
2. TraZODone 50 mg PO HS:PRN insomnia
3. Vitamin D 1000 UNIT PO DAILY
4. Acetaminophen ___ mg PO BID:PRN pain
5. Aspirin 325 mg PO DAILY
6. Furosemide 20 mg PO TWICE WEEKLY MON + ___
7. Omeprazole 40 mg PO DAILY
8. Senna 1 TAB PO BID:PRN constipation
9. Cyanocobalamin 1000 mcg IM/SC MONTHLY
Discharge Medications:
1. Cyanocobalamin 1000 mcg IM/SC MONTHLY
2. Furosemide 20 mg PO TWICE WEEKLY MON + ___
3. Metoprolol Succinate XL 100 mg PO DAILY
4. TraZODone 50 mg PO HS:PRN insomnia
5. Citalopram 10 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Senna 1 TAB PO BID:PRN constipation
8. Aspirin 325 mg PO DAILY
9. Acetaminophen 650 mg PO TID Pain
10. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
DEPRESSION
ATRIAL FIBRILLATION
DYSPHAGIA
OSTEOARTHRITIS (BILATERAL KNEES)
DEMENTIA
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
STUDY: Bilateral knees, ___.
CLINICAL HISTORY: ___ woman status post fall ___ days ago, now with
knee pain.
FINDINGS:
LEFT KNEE: There are severe degenerative changes involving predominantly the
medial compartment where there is marked joint space narrowing. Spurring
within all three compartments is seen and there is a small left knee joint
effusion.
RIGHT KNEE: There is moderate narrowing of the medial compartment; however,
these are non-weightbearing views. There is also a small right knee joint
effusion. Degenerative changes within all three compartments are present.
Vascular calcifications are seen posteriorly.
IMPRESSION:
Severe degenerative changes of both knees involving predominantly the medial
compartment which appear stable, allowing for differences in patient
positioning from the ___ study.
Radiology Report
PORTABLE CHEST, ___
COMPARISON: Radiograph of two days earlier.
FINDINGS: There is a worsening area of opacity in the left retrocardiac
region, which could potentially be due to aspiration given the history of
clinical suspicion for this entity. Lungs are otherwise remarkable for right
lower lobe atelectasis, moderate elevation of right hemidiaphragm, and an
apparent calcified granuloma in the left lung apex. Cardiomediastinal
contours are stable in appearance.
Radiology Report
PA AND LATERAL CHEST, ___
COMPARISON: Radiograph of earlier the same date.
FINDINGS: Mild pulmonary vascular congestion is new. Right middle and right
lower lobe atelectasis has slightly worsened, with persistent adjacent
elevation of right hemidiaphragm. Slight improvement in left retrocardiac
opacity, likely due to atelectasis. Small left pleural effusion is unchanged.
No visible pneumothorax.
Radiology Report
HISTORY: Patient with atrial fibrillation (no anticoagulation) who has no
focal deficits but has delirium superimposed on dementia, evaluate for
evidence of 1) diffuse global atrophy consistent with Alzheimer's dementia; 2)
old ischemic CVA.
COMPARISON: NECT of the head on ___.
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.
CTDI vol: 162 mGy, DLP: 1560 mGy-cm
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or large vascular
territorial infarction. Again seen is an arachnoid cyst in the left temporal
lobe, unchanged since prior study. There is diffuse supra and infratentorial
atrophy compatible with age without medial temporal predominance to suggest
Alzheimer's disease. 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. There is mild mucosal thickening of the right
maxillary sinus and air-fluid level in the left sphenoid sinus. The remaining
visualized paranasal sinuses, mastoid air cells, and middle ear cavities are
clear. Atherosclerotic mural calcifications of the bilateral cavernous
segments of the internal carotid arteries are noted. The globes are
unremarkable.
IMPRESSION:
1. No evidence of acute intracranial process. Diffuse global atrophy without
medial temporal predominance to suggest possible Alzheimer's disease.
2. Chronic small vessel ischemic disease.
Gender: F
Race: WHITE - RUSSIAN
Arrive by WALK IN
Chief complaint: Dyspnea, Weakness
Diagnosed with OTHER MALAISE AND FATIGUE
temperature: 96.6
heartrate: 78.0
resprate: 18.0
o2sat: 100.0
sbp: 174.0
dbp: 74.0
level of pain: 0
level of acuity: 3.0 | ___ year old ___ speaking woman with a history of
hypertension, hyperlipidemia, paroxysmal afib (not on coumadin),
depression, chronic leukocytosis (thought to be due to CLL) and
recurrent UTIs who is admitted with subjective symptoms of
weakness and lethagy. Found to have signficant deconditioning
and depression, course complicated by afib with RVR. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abd discomfort, nausea/vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yoM with ESRD ___ DMII and HTN on dialysis, diabetic
retinopathy, and gastroparesis who presents with 1 week of
epigastric burning and nausea. He was at dialysis today but only
received 26 min due to nausea/vomiting, upper abd to throat
burning, and hypotension, prompting transfer to the ED. The
patient has a chronic history of GERD for which he takes
antacids. He usually experiences these symptoms for several
hours which resolves with antacids or vomiting. However, his
current symptoms have persisted for 1 week. He denies f/c,
cough, or dysuria. He endorses diarrhea but think this is due to
laxatives as he usually has constipation.
- In the ED, initial vital signs were: 97.9 98 173/88 16 97%RA
- Labs were notable for: lactate 1, nl coags, trop 0.05, Na 132,
BUN/Cr 35/8, alk phos 233, 15.5>12.3/39.4<428 with neutrophilic
predominance.
- EKG: SR, NA, NI, no acute STT changes
- CXR: Moderate sized bilateral pleural effusions with probable
associated loculation. An underlying focal opacity however
cannot be entirely excluded.
- Patient was given:
___ 15:45 IV Ondansetron 4 mg
___ 16:31 PO Pantoprazole 40 mg
___ 16:31 PO Aluminum-Magnesium Hydrox.-Simethicone 30 mL
Decision was made to admit for cardiac w/u and dialysis. No
emergent need for drainage of pleural effusions given chronic
and no new respiratory symptoms. Does not have fevers or cough
indicative of empyema. Of note, patient has history of chronic
bilateral pleural effusions. Is on 3L NC at baseline.
Of note, patient saw PCP ___ when he was experiencing
worsening abd pain and nausea despite taking protonix, reglan,
and promethazine. His sxs were presumed to be from gastroparesis
and his meds were continued. He was referred to GI but never
made appointment. He had colonoscopy ___ yrs ago in ___ but
was never told of a diagnosis. He has never had an upper
endoscopy. He eats 5 small meals per day for gastroparesis.
On Transfer Vitals were: 98.3 99 171/88 18 99%RA
On the floor, patient denies current nausea or abd pain. He
experienced relief with Maalox and Zofran.
Past Medical History:
PAST MEDICAL HISTORY:
- END STAGE RENAL DISEASE: ___ diabetes and HTN. On HD MWF at
___ in ___
- HYPERTENSION
- DIABETIC RETINOPATHY
- GASTROPARESIS
- TOBACCO ABUSE
- H/O DIABETES TYPE II: was on insulin for ___ years, lost 60lbs
and hgbA1C have been well controlled off of medication
PAST SURGICAL HISTORY:
- APPENDECTOMY
- SPLENECTOMY: after trauma/fall
- CATARACT SURGERY
- AV FISTULA REPAIR
Social History:
___
Family History:
Mother with hyperlipidemia, MI s/p PCI
Physical Exam:
ON ADMISSION:
Vitals: 98.2 159/87 100 18 98%3L
General: Chronically ill appearing, in NAD
HEENT: PERRL, sclera anicteric, oropharynx clear, MMM, JVP 8cm,
no cervical LAD
CV: RRR, no m/r/g
Lungs: Bibasilar crackles, no wheezing or rhonchi
Abdomen: Distended but soft, nontender to palpation, midline
incision scar (from splenectomy)
GU: No foley, anuric
Ext: WWP, fistula on R, pulses intact bilaterally, no edema
Neuro: AAOx3, non-focal
Skin: No rashes
ON DISCHARGE:
Vitals: 98.3 140s-150s/60s-80s ___ 18 97-98%3L
General: Chronically ill appearing, in NAD
HEENT: PERRL, sclera anicteric, oropharynx clear, MMM, JVP 8cm,
no cervical LAD
CV: RRR, no m/r/g
Lungs: Bibasilar crackles, no wheezing or rhonchi
Abdomen: Distended but soft, nontender to palpation, midline
incision scar (from splenectomy)
GU: No foley, anuric
Ext: WWP, fistula on R, pulses intact bilaterally, no edema
Neuro: AAOx3, non-focal
Skin: No rashes
Pertinent Results:
ON ADMISSION:
___ 02:30PM BLOOD WBC-15.5* RBC-3.99* Hgb-12.3* Hct-39.4*
MCV-99* MCH-30.8 MCHC-31.2* RDW-13.3 RDWSD-48.0* Plt ___
___ 02:30PM BLOOD Neuts-80.1* Lymphs-8.3* Monos-8.5 Eos-2.1
Baso-0.5 Im ___ AbsNeut-12.42* AbsLymp-1.29 AbsMono-1.32*
AbsEos-0.33 AbsBaso-0.08
___ 03:17PM BLOOD ___ PTT-30.1 ___
___ 02:30PM BLOOD Glucose-160* UreaN-35* Creat-8.0* Na-132*
K-4.9 Cl-86* HCO3-33* AnGap-18
___ 02:30PM BLOOD ALT-12 AST-12 CK(CPK)-49 AlkPhos-233*
TotBili-0.3
___ 02:30PM BLOOD CK-MB-2
___ 02:30PM BLOOD cTropnT-0.05*
___ 07:45AM BLOOD Albumin-4.0 Calcium-9.6 Phos-4.0 Mg-4.5*
___ 03:20PM BLOOD Lactate-1.0
___ 02:30PM BLOOD Lipase-29
ON DISCHARGE:
___ 07:45AM BLOOD WBC-10.0 RBC-3.68* Hgb-11.4* Hct-36.6*
MCV-100* MCH-31.0 MCHC-31.1* RDW-13.3 RDWSD-48.8* Plt ___
___ 07:45AM BLOOD Glucose-100 UreaN-42* Creat-9.6*# Na-133
K-5.8* Cl-87* HCO3-31 AnGap-21*
___ 07:45AM BLOOD ALT-13 AST-10 LD(LDH)-171 AlkPhos-215*
TotBili-0.3
___ 07:45AM BLOOD CK-MB-1 cTropnT-0.06*
___ 07:45AM BLOOD Albumin-4.0 Calcium-9.6 Phos-4.0 Mg-4.5*
OTHER STUDIES:
___ CXR: Possible bilateral pleural effusions with
pleural-based thickening and/or prominent extrapleural fat.
More rounded opacity posterior on the lateral view may be due to
loculated fluid however underlying focal parenchymal opacity is
possible. Correlation with prior imaging would be helpful to
document stability. If not available, CT should be performed to
further characterize, the acuity of which can be determined
clinically
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoclopramide 10 mg PO QIDACHS
2. Pantoprazole 40 mg PO Q24H
3. Amlodipine 10 mg PO DAILY
4. CloniDINE 0.2 mg PO BID
5. Promethazine 25 mg PO TID:PRN nausea
6. Nephrocaps 1 CAP PO DAILY
7. TraZODone 100 mg PO QHS
8. Cinacalcet 60 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Metoclopramide 10 mg PO QIDACHS
3. Promethazine 25 mg PO TID:PRN nausea
4. TraZODone 100 mg PO QHS
5. Pantoprazole 40 mg PO Q24H
6. Nephrocaps 1 CAP PO DAILY
7. CloniDINE 0.2 mg PO BID
8. Cinacalcet 60 mg PO DAILY
9. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN abd
discomfort
RX *alum-mag hydroxide-simeth [Maalox Maximum Strength] 400
mg-400 mg-40 mg/5 mL 15 mL by mouth four times a day Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Gastroparesis
SECONDARY:
Diabetes mellitus type 2
End stage renal disease on hemodialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: ___ with nausea, vomiting // eval for CHF/pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: None available.
FINDINGS:
Pleural based opacities, right greater than left are possible bilateral
pleural effusions with possible pleural thickening and/or prominent pleural
fat. Opacity on the lateral view posteriorly may be a loculated effusion
however, an underlying focal parenchymal opacity is possible. There is
associated bibasilar atelectasis. There is no pneumothorax. The cardiac
silhouette is obscured by the pleural fluid. The hilar and mediastinal
contours are normal. Vascular stent projects over the left upper chest.
Vascular stents project in the left subclavian/axillary regions.
IMPRESSION:
Possible bilateral pleural effusions with pleural-based thickening and/or
prominent extrapleural fat. More rounded opacity posterior on the lateral
view may be due to loculated fluid however underlying focal parenchymal
opacity is possible. Correlation with prior imaging would be helpful to
document stability. If not available, CT should be performed to further
characterize, the acuity of which can be determined clinically
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: n/v/d
Diagnosed with Nausea, Dizziness and giddiness
temperature: 97.9
heartrate: 98.0
resprate: 16.0
o2sat: 97.0
sbp: 173.0
dbp: 88.0
level of pain: 6
level of acuity: 3.0 | ___ yoM with ESRD ___ DMII and HTN on dialysis, diabetic
retinopathy, and gastroparesis who presents with 1 week of
epigastric burning and nausea and inability to complete HD on
day of admission due to hypotension. In the ED he was noted to
have elevated troponin of 0.05 was therefore admitted to
medicine for cardiac w/u and HD.
However, patient's EKG showed no ischemic and his CK-MB was
flat. Patient also denied chest pain but rather epigastric
burning radiating to his throat which is typical of his existing
GERD symptoms. His elevated trop was therefore interpreted in
the setting of ESRD. Patient received HD day of discharge.
Patient's nausea was thought to be due to worsening of his known
gastroparesis, as he reported no change in the quality of his
nausea or abdominal pain. He was treated with Maalox with
notable improvement in his symptoms. He was also continued on
his home pantoprazole, metoclopramide, and promethazine. During
admission he was able to tolerate po without nausea or vomiting. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L hip pain
Major Surgical or Invasive Procedure:
___ L proximal femur replacement
History of Present Illness:
___ hx colon cancer s/p radiation therapy and resection ___
ago now w L hip pain since ___ when getting out of car w L
femoral neck fx identified on MRI, pain acutely worse x2days w
repeat XR showing displacement of fx. Denies trauma, fevers,
chills, other complaints.
Past Medical History:
HTN
pre-diabetes
colon cancer s/p colectomy and ileostomy reversal in ___
Social History:
denies smoking or illicits, social EtOH
Physical Exam:
admit:
AFVSS
AOx3, well appearing
LLE:
slightly shortened and externally rotated
ttp over greater troch, + pain w logroll and hip flexion
___
SILT throughout
DP2+, wwp
d/c:
AFVSS
AOx3, well appearing
LLE:
incision c/d/i
___
SILT throughout
DP2+, wwp
Pertinent Results:
___ 11:00AM GLUCOSE-208* UREA N-38* CREAT-1.3* SODIUM-134
POTASSIUM-4.5 CHLORIDE-96 TOTAL CO2-27 ANION GAP-16
___ 11:00AM estGFR-Using this
___ 11:00AM CALCIUM-10.0 PHOSPHATE-2.8 MAGNESIUM-2.0
___ 11:00AM WBC-9.5 RBC-3.82* HGB-12.0* HCT-35.7* MCV-93
MCH-31.4 MCHC-33.6 RDW-12.9
___ 11:00AM NEUTS-89.0* LYMPHS-6.7* MONOS-3.8 EOS-0.3
BASOS-0.2
___ 11:00AM PLT COUNT-153
___ 11:00AM ___ PTT-26.7 ___
Radiology Report
CHEST RADIOGRAPH
INDICATION: Left hip pain, preoperative chest x-ray.
COMPARISON: No comparison available at the time of dictation.
FINDINGS: The lung volumes are normal. Normal size of the cardiac
silhouette. Moderate tortuosity of the thoracic aorta. No pulmonary edema.
No pneumonia, no pleural effusions.
Radiology Report
EXAM: AP view of the pelvis and AP and lateral views of the left femur.
___ at 14:32.
HISTORY: Known hip fracture on pelvic x-rays.
TECHNIQUE: AP view of the pelvis and AP and lateral views of the left femur.
FINDINGS: Left femoral neck fracture with foreshortening of the left femur is
again seen. There is evidence of sclerosis in the region and just distal to
the fracture suggesting that it may be pathologic. No evidence of dislocation
is seen. No fracture of the more distal left femur is identified.
Degenerative changes are noted at the left sacroiliac joint and mildly at the
pubic symphysis as well as at the right hip. There is no diastasis of the
pubic symphysis or sacroiliac joints. Chain sutures are noted in the pelvis.
IMPRESSION: Left femoral neck fracture with sclerosis in the region and just
distal to it with a somewhat mottled appearance raising concern for pathologic
fracture. No dislocation is seen. There is no evidence of acute fracture of
the more distal left femur.
Radiology Report
INDICATION: ___ man with recent pathologic fracture.
COMPARISON: Hip radiograph dated ___.
TECHNIQUE: MDCT-acquired contiguous CT imaging through the abdomen and pelvis
was obtained with intravenous contrast. Coronally and sagittally reformatted
images are provided.
CT OF THE ABDOMEN AND PELVIS:
ABDOMEN:
There is a small right and a trace left pleural effusion and associated
atelectasis. There is a small hiatal hernia and reflux of contrast into the
esophagus.
There is a 5 mm indeterminate liver lesion in the inferior right hepatic lobe,
which is predominantly hypodense though too small to characterize; tiny focus
of hyperdensity near its periphery may represent an adjacent vessel or focus
of peripheral enhancement. The liver otherwise enhances normally. There is no
evidence of intrahepatic or extrahepatic biliary ductal dilatation. The
portal vein is patent. The gallbladder is incompletely distended. There is
no gallbladder wall edema or pericholecystic fluid collection to suggest acute
inflammation. No calcified gallstones are seen within its lumen. The spleen
is unremarkable. The pancreas enhances homogeneously without ductal
dilatation or peripancreatic fluid collection. The adrenal glands are normal.
The kidneys enhance and excrete contrast symmetrically without evidence of
hydronephrosis. There are bilateral parapelvic renal cysts. No suspicious
renal masses. There is no free air or free fluid within the abdomen. There
is no mesenteric or retroperitoneal lymphadenopathy. No evidence of bowel
obstruction.
CT OF THE PELVIS: There is a Foley catheter within a collapsed urinary
bladder. The distal ureters, prostate gland, seminal vesicles are
unremarkable. There is a colorectal anastamosis, which appears patent. No
free air or free fluid within the pelvis. No pelvic wall or inguinal
lymphadenopathy.
There is a left hip replacement with adjacent staple and foci of gas, which
are consistent with recent surgery. There is a hematoma in the left adductor
musculature.
There is aortic atherosclerosis and tortuousity.
IMPRESSION:
1. 5 mm indeterminate liver lesion in the inferior right hepatic ___
represent a cyst or hemangioma, however, in the current clinical setting, if
further characterization is indicated, recommend ultrasound for further
evaluation.
2. No definite evidence of malignancy in the abdomen or pelvis.
3. Coloanal anastomosis noted. Review of clinical record indicates a history
of colon cancer.
Radiology Report
HISTORY: ORIF.
FINDINGS: Views from the operating suite show placement of a
hemiarthroplasty, which appears to be well seated and without evidence of
acute complication.
Radiology Report
HISTORY: Femur replacement.
FINDINGS: In comparison with study of ___, there has been a
hemiarthroplasty performed with the device apparently well seated.
Post-surgical changes are seen in soft tissues.
Radiology Report
INDICATION: ___ man with recent pathologic fracture.
COMPARISON: Hip radiograph dated ___.
TECHNIQUE: Multidetector CT imaging of the chest was performed after the
uneventful intravenous administration of 130 cc of Omnipaque intravenous
contrast. Sagittal and coronal reformations were performed and reviewed.
FINDINGS: The heart is normal in size. No pericardial effusion. The
mediastinal great vessels are normal. No pathologic mediastinal, hilar or
axillary lymphadenopathy. The major airways are patent to subsegmental levels
bilaterally. No suspicious pulmonary nodules or masses are seen. There is a
small right and a trace left pleural effusion and associated atelectasis.
There is a small hiatal hernia and reflux of contrast into the esophagus. No
bone lesions worrisome for infection or malignancy are detected.
IMPRESSION: No evidence for metastatic disease in the chest. Small right and
trace left pleural effusions.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: FX L FEMUR
Diagnosed with PATHOLOGIC FX FEMUR NECK, SECONDARY MALIG NEO BONE
temperature: 98.6
heartrate: 58.0
resprate: 16.0
o2sat: 99.0
sbp: 162.0
dbp: 74.0
level of pain: 8
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L intertroch hip fx and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for L proximal femur replacement, which the patient
tolerated well (for full details please see the separately
dictated operative report). The patient was taken from the OR to
the PACU in stable condition and after recovery from anesthesia
was transferred to the floor. The patient was initially given
IV fluids and IV pain medications, and progressed to a regular
diet and oral medications by POD#1. The patient was given
perioperative antibiotics and anticoagulation per routine. The
patients home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is WBAT in the LLE extremity, and
will be discharged on lovenox 40mg x2wks for DVT prophylaxis.
The patient will follow up in two weeks per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Trauma: fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a ___ year old gentleman who was walkign down the
street and attempted to avoid a group of children and tripped
over a curb striking his head on the side of a building. He
developed pain in his posterior cervical spine as well as in his
chest. He was taken to an OSH where imaging showed a C2 anterior
inferior body frcture without canal compromise, as well as right
___ and 2nd rib fractures. He was transferred to ___ for
further care.
Past Medical History:
none
Social History:
___
Family History:
none
Physical Exam:
PHYSICAL EXAM: upon admission: ___
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact without nystagmus
Neck: in hard cervical collar, Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes:
No Hoffmans
No Clonus
Propioception intact
Toes downgoing bilaterally
Pertinent Results:
___ 07:01AM BLOOD WBC-6.3 RBC-4.36* Hgb-14.0 Hct-40.7
MCV-93 MCH-32.2* MCHC-34.5 RDW-12.4 Plt ___
___ 08:55PM BLOOD WBC-6.4 RBC-4.64 Hgb-15.0 Hct-43.3 MCV-93
MCH-32.4* MCHC-34.7 RDW-12.8 Plt ___
___ 07:01AM BLOOD Plt ___
___ 08:55PM BLOOD Glucose-109* UreaN-8 Creat-0.7 Na-139
K-3.6 Cl-102 HCO3-26 AnGap-15
___ 08:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___: chest cat scan:
1. Right first rib fracture. No other acute traumatic findings.
Left first and right second rib fractures were better
characterized on outside C-spine study.
2. Small hiatal hernia.
___: cat scan of the c-spine:
Hyperextension injury of the ALL with fracture at the base of
C2.
___: cat scan of the c-spine:
Hyperextension injury of the ALL with fracture at the base of
C2.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*8 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Trauma: fall:
C2 vert body fx
bil. 1st rib
Right 2nd rib fracture
Discharge Condition:
Mental Status: Clear and coherent( ___ speaking)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ with fall, head-strike injury, ___ and 2nd rib fractures,
assess for other rib fractures. // Diffuse chest tenderness, assess for other
rib fractures
TECHNIQUE: Multidetector helical scanning of the chest was performed without
intravenous contrast agent reconstructed as contiguous 5- and 1.25-mm thick
axial, 2.5-mm thick coronal and parasagittal, and 8 x 8 mm MIPs axial images.
DOSE: DLP: 463.7
COMPARISON: Same day chest radiograph.
FINDINGS:
The imaged thyroid is unremarkable. Heart size is top-normal. There is no
significant pericardial fluid. There are 3 vessel coronary artery
calcifications. The thoracic aortic arch is normal in caliber with mild
atherosclerotic calcifications. The main pulmonary artery is normal in
caliber. There is no supraclavicular, axillary, hilar or mediastinal
lymphadenopathy.
Though this study is not tailored for subdiaphragmatic diagnosis, note is made
of a few colonic diverticula without evidence of diverticulitis as well as a
small hiatal hernia. The remainder of the upper abdomen is unremarkable.
There is mild bilateral dependent atelectasis. The airways are patent to the
subsegmental level. Punctate calcified granuloma is noted in the right upper
lobe. There is an additional 4 mm calcified granuloma in the left apex. Lungs
are otherwise clear. Pleural surfaces are clear without effusion or
pneumothorax.
Osseous structures: There is no suspicious focal osseous lesion. There is a
right first rib fracture. Thoracic cage is otherwise intact. The thoracic
vertebral body heights and alignment are well maintained. Minimal contour
irregularity of the mid sternum appears chronic.
IMPRESSION:
1. Right first rib fracture. No other acute traumatic findings. Left first and
right second rib fractures were better characterized on outside C-spine study.
2. Small hiatal hernia.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with head strike injury, fall, C2 fracture, ___ and 2nd rib
fractures reported by OSH.
TECHNIQUE: This of the study obtained at outside hospital and submitted for
second read.
CTDIvol: 30.27 mGy
DLP: 544.85 mGy-cm
COMPARISON: None
FINDINGS:
There is a hyperextension injury with an avulsion fracture at the anterior
inferior base of C2 at the insertion of the ALL, which is minimally displaced.
There is no additional fracture seen throughout the cervical spine. Bilateral
first rib and right second rib fractures are also present. There is no
significant prevertebral soft tissue swelling. Multilevel degenerative changes
are present with anterior and posterior osteophyte formation and multilevel
small disc bulges. The lung apices are clear. The thyroid gland is
unremarkable.
IMPRESSION:
Hyperextension injury of the ALL with fracture at the base of C2.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: s/p Fall, Transfer
Diagnosed with FX C2 VERTEBRA-CLOSED, FRACTURE ONE RIB-CLOSED, UNSPECIFIED FALL
temperature: 98.1
heartrate: 72.0
resprate: 20.0
o2sat: 98.0
sbp: 171.0
dbp: 96.0
level of pain: 0
level of acuity: 2.0 | The patient was admitted to the hospital from a fall he
sustained after tripping on a curb. Upon admission, he reported
pain in his neck and chest. He underwent imaging at an outside
hospital where he was reported to have a C2 anterior inferior
body fracture. There was no canal compromise and he was
neurologically stable. He was also noted to have right ___ and
2nd rib fractures. Because of the C2 fracture, the patient was
evaluated by the neurosurgery service. The patient was placed
in a cervical collar and a 4 week follow-up visit was
recommended with additional imaging.
The patient's rib pain was controlled with oral analgesia. His
oxygen saturation was closely monitored and he was encouraged to
use the incentive spirometer. He was tolerating a regular diet
and voiding without difficulty. On HD #4, the patient was
discharged home in stable condition. An appointment for
follow-up was made with Dr. ___ ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Propoxyphene / Methadone / pseudoephedrine / Peanut / Adhesive
Bandage / Banana
Attending: ___.
Chief Complaint:
Fevers, RUE swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo incarcerated M with ESRD on HD MWF, HIV (CD4 early ___
___), HTN, DM who was discharged ___ after being found to
have MSSA bacteremia, thought to be ___ an infected femoral HD
line. Today he is sent in for evaluation of his R. AV graft, he
reports a small amount of purulent drainage from the site as
well as warmth and tenderness to the touch. He was given ancef
at HD yesterday.
The patient has a long and complicated course of access issues.
The patient was admitted from ___ for MRSA bacteremia. He
completed a course of vancomycin. He has had multiple attempts
at UE grafts and fistulas, most recently with a right forearm
loop AV graft done by Dr. ___ on ___.
.
Of note the patient missed the "medicine line" at jail this
morning and took none of his BP meds.
.
In the ED, initial VS: 10 98.4 72 222/104 18 99%. Exam was
notable for +bruit/thrill. The patient was given his home BP
meds, and morphine for pain. He was also given a metoprolol 5mg
IV dose. Transplant surgery saw the patient and requested
vancomycin and BP control. The patient is being admitted to
medicine for antibiotics, bp control, and further transplant
surgery work-up.
REVIEW OF SYSTEMS:
Denies night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, abdominal
pain, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
.
Past Medical History:
ESRD on HD since ___ years due to HTN
HIV (CD4 308 in ___ with undetectable VL)
H/O ESBL sepsis last year
AV graft failure complicated by amputation of right forearm and
hand
HTN
DMII
Asthma
GERD
Chronic phantom limb pain
Social History:
___
Family History:
Per patient, hypertension, heart disease, COPD, bone cancer
Physical Exam:
Admission:
VS - 98.5 ___ 93% RA
GENERAL - Alert, interactive, chronically ill appearing in mild
pain
HEENT - PERRL right eye, left eye scarred, EOMI, sclerae
anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, JVP obscured by habitus, no
carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - bibasilar crackles
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 1+ DP pulses, 2+ edema to knees
bilaterally, RUE graft with faint thrill, +bruit. Large 4-5cm
firm mass at proximal end of graft - +bruit over mass, TTP, no
overlying erythema or warmth. Right thigh with firm mass
overlying former HD cath site, no drainage/fluctuance
appreciated.
Right hand amputation.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout,
.
Discharge:
VS - 98.5F, 180-154/80s, 84-66, 18 98% 1L ___ 132
GENERAL - Alert, interactive,NAD
HEENT - PERRL right eye, left eye scarred, EOMI, sclerae
anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, JVP obscured by habitus, no
carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - faint bibasilar crackles
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 1+ DP pulses, 2+ edema to knees
bilaterally, RUE graft with faint thrill, +bruit. Large 4-5cm
firm mass at proximal end of graft - +bruit over mass, TTP, no
overlying erythema or warmth. Right thigh with firm mass
overlying former HD cath site, no drainage/fluctuance
appreciated.
Right hand amputation.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout,
Pertinent Results:
I) Admission Labs:
CBC
___ 06:55PM BLOOD WBC-5.0 RBC-4.04* Hgb-9.2* Hct-29.8*
MCV-74* MCH-22.8* MCHC-30.9*# RDW-21.7* Plt ___
___ 06:55PM BLOOD Neuts-60.6 ___ Monos-6.9 Eos-4.8*
Baso-1.8
Coags:
___ 06:55PM BLOOD ___ PTT-35.4 ___
Chem:
___ 06:55PM BLOOD Glucose-87 UreaN-31* Creat-7.0*# Na-141
K-3.7 Cl-93* HCO3-37* AnGap-15
___ 07:45AM BLOOD Calcium-9.7 Phos-5.5* Mg-2.3
Tox:
___ 11:43PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
II) Micro:
Blood cultures 2x ___: Pending
Blood cultures 2x ___: Pending
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___:
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
III) Imaging:
Chest Xray:
In comparison with the study of ___, there are patchy areas of
opacification in the right perihilar region and left base. In
view of the
clinical history, this could well reflect regions of pneumonia
bilaterally.
Ill-defined pulmonary vessels may be a manifestation of elevated
pulmonary
venous pressure in this patient with mild enlargement of the
cardiac
silhouette.
IV) Discharge Labs:
Note patient is s/p HD on ___. These labs were drawn PRIOR to
HD.
___ 06:12AM BLOOD WBC-5.3 RBC-3.53* Hgb-7.9* Hct-25.8*
MCV-73* MCH-22.3* MCHC-30.5* RDW-21.9* Plt ___
___ 06:12AM BLOOD Glucose-125* UreaN-62* Creat-8.8*# Na-142
K-4.6 Cl-100 HCO3-28 AnGap-19
___ 06:12AM BLOOD Calcium-9.6 Phos-6.4*# Mg-2.6
___ 06:12AM BLOOD Vanco-12.8
V) Studies Pending at Discharge:
1. Blood Cultures: no growth to date
Medications on Admission:
amlodipine 10 mg Tablet DAILY
abacavir 600 mg Tablet ___: daily.
Tylenol #3 two tabs BID prn pain x 10d
albuterol HFA 2 puffs BID
CefazoLIN 3 g IV ___ WITH HD last dose ___
CefazoLIN 2 g IV ___ with HD ___
diphenhydramine 25mg prn itch
digoxin .25mg qd
emtricitabine 200 mg PO QHSMOFRI
Epo 10k units MWF
Ferric glugconate 62.5mg/5ML INJ 125mg q72
Ferrous gluconate 324 MG tab TID
levetiracetam 1000 mg PO BID
labetalol 800 mg Tablet ___: PO TID
lisinopril 40 mg Tablet PO DAILY
minoxidil 10 mg PO bid
Dilantin 600mg QD
zoloft 50mg qd
sevelamer carbonate 3200mg PO TID W/MEALS
Nephrocaps 1 mg Capsule daily
omeprazole 20 mg Capsule, Delayed Release(E.C.) PO DAILY
albuterol sulfate prn
Colace 100 mg PO twice a day.
lispro
Vitamin A-D ointment for feet
Discharge Medications:
1. sevelamer carbonate 800 mg Tablet ___: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. B complex-vitamin C-folic acid 1 mg Capsule ___: One (1) Cap
PO DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) ___: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. ferrous sulfate 300 mg (60 mg iron) Tablet ___: One (1)
Tablet PO DAILY (Daily).
5. efavirenz 600 mg Tablet ___: One (1) Tablet PO HS (at
bedtime).
6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler ___:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
SOB/Wheezing.
7. docusate sodium 100 mg Capsule ___: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. emtricitabine 200 mg Capsule ___: One (1) Capsule PO QMONFRI
().
9. labetalol 200 mg Tablet ___: Four (4) Tablet PO TID (3 times
a day).
10. insulin lispro 100 unit/mL Solution ___: SSI units
Subcutaneous ASDIR (AS DIRECTED): As directed per sliding scale.
.
11. minoxidil 10 mg Tablet ___: One (1) Tablet PO BID (2 times a
day).
12. metronidazole 500 mg Tablet ___: One (1) Tablet PO Q8H
(every 8 hours) for 2 weeks: Day ___.
13. Ferrlecit 62.5 mg/5 mL Solution ___: One Hundred ___
(125) mg Intravenous qHD.
14. Epogen 10,000 unit/mL Solution ___: ___ units
Injection qHD.
15. Vitamin A & D GRx Topical
16. Tylenol-Codeine #3 300-30 mg Tablet ___: Two (2) Tablet PO
twice a day as needed for pain for 10 days.
17. lisinopril 40 mg Tablet ___: One (1) Tablet PO once a day.
18. amlodipine 10 mg Tablet ___: One (1) Tablet PO once a day.
19. abacavir 300 mg Tablet ___: Two (2) Tablet PO once a day.
20. Keppra 1,000 mg Tablet ___: One (1) Tablet PO twice a day.
21. vancomycin in D5W 1 gram/200 mL Piggyback ___: One (1)
Intravenous Sliding Scale HD protocol for 14 days: Dose at HD
per sliding scale protocol. .
***Patient was not placed on dilantin during admission. He was
also not placed on digoxin. It is unclear why he is taking these
medications and he has never been prescribed them at ___.
Evaluate restarting these medications after discussing the risks
and benefits of these medications with the patients primary care
physician ___ ___
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis:
1. Clostridium difficile colitis
2. Right arm seroma
3. MRSA bacteremia
Secondary Diagnosis:
4. End stage renal disease
5. HIV
6. Hypertension
7. Chronic phantom limb pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Graft infections with subjective fever, to assess for pneumonia.
FINDINGS: In comparison with the study of ___, there are patchy areas of
opacification in the right perihilar region and left base. In view of the
clinical history, this could well reflect regions of pneumonia bilaterally.
Ill-defined pulmonary vessels may be a manifestation of elevated pulmonary
venous pressure in this patient with mild enlargement of the cardiac
silhouette.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: FISTULA EVAL
Diagnosed with SEROMA COMPLIC PROCEDURE, ABN REACT-RENAL DIALYSIS, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, ASYMPTOMATIC HIV INFECTION
temperature: 98.4
heartrate: 72.0
resprate: 18.0
o2sat: 99.0
sbp: 222.0
dbp: 104.0
level of pain: 10
level of acuity: 3.0 | ___ year old male with HIV on ART, end stage renal disease on
hemodialysis, type II diabetes, hypertension, recent
hospitalization for MSSA bacteremia, who was admitted for fevers
and swelling at the site of his AV-graft and was found to have
c-diff colitis.
Problems:
1. C. Diff colitis
2. Right upper extremity seroma with possible infection
3. End Stage Renal Disease on dialysis
4. HIV
5. Chronic phantom limb pain
6. Hypertension
7. Type 2 Diabetes
#Fever/C. difficile colitis:
The patient presented to the BI with reports of subjective
fevers and frequent loose stools. He was subsequently tested for
C-Diff toxin which was positive. Given his age, frequency of
bowel movements <10 per day, and lack of leukocytosis, we
elected to start treatment for C-Diff with metronidazole. He
received his first dose on ___. We would like him to take a
two week course of oral flagyl which should end 2 weeks after he
completes his course of Vancomycin for empiric coverage of
possibly infected seroma (see below).
-Oral Flagyl 500mg TID x 28d total (Last day ___.
# Right upper extremity seroma:
The patient presented to ___ with reported fevers and purulent
drainage from his right arm mass although no drainage was noted
after presentation to ___. Of note, this mass was previously
drained at the beginning of ___ secondary to concern for
infection. At that time, he had positive blood cultures for
MSSA. He was discharged to prison on cefazolin per hd protocol
with the intention of completing therapy on ___. Given his
previous history of MRSA positive bacteremia, transplant surgery
recommended to start treatment empirically for possibly infected
seroma with IV vancomycin per sliding scale HD protocol.
Although the site was tender, it was not particularly
erythematous and the patient did not have a leukocytosis or
systemic symptoms other than fever. That said, given previous
infectious complications and location near his AV graft the
decision was made to empirically treat with Vancomycin for 2
weeks pending re-assessment at outpatient ID and Transplant
Surgery follow up appointments.
#End Stage Renal Disease:
The patient's right arm mass has not prevented him from getting
HD. His AV graft is functioning well and he was dialyzed
successfully twice during his stay here. He received
hemodialysis on ___. He should remain on his normal HD
schedule of ___. Given the lack of vascular access, it is very
likely in the future that he will require peritoneal dialysis,
as he is not a candidate for femoral access. This will be
disscussed at his follow up appointment with Drs. ___
___ from the Department of Transplant Surgery at ___ in
approximately 2 weeks.
#Prevous MSSA bacteremia:
The patient was treated for MSSA bacteremia from prior
admission. He was due to finish his course on ___. All of
his blood cultures, during this admission have shown no growth
to date.
Chronic Problems:
#HIV, on ART:
His last viral load was undetectable. He had an infectious
disease appointment to manage his HAART on ___. Of note, he
was admitted on abacavir and emtircitabine. He should also be
taking efavirenz. It is unclear as to why the patient was not
taking efavirenz. In the hospital, he was put on the HAART,
therapy that he had previously been on which is emtircitabine,
efavirenz, and abacavir.
-Please resume
abacavir 600 mg Tablet ___: daily.
emtricitabine 200 mg PO QHSMOFRI
efavirenz 600 mg
# Chronic phantom pain:
The patient experiences chronic phantom pain secondary to hand
amputation. His pain is chronic in origin and was treated with
inpatient oxycodone-apap. He can resume his outpatient regimen
of tylenol 3 upon return to prison.
#Hypertension:
The patient has multi-drug resistant hypertension. Presented
with hypertensive emergency as his systolic blood pressure was
greater than 200. He was showing no signs of end organ damage
such as head ache, altered mental status, agitation, blurred
vision ect. His hypertensive emergency was secondary to him
missing his anti-hypertensives during the day. His blood
pressure corrected after receiving his normal outpatient dose of
antihypertensives. Of note, he still remains hypertensive with
systolic blood pressures in the 170s prior to dialysis. No
signficant changes were made to the patient's anti-hypertensive
regimen.
#Patient has mild type 2 diabetes. Good glycemic control was
achieved with a humalog sliding scale which was continued from
prison.
Transitional Issues:
1. Appropriate HIV medications: Patient has follow up with
infectious disease. However, in the interim he should continue
to take triple therapy consisting of abacavir, emtricitabine,
and efavirenz. The patient had an appointment with ID at ___
on the ___, however he missed this appointment for unclear
reasons.
2. Follow up final results of blood cultures which have shown no
growth to date. When the final results of the cultures are
available, a member of our team will contact the patient's PCP.
3. We held the patient's digoxin. There is no clear indication
as to why the patient should be on digoxin. He has a normal
ejection fraction and renal failure. If you feel that there is
an indication for restarting digoxin, please let us know why as
to aid the transition of care between ___ and prison. Also,
dilantin was not given during this hospitalization. The patient
has never been on dilantin during hospitalazation at ___.
Please meet with the patient on ___ to discuss resuming these
medications.
4. Vascular access: The patient is running out of options for
dialysis. He will likely require peritoneal dialysis. This will
be arranged at his follow up visit with transplant surgery.
5. Antibiotic therapy: The patient should be treated with flagyl
for C-diff as stated above. He should be dosed with vancomycin
sliding scale per HD protocol as stated above. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o female with a past medical history of
alcohol abuse, depression, COPD, hemochromatosis (homozygosity
___ mutation HFE gene), ?porphyria, h/o multiple falls who
presented to the hospital on ___ s/p fall in the setting of
alcohol use and was found to have a small left parietal SDH on
CT. Patient was admitted to the neurosurgery service and was
noted to have a stable neuro exam. She had a repeat head CT on
___ that showed a stable SDH. She was started on keppra 1 g BID
for seizure prophylaxis. While hospitalized the patient was
placed on a CIWA scale and required benzos for withdrawal. Her
home diazepam was restarted. She was started on precedex gtt and
received Haldol/valium on ___. On ___ her precedex was
discontinued and she was called out of the ICU on ___. The
neurosurgery service is requesting transfer to medicine
formanagement of alcohol withdrawal, failure to thrive, and
management of chronic hemochromatosis. With regards to her
hemochromatosis, she has been seeing hematology in the clinic
and has been scheduled for therapeutic phlebotomy every ___
weeks to induce iron deficiency (notably she has only attended
one appt so far). Her goal Hb is ___, Ferritin ___, TIBC
>300, and iron/TIBC ratio ___. She had therapeutic
phlebotomy on ___ (which was her first and only session).
Past Medical History:
COPD - no PFT's in system
Alcoholism - drinks 1 pint of vodka daily, last drink 2 days ago
Major depression - denies
GERD
Vestibular Neuritis - taking diazepam prn, controlled as per
patient, no recent falls.
Nondepressed L skull fracture s/p fall in ___ associated with
ETOH
Social History:
___
Family History:
Her mother passed away at ___ from probable cancer. Father passed
away at ___ from a ruptured gallbladder. She has ___ and
___ sisters. Her daughter committed suicide at age ___.
She has a ___ son w/ h/o depression. Sister with bladder
cancer.
Physical Exam:
>> ADMISSION PHYSICAL EXAM:
O: T: 97.5 BP: 103/71 HR:94 R:20 O2Sats:100%RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___, bilat 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. Confused with
inappropriate speech at times.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right ___ 2 2
Left ___ 2 2
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
.
>> DISCHARGE PHYSICAL EXAM:
VS: Tmax 98.3 BP ___ P ___ RR 16 Sat 97-100% RA
Gen: thin woman lying in bed comfortably
HEENT: PERRL. Mild R ptosis. MMM, OP clear.
Pulm: mild diffuse rhonchi bilaterally
Cor: RRR, S1S2nl, no m/r/g
Abd: soft, NTND, no rebound or guarding
MSK/Ext: WWP no edema
Neuro: AOX3, CN III-XII intact
Skin: nonblanching red lesions, generally round with irregularly
borders, ranging from 2 to 4cm in diameter, concentrated
predominantly on forearms and legs bilaterally. Some lesions
with ulceration, some with scarring and scabbing, one lesion on
L forearm with heaped up necrotic substance.
Pertinent Results:
>> ADMISSION LABS:
___ 12:55PM BLOOD WBC-6.4 RBC-3.56* Hgb-12.9 Hct-38.6
MCV-108* MCH-36.2* MCHC-33.4 RDW-13.1 RDWSD-52.2* Plt ___
___ 12:55PM BLOOD Neuts-70.7 ___ Monos-7.6 Eos-0.6*
Baso-0.5 Im ___ AbsNeut-4.53 AbsLymp-1.31 AbsMono-0.49
AbsEos-0.04 AbsBaso-0.03
___ 12:55PM BLOOD ___ PTT-29.8 ___
___ 12:55PM BLOOD Glucose-97 UreaN-15 Creat-0.6 Na-136
K-3.3 Cl-97 HCO3-25 AnGap-17
___ 12:55PM BLOOD ALT-33 AST-72* AlkPhos-123* TotBili-0.9
___ 12:55PM BLOOD Lipase-14
___ 12:55PM BLOOD Albumin-4.5 Calcium-9.7 Phos-3.1 Mg-2.2
___ 12:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
___ 01:06PM BLOOD Lactate-1.8
.
>> DISCHARGE LABS:
___ 05:40AM BLOOD WBC-5.3 RBC-3.29* Hgb-12.1 Hct-35.7
MCV-109* MCH-36.8* MCHC-33.9 RDW-13.4 RDWSD-52.8* Plt ___
___ 05:40AM BLOOD Glucose-92 UreaN-7 Creat-0.4 Na-136 K-3.3
Cl-100 HCO3-21* AnGap-18
___ 05:40AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.1
___ 05:40AM BLOOD VitB12-792 Folate-7.9
.
>> IMAGING:
___ CHEST (PA & LAT)
IMPRESSION:
Patchy right base opacity concerning for pneumonia or
aspiration.
___ CT HEAD W/O CONTRAST
IMPRESSION:
Limited examination due to patient motion.
1. 5 mm in width left subdural hemorrhage. No midline shift.
2. Possible additional site of subdural hemorrhage along the
anterior falx.
3. Posterior scalp hematoma.
___ CT C-SPINE W/O CONTRAST
IMPRESSION:
1. No acute fracture.
2. Mild degenerative disease.
___ CT CHEST/ABD/PELVIS W/
IMPRESSION:
1. No acute intrathoracic or intraabdominal injury.
2. Mucous plugging in the right lower lobe bronchus appears
worse compared to the prior chest CT of ___ with associated
atelectasis. Bibasilar
atelectasis appears unchanged.
3. Bilateral rib and sternal fractures were present on the prior
CT of ___.
___ CT HEAD W/O CONTRAST
IMPRESSION:
1. Stable left subdural hematoma.
___ CT HEAD W/O CONTRAST
IMPRESSION:
1. New linear hyperdensity along a right parietal sulcus is most
consistent
with a small subarachnoid hemorrhage.
2. Stable small left hyperdense subdural hematoma.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Betamethasone Dipro 0.05% Lot. 1 Appl TP DAILY:PRN psoriasis
2. LamoTRIgine 400 mg PO DAILY
3. Tiotropium Bromide 1 CAP IH DAILY
4. Benzonatate 100 mg PO TID:PRN cough
5. hydrocodone-chlorpheniramine ___ mg suspension Q12H
6. Zolpidem Tartrate 12.5 mg PO QHS
7. Nicotine Patch 21 mg TD DAILY
8. Diazepam 10 mg PO Q8H:PRN anxiety
9. LORazepam 1 mg PO TID:PRN anxiety
10. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm
11. Ranitidine 300 mg PO QHS
12. Multivitamins 1 TAB PO DAILY
13. Pramipexole 1 mg PO QHS
14. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
15. Fluticasone Propionate 110mcg 2 PUFF IH BID
16. Nystatin Cream 1 Appl TP BID
17. Pantoprazole 40 mg PO Q12H
18. albuterol sulfate 5 mg/mL inhalation Q6H:PRN
19. Sertraline 50 mg PO DAILY
20. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Benzonatate 100 mg PO TID:PRN cough
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. LamoTRIgine 25 mg PO BID
4. Pantoprazole 40 mg PO Q12H
5. Pramipexole 1 mg PO QHS
6. Ranitidine 300 mg PO QHS
7. Sertraline 50 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Nicotine Patch 21 mg TD DAILY
10. Ascorbic Acid ___ mg PO BID
11. LevETIRAcetam 1000 mg PO BID
12. albuterol sulfate 5 mg/mL inhalation Q6H:PRN
13. Betamethasone Dipro 0.05% Lot. 1 Appl TP DAILY:PRN psoriasis
14. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm
RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth every 8 hours Disp
#*12 Tablet Refills:*0
15. FoLIC Acid 1 mg PO DAILY
16. LORazepam 1 mg PO TID:PRN anxiety
RX *lorazepam 1 mg 1 tab by mouth every 8 hours Disp #*12 Tablet
Refills:*0
17. Nystatin Cream 1 Appl TP BID
18. rOPINIRole 3 mg PO QPM
19. Thiamine 100 mg PO DAILY
20. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRINCIPAL DIAGNOSIS
1. Subdural hematoma
2. Alcohol withdrawal
3. Subarachnoid hemorrhage
SECONDARY DIAGNOSIS
1. Alcohol use disorder
2. COPD
3. Hemochromatosis
4. GERD
5. Depression
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 confusion // ? PNA
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Patient is rotated to the left.Patchy right base opacity raises concern for
pneumonia or aspiration. Left base atelectasis is seen. No large pleural
effusion is seen. Mid lung linear atelectasis/ scarring is again seen on the
lateral view. No evidence of pneumothorax is seen. The cardiac and
mediastinal silhouettes are stable.
IMPRESSION:
Patchy right base opacity concerning for pneumonia or aspiration.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ woman status post fall.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.6 cm; CTDIvol = 48.5 mGy (Head) DLP =
903.1 mGy-cm.
2) Sequenced Acquisition 4.0 s, 4.1 cm; CTDIvol = 48.5 mGy (Head) DLP =
200.7 mGy-cm.
Total DLP (Head) = 1,104 mGy-cm.
COMPARISON: CT head ___.
FINDINGS:
Acute subdural hemorrhage layers along the left convexity and has a maximum
width of 5 mm. A possible additional small focus of subdural hemorrhage is
seen along the anterior falx. There is no midline shift. Gray-white matter
differentiation is preserved. The ventricles and sulci are normal in size and
configuration.
There is no acute evidence of fracture. Old fracture of the left occipital
bone is unchanged. There is mucosal thickening in the right maxillary sinus.
Otherwise, the visualized portion of the paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The visualized portion of the orbits are
unremarkable. There is a left posterior scalp hematoma.
IMPRESSION:
Limited examination due to patient motion.
1. 5 mm in width left subdural hemorrhage. No midline shift.
2. Possible additional site of subdural hemorrhage along the anterior falx.
3. Posterior scalp hematoma.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ woman status post fall.
TECHNIQUE: Non-contrast helical multidetector CT of the cervical spine was
performed. Soft tissue and bone algorithm images were generated. Coronal and
sagittal reformations were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.6 s, 21.8 cm; CTDIvol = 37.1 mGy (Body) DLP = 809.7
mGy-cm.
Total DLP (Body) = 810 mGy-cm.
COMPARISON: CT cervical spine ___.
FINDINGS:
There is exaggerated lordosis. No acute fracture is identified. There is
mild multilevel degenerative changes including intervertebral disc space
narrowing and small posterior osteophytes that are most marked at the C6-C7
and T2-T3 levels. There is no prevertebral soft tissue swelling. The lung
apices are clear.
IMPRESSION:
1. No acute fracture.
2. Mild degenerative disease.
Radiology Report
INDICATION: ___ woman status post fall.
TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and
pelvis following intravenous contrast administration with split bolus
technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 31.3 mGy (Body) DLP =
15.6 mGy-cm.
2) Spiral Acquisition 8.2 s, 64.1 cm; CTDIvol = 7.1 mGy (Body) DLP = 454.5
mGy-cm.
Total DLP (Body) = 470 mGy-cm.
COMPARISON: CT torso ___.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The ascending aorta is top normal in diameter measuring
4 cm. The thoracic aorta is without evidence of intramural hematoma or
dissection. The heart size is normal. No pericardial effusion is seen. There
are coronary artery calcifications.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is minimal right and moderate left lower lobe
atelectasis, unchanged since ___ examination. The right lower lobe
bronchi air completely occluded with mucous impaction, slightly increased in
severity since the prior examination. There is no focal consolidation.
BASE OF NECK: A 5 mm nodule in the left lobe of the thyroid does not warrant
follow-up imaging.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesion or laceration. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder contains
gallstones without wall thickening or surrounding inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesion or laceration.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: 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. There is no
evidence of mesenteric injury.
There is no free fluid or free air in the abdomen.
PELVIS: The urinary bladder contains a Foley catheter. There is no free fluid
in the pelvis.
REPRODUCTIVE ORGANS: The uterus is of normal size and enhancement. There is no
evidence of adnexal abnormality bilaterally.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Moderate atherosclerotic disease is noted.
BONES: There is no acute fracture. Bilateral old rib fractures were present
on the prior CT of ___. A sternal fracture appears chronic. There are
multilevel degenerative changes in the spine including grade I anterolisthesis
of L4 on L5.
SOFT TISSUES: Bilateral inguinal hernias containing fat are noted.
IMPRESSION:
1. No acute intrathoracic or intraabdominal injury.
2. Mucous plugging in the right lower lobe bronchus appears worse compared to
the prior chest CT of ___ with associated atelectasis. Bibasilar
atelectasis appears unchanged.
3. Bilateral rib and sternal fractures were present on the prior CT of ___.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: ___ year old woman with acute left parietal SDH // eval for
interval change - please obtain @ 2300.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 17.0 cm; CTDIvol = 47.1 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 4.0 s, 4.3 cm; CTDIvol = 47.1 mGy (Head) DLP =
200.7 mGy-cm.
Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: CT head without contrast ___ 15:57
FINDINGS:
Left subdural hematoma is stable compared to 8 hr ago, measuring 5 mm in
thickness. There is no shift of midline structures. Appearance of anterior
falx is not changed. The ventricles and sulci are stable in size and
configuration.
Old left occipital fracture is again noted (image 8, series 3a). There is
mucosal thickening of right maxillary sinus. The visualized portion of the
orbits are unremarkable. Posterior superior scalp hematoma is stable.
IMPRESSION:
1. Stable left subdural hematoma.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with left subdural hematoma, now with worsening
anisocoria. // interval change
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 11.0 s, 18.7 cm; CTDIvol = 48.8 mGy (Head) DLP =
911.9 mGy-cm.
Total DLP (Head) = 925 mGy-cm.
COMPARISON: Head CT from ___
FINDINGS:
A small hyperdense left subdural hematoma along the left lateral convexity is
stable. There is a small hyperdensity tracking along a right parietal sulcus
which is new compared to the prior examination and likely represents a small
subarachnoid hemorrhage (03:26, 602a:66). There is no shift of normally
midline structures. Gray-white matter differentiation is preserved.
Ventricles are stable in size and configuration.
Moderate mucosal thickening in the right maxillary sinus is unchanged. The
mastoid air cells and middle ear cavities are clear. The orbits are
unremarkable.
IMPRESSION:
1. New linear hyperdensity along a right parietal sulcus is most consistent
with a small subarachnoid hemorrhage.
2. Stable small left hyperdense subdural hematoma.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 7:55 ___, 30 min after discovery
of the findings.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Confusion, s/p Fall
Diagnosed with Altered mental status, unspecified, Alcohol abuse with intoxication, unspecified, Fall on same level, unspecified, initial encounter
temperature: 97.6
heartrate: 94.0
resprate: 20.0
o2sat: 100.0
sbp: 103.0
dbp: 71.0
level of pain: 5
level of acuity: 2.0 | ___ with a history of alcohol use disorder c/b recurrent falls
and aspirations, hemochromatosis, COPD, GERD and depression who
presented with L SDH after a mechanical fall and was transferred
to medicine for further management of alcohol withdrawal.
.
>> ACTIVE ISSUES:
# Subdural hematoma: On ___, the patient was brought to the
ED after her family noted her to be confused after multiple
falls. Her CT revealed a small left parietal subdural hematoma.
She was admitted to the ICU for close neurologic monitoring and
to monitor for withdrawal given her history of alcohol use
disorder. Repeat head CT in the ICU was stable. She was started
on Keppra for seizure prophylaxis. She was seen by physical
therapy who recommended ___ rehab to reduce fall risk.
# Subarachnoid hematoma: On ___, a new anisocoria was noted
(L>R), so a NCHCT was ordered. This showed a small R parietal
sulcus SAH. This finding was discussed with neurosurgery who
recommended no changes to her management.
# Alcohol withdrawal: On the second hospital day, Ms. ___
became impulsive, attempting multiple times to get out of bed
unassisted. She had increased agitation and hallucinations
requiring Haldol, Ativan and ultimately precedex. She was placed
in restraints for safety. Over the next two days, her agitation
improved and Haldol and Precedex were discontinued. She
continued to receive diazepam and lorazepam per CIWA for one
more day. She was off withdrawal medications for >48 hours prior
to discharge.
# Alcohol use disorder: Ms. ___ has longstanding alcohol
use disorder and exhibited confabulation on the floor concerning
for Wernicke-Korsakoff syndrome. She was treated with IV
thiamine, folate and multivitamin. She spoke with social worker
who recommended outpatient addiction treatment programs.
.
>> CHRONIC ISSUES:
# COPD: The patient has an extensive smoking history with known
COPD (FEV1 83% predicted in ___. She had a stable lung exam
and oxygen saturations while inpatient. She was continued on her
home Flovent, Spiriva and albuterol nebs, in addition to a
nicotine patch. She reports she is not interested in smoking
cessation at this time.
# Depression: Takes sertraline and lamotrigine at home. Home
lamotrigine was initially held while she was receiving
benzodiazepines for withdrawal. She will restart with slow
up-titration of lamotrigine dose to avoid rash associated with
abruptly starting high doses.
# Restless legs syndrome: Continued on home ropinirole and
pramipexole without issue.
# Insomnia: Home Zolpidem was held
# Anxiety: Home lorazepam and diazepam were held given
benzodiazepine administration for withdrawal treatment.
.
>> TRANSITIONAL ISSUES:
# Basal cell carcinoma: It appears that this was biopsied but
not excised. Please ensure that the she follows up in ___
clinic for further management.
# SDH: Has neurosurgery follow-up appointment on ___. They will
contact her to schedule a same-day noncontrast head CT. She will
continue on Keppra for seizure prophylaxis until then.
# Alcohol use d/o: Met with social worker who provided resources
for outpatient treatment. Please encourage her to utilize these
resources.
# Hemochromatosis: She has scheduled phlebotomy appointments
weekly through ___. She will coordinate with Drs. ___
___ for further management of her hemochromatosis.
# Depression: Lamotrigine was held for the first five days of
her hospital stay. Due to risk of rash with restarting this
medication at a high dose, she will restart with a slow increase
(starting ___: 25mg x 2wks, 50mg x 2wks, 100mg x1wk, 200mg
x1wk, then 400mg (home dose).
# Skin lesions: Vitamin C levels low normal, now receiving
supplementation. Please continue follow-up in dermatology and
hematology clinics.
# ___: Patient meets ___ criteria for We___
encephalopathy. Please continue thiamine, folate, MVI and follow
up vitamin B1 level.
# Code status: Full
# Communication: HCP ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lithium Benzoate / Tagamet
Attending: ___.
Chief Complaint:
Nausea, vomiting, abnormal labs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with a PMHx notable for NASH, GERD, PUD,
prediabetes (HgbA1c 6.6 ___, depression with h/o
parasuicidal behavior, and multiple somatic complaints including
abdominal and back pain which have had negative workups, as well
as vauge complaints of memory difficulty who is presenting with
3 weeks of nausea, vomiting and recent abnormal labs after
returning from a trip to ___.
The patient was seen in clinic on ___ for an epi visit. She
had recently returned from a trip to ___ (___),
where she ate seafood that she considered "questionable."
Several days later, she started to develop a cough and what she
described as "the flu." She took Robiussen to help relieve her
symptoms (___). Upon her return to the ___, she has been
having nausea and vomiting associated with epigastric and
RUQ/LUQ pain. She has been having mild diarrhea. She reports
seeing "tiny specks of redness" in her stool, but denies any
melena. She also denies any blood in her vomit. She endorsed
fevers to the low 100s. While she was at her PCP, labs performed
demonstated a WBC of 7.8 with 4% atypicals and an H/H of
11.7/33, which is below her baseline (___). Her AST was 51 and
ALT 47, which was slightly above her baseline, and her TBili was
1.5. Her Cr was normal but her K was 2.9. Monospot was negative.
Hep serologies were sent and were pending. She had a liver U/S,
which demonstrated a steatotic liver and splenomegaly (17cm),
which was a new finding. She was referred to the ED, but ended
up going to ___. Unclear what happened there, but she
was sent out and re-presented to clinic on ___ feeling
worse. She was then referred to the ___ ED for further
evaluation.
Of note, she was seen by Hepatology in ___ for evaluation of
her underlying NASH. She had a MRI which showed moderate
steatosis, without e/o fibrosis or cirrhosis. She was also
recently seen by ___ clinic to follow her hematuria,
which was found to be glomerular in nature. The plan was to
follow this prospectively for now since her Cr was normal.
Vitals in the ED: 99.3 113 147/62 18 100%
Labs notable for: WBC 6.3 with 18% atypicals. H/h ___, Plt
186. Na 147. Cr 0.7. AST 51, ALT 44, LDH 451, TB 0.9. UA with
trace blood
Patient given: Nothing
Exam: Notable for LUQ TTP with splenomegaly. Negative guaiac.
Vitals prior to transfer: 98 88 124/67 14 98% RA
On the floor, patient was examined in her bed in NAD. She
confirmed the above story and explained that she has been
feeling fatigued and weak for the past three weeks since she has
returned. She has had poor PO intake and has not been able to
keep food down. She denies any headaches, rashes, bleeding,
weight loss, or recent sexual activity. She also denies any
IVDU.
Review of Systems:
(+) per HPI, fevers, nausea, vomiting, diarrhea, cough,
myalgias, weakness, abdominal pain
(-) night sweats, headache, vision changes, chest pain,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Allergic Rhinitis
- Depression / Borderline Personality / Bulemia / PTSD
- Gallstones
- GERD / PUD (EGD ___ with antral gastric ulcer)
- NASH (s/p MRI in ___ without cirrhosis)
- Parasuicidal Behavior
- Nephrolithiasis
- T2DM
- Hematuria (seen by renal in ___
- H/o of benign heart murmur
- H/o abnormal pap smear
- H/o iron deficiency anemia
PAST SURGICAL HISTORY:
- S/p cholecystectomy
- S/p tonsillectomy
Social History:
___
Family History:
Mother with T2DM and hx of DVT. Father with ___ and T2DM and
HTN. Sister with T2DM.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 98.1 116/73 98 18 98% 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, I/VI systolic murmur heard throughout the
percordium (chronic)
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, TTP in LUQ with splenomegaly
EXTREMITIES: no edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals - 98.6 97.6 86 106/71 18 98% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
CARDIAC: RRR, S1/S2, I/VI systolic murmur
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, TTP in LUQ with splenomegaly
EXTREMITIES: no edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
___ 09:04PM BLOOD WBC-6.3 RBC-3.38* Hgb-10.0* Hct-28.0*
MCV-83 MCH-29.5 MCHC-35.6* RDW-15.6* Plt ___
___ 09:04PM BLOOD Neuts-46* Bands-0 ___ Monos-4 Eos-0
Baso-1 Atyps-18* ___ Myelos-0
___ 09:04PM BLOOD Hypochr-OCCASIONAL Anisocy-1+
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-1+
___ 09:04PM BLOOD Plt Smr-NORMAL Plt ___
___ 09:04PM BLOOD Parst S-NEG
___ 09:04PM BLOOD Ret Aut-4.2*
___ 09:04PM BLOOD Glucose-127* UreaN-6 Creat-0.7 Na-140
K-3.3 Cl-103 HCO3-29 AnGap-11
___ 09:04PM BLOOD ALT-44* AST-51* LD(LDH)-451* AlkPhos-57
TotBili-0.9
___ 12:10PM BLOOD Lipase-31
___ 09:04PM BLOOD Albumin-3.7 Calcium-9.3 Phos-3.1 Mg-2.0
UricAcd-6.3* Iron-64
___ 09:04PM BLOOD calTIBC-264 Hapto-<5* Ferritn-246*
TRF-203
___ 09:04PM BLOOD GreenHd-HOLD
___ 09:12PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:12PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.5 Leuks-NEG
___ 09:12PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
___ 09:12PM URINE UCG-NEGATIVE
PERTINENT LABS/DISCHARGE LABS
___ 05:38AM BLOOD WBC-5.9 RBC-3.40* Hgb-10.1* Hct-28.9*
MCV-85 MCH-29.7 MCHC-34.9 RDW-16.5* Plt ___
___ 09:04PM BLOOD Neuts-46* Bands-0 ___ Monos-4 Eos-0
Baso-1 Atyps-18* ___ Myelos-0
___ 05:38AM BLOOD Neuts-44.1* Lymphs-49.1* Monos-4.0
Eos-1.8 Baso-1.0
___ 03:40AM BLOOD Hypochr-NORMAL Anisocy-1+
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-1+ Polychr-1+
Ovalocy-OCCASIONAL
___ 06:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 07:35AM BLOOD Ret Aut-4.6*
___ 07:35AM BLOOD ___ 07:35AM BLOOD Parst S-NEGATIVE
___ 05:38AM BLOOD Glucose-165* UreaN-8 Creat-0.6 Na-138
K-4.0 Cl-103 HCO3-27 AnGap-12
___ 09:04PM BLOOD ALT-44* AST-51* LD(LDH)-451* AlkPhos-57
TotBili-0.9
___ 07:35AM BLOOD ALT-48* AST-52* LD(LDH)-468* AlkPhos-62
TotBili-1.2
___ 09:04PM BLOOD calTIBC-264 Hapto-<5* Ferritn-246*
TRF-203
___ 06:00AM BLOOD Hapto-<5*
___ 06:00AM BLOOD ___ HAV-NEGATIVE
___ 03:40AM BLOOD HIV Ab-NEGATIVE
IMAGING:
CXR
In comparison with the study of ___, there is no
change or
evidence of acute cardiopulmonary disease. No pneumonia,
vascular congestion,
or pleural effusion. There is suggestion of some enlargement of
the splenic
shadow, though this is difficult to appreciate on plain
radiographs.
MICROBIOLOGY
Test Result Reference
Range/Units
CHIKUNGUNYA IGG SCREEN NEGATIVE
CHIKUNGUNYA ___ SCREEN POSITIVE A
REFERENCE RANGE: NEGATIVE
DENGUE FEVER ANTIBODIES (IGG, ___
Test Result Reference
Range/Units
DENGUE FEVER IGG 5.31 H
DENGUE FEVER ___ 0.61
INTERPRETATION PAST INFECTION
REFERENCE RANGE: IgG <0.90
___ <0.90
LEPTOSPIRA ANTIBODY
Test Result Reference
Range/Units
LEPTOSPIRA AB SCREEN NEGATIVE
W/REFLEX TO TITER
EBV PCR, QUANTITATIVE, WHOLE BLOOD
Test Result Reference
Range/Units
SOURCE Whole Blood
EBV DNA, QN PCR <200 <200 copies/mL
ANAPLASMA PHAGOCYTOPHILUM (HUMAN GRANULOCYTIC EHRLICHIA AGENT)
___
Test Result Reference
Range/Units
A. PHAGOCYTOPHILUM IGG <1:64 <1:64
A. PHAGOCYTOPHILUM ___ <1:20 <1:20
___ 3:40 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:40 am Blood (EBV) Source: Venipuncture.
**FINAL REPORT ___
___ VIRUS VCA-IgG AB (Final ___:
Test canceled and patient credited due to a prior EBV
panel sent on
___ indicating evidence of past infection (EBV
VCA-IgG positive,
EBNA IgG positive and EBV ___ negative). A repeat
panel is
unlikely to detect EBV reactivation. Serum will be held
for 3 months.
For any questions, contact the Microbiology Medical
Director.
___ VIRUS EBNA IgG AB (Final ___:
TEST CANCELLED, PATIENT CREDITED.
___ VIRUS ___ AB (Final ___:
TEST CANCELLED, PATIENT CREDITED.
CMV IgG ANTIBODY (Final ___:
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
6 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV ___ ANTIBODY (Final ___:
POSITIVE FOR CMV ___ ANTIBODY BY EIA.
INTERPRETATION: SUGGESTIVE OF RECENT/ACTIVE INFECTION.
___ 3:40 am IMMUNOLOGY Source: Venipuncture.
**FINAL REPORT ___
HIV-1 Viral Load/Ultrasensitive (Final ___:
HIV-1 RNA is not detected.
___ 8:25 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
___ 10:05 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
___ 6:00 am Immunology (CMV)
**FINAL REPORT ___
CMV Viral Load (Final ___:
5,250 IU/mL.
___ 6:00 am Blood (Toxo) CHEM ___ ___.
**FINAL REPORT ___
TOXOPLASMA IgG ANTIBODY (Final ___:
POSITIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA.
14 IU/ML.
Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml.
___ 12:09 pm URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation as
needed
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
2. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*7 Tablet Refills:*0
3. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation as
needed
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Cytomegalovirus mononucleosis
___ virus infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with fever upon returning from ___, now
with splenomegaly and anemia. // eval for pneumonia or consolidation eval
for pneumonia or consolidation
IMPRESSION:
In comparison with the study of ___, there is no change or
evidence of acute cardiopulmonary disease. No pneumonia, vascular congestion,
or pleural effusion. There is suggestion of some enlargement of the splenic
shadow, though this is difficult to appreciate on plain radiographs.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by WALK IN
Chief complaint: Abnormal labs
Diagnosed with ANEMIA NOS, SPLENOMEGALY
temperature: 99.3
heartrate: 113.0
resprate: 18.0
o2sat: 100.0
sbp: 147.0
dbp: 62.0
level of pain: 0
level of acuity: 3.0 | This is a ___ year old female with past medical history of NASH,
recent travel to ___, admitted ___ with
constellation of symptoms including cough, malaise,
nausea/vomitting, joint pain, abdominal pain, found to have
splenomegaly and hemolytic anemia, thought to be reactive to an
infectious process, found to have positive chikungunya ___ as
well as positive CMV ___ and viral load, seen by ID consult
service who believe patient likely had both acute chikungunya
and
CMV infections (the second possibly being a reactivation),
started on empiric doxycycline for leptospirosis coverage,
returning to baseline health status, discharged home with close
outpatient ___.
# Chikungunya / Acute CMV Reactivation Infection: Patient
admitted from clinic following sub-acute presentation with
abdominal/epigastric pain, diarrhea, slightly elevated LFTs,
elevated LDH, atypical lymphocytes, and splenomegaly following a
trip to ___. Given her recent travel there was a broad
differential for fever in a traveller in an area where several
bacterial, viral and parasitic infections are endemic. The
patient also had multiple clinic/ED visits with limited work up.
The patient was appropriately admitted for further work up.
Infectious disease was consulted and recommended a broad work
up. Infectious disease evaluation including Dengue, Typhoid,
Leptospirosis, Legionella, Chikengunya, Dengue, EBV, CMV, and
HIV. Patient tested positive for Chikungunya, and CMV ___ and
IgG, suggesting an active/acute infection. She was initiated on
doxycycline empirically throughout her evaluation, given that
her cough and splenomegaly were potentially consistent with
Leptospirosis. She also had endorsed seafood exposure so there
was initially concern for Hepatitis or vibrio parahemolyticus.
During the work up CMV ___ returned positive. Chikungunya ___
positivity suggested concurrent Chikungunya infection, which
possibly led to reactivation of latent CMV (given IgG
positivity). Serologies also suggested past Dengue/Toxoplasma
exposure. Patient was otherwise treated conservatively with
improvement in symptoms to her baseline. She was discharged to
complete empiric leptospirosis coverage and with close PCP and
subspecialist ___.
# Atypical lymphocytosis / Splenomegaly - this was felt to be in
response to her ongoing infection; patient is recommended for
repeat blood work and splenic ultrasound to reassess.
# Acute Hemolytic Anemia: Admitted with elevated LDH, low
haptoglobin and elevated reticulocyte. There were no
schistocytes on peripheral smear, Coombs was negative. Guaiac
negative. Hgb remained stable during admission, thought to be
related to a self resolving hemolysis in the setting of her
above infections. Hgb at discharge was 10.1.
# Psych history: patient has hx of depression and multiple
hospital stays. Has been prescribed several medications which
she states she has not been taking recently. They were held
given she reports she has been off of them for several months.
Patient will need outpatient follow up |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillin V / Latuda / shellfish derived
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
LABORATORY RESULTS:
___ 07:10AM BLOOD WBC-6.6 RBC-4.46 Hgb-12.5 Hct-39.6 MCV-89
MCH-28.0 MCHC-31.6* RDW-13.5 RDWSD-44.1 Plt ___
___ 03:14PM BLOOD WBC-9.6 RBC-4.43 Hgb-12.1 Hct-39.5 MCV-89
MCH-27.3 MCHC-30.6* RDW-13.7 RDWSD-44.8 Plt ___
___ 07:10AM BLOOD Neuts-51 ___ Monos-9 Eos-7 Baso-0
Plasma-2* AbsNeut-3.37 AbsLymp-2.05 AbsMono-0.59 AbsEos-0.46
AbsBaso-0.00*
___ 03:14PM BLOOD Neuts-53 Bands-1 ___ Monos-8 Eos-2
Baso-0 Atyps-2* Plasma-2* AbsNeut-5.18 AbsLymp-3.26 AbsMono-0.77
AbsEos-0.19 AbsBaso-0.00*
___ 03:41PM BLOOD ___ PTT-33.8 ___
___ 03:14PM BLOOD Plt Smr-NORMAL-PLA Plt ___
___ 07:10AM BLOOD Parst S-NEGATIVE FOR INTRACELLULAR AND
EXTRACELLULAR PARASITES
___ 03:14PM BLOOD Parst S-NEGATIVE
___ 07:10AM BLOOD Glucose-96 UreaN-15 Creat-0.9 Na-144
K-4.6 Cl-105 HCO3-26 AnGap-13
___ 03:14PM BLOOD Glucose-89 UreaN-17 Creat-0.9 Na-144
K-3.8 Cl-103 HCO3-25 AnGap-16
___ 07:10AM BLOOD ALT-19 AST-21 AlkPhos-95 TotBili-0.3
___ 04:52PM BLOOD ALT-19 AST-29 AlkPhos-93 TotBili-0.3
___ 04:52PM BLOOD Lipase-27
___ 07:10AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.1
___ 04:52PM BLOOD Albumin-4.0
___ 04:52PM BLOOD Trep Ab-NEG
___ 03:14PM BLOOD Lyme Ab-PND
___ 07:10AM BLOOD HIV Ab-NEG
___ 07:10AM BLOOD DENGUE FEVER ANTIBODIES (IGG, IGM)-PND
___ 07:10AM BLOOD CHIKUNGUNYA ANTIBODIES W/ REFLEX(ES) TO
TITER-PND
___ 04:52PM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIA AGENT) IGG/IGM-PND
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg PO BID:PRN anxiety
2. olopatadine 0.1 % ophthalmic (eye) BID:PRN itchiness
3. Verapamil SR 300 mg PO Q24H
4. Levothyroxine Sodium 50 mcg PO 5X/WEEK (___)
5. Levothyroxine Sodium 100 mcg PO 2X/WEEK (___)
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
2. ALPRAZolam 0.5 mg PO BID:PRN anxiety
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Levothyroxine Sodium 50 mcg PO 5X/WEEK (___)
5. Levothyroxine Sodium 100 mcg PO 2X/WEEK (___)
6. olopatadine 0.1 % ophthalmic (eye) BID:PRN itchiness
7. Verapamil SR 300 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
Pustular skin lesion
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 fever/chills.***//Pneumonia?
COMPARISON: Prior exam is dated ___
FINDINGS:
PA and lateral views of the chest provided. A VP shunt is seen crossing the
right neck and chest, without definite kink or discontinuity, extending into
the upper abdomen along the midline. Lungs are clear. No signs of pneumonia
or edema. No large effusion or pneumothorax. The heart appears top-normal in
size. Mediastinal contour is normal. Bony structures are intact.
IMPRESSION:
Top-normal heart size. No signs of pneumonia. VP shunt seen.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Body pain, Fever
Diagnosed with Rash and other nonspecific skin eruption
temperature: 98.3
heartrate: 75.0
resprate: 18.0
o2sat: 100.0
sbp: 139.0
dbp: 80.0
level of pain: 7
level of acuity: 3.0 | On admission, ___ reported feeling back at her baseline, and
she had no fevers or any constitutional symptoms. An extensive
work up was sent:
SMEAR x 2 negative for organisms
HIV negative
MALARIAL ANTIGEN TEST: negative
URINE CULTURE: negative
DENGUE: pending
CHIKUNGUNYA: pending
Anaplasma: pending
URINE GC/Chlamidya: PENDING
THROAT GC/Chlamidya: PENDING
rectal GC/chlamidya: PENDING
BLOOD CULTURE x2: PENDING
UA: trace protein, few mucous, otherwise normal |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / zolpidem
Attending: ___.
Chief Complaint:
Shortness of breath, orthopnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ HTN, HLD, DMII, CKD, a-fib on Xarelto, CHF, cerebellar
hemorrhage in ___ presenting as a transfer from ___ for
shortness of breath and large left pleural effusion. Patient
states that he became short of breath 2 weeks prior, with
increasing dyspnea on exertion, and increasing orthopnea
preventing him from sleeping starting 2 days prior. He denies
any
chest pain, cough, fevers, chills, leg swelling, changes in
weight, recent changes in medication. He presented to ___ and
was found to have a large left pleural effusion and transferred
here for further care. He was given 1 inch of Nitropaste and IV
Lasix prior to transfer, and remained hemodynamically stable
during transport. OSH labs: Trop 0.2, BNP >35,000. Patient had a
left pleural effusion at ___ admission which was tapped and
found to be transudative. Patient felt much better after
thoracentesis.
Past Medical History:
Sludge in CBD s/p ___ ERCP with sphincterectomy
s/p cholecystectomy in ___
HTN
DM2 on insulin
CKD (baseline Cr ___
diabetic retinopathy
A-fib on Xarelto
AVNRT
CHF with recovered LVEF (20% -> 65%)
Nephrolithiasis (uric acid stones)
UTI (most recently pan-sensitive Klebsiella in ___
Osteoarthritis
Cerebellar hemorrhage/CVA ___ secondary to hypertension per
records)
BPPV
Hypothyroidism
Heterozygous for hemochromatosis
Bilateral knee replacements.
Social History:
___
Family History:
Both parents died of CVAs in their ___.
Physical Exam:
ADMISSION EXAM:
===============
VS: 97.7 PO 157 / 90 71 18 94 RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM. Stabismus.
NECK: supple, no LAD, no JVD
HEART: Irregularly irregular with systolic murmur, S1/S2
LUNGS: CTAB, Decreased breath sounds on the left. breathing
comfortably without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema. JVD not elevated.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
===============
VS: 97.4 PO 126/75 R Lying 66 20 98 RA
I/O/FB: ___ (24H), ___ (since MN)
Weight: 88.5 from 88.9 kg
TELE: NSVT overnight
GENERAL: Sleeping comfortably in bed, NAD
HEENT: PERRL, EOMI, OP clear, MM dry, neck supple, no LAD, JVD
not visualized when seated upright
LUNGS: CTAB
HEART: Irregular rate, S1 + S2 present, ___ D-C SEM loudest RUSB
ABDOMEN: SNTND, +BS, no rebound/guarding
EXT: WWP, no ___ edema, PPP
SKIN: No rashes/lesions/bruises
Pertinent Results:
ADMISSION LABS:
===============
___ 08:55PM GLUCOSE-412* UREA N-53* CREAT-3.1* SODIUM-141
POTASSIUM-3.9 CHLORIDE-97 TOTAL CO2-28 ANION GAP-16
___ 08:55PM CALCIUM-9.5 PHOSPHATE-4.4 MAGNESIUM-1.9
___ 01:15PM GLUCOSE-433* UREA N-49* CREAT-2.9* SODIUM-141
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-26 ANION GAP-18
___ 01:15PM CK(CPK)-51
___ 01:15PM cTropnT-0.17*
___ 01:15PM CK-MB-5
___ 01:15PM CALCIUM-9.3 PHOSPHATE-4.3 MAGNESIUM-1.9
___ 06:10AM COMMENTS-GREEN TOP
___ 06:10AM LACTATE-2.5*
___ 06:00AM GLUCOSE-241* UREA N-46* CREAT-2.9* SODIUM-143
POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-27 ANION GAP-18
___ 06:00AM estGFR-Using this
___ 06:00AM CK(CPK)-80
___ 06:00AM cTropnT-0.21*
___ 06:00AM CK-MB-5 ___
___ 06:00AM CALCIUM-9.2 PHOSPHATE-4.2 MAGNESIUM-1.9
___ 06:00AM WBC-9.0 RBC-4.90 HGB-14.2 HCT-44.1 MCV-90
MCH-29.0 MCHC-32.2 RDW-18.2* RDWSD-58.4*
___ 06:00AM NEUTS-64.0 ___ MONOS-5.6 EOS-3.0
BASOS-0.8 IM ___ AbsNeut-5.75 AbsLymp-2.33 AbsMono-0.50
AbsEos-0.27 AbsBaso-0.07
___ 06:00AM PLT COUNT-234
___ 06:00AM ___ PTT-37.6* ___
DISCHARGE LABS:
===============
___ 04:18AM BLOOD WBC-8.4 RBC-4.13* Hgb-12.0* Hct-37.5*
MCV-91 MCH-29.1 MCHC-32.0 RDW-17.9* RDWSD-59.3* Plt ___
___ 04:18AM BLOOD Glucose-63* UreaN-55* Creat-3.2* Na-144
K-4.0 Cl-102 HCO3-29 AnGap-13
___ 04:18AM BLOOD Calcium-9.0 Phos-4.8* Mg-2.1
___ 03:09PM BLOOD FreeKap-135.5* FreeLam-97.9* Fr K/L-1.38
ECHO ___:
================
The left atrial volume index is moderately increased. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. There is moderate global left ventricular hypokinesis
(LVEF = 35%). The right ventricular free wall is hypertrophied.
with moderate global free wall hypokinesis. The aortic valve
leaflets are moderately thickened. There is moderate aortic
valve stenosis (valve area 1.0-1.2cm2). No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened.
Moderate (2+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. There is a small pericardial effusion.
Bilateral pleural effusions are present.
IMPRESSION: Biventricular hypertrophy. Moderate global
biventricular systolic dysfunction. Moderate aortic stenosis.
Moderate mitral regurgitation. Mild pulmonary hypertension.
Compared with the prior study (images reviewed) of ___, LV
function has declined. There is a small pericardial effusion.
Findings could be compatible with an infiltrative
cardiomyopathy. Discussed in person with Dr. ___ at 1327
hours on the day of the study.
CHEST X-RAY ___:
=======================
Comparison to ___. The left pleural effusion has
minimally
decreased. The effusion is better visualized on the lateral
than on the
frontal image and still causes substantial left lower lung
atelectasis.
Stable borderline size of the cardiac silhouette. No pulmonary
edema.
CHEST X-RAY ___:
=======================
Unchanged, left pleural effusion. There is increased left
retrocardiac
opacification which is could possibly represent atelectasis
and/or
consolidation in the appropriate clinical setting. Attention
should be paid to the left retrocardiac area on follow up to
rule out infectious process. Stable, pulmonary vascular
congestion and increased pulmonary edema. The cardiomediastinal
silhouette is stable. The right lung is well expanded and
clear. There is no evidence of a right pleural effusion.
IMPRESSION:
Unchanged left pleural effusion.
In the appropriate clinical setting, interval increase of left
retrocardiac opacification could possibly represent atelectasis
and/or consolidation. Stable pulmonary vascular congestion and
increased pulmonary edema.
PYROPHOSPHATE ___:
=========================
FINDINGS: Static planar images of the chest demonstrate tracer
uptake in the heart, which on SPECT/CT is consistent with uptake
in the myocardium.
Limited views of the chest and abdomen demonstrate bilateral
pleural effusions with compressive atelectasis at the left lung
base. Right-sided eleventh and twelfth rib fractures are also
identified. The gallbladder is surgically absent.
IMPRESSION: Tracer uptake in the myocardium compatible with
transthyretin-related amyloidosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Rivaroxaban 15 mg PO DAILY
5. Tamsulosin 0.4 mg PO QHS
6. TraZODone 100 mg PO QHS
7. Metoprolol Succinate XL 75 mg PO DAILY
8. Acetaminophen 650 mg PO Q6H:PRN Pain
9. Potassium Chloride 40 mEq PO DAILY
10. Torsemide 100 mg PO BID
11. 70/30 25 Units Breakfast
70/30 20 Units Bedtime
12. Lisinopril 10 mg PO DAILY
13. Pravastatin 40 mg PO QPM
Discharge Medications:
1. HydrALAZINE 25 mg PO Q8H
RX *hydralazine 25 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
2. Isosorbide Dinitrate 20 mg PO TID
RX *isosorbide dinitrate 20 mg 1 tablet(s) by mouth three times
a day Disp #*90 Tablet Refills:*0
3. 70/30 25 Units Breakfast
70/30 20 Units Bedtime
RX *insulin NPH and regular human [Humulin 70/30] 100 unit/mL
(70-30) AS DIR 25 Units before BKFT; 20 Units before BED; Disp
#*10 Vial Refills:*0
4. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. Torsemide 100 mg PO DAILY
Instructed patient to take 200 mg of Torsemide if notices weight
gain
RX *torsemide 100 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
6. Acetaminophen 650 mg PO Q6H:PRN Pain
7. Allopurinol ___ mg PO DAILY
8. Calcitriol 0.25 mcg PO DAILY
9. Levothyroxine Sodium 50 mcg PO DAILY
10. Pravastatin 40 mg PO QPM
11. Rivaroxaban 15 mg PO DAILY
12. Tamsulosin 0.4 mg PO QHS
13. TraZODone 100 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
===================
Acute on chronic systolic heart failure
Transthyretin-related cardiac amyloidosis
Pleural effusion
SECONDARY DIAGNOSIS:
====================
Acute on chronic kidney disease
Type II NSTEMI
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ w/ HTN, HLD, afib on rivaroxaban, CVA,diastolic CHF (EF 48%),
presenting for shortness of breath andfound to have left pleural effusion c/f
CHF exacerbation.// interval change on effusion? interval change on
effusion?
IMPRESSION:
Comparison to ___. The left pleural effusion has minimally
decreased. The effusion is better visualized on the lateral than on the
frontal image and still causes substantial left lower lung atelectasis.
Stable borderline size of the cardiac silhouette. No pulmonary edema.
Radiology Report
EXAMINATION: Chest portable radiograph
INDICATION: ___ year old man with effusion// Interval change
TECHNIQUE: Chest portable radiograph
COMPARISON: Chest radiograph done on ___
FINDINGS:
Unchanged, left pleural effusion. There is increased left retrocardiac
opacification which is could possibly represent atelectasis and/or
consolidation in the appropriate clinical setting. Attention should be paid
to the left retrocardiac area on follow up to rule out infectious process.
Stable, pulmonary vascular congestion and increased pulmonary edema. The
cardiomediastinal silhouette is stable. The right lung is well expanded and
clear. There is no evidence of a right pleural effusion.
IMPRESSION:
Unchanged left pleural effusion.
In the appropriate clinical setting, interval increase of left retrocardiac
opacification could possibly represent atelectasis and/or consolidation.
Stable pulmonary vascular congestion and increased pulmonary edema.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Transfer
Diagnosed with Heart failure, unspecified
temperature: 97.7
heartrate: 62.0
resprate: 20.0
o2sat: 98.0
sbp: 141.0
dbp: 105.0
level of pain: 0
level of acuity: 2.0 | PATIENT SUMMARY:
================
Mr. ___ is a ___ year old man with PMH of HTN, HLD, DMII,
CKD, a-fib on Xarelto, CHF, and cerebellar hemorrhage in ___
who presented as a transfer from ___ for shortness of
breath and large left pleural effusion. Patient reported that he
became short of breath 2 weeks prior, with increasing dyspnea on
exertion, and increasing orthopnea preventing him from sleeping
starting 2 days prior. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ilosone / Dicloxacillin / Ace Inhibitors
Attending: ___
Chief Complaint:
acute kidney injury
rhabdomyolysis
pulmonary hypertension
congestive heart failure
Major Surgical or Invasive Procedure:
left internal jugular CVC placement
History of Present Illness:
In the ED, initial VS were:T-97.8 ___ BP-112/70 R-18 O2%-90%
RA
___ man with a history of HIV on HAART, hepatitis C, CAD
status post CABG in ___, CHF with an EF of 50%, hypertension,
hyperlipidemia, and a severe stroke in ___ with residual
dysarthria and left greater than right-sided weakness who
presents after falling from his wheelchair and hitting his
head. On ground for around an hr. Pt recently d/c'd ___ with
desats to ___ PNA. Pt denies any CP, SOB, dizziness before
the fall or after.
IN the ED:
___ triggered for hypoxia to ___. ___ up and did well and came
back up to 100% w/ a NRB. hypoT, never tachy . Got labs from art
stick. Had no access for peripheral and given L-IJ central line.
Pt received 1.5 l NS. Elevated trop with normal CK index. Had
negative CT head and neck.
On arrival to the MICU:
Pt had foley placed with 300CC of tea colored urine produced and
received 1.5 L of NS bolus. ABG was drawn.
Past Medical History:
-HIV: dx ___, likely through IVDU (last CD4 count 438/30% vl
128 on ___
-HCV: no therapy, stage I to II fibrosis on liver biopsy in
___, genotype 1A
-CAD: CABB x 1 Lima to LAD ___ s/p MI ___
-Diastolic CHF, EF 50-55%
-CVA: ___ intercerebral hemorrhage in medial/superior
cerebellar peduncle, wheelchair bound w/ residual L paresis
-HTN
-hypercholesterolemia
Social History:
___
Family History:
There is a significant family history of premature coronary
artery disease of the father who had an MI at age ___ and uncles
who have had heart attacks in the past. Otherwise, there is no
other history of unexplained heart failure or sudden death.
Physical Exam:
Admission physical exam:
Vitals: T:afeb BP:113/72 P:82 R:18 O2:96
General: Alert, oriented,
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Wheezing and crackles in all lung fields
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: Hypospadias foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Baseline left facial droop with markedlydysarthric
speech,LUE and LLE with ___ strength, RUE and RLE ___. Sensation
grossly intact
Discharge Physical Exam:
VS - 98.7 118/54 70 20 93% on shovel face mask 10L
GEN: Awake, alert and oriented. No acute cardiopulmonary
distress
HEENT: Sclera anicteric, MMM, OP clear
NECK: Supple, elevated JVP
PULM: Good aeration, CTAB, without w/r/r.
CV: RRR normal S1/S2, no mrg/
ABD: Soft, non-tender, obese, nondistended, no rebound or
guarding.
EXT: WWP. 2+ right radial pulse. left radial pulse not palpable,
but left hand is well perfused. ___ pulses difficult to
palpate ___ edema. 2+ pitting edema b/l LEs to knee, improved
from yesterday.
NEURO: awake, A&Ox3, dysarthric. left facial droop. left upper
and lower extremities ___ strength. Right extremities ___
strength.
SKIN: no ulcers or lesions. venous stasis/chronic edema changes
in b/l lower extremities
Pertinent Results:
Admission labs:
___ 06:30PM BLOOD WBC-11.8* RBC-4.81 Hgb-15.5 Hct-47.7
MCV-99* MCH-32.2* MCHC-32.4 RDW-16.7* Plt ___
___ 06:30PM BLOOD ___ PTT-33.7 ___
___ 06:30PM BLOOD Glucose-115* UreaN-42* Creat-3.6*# Na-141
K-3.5 Cl-95* HCO3-32 AnGap-18
___ 06:30PM BLOOD ___
___ 06:30PM BLOOD CK-MB-34* MB Indx-0.2 cTropnT-1.67*
___ 06:37PM BLOOD ___ pO2-49* pCO2-53* pH-7.41
calTCO2-35* Base XS-6
___ 06:37PM BLOOD Lactate-2.6*
Pertinent labs:
___ 04:13AM BLOOD CK-MB-26* MB Indx-0.2 cTropnT-1.69*
___ 04:13AM BLOOD ALT-42* AST-316* ___
AlkPhos-52
___ 04:13AM BLOOD Glucose-154* UreaN-41* Creat-2.9* Na-140
K-3.5 Cl-100 HCO3-33* AnGap-11
___ 01:14AM BLOOD WBC-11.3* RBC-3.79* Hgb-12.2* Hct-38.7*
MCV-102* MCH-32.1* MCHC-31.4 RDW-17.8* Plt ___
___ 01:35AM BLOOD WBC-9.0 RBC-4.14* Hgb-13.1* Hct-41.0
MCV-99* MCH-31.8 MCHC-32.0 RDW-17.5* Plt ___ 03:43AM
BLOOD WBC-7.4 RBC-4.16* Hgb-13.0* Hct-41.7 MCV-100* MCH-31.3
MCHC-31.2 RDW-16.5* Plt ___
___ 05:11AM BLOOD WBC-7.1 RBC-3.90* Hgb-12.4* Hct-38.5*
MCV-99* MCH-31.8 MCHC-32.2 RDW-16.4* Plt ___
___ 04:54AM BLOOD Glucose-90 UreaN-64* Creat-3.0* Na-143
K-3.9 Cl-108 HCO3-23 AnGap-16
___ 01:14AM BLOOD Glucose-84 UreaN-67* Creat-2.7* Na-149*
K-3.3 Cl-110* HCO3-27 AnGap-15
___ 01:30AM BLOOD Glucose-93 UreaN-59* Creat-2.2* Na-150*
K-3.3 Cl-109* HCO3-32 AnGap-12
___ 04:32AM BLOOD Glucose-110* UreaN-50* Creat-1.7* Na-150*
K-3.3 Cl-107 HCO3-39* AnGap-7*
___ 03:43AM BLOOD Glucose-116* UreaN-37* Creat-1.6* Na-143
K-3.7 Cl-97 HCO3-39* AnGap-11
___ 05:11AM BLOOD Glucose-108* UreaN-36* Creat-1.7* Na-140
K-4.0 Cl-94* HCO3-40* AnGap-10
___ 06:30PM BLOOD ___
___ 04:13AM BLOOD ALT-42* AST-316* ___
AlkPhos-52
___ 04:45PM BLOOD CK(CPK)-724*
___ 05:05AM BLOOD Type-ART Temp-38.6 pO2-89 pCO2-74*
pH-7.17* calTCO2-28 Base XS--3 Intubat-NOT INTUBA
___ 01:34PM BLOOD Type-ART pO2-67* pCO2-59* pH-7.40
calTCO2-38* Base XS-8
___ 11:21AM BLOOD ___ pO2-40* pCO2-71* pH-7.40
calTCO2-46* Base XS-14
___ 05:31AM BLOOD ___ pO2-57* pCO2-72* pH-7.39
calTCO2-45* Base XS-14
___ 01:28AM BLOOD Lactate-2.2*
___ 01:34PM BLOOD Lactate-1.0
Imaging
___ CXR
PORTABLE CHEST: ___.
HISTORY: ___ man with shortness of breath and acute
hypoxia.
FINDINGS: Single portable view of the chest is compared to
previous exam from
___. Compared to prior, there has been interval
improvement of
aeration at the lung bases. There are some persistent bibasilar
opacities,
right greater than left. Cardiomediastinal silhouette is stable
as are the
osseous and soft tissue structures.
IMPRESSION: Mild interval improvement in the previously seen
bibasilar
opacities which persist. These could be due to resolving
infiltrates or
atelectasis or potentially aspiration.
___ CT head
FINDINGS: There is no acute intra-axial or extra-axial
hemorrhage, mass,
midline shift, or territorial infarct. Right occipital lobe
encephalomalacia
as well as regions of encephalomalacia centered in the right
middle cerebellar
peduncle are again seen. Global volume loss of the cerebellum
is again noted.
Elsewhere, gray-white matter differentiation is preserved.
There is partial opacification of the inferior right mastoid air
cells.
Mucous retention cyst seen in the right maxillary sinus. Other
paranasal
sinuses and left mastoids are clear. The skull and extracranial
soft tissues
are unremarkable.
IMPRESSION:
No acute intracranial process. Encephalomalacia within the
right occipital
lobe and right middle cerebellar peduncle, unchanged from prior
___
TTE: Poor image quality.The left atrium is normal in size. No
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. No late
contrast is seen in the left heart (suggesting absence of
intrapulmonary shunting). There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. The right ventricular cavity is
dilated with mild global free wall hypokinesis. There is
abnormal septal motion/position. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The tricuspid regurgitation
jet is eccentric and may be underestimated. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of ___,
due to poor image quality on prior study, a direct comparison of
RV size nad function is not possible. The current study suggests
a more dilated/dysfunctional RV though.
___ lower-extremity venous u/s
IMPRESSION: No deep vein thrombosis.
___ CXR
1. Nasogastric tube is seen coursing below the diaphragm with
the tip not identified. Left internal jugular central line has
its tip in the proximal SVC. There continues to be diffuse
bilateral airspace process with probable associated layering
effusions. This may reflect worsening pulmonary edema, although
superimposed bilateral pneumonia cannot be entirely excluded.
Clinical correlation is advised. No pneumothorax is seen.
Overall, cardiac and mediastinal contours are likely stable, but
somewhat difficult to assess due to diffuse airspace process.
___ Head CT
IMPRESSION: No acute intracranial process identified to explain
patient's neurologic decline.
___ EEG (from neurology note)
EEG was done and showed spikes of 3Hz with right hemispheric
predominance.
___ Video Swallow
FINDINGS: Barium passes freely through the oropharynx and
esophagus without evidence of obstruction. There was evidence of
intermittent penetration of thin, as well as intermittent
aspiration of nectar consistency. For further details, please
refer to speech and swallow division note in OMR.
Preliminary Report IMPRESSION:
Penetration of thin consistency and aspiration of nectar
consistency, both intermittently.
Medications on Admission:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 50 mg PO TID
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Rosuvastatin Calcium 40 mg PO DAILY
5. Saquinavir (Invirase) Cap 400 mg PO BID
6. RiTONAvir 400 mg PO BID
7. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
8. Levofloxacin 750 mg PO DAILY
Day 1= ___, finishes on ___
9. Tiotropium Bromide 1 CAP IH DAILY
10. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing, shortness of
breath
11. oxygen
416.8 Other chronic pulmonary heart diseases
Home oxygen @ 5 LPM continuous via shovel mask, conserving
device for portablity
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. RiTONAvir 400 mg PO BID
3. Saquinavir (Invirase) Cap 400 mg PO BID
4. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze/SOB
5. Furosemide 40 mg IV BID
6. LeVETiracetam 500 mg PO BID
7. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
8. Docusate Sodium 50 mg PO BID
9. Metoprolol Succinate XL 12.5 mg PO DAILY (being held for
continued diuresis)
10. Tiotropium Bromide 1 CAP IH DAILY
11. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Rhabdomyolysis
Acute Kidney Injury
Acute on chronic diastolic congestive heart failure
Non-convulsive seizure activity
Discharge Condition:
Mental status: clear, oriented
Ambulatory status: requires wheelchair. Full assist for
transfers
Followup Instructions:
___
Radiology Report
PORTABLE CHEST: ___.
HISTORY: ___ man with shortness of breath and acute hypoxia.
FINDINGS: Single portable view of the chest is compared to previous exam from
___. Compared to prior, there has been interval improvement of
aeration at the lung bases. There are some persistent bibasilar opacities,
right greater than left. Cardiomediastinal silhouette is stable as are the
osseous and soft tissue structures.
IMPRESSION: Mild interval improvement in the previously seen bibasilar
opacities which persist. These could be due to resolving infiltrates or
atelectasis or potentially aspiration.
Radiology Report
HEAD CT WITHOUT CONTRAST: ___.
HISTORY: ___ male with fall on to head and hypoxia.
TECHNIQUE: Contiguous axial images were obtained from skull base to vertex
without intravenous contrast. Coronal and sagittal reformats were reviewed.
COMPARISON: Head CT from ___ and brain MR from ___.
FINDINGS: There is no acute intra-axial or extra-axial hemorrhage, mass,
midline shift, or territorial infarct. Right occipital lobe encephalomalacia
as well as regions of encephalomalacia centered in the right middle cerebellar
peduncle are again seen. Global volume loss of the cerebellum is again noted.
Elsewhere, gray-white matter differentiation is preserved.
There is partial opacification of the inferior right mastoid air cells.
Mucous retention cyst seen in the right maxillary sinus. Other paranasal
sinuses and left mastoids are clear. The skull and extracranial soft tissues
are unremarkable.
IMPRESSION:
No acute intracranial process. Encephalomalacia within the right occipital
lobe and right middle cerebellar peduncle, unchanged from prior.
Radiology Report
INDICATION: ___ male status post fall. Evaluate for cervical spine
fracture or any other abnormalities.
COMPARISON: CT head without contrast performed prior to this study as well as
video oropharyngeal swallow from ___.
TECHNIQUE: Axial contiguous MDCT images were obtained through the cervical
spine with 2.5-mm slice thickness. Images were obtained from the skull base
to the level of T1. Coronal and sagittal reformations were generated as well
as thin-slice bone images.
FINDINGS: There is straightening with reversal of the cervical lordosis,
likely secondary to external collar devise. Otherwise, there is no fracture
or malalignment. Mild-to-moderate degenerative changes are noted throughout
the cervical spine with disc height loss and enplate osteophyte formation,
most notablely posteriorly at C5-C6 with probable mild overall canal
narrowing. There is no prevertebral soft tissue swallowing. The
aerodigestive tract is unremarkable. Right maxillary mucous retention cyst
noted.
For further details on intracranial structures, please refer to CT head report
from same date in OMR.
IMPRESSION: No evidence of fracture or malalignment. Mild-to-moderate
degenerative changes as described above.
Radiology Report
PORTABLE CHEST; ___
HISTORY: ___ male with new left central venous line.
FINDINGS: Single portable view of the chest compared to previous exam from
earlier the same day. New left IJ central venous line is seen with catheter
tip in the proximal superior vena cava. There is no visualized pneumothorax.
No other change.
Radiology Report
INDICATION: Hypoxia and tachycardia. Evaluation for DVT.
TECHNIQUE: Grayscale and pulse wave Doppler of the bilateral lower
extremities.
COMPARISONS: None.
FINDINGS: The common femoral veins demonstrate normal respiratory phasicity
bilaterally. There is normal compressibility, flow, and augmentation of the
bilateral common femoral, superficial femoral, and popliteal veins. Normal
flow and compressibility is demonstrated in the bilateral posterior tibial and
deep peroneal veins.
IMPRESSION: No deep vein thrombosis.
Radiology Report
AP CHEST, 9:52 A.M. ON ___
HISTORY: ___ man with renal insufficiency and hypoxemia.
IMPRESSION: AP chest compared to ___:
Lung volumes have decreased since ___, which may account for the
apparent worsening of moderately extensive opacification in both lower lungs,
left greater than right. Since the mediastinal veins are dilated, I suspect
much of this is edema related to intravascular volume. Because it is
heterogeneous, concurrent pneumonia is a possibility.
Heart size is exaggerated by low lung volumes, not particularly dilated. Left
central venous catheter ends in upper SVC. There is no pneumothorax. Small
bilateral pleural effusions are new or increased since ___.
Radiology Report
STUDY: Portable AP chest radiograph.
COMPARISON EXAM: Portable AP chest radiograph ___.
INDICATION: ___ with new NG placement.
FINDINGS: This film is centered in the thoracoabdominal region to assess the
placement of the NG tube, and evaluation of the thorax is limited. There is a
new NG tube with tip terminating in the GE junction.
IMPRESSION: NG tube with tip in the GE junction. Advancement is recommended.
Radiology Report
PORTABLE AP CHEST FILM, ___ AT 15:51
CLINICAL INDICATION: ___ with respiratory failure, question
pneumonia.
Comparison is made to the patient's prior study dated ___ at 17:36.
A portable AP upright chest film, ___ at 15:51 is submitted.
IMPRESSION:
1. Nasogastric tube is seen coursing below the diaphragm with the tip not
identified. Left internal jugular central line has its tip in the proximal
SVC. There continues to be diffuse bilateral airspace process with probable
associated layering effusions. This may reflect worsening pulmonary edema,
although superimposed bilateral pneumonia cannot be entirely excluded.
Clinical correlation is advised. No pneumothorax is seen. Overall, cardiac
and mediastinal contours are likely stable, but somewhat difficult to assess
due to diffuse airspace process.
Radiology Report
PORTABLE AP CHEST FROM ___ AT 19:48.
CLINICAL INDICATION: ___ with CHF, pulmonary hypertension, evaluate
orogastric tube placement.
Comparison is made to the patient's prior study of ___ at 15:51.
A portable supine chest film dated ___ at 19:48 is submitted.
IMPRESSION:
1. Orogastric tube is seen which courses below the diaphragm and the tip
projects over the expected location of the stomach. Left internal jugular
central line with its tip in the proximal SVC. There has been some interval
improvement in bilateral airspace process associated with layering effusions.
Given the interval change, this would favor resolving pulmonary edema, but
superimposed pneumonia cannot be entirely excluded. Cardiac and mediastinal
contours are likely stable. No pneumothorax is seen, although the sensitivity
to detect pneumothorax is diminished given supine technique.
Radiology Report
INDICATION: The patient with complex medical history and prior history of CVA
in ___ with baseline dysarthria, left-sided weakness, treated with heparin
GTT this admission, for possible pulmonary emboli. Now presenting with
confusion, echolalia and leftward saccades.
COMPARISON: CT head from ___.
TECHNIQUE: MDCT acquired contiguous axial images were obtained through the
head. No contrast was administered. Coronal and sagittal reformats reviewed.
FINDINGS: Evaluation of the posterior fossa is limited by motion artifact.
There is no acute intracranial hemorrhage, edema, mass, or mass effect. There
is no evidence of acute vascular territorial infarction. There is volume loss
in the cerebellum, unchanged from the prior examination with malacic change in
the right middle cerebellar peduncle. These areas are not well seen on this
study. The ventricles and sulci are unchanged. There is no fracture. There
is a mucus retention cyst in the right maxillary sinus and mucosal thickening
of the ethmoid air cells. The remainder of the paranasal sinuses are clear.
There is new, partial fluid opacification of several mastoid air cells
bilaterally. The middle ear cavities are clear bilaterally.
IMPRESSION: No acute intracranial process identified to explain patient's
neurologic decline.
Radiology Report
HISTORY: ___ old male with shortness of breath and increased O2
requirement.
STUDY: Bilateral lower extremity venous ultrasound.
COMPARISON: ___.
FINDINGS: Grayscale and color Doppler sonographic imaging was performed of
the bilateral common femoral, superficial femoral, popliteal, peroneal, and
posterior tibial veins. Normal compressibility, flow, and augmentation was
demonstrated.
IMPRESSION: No evidence of DVT in either lower extremity.
Radiology Report
INDICATION: ___ male with a history of a right-sided stroke and
residual left-sided weakness and dysphagia who presents for evaluation of
swallowing for diet modifications.
COMPARISONS: Video swallow from ___.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
FINDINGS: Barium passes freely through the oropharynx and esophagus without
evidence of obstruction. There was evidence of intermittent penetration of
thin, as well as intermittent aspiration of nectar consistency. For further
details, please refer to speech and swallow division note in OMR.
IMPRESSION:
Penetration of thin consistency and aspiration of nectar consistency, both
intermittently.
Radiology Report
CHEST RADIOGRAPH
INDICATION: PICC line placement.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient has received a
right-sided PICC line. The course of the line is unremarkable. The tip of
the line projects over the mid-to-low SVC. There is no evidence of
complications, notably no pneumothorax.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with RHABDOMYOLYSIS, ACUTE KIDNEY FAILURE, UNSPECIFIED, FALL FROM WHEELCHAIR, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA, ASYMPTOMATIC HIV INFECTION
temperature: 97.8
heartrate: 103.0
resprate: 18.0
o2sat: 90.0
sbp: 112.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Active Problems
#rhabdomyolysis- Pt found on the ground for an extended period
of time which could be the cause for his rhabdo. ___ received
aggressive IV fluid to try to maintaine a 200CC urine output
while not compromissing his respiratory status. His CK
eventually came down but CR was still elevated. Renal was
consulted and recommended no HD. ___ still producing urine and CR
was stable. Creatinine stabilized at 1.6-1.7. This likely
represents his new baseline. He continued to have good urine
output throughtout rest of admission.
#elevated trop- Pt has signigicant elevation of trop. EKG
similar to previous. Pt received 325 ASA. His CK-MB index was
never elevated and trop was not raising so a cards consult was
not obtained.
#ATN: Muddy brown cast found in urine ___. Most likely ___ to
rhabdo. Improving toward baseline. Most likely CKD at this
point. Cr remains stable at 1.7. Good urine output maintained
throughout admission. Pt. to follow-up with renal as outpatient
#Hypoxemia- Chronic O2 requirment likely multifactorial related
to pulmonary HTN, COPD, OSA, OHS. Current increase in O2
requirement likely ___ PE vs heart failure. Unable to obtain CTA
at this time due to pt ___. Has been improving with diuresis and
thus it is most likely ___ CHF/pulmonary edema, less likely PE,
heparin was switched to subcut. As patient continues to improve
with diuresis, did not pursue further PE work-up. Treated with
vanco and cefipime after 8 day HCAP coverage. Currently no
clinical evidence of pneumonia. Pt. responded well to IV Lasix
40mg BID. Upon discharge, pt. likely at his baseline hypoxemia.
No evidence of significant pulmonary edema on most recent CXR
and only mild bibasilar crackles on exam. Still 5 liters net
positive for length of stay ___ aggressive fulid resuscitation
for severe rhabdo upon initial presentation. Would recommend
continued diuresis to achieve euvolemia and optimize respiratory
status. Renal function slowly improving, so patient likely able
to autodiurese soon. Though not confirmed, pt. likely has
significant pulmonary HTN based on old TTE, recent chest CT with
enlarged PA, and multiple pulmonary HTN risk factors as outlined
above. Pt. scheduled to follow in pulmonary clinic with Dr.
___ further w/u and treatment of this presumed pulmonary
HTN. At time of discharge, pt. saturating in low ___ on nasal
canula, which is likely around his baseline oxygenation. No
pulmonary symptoms.
#new onset seizure activity- ___ experienced change in mental
status while in the ICU with echolalia, confusion, and leftward
gaze deviation with random leftward saccadic eye movements.. A
CT head was ordered which showed NAP and EEG which showed
epileptiform discharges. Neurology was called and pt was placed
on Keppra. His mental status improved significantly back to
baseline without any further evidence of seizure activity or
changes in mental status. Pt. to be discharged on Keppra 500mg
BID. Pt. will f/u in epilepsy clinic in ___ weeks time after
discharge for furthur management.
#Nutrition - video swallow. Speech therapy recommend ground
solids with nectar thickened liquids. Likely chronic aspirator
___ to prior CVA. Pt. to be discharged on this diet.
Chronic Problems
#HTN - antihypertensives were held throughout admission,
particularly in setting of agressive diuresis following
resolution of rhabdo. Metoprolol and triamterene-HCTZ can be
restarted once pt. back to euvolemia.
#HIV - pt. was maintained on his regimen of Saquinavir and
Ritonavir
Transitional Issues
#Volume overload - upon discharge, pt. net positive 5 liters for
length of stay. has been getting IV lasix 40mg BID. Would
recommend continuing diuresis with goal of euvolemia. Diuresis
was associated with significant improvement of pt.'s respiratory
status. Discharged on 5L nc, with saturations in low ___.
Probably will only require a couple more days of diuresis, as
renal function continues to improve toward his baseline. Would
recommend checking daily electrolytes while actively diuresing
and while Cr continuing to normalize. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left intertrochanteric hip fracture
Major Surgical or Invasive Procedure:
Open Reduction Internal Fixation ___
History of Present Illness:
___ with a h/o osteoporosis and dementia A&O x1 baseline, who
sustained a spontaneeous L hip fx at her nursing home. Patient
is ___ at baseline, but does get up to transfer to
toilet/chair. Patient had been experiencing pain for several
days at the nursing home, which staff attributed to vaginal
infection. Upon further evaluation patient was found to have a
left intertrochanteric hip fx. She was brought by ambulance to
the ED, seen by Orthopedics and brought immediately to the OR
for fixation. CT head and ___ were negative.
Patient was hypoxic to ___ requiring 4L NC to maintain sats in
___. Anesthesia concerned about chronic aspiration based on
trachea suction material intraopertively. No evid of PNA or
pneumonitis on initial CXR taken prior to presumed aspiration
event. Of note, she is not on home oxygen and does not have a
h/o lung disease (remote h/o smoking). She has been on a pureed
diet at the nursing home since losing her dentures.
Patient was also found to have UTI with UA with postive
leukocytestrase, nitrites, many WBCs and Many bacteria. Patient
has a h/o of UTI's, but it is unknown how many she has had in
the past year. She was started on CTX 1g q24hrs pending culture
results.
Patient with baseline dementia oriented x1. Per her daughter,
she was functional prior to a fall with head strike, with
develoopment of a subdural hematoma ___ years ago.
On the floor, Patient was sat'ing 95% on 2L O2 by NC, shovel
mask with 50% O2. She oriented x1 and was having pain with
movement of L ___.
Past Medical History:
psychosis
osteoporosis
gerd
hyperlipidemia
dementia and delusions
auditory hallucinations
osteoporosis
subdural hematoma
s/p back surgery
Social History:
___
Family History:
Reviewed. Not pertinent to this hospitalization
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.2 BP:112/50 P: 79 R: O2:96% 2L by NC, humidified
50%O2 by shovel mask
General: elderly, frail, oriented x1 (baseline)
HEENT: Sclera anicteric, adentulous
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, but with occasional
mild crackles
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, suprapubic tenderness on palpation,
___, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. L thigh/hip with surgical dressing c/d/i, pneumoboots and
compression stockings
Skin: UE echymoses
Neuro: Oriented x1 at baseline
DISCHARGE PHYSICAL EXAM:
97.9 152/62 64 20 98% 3L NC
General: elderly, AAOx1
HEENT: Sclera anicteric, MMM
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, NTP, ___, bowel sounds present
GU: foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. L thigh/hip with surgical dressing c/d/i, mild tenderness
to palpation
Neuro: Oriented x1 at baseline
Pertinent Results:
ADMISSION LABS:
___ 02:55PM ___
___
___ 02:55PM PLT ___
___ 12:30PM ___ TO ___ TO ___ TO
___ TO ___ TO ___ TO ___ TO
___ TO
___ 12:30PM PLT ___ TO
___ 02:40AM URINE ___
___ 02:40AM URINE ___
___ 02:40AM URINE ___
___ 02:40AM URINE GR ___
___ 02:40AM URINE ___ SP ___
___ 02:40AM URINE ___
___
___ 02:40AM URINE ___
___
___ 02:40AM URINE ___
___ 02:40AM URINE ___
___ 02:24AM ___
___ 02:20AM ___ UREA ___
___ TOTAL ___ ANION ___
___ 02:20AM ___ this
___ 02:20AM ___
___ 02:20AM ___
___
___ 02:20AM ___
___
___ 02:20AM PLT ___
___:20AM ___ ___
DISCHARGE LABS:
___ 05:30AM BLOOD ___
___ Plt ___
___ 05:30AM BLOOD ___
___
___ 05:30AM BLOOD ___
MICROBIOLOGY:
Urine culture ___:
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
RADIOLOGY:
CXR ___:
IMPRESSION:
No acute abnormality.
Chronic interstitial pulmonary abnormality ro emphysema.
LEFT FEMUR AP/LATERAL ___:
IMPRESSION: Comminuted left femur intertrochanteric fracture in
varus
alignment.
HIP BILATERAL ___:
IMPRESSION: Comminuted left femur intertrochanteric fracture in
varus
alignment.
BILATERAL LOWER EXTREMITY DOPPLERS ___:
IMPRESSION:
Extremely limited study, however no evidence of a DVT in the
visualized
bilateral lower extremity veins.
CT ___ w/ contrast ___:
IMPRESSION: No acute cervical spine fractures identified.
CT HEAD W/O CONTRAST ___:
IMPRESSION:
1. No acute intracranial abnormalities identified.
2. Irregularity of the nasal bones may be secondary to old
fractures. Please correlate clinically.
LOWER EXTREMITY FLUORO ___:
FINDINGS: These views show interval open reduction and internal
fixation of a fracture involving the intertrochanteric region of
the proximal left femur.
HIP NAILING W/O FRACTURE in OR ___:
FINDINGS: These views show interval open reduction and internal
fixation of a fracture involving the intertrochanteric region of
the proximal left femur.
CXR PA and Lateral ___:
IMPRESSION:
Allowing for technical differences, there is new left lower lobe
collapse
and/or consolidation and possible new opacity at the right base,
with
equivocal small right effusion. Differential diagnosis
includes pneumonia and aspiration. Possibility of some degree
of CHF superimposed on existing background COPD would also be
difficult to exclude.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Milk of Magnesia 30 mL PO DAILY:PRN constipation
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. ___ 3,875 mg/30 mL oral
bid
4. cyanocobalamin (vitamin ___ 1,000 mcg/mL injection q
monthly
5. Vitamin D 50,000 UNIT PO QMONTHLY
6. Calcium Carbonate 1000 mg PO QDAILY
7. Lexapro (escitalopram oxalate) 10 mg oral qdaily
8. Lactulose 30 mL PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Pyridoxine 50 mg PO DAILY
11. TraZODone 25 mg PO 5PM
12. Omeprazole 20 mg PO BID
13. QUEtiapine Fumarate 25 mg PO BID
14. Senna 17.2 mg PO BID
15. QUEtiapine Fumarate 50 mg PO QHS
16. Acetaminophen 650 mg PO Q6H:PRN pain/fever
17. DuoNeb (___) 0.5 ___ mg(2.5 mg base)/3 mL
inhalation q4hr prn congestion/cough
18. Polyethylene Glycol 17 g PO BID:PRN constipation
19. Guaifenesin 15 mL PO Q4H:PRN cough
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
2. Calcium Carbonate 1000 mg PO QDAILY
3. Omeprazole 20 mg PO BID
4. QUEtiapine Fumarate 25 mg PO BID
5. QUEtiapine Fumarate 50 mg PO QHS
6. Senna 17.2 mg PO BID
7. TraZODone 25 mg PO 5PM
8. Vitamin D 50,000 UNIT PO QMONTHLY
9. ___ Acid ___ mg PO Q12H
10. Guaifenesin 15 mL PO Q4H:PRN cough
11. Lactulose 30 mL PO DAILY
12. Escitalopram Oxalate (escitalopram oxalate) 10 mg ORAL
QDAILY
13. Milk of Magnesia 30 mL PO DAILY:PRN constipation
14. Multivitamins 1 TAB PO DAILY
15. Polyethylene Glycol 17 g PO BID:PRN constipation
16. Pyridoxine 50 mg PO DAILY
17. ___ 3,875 mg/30 mL
oral bid
18. DuoNeb (___) 0.5 ___ mg(2.5 mg base)/3 mL
inhalation q4hr prn congestion/cough
19. Miconazole Nitrate Vag Cream 2% 1 Appl VG HS Duration: 7
Days
20. Morphine Sulfate (Oral Soln.) 2 mg PO Q6H:PRN breakthrough
pain
RX *morphine 10 mg/5 mL 2 mg by mouth every six (6) hours
Refills:*0
21. Enoxaparin Sodium 30 mg SC Q24H
Start: Today - ___, First Dose: Next Routine Administration
Time
22. Acetaminophen 650 mg PR Q8H pain
23. cyanocobalamin (vitamin ___ 1,000 mcg/mL injection q
monthly
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Hip fracture
Pneumonia
UTI
Secondary:
Dementia
Osteoporosis
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: History of left hip fracture. Please evaluate chest.
COMPARISONS: None.
TECHNIQUE: Frontal AP radiograph of the chest.
FINDINGS: Generalized pulmonary reticulation reflects a chronic pulmonary
problem, probably of no active clinical concern in a patient of this age.
There is no evidence of intrathoracic trauma, infection, or cardiac
decompensation. Heart size is normal. The aorta is tortuous and heavily
calcified but not aneurysmal. Mild left lower costal thickening is the only
pleural abnormality. There is no evidence of a pneumothorax.
IMPRESSION:
No acute abnormality.
Chronic interstitial pulmonary abnormality ro emphysema.
Radiology Report
INDICATION: History of fall. Please evaluate for fracture.
COMPARISONS: None.
TECHNIQUE: Frontal view of the pelvis with two additional views of the left
hip and one lateral view of the left knee.
FINDINGS: There is an oblique comminuted intertrochanteric fracture with mild
superolateral displacement and varus angulation. No other fractures are
identified. Vascular calcifications are noted. The femoral head appears to
be well seated within the acetabulum.
IMPRESSION: Comminuted left femur intertrochanteric fracture in varus
alignment.
Radiology Report
INDICATION: History of bilateral leg swelling. Please evaluate.
COMPARISONS: None.
TECHNIQUE: Grayscale, color and spectral Doppler evaluation of the bilateral
lower extremity veins.
FINDINGS: This is a very limited study due to decreased patient's
cooperation. There is good flow, compressibility in the left common femoral
vein, proximal superficial femoral vein, mid superficial femoral vein, distal
superficial femoral vein and popliteal veins. The left calf veins were not
visualized.
Good compressibility and flow were obtained in the right common femoral vein,
superficial femoral vein and popliteal veins. The right calf veins were not
visualized.
IMPRESSION:
Extremely limited study, however no evidence of a DVT in the visualized
bilateral lower extremity veins.
Radiology Report
INDICATION: History of fall, possible intracranial hemorrhage. Please
evaluate.
COMPARISONS: None.
TECHNIQUE: ___ MDCT images were obtained through the brain without the
administration of IV contrast. Multiplanar reformatted images in coronal and
sagittal axes were generated and reviewed.
FINDINGS: There is no evidence of acute intracranial hemorrhage, mass, mass
effect or large territorial infarction. Periventricular hypodensities are
likely related to chronic small vessel ischemic disease. The basilar cisterns
are patent and there is otherwise good preservation of the gray-white matter
differentiation.
Irregularity of the nasal bones may be secondary to old fractures. Please
correlate clinically. No other acute fracture is identified. The visualized
paranasal sinuses, mastoid air cells and middle ear cavities are clear.
The globes are unremarkable.
IMPRESSION:
1. No acute intracranial abnormalities identified.
2. Irregularity of the nasal bones may be secondary to old fractures. Please
correlate clinically.
Radiology Report
INDICATION: History of possible fall. Please evaluate.
COMPARISONS: None.
TECHNIQUE: ___ MDCT images were obtained through the cervical spine without
the administration of IV contrast. Multiplanar reformatted images in coronal
and sagittal axes were generated and reviewed.
FINDINGS: There is no evidence of fracture or prevertebral soft tissue
swelling. There is no evidence of significant malalignment.
Multilevel, multifactorial degenerative changes are seen with evidence of
intervertebral disc space narrowing, worse from C6/C7. There is also mild
anterior and posterior osteophytosis, worse at C5/C6 with mild thecal sac
narrowing.
The thyroid is normal. The visualized apices of the lungs are clear aside
from mild apical scarring. No cervical lymphadenopathy is identified.
IMPRESSION: No acute cervical spine fractures identified.
Radiology Report
INTRAOPERATIVE FLUOROSCOPY OF THE LEFT HIP
HISTORY: Ongoing ORIF of left hip fracture.
COMPARISONS: Earlier in the same day.
TECHNIQUE: Intraoperative left hip fluoroscopy, two views.
FINDINGS: These views show interval open reduction and internal fixation of a
fracture involving the intertrochanteric region of the proximal left femur.
Radiology Report
HISTORY: Left hip fracture status post fixation, hypoxia, pneumonia,
pneumonitis or other acute process.
CHEST, SINGLE AP PORTABLE VIEW:
Rotated positioning. As before, there is cardiomegaly. Direct comparison for
any increase in cardiac size is difficult due to rotated positioning and
technical differences. The possibility of some interval increase in the
degree of cardiac enlargement cannot be excluded. As before, as well, the
aorta is calcified and unfolded. There is a possible small right effusion as
well as some atelectasis and scarring at the right base superimposed on a
known elevated right hemidiaphragm. Possibility of some interval worsening of
these findings cannot be excluded. There is new increased retrocardiac
density with obscuration of the left hemidiaphragm, consistent with left lower
lobe collapse and/or consolidation. No gross left effusion. Left apical
pleural thickening is more apparent on the current film.
IMPRESSION:
Allowing for technical differences, there is new left lower lobe collapse
and/or consolidation and possible new opacity at the right base, with
equivocal small right effusion. Differential diagnosis includes pneumonia
and aspiration. Possibility of some degree of CHF superimposed on existing
background COPD would also be difficult to exclude.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with FX NECK OF FEMUR NOS-CL, OVEREXERTION FROM SUDDEN STRENUOUS MOVEMENT
temperature: 98.0
heartrate: 78.0
resprate: 24.0
o2sat: 97.0
sbp: 151.0
dbp: 69.0
level of pain: 8
level of acuity: 2.0 | ___ with h/o dementia A&O x1 baseline and osteoporosis, presents
with spontaneous L hip fracture at intertrochanteric hip
fracture nursing home now s/p ORIF, with course complicated by
PNA and UTI. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Hydralazine And Derivatives / Bumex / Sulfa (Sulfonamide
Antibiotics) / Lactose / banax / Neurontin
Attending: ___.
Chief Complaint:
abdominal pain, nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ F with distant history of gastric volvulus s/p
repair, s/p appy and s/p CCY, recent admission for ischemic
colitis ___ and also with history of prior C.Diff colitis
who presents now with abdominal pain and vomiting that started
around noon ___. Daughter, ___, accompanies patient and
corrobarates story. The patient initiall started feeling
slightly unwell last week, with some stomach discomfort and so
starting eating a BRAT diet with improvement in symptoms.
Symptoms resolved until ___ when after dinne she
began feling unwell again, again symptoms resolved. Morning of
admission (___) she ate breakfast and then 1 hour later
began having terrible abdominal pain, nausea, vomiting and
profuse watery diarrhea. Patient reports that pain is mostly
left-sided and she has had frequent non-bloody, non-bilious
emesis thoughout the afternoon as well as non-bloody,
non-melanotic diarrhea. She has not had fevers, chills, has not
traveled and has no sick contacts.
In the ED, initial VS were: 97.5 89 146/75 16 97%. CT abdomen
was peformed showing evidence of colitis but without evidence of
obstruction. ED evaluation not concerning for mesenteric
ischemia or ischemic colitis and given CT abdominal findings not
showing obstruction surgery was not consulted. Lactate was
normal so no concern for end organ damage. She received 2L NS,
Cipro and Flagyl pior to transfer. Vitals prior to transfer 99.2
67 119/53 18 96
On arrival to the floor, the patient arrives overall stable
appearing, continued abdominal pain but without nausea, vomiting
or diarrhea. Cipro is infusing. She is in good humor and making
jokes throughout interview, she is also accompanied by daughter.
REVIEW OF SYSTEMS:
(+) pe HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, ___, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Gastric volvulus ___ yrs ago) s/p repair
- Internal hemorrhoids
- legally blind
- IBS
- C diff colitis
- HTN
- Hyperlipidemia
- CAD
- RBBB
- DOE s/p extensive negative work up
- Hypothyroidism
- OA
- PUD
- GERD
- Depression
- Prior GYN surgeries remotely
- s/p hiatal hernia repair
- s/p cholecystectomy
- s/p appendectomy
- s/p ORIF L radius ___
Social History:
___
Family History:
- Mother: CAD, CVA
- Aunt: ___ cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.2 125/59 62 18 98%RA
GENERAL - Acutely ill but non-toxic appearing robust ___ F,
wearing sunglasses an in good humor
HEENT - dry mucous membranes
NECK - no JVD no ___
LUNGS - Reduced air movement but clear to auscultation thoughout
all lung fields
HEART - PMI non-displaced, RRR S1-S2 clear and of good quality,
no MRG appreciated
ABDOMEN - Distended and obese, prior sugical scars are well
healed. Slightly tense with voluntary guarding, tender to
palpation over LLQ and LUQ but non tender on right. No rebound.
Hyperactive bowel sounds throughout.
EXTREMITIES - 1+ ___ bilaterally with tenderness
NEURO - awake, A&Ox3
DISCHARGE PHYSICAL EXAM:
VS - 97.7 115/50 61 18 96%RA
GENERAL - NAD
HEENT - mucous membranes moist
NECK - no JVD
LUNGS - CTABL, no crackles or wheezes, good air movement
HEART - RRR S1-S2 clear and of good quality, no MRG appreciated
ABDOMEN - Distended and obese, prior sugical scars are well
healed. 1 cm umbilical palpated above umbilicus, not reducible,
not painful. Minimal voluntary guarding, mildly tender to
palpation over LLQ but non tender on right. No rebound. Normal
bowel sounds throughout.
EXTREMITIES - 1+ ___ bilaterally
NEURO - awake, A&Ox3
Pertinent Results:
ADMISSION LABS
___ 07:50PM URINE COLOR-Red APPEAR-Clear SP ___
___ 07:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5
LEUK-MOD
___ 07:50PM URINE RBC-3* WBC-46* BACTERIA-NONE YEAST-NONE
EPI-1
___ 07:50PM URINE HYALINE-2*
___ 07:50PM URINE MUCOUS-RARE
___ 06:11PM LACTATE-1.9
___ 05:30PM GLUCOSE-155* UREA N-20 CREAT-1.2* SODIUM-138
POTASSIUM-3.4 CHLORIDE-97 TOTAL CO2-28 ANION GAP-16
___ 05:30PM estGFR-Using this
___ 05:30PM WBC-13.7*# RBC-5.11 HGB-13.4 HCT-42.1 MCV-82
MCH-26.2* MCHC-31.9 RDW-17.7*
___ 05:30PM NEUTS-88.5* LYMPHS-7.4* MONOS-3.6 EOS-0.4
BASOS-0.1
___ 05:30PM PLT COUNT-283
CT abd and pelvis with contrast
1. Mild bowel wall thickening and mucosal enhancement with
surrounding inflammatory change of the sigmoid ___ and to a
lesser degree the descending ___ tapering to the level of the
splenic flexure, consistent with colitis with etiologies
including infectious, inflammatory or ischemic. Of note, the
ostia of the celiac and superior mesenteric and inferior
mesenteric arteriesdo not appear to have critical stenosis and
mesenteric vessels are overall patent.
2. Moderate stable intrahepatic and extrahepatic biliary ductal
dilatation, not significantly changed.
3. Prominent intermittent fluid filled loops of small bowel
with intervening areas of collapse without secondary evidence of
obstruction; however, if abdominal symptoms worsen, low
threshold to repeat scan to assess for developing small bowel
obstruction.
Stool Studies
___ 9:21 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
ADDON FOR CGD FEC CCU ROE ___ PER FAX BY ___
___
___ @ 1118.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ ___
___ 3PM.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
DISCHARGE LABS
___ 06:55AM BLOOD WBC-5.2 RBC-4.06* Hgb-10.6* Hct-33.3*
MCV-82 MCH-26.0* MCHC-31.7 RDW-18.4* Plt ___
___ 06:55AM BLOOD Glucose-88 UreaN-7 Creat-0.9 Na-142 K-3.5
Cl-109* ___ AnGap-14
Radiology Report
INDICATION: Left abdominal pain and tenderness, history of colitis thought to
be due to dehydration on prior admission. Please evaluate for colitis.
COMPARISON: Comparison is made to CTA abdomen and pelvis performed ___.
TECHNIQUE: Contrast-enhanced axial images were obtained from the lung bases
to the pelvic outlet. Coronal and sagittal reformations are provided.
FINDINGS: Heart size is normal and without pericardial effusion. Atelectatic
changes are noted in the dependent portions of the lung bases. No pleural
effusions or pneumothorax identified.
Redemonstration of moderate-to-severe intrahepatic and extrahepatic biliary
ductal dilatation, relatively unchanged compared to prior study. There is a
stable wedge-shaped peripheral hypodensity in hepatic segment VI (2:13)
thought to represent prior insult. Multiple tiny hypodensities throughout the
right hepatic lobe, too small to fully characterize, statistically represent
biliary hamartomas or cysts. The pancreas contains interdigitating fat
without concerning mass or lesion. No pancreatic duct dilatation identified.
The spleen is unremarkable. Two small splenules are identified. There is
stable mild fullness in the left adrenal gland. Right adrenal gland is
normal. The bilateral kidneys are without masses or hydronephrosis. Several
areas of cortical thinning seen in the left kidney, unchanged, potentially
from prior infection. No hydroureter identified.
The stomach is unremarkable noting a hiatal hernia. Multiple intermittent
loops of small bowel are somewhat prominent and filled with air and fluid
(maximum diameter of 2.8 cm), with intervening areas of collapse, likely
reflecting peristalsis. There are no secondary indications of small-bowel
obstruction with no small bowel wall thickening, mesenteric edema or abnormal
enhancement pattern. Scattered diverticula are noted throughout the colon
though not focused surrounding inflammatory changes to suggest diverticulitis.
However, there is a mild bowel wall thickening with hyperemia mucosa and mild
surrounding inflammatory change noted within the sigmoid colon extending to a
lesser degree into the descending colon, terminating at the level of the
splenic flexure.
The rectum, bladder and distal ureters are unremarkable. The uterus and
adnexa are normal.
Atherosclerotic changes noted throughout the abdominal aorta without evidence
of aneurysmal dilatation. Calcifications are present at the ostia of the
celiac and superior mesenteric arteries; however, there is no evidence to
suggest critical stenosis. The mesenteric vessels are well opacified.
Incidental note is made of a replaced right hepatic artery extending from the
superior mesenteric artery (2:19). The hepatic, left, right and main portal
veins are unremarkable. No free air or fluid noted within the abdomen.
No suspicious lytic or blastic lesions identified. Multilevel degenerative
changes are identified including joint space narrowing, endplate sclerosis at
the L2-L3 level and mild retrolisthesis of L1 on L2 and L2 on L3 and a grade 1
anterolisthesis at L5 on S1. No fractures identified.
IMPRESSION:
1. Mild bowel wall thickening and mucosal enhancement with surrounding
inflammatory change of the sigmoid colon and to a lesser degree the descending
colon tapering to the level of the splenic flexure, consistent with colitis
with etiologies including infectious, inflammatory or ischemic. Of note, the
ostia of the celiac and superior mesenteric and inferior mesenteric arteries
do not appear to have critical stenosis and mesenteric vessels are overall
patent.
2. Moderate stable intrahepatic and extrahepatic biliary ductal dilatation,
not significantly changed.
3. Prominent intermittent fluid filled loops of small bowel with intervening
areas of collapse without secondary evidence of obstruction; however, if
abdominal symptoms worsen, low threshold to repeat scan to assess for
developing small bowel obstruction.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABDOMINAL PAIN
Diagnosed with NONINF GASTROENTERIT NEC
temperature: 97.5
heartrate: 89.0
resprate: 16.0
o2sat: 97.0
sbp: 146.0
dbp: 75.0
level of pain: 8
level of acuity: 3.0 | The patient is a ___ woman with distant history of gastric
volvulus s/p repair, s/p appy and s/p cholcystectomy, recent
admission for ischemic colitis ___ and also with history of
prior C.Diff colitis who presents now with abdominal pain,
vomiting, and diarrhea, found to be C diff positive.
# C diff infection: likely causing abdominal pain, nausea,
diarrhea. The patient has a prior h/o C diff infection, and per
daughter she was told she had to take oral Vancomycin for that
infection. Since this represents a recurrent infection and the
patient required Vancomyin during last infection, we decided to
pursue PO vanc as treatment. GI also saw the patient and
recommends probiotics as well upon discharge. The patient was
able to tolerate a BRAT diet upon discharge, and pain was
greatly improved since admission. First day of oral Vancomycin
therapy was ___.
- Oral Vancomicin 125 mg Q6 for 2 weeks, followed by a taper (1
weeks of BID the 1 week QD). Thus, the patient will get a total
of 4 weeks of therapy including the taper. First day of therapy
was ___.
- Supplement with probiotics: Florastor (Take two sachets daily
during treatment with Vancomycin and once daily thereafter)
# Colitis: Recent CTA scan did not show evidence of ischemia,
lactate not elevated. IV fluids were continued in the hospital
to prevent ischemia from developing in the setting of
dehydration. HCTZ was held. The patient was also found to have
guiac positive stool. Patient was diagnosed with iron
deficiency. Because of the prior noted CT findings of extensive
colitis in ___ in ABSENCE of C.diff or mesenteric stenosis,
GI was consulted. They recommended outpatient follow up once
acute C diff infection resolved, and further discussion of the
need for colonoscopy vs flex sigmoidoscopy. The patient was also
started on iron supplimentation.
# Dirty UA: UCx shows contamination. No Sx of UTI
- no treatment indicated at this time
# PUD: Chronic, stable
- Hold off on Omeprazole 40mg BID given C.Diff
# CAD, stable angina: No acute changes in SOB or chest pain.
- hold HTN meds (See below)
- maintain hydration
# HTN: Chronic, stable. Held HCTZ and metoprolol on admission
given concern for prior ischemic colitis, and current
dehydration. Her BP remained well controlled without either of
these medications. Metoprolol was restarted at home dose and
HCTZ was continued to be held.
- recommend holding HCTZ indefinently given history of
questionable ischemic colitis and well controlled BP on
metoprolol
- Coninue Aspirin 81 mg PO DAILY
# HYPOTHYROIDISM: Chronic, stable
- Continue Levothyroxine Sodium 75 mcg PO DAILY
# DEPRESSION: Chronic, stable
- Continue Citalopram 20 mg PO DAILY
# HLD: Chronic, stable
- Continue Simvastatin 20 mg PO DAILY
# PPX: heparin SQ, hold off on bowel regimen given diarrhea
# CODE: DNR/DNI(confirmed with patient and HCP)
# CONTACT: Daughter and HCP ___ ___,
___ Son ___ ___
TRANSITIONAL ISSUES
- F/U with GI once infection resolved
- follow up with PCP |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
pollen and seasonal
Attending: ___.
Chief Complaint:
Bacteremia
Major Surgical or Invasive Procedure:
Partial excision left loop forearm graft.
Tunneled dialysis line
History of Present Illness:
Mr. ___ is a ___ y/o male w/ PMHx IDDM c/b neuropathy, PVD,
OSA, HTN, obesity, ESRD on HD who presents with positive MRSA
blood cultures from dialysis and concern for AV graft infection.
The patient was noted to be febrile at HD on ___.
He had blood cultures done and was given vancomycin 1.5gm IV.
There was concern his graft was infected, however he refused to
come to the ED at that time as he felt generally well. Of note
they had difficulty accessing the venous limb of his graft but
were able to complete a full HD run with both needles in the
arterial limb. ___ blood cultures returned positive for GPCs
today that are speciated as MRSA and he was instructed to come
to the ED. He overall feels well apart from several episodes of
diarrhea.
Of note, the patient was admitted ___ for graft revision.
Since that time the patient has had a small, non-healing wound
just proximal to the graft site.
In the ED, initial vital signs were 0 100.2 86 132/51 22 96%.
Exam showed AV graft is red and tender. Labs showed stable CBC
with WBC of 9, Na of 132, Cl of 87, bicarb of 26. Vanco level
was 10.2. Lactate was 1.9. CXR was ordered but has not yet been
done. Patient was given vancomycin 1gm IV, zofran 4mg IV,
acetaminophen 1000mg PO x1 Transplant surgery was consulted who
felt the graft site looked ok but was the most likely source of
infection. Patient admitted to medicine with txp surgery
following.
On arrival to the floor, the patient appeared well but was
febrile to 102.9. Also with blood glucose of 402.
Past Medical History:
- Insulin dependent diabetes mellitus 2
- ESRD on HD
- History of line infections
- Peripheral neuropathy and peripheral vascular disease
- Leukocytoclastic Vasculitis
- Hypertension
- Obstructive sleep apnea
- Obesity
- GERD
- Anemia in setting of ESRD
- Secondary hyperparathyroidism in setting of ESRD
- Low-attenuation lesions in kidneys detected by CT in ___
- C. difficile infection in ___ and ___
- S/p open cholecystectomy in ___
Social History:
___
Family History:
NIDDM in both parents and two siblings. Mother with additional
hyperlipidemia, hypercholesterolemia, hypertension, and
Alzheimer's.
Physical Exam:
ADMISSION
Vitals: 0 102.9 141/59 92 22 96%RA
General: Well appearing and in NAD
HEENT: PERRLA, EOMI, anicteric
Neck: Large circumference, cannot apprectiate venous pulsations
CV: Distant heart sounds, RRR, S1 and S2, no murmur
Lungs: CTAB
Abdomen: Obese, NT/ND
Ext: Left arm fistula with shallow, non-healing wound just
proximal. Amputated left toes.
DISCHARGE
Vitals: 98.3 ___ 18 98% RA
General: Seen in HD. obese man in NAD
HEENT: PERRLA, EOMI, anicteric
Neck: cannot apprectiate venous pulsations d/t body habitus
CV: Distant heart sounds, RRR, S1 and S2, no murmur
Lungs: Distant lung sounds but CTAB with limitation
Chest: Tunneled HD line in place right chest, no erythema or
tenderness
Abdomen: NTND, NABS
Ext: Left arm fistula surgical site with sutures in place, c/d/i
Pertinent Results:
ADMISSION
___ 05:11PM LACTATE-1.9
___ 04:18PM GLUCOSE-344* UREA N-49* CREAT-9.6*#
SODIUM-132* POTASSIUM-3.9 CHLORIDE-87* TOTAL CO2-26 ANION
GAP-23*
___ 04:18PM estGFR-Using this
___ 04:18PM VANCO-10.2
___ 04:18PM WBC-6.2 RBC-3.39* HGB-10.1* HCT-31.7* MCV-94
MCH-29.8 MCHC-31.9 RDW-15.0
___ 04:18PM NEUTS-76* BANDS-9* LYMPHS-10* MONOS-3 EOS-2
BASOS-0 ___ MYELOS-0
___ 04:18PM HYPOCHROM-NORMAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
TEARDROP-OCCASIONAL
___ 04:18PM PLT SMR-NORMAL PLT COUNT-151
DISCHARGE
___ 05:25AM BLOOD WBC-7.1 RBC-3.10* Hgb-9.4* Hct-28.6*
MCV-93 MCH-30.4 MCHC-32.9 RDW-15.5 Plt ___
___ 05:25AM BLOOD Glucose-155* UreaN-44* Creat-9.5*# Na-136
K-4.6 Cl-91* HCO3-30 AnGap-20
___ 05:25AM BLOOD Calcium-9.7 Phos-3.8 Mg-2.4
MICROBIOLOGY
___ 6:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
Reported to and read back by ___. ___ ___ @
12:01 ___.
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
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.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ 2142 ON
___ - ___.
GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
___ 4:00 pm BLOOD CULTURE #1 SOURCE: VENIPUNCTURE.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
Daptomycin Sensitivity testing per ___ ___.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
Daptomycin = SENSITIVE (0.19 MCG/ML), Sensitivity
testing
performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
DAPTOMYCIN------------ S
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
___ 2:00 pm FOREIGN BODY LEFT ARM AV-GRAFT.
**FINAL REPORT ___
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Blood Cultures ___ still pending (NGTD) at time of
discharge - FINAL, NO GROWTH
IMAGING/STUDIES
TEE ___
No atrial septal defect is seen by 2D or color Doppler. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. Aortic root
calcifications are present. No masses or vegetations are seen on
the aortic valve. No aortic valve abscess is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. There is no pericardial effusion.
IMPRESSION: No valvular vegetations or abscesses appreciated. No
pathologic valvular regurgitation. Suboptimal image quality due
to poor patient cooperation despite moderate sedation by
anesthesia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Calcium Acetate 667 mg PO TID W/MEALS
3. Cinacalcet 60 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. NPH 28 Units Breakfast
NPH 18 Units Dinner
Insulin SC Sliding Scale using Humulin Insulin
6. Renal Caps *NF* (B complex-vitamin C-folic acid) 1 mg Oral
Daily
7. NexIUM *NF* (esomeprazole magnesium) 40 mg Oral Daily
8. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
Maximum 8 tablets daily , do not combine with tylenol
9. sevelamer CARBONATE 3200 mg PO TID W/MEALS
10. Lisinopril 5 mg PO DAILY
Check blood pressure and hold medication for blood pressure less
than 110 systolic
11. NIFEdipine CR 60 mg PO DAILY
Check blood pressure and hold medication for blood pressure less
than 110 systolic
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Calcium Acetate 667 mg PO TID W/MEALS
3. Docusate Sodium 100 mg PO BID
4. NPH 28 Units Breakfast
NPH 18 Units Dinner
Insulin SC Sliding Scale using Humulin Insulin
5. NIFEdipine CR 30 mg PO DAILY
6. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
7. sevelamer CARBONATE 3200 mg PO TID W/MEALS
8. Cinacalcet 60 mg PO DAILY
9. Lisinopril 5 mg PO DAILY
10. NexIUM *NF* (esomeprazole magnesium) 40 mg Oral Daily
11. Renal Caps *NF* (B complex-vitamin C-folic acid) 1 mg Oral
Daily
12. Vancomycin 1000 mg IV HD PROTOCOL
Discharge Disposition:
Home
Discharge Diagnosis:
MRSA bactermemia
ESRD
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: Fever, assess for pneumonia.
COMPARISON: ___.
FINDINGS: Two views were obtained of the chest. The examination is limited by
poor penetration likely secondary to the patient's body habitus. Within this
limitation, the lungs appear well expanded without focal consolidation to
suggest infectious process. No pleural effusion or pneumothorax is seen. The
heart and mediastinal contours are unchanged.
IMPRESSION: No acute intrathoracic process.
Radiology Report
INDICATION:
___ male with end-stage renal disease, graft infection and removal,
comes in today for placement of a tunneled hemodialysis catheter.
PHYSICIANS:
Dr. ___, ___ fellow, Dr. ___, ___ fellow, and Dr. ___
___, ___ attending, was present and supervising.
Moderate sedation was provided by administering divided doses for a total of
125 mcg of fentanyl and 1.5 mg of Versed for this total intraservice time of
115 minutes during which patient's hemodynamic parameters were continuously
monitored. Additionally, 1% lidocaine and 1% lidocaine with epinephrine were
used for local anesthesia.
PROCEDURES:
1. Venogram of the right upper anterior chest wall.
2. Placement of a tunneled hemodialysis catheter through a neck collateral.
PROCEDURE DETAILS:
Written informed consent was obtained after explaining risks, benefits and
alternatives to the procedure. The patient was brought to the angiography
suite and placed supine on the imaging table. A preprocedure timeout was
performed as per ___ protocol.
Using ultrasound guidance, the right internal jugular vein was punctured with
a micropuncture needle and a 0.018 nitinol wire was then attempted to advance
into the superior vena cava, however, unsuccessful. Following, again under
ultrasound guidance, the junction of the IJ with the brachiocephalic vein was
punctured, with a micropuncture needle an attempt was made to navigate the
wire distally, however, unsuccessful. The wire kept buckling back into the
subclavian vein. Following, the inner part of the micropuncture sheath was
advanced over the nitinol wire and subsequently a small venogram was obtained.
The venogram demonstrated significant reflux into some neck collaterals and
the proximal superior vena cava appeared to be occluded. Based on these
findings, decision was made to puncture one of these neck collaterals that
appeared to connect centrally. Following, using ultrasound guidance, a
superficial right anterior chest wall vein was punctured using a micropuncture
needle, and a 0.018 nitinol wire was navigated distally; however, the wire did
not go centrally. The wire was advanced into the contralateral subclavian
vein. Following, initially using a C2 glide and an angled Glidewire, access
was attempted into the distal SVC, however, unsuccessful. Subsequently, a
digital subtraction angiogram was again performed, which demonstrated
significant kinking of the junction of this chest wall collateral with the
distal SVC. Attempt again was made to navigate the C2 glide catheter and the
Glidewire through the tortuous area, however, was also unsuccessful.
Subsequently, an Omniflush 5 ___ catheter was then navigated to this area
of tortuosity and with aid of a Glidewire, access was gained further down into
the superior vena cava. Following, the catheter was exchanged for a C2 glide,
which was then navigated down into the IVC. The wire was exchanged for a
___ wire. Appropriate measurements for the catheter were then performed.
Subsequently, we chose a tunnel exit site and applied local anesthesia to the
planned tunnel tract. The catheter was then tunneled from the subcutaneous
tissue of the upper anterior chest wall into the venotomy site using a metal
tunneler device. Following, the venotomy site was dilated using a 10, 12 and
finally a 14 dilators. Subsequently, a 16 ___ 30 cm long peel-away sheath
was then navigated over the wire down into the inferior vena cava. The inner
stiffener and the wire were removed, and the catheter was advanced through the
peel-away sheath into the right side of the heart. Final fluoroscopic spot
image of the chest demonstrated adequate catheter positioning, with no acute
kinks and turns, and tip of the catheter in the right atrium. Both lumens
aspirated and flushed easily. The catheter was secured to the skin using a 0
silk suture on either sides. The venostomy site was closed using a
subcuticular stitch. Dry sterile dressing was applied. The patient tolerated
the procedure well without immediate complications.
IMPRESSION:
Successful placement of a 31-cm (tip to cuff) 15.5 ___ tunneled
hemodialysis catheter, through a right neck collateral, with its tip
positioned distally in the right atrium. The catheter is ready for use.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: LEFT ARM INFECTION
Diagnosed with DUE TO RENAL DIALYSIS DEVICE,IMPLANT,GRAFT, ACCIDENT NOS, BACTEREMIA NOS
temperature: 100.2
heartrate: 86.0
resprate: 22.0
o2sat: 96.0
sbp: 132.0
dbp: 51.0
level of pain: 0
level of acuity: 2.0 | ___ y/o male w/ PMHx NIDDM c/b neuropathy, PVD, OSA, HTN,
obesity, ESRD on HD who presents with positive MRSA blood
cultures from AV graft infection.
ACTIVE ISSUES
# MRSA Sepsis - Patient started on vancomycin on admission.
Source found to be left AV graft, which also grew MRSA. Other
sources ruled out. Patient underwent TEE to rule out infectious
endocarditis, which was negative. He will continue a 2 week
total course of vancomycin, to be dosed with HD based on levels.
Last day ___.
# ESRD on HD - ___ schedule. Missed scheduled dialysis day
due to AVG removal as above. Tunneled HD line placed by ___, and
patient received HD both ___ and ___. On discharge he should
return to ___. Continued calcium acetate 667 mg PO TID
W/MEALS, Cinacalcet 60 mg PO DAILY, nephrocaps, sevelamer.
# Diabetes - on insulin. Hypoglycemic episode once during
admission in early AM in setting of not eating dinner and then
NPO after MN. Subsequently, daytime BGs high so AM NPH
increased from 28 to 30 units. Evening NPH keep at 18 Units.
Continued with home humalog sliding scale.
CHRONIC ISSUES
# Anemia - Had slow downtrend in Hct from arrival, but mild and
likely related to small amount of blood loss related to surgery,
stabilized prior to discharge. No signs of bleeding. H/H were
above his recent baseline throughout entire admission.
# Hypertension - continued lisinopril and nifedipine.
# GERD - stable, continued nexium.
# Pain - continued home percocet.
TRANSITIONAL ISSUES
1. continue IV Vancomycin dosed by HD for MRSA septicemia due
to AVG infection till ___
2. f/u with Transplant Surgery after completing ABX for acute
infection for consideration of more permanent HD access
3. continue outpt HD |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Estrogens
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
___ 08:00PM ___ PTT-80.4* ___
___ 02:40PM ___ PTT-93.3* ___
___ 12:36PM LACTATE-1.6
___ 12:30PM GLUCOSE-121* UREA N-10 CREAT-0.6 SODIUM-137
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-22 ANION GAP-14
___ 12:30PM ALT(SGPT)-31 AST(SGOT)-28 LD(LDH)-196 ALK
PHOS-101 TOT BILI-0.7
___ 12:30PM LIPASE-26
___ 12:30PM ALBUMIN-3.6
___ 12:30PM WBC-10.5* RBC-4.14 HGB-12.2 HCT-38.1 MCV-92
MCH-29.5 MCHC-32.0 RDW-13.0 RDWSD-43.5
___ 12:30PM PLT COUNT-263
___ 09:13AM ___ PTT-54.8* ___
___ 03:05AM ___ PTT-104.0* ___
___ 05:38PM URINE HOURS-RANDOM
___ 05:38PM URINE UCG-NEGATIVE
___ 05:38PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:38PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 05:38PM URINE RBC-<1 WBC-<1 BACTERIA-FEW* YEAST-NONE
EPI-0
___ 05:38PM URINE MUCOUS-RARE*
___ 04:28PM ALT(SGPT)-32 AST(SGOT)-28 CK(CPK)-72 ALK
PHOS-124* TOT BILI-0.7
___ 04:28PM LIPASE-30
___ 04:28PM ALBUMIN-4.2
___ 04:28PM WBC-10.4* RBC-4.52 HGB-13.4 HCT-41.4 MCV-92
MCH-29.6 MCHC-32.4 RDW-13.0 RDWSD-43.8
___ 04:28PM NEUTS-57.4 ___ MONOS-6.9 EOS-4.2
BASOS-1.1* IM ___ AbsNeut-5.95 AbsLymp-3.11 AbsMono-0.71
AbsEos-0.44 AbsBaso-0.11*
___ 04:28PM PLT COUNT-273
___ 04:28PM ___ PTT-30.2 ___
___ 11:18AM GLUCOSE-101* UREA N-14 CREAT-0.7 SODIUM-137
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-21* ANION GAP-14
___ 11:18AM estGFR-Using this
___ 11:18AM D-DIMER-4656*
CTA Chest
1. No evidence of pulmonary embolism or aortic abnormality.
2. Findings suspicious for an acute thrombus of the left portal
vein as
described above, incompletely assessed on the current exam. A
dedicated
abdominal CT is recommended.
3. Diffuse ground-glass parenchymal changes are nonspecific and
may reflect
combination of small airways disease and atelectasis.
CT A/P
1. Occlusive thrombus is seen within the left portal vein. In
addition,
nonocclusive thrombus is seen within the distal main portal vein
with
extension into the anterior right portal vein and likely also to
a lesser
extent in the posterior branch of the right portal vein.
2. The SMV and splenic vein are patent. No portal venous
collaterals are
identified.
3. No inflammatory process in the abdomen or pelvis to explain
the portal
venous thrombosis.
4. Fibroid uterus.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Propranolol 10 mg PO BID:PRN essential tremor
2. Escitalopram Oxalate 10 mg PO DAILY
3. Cetirizine 10 mg PO DAILY
Discharge Medications:
1. Apixaban 10 mg PO BID Duration: 6 Days
10mg PO BID through ___, then 5mg PO BID for life
RX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth twice a day
Disp #*66 Tablet Refills:*0
2. Cetirizine 10 mg PO DAILY
3. Escitalopram Oxalate 10 mg PO DAILY
4. Propranolol 10 mg PO BID:PRN essential tremor
Discharge Disposition:
Home
Discharge Diagnosis:
Portal vein thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with headache// Headache, h/o blood clots currently
on heparin
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 7.0 s, 0.5 cm; CTDIvol = 34.9 mGy (Body) DLP =
17.4 mGy-cm.
3) Spiral Acquisition 4.9 s, 38.7 cm; CTDIvol = 15.2 mGy (Body) DLP = 587.6
mGy-cm.
Total DLP (Body) = 605 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
Mild degradation of the study secondary to suboptimal contrast enhancement.
CT HEAD WITHOUT CONTRAST:
There is no evidence of infarction, edema, hemorrhage or mass. The ventricles
and frontal sulci are prominent, likely related to involutional changes.
There is no gross evidence of acute fracture. The ethmoid, sphenoid, frontal
and maxillary sinuses are clear. The middle air cavities are unremarkable. The
visualized portion of the orbits are unremarkable.
CTA neck:
Conventional 3 vessel arch with minimal calcification at the level of aortic
arch and carotid bifurcations. No stenosis in the internal carotid arteries by
NASCET criteria. CT angiography of the neck shows normal appearance of the
carotid and vertebral arteries without stenosis or occlusion or dissection.
CTA head:
Minimal calcification of the carotid siphons. CT angiography of the head shows
normal appearance of the arteries of the anterior and posterior circulation
without stenosis or occlusion or aneurysm greater than 3 mm in size. Patent
dural venous sinuses.
Other: The visualized lung apices and thyroid gland appear unremarkable. No
lymphadenopathy by CT criteria. Minimal degenerative changes of the visualized
spine without evidence of canal or neural foramen narrowing.
IMPRESSION:
1. Normal head CT.
2. Patent circle of ___ without evidence of stenosis,occlusion,or aneurysm.
3. Patent bilateral cervical carotid and vertebral arteries without evidence
of stenosis, occlusion, or dissection.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal CT
Diagnosed with Portal vein thrombosis
temperature: 98.1
heartrate: 78.0
resprate: 16.0
o2sat: 98.0
sbp: 106.0
dbp: 72.0
level of pain: 3
level of acuity: 2.0 | Ms. ___ is a ___ year old lady with a past medical history of
pulmonary
embolism in the setting of taking birth control and MTHFR
mutation who presents with a unprovoked portal vein thrombus.
#Portal vein thrombus
CT abdomen shows portal vein thrombus without collaterals
suggesting an acute process, there is no inflammatory process
seen in the imaging as a cause. Hematology was consulted and
recommended heparin drip while she is an inpatient but she was
transitioned to Apixiban upon discharge (10mg PO BID through
___, then 5mg PO BID ongoing).
She will complete a hypercoagulable work-up as an outpatient
(scheduled ___. They
recommended age-appropriate cancer screenings. At the time of
discharge, she was
not having any pain, able to tolerate PO with normal LFTs.
[] recommend bilateral diagnostic mammogram after discharge
given calcifications in left breast noted > ___ year ago.
[] Pap/HPV testing normal in ___. Next due ___
[] Hypercoagulable workup with Heme (scheduled ___
#Cough
#Shortness of Breath
CTA negative for PE but did show Diffuse ground-glass
parenchymal
changes which could be small airways disease. She does endorse
exercise induced asthma.
[] Should have PFTs as outpatient
#Depression
Continue home Lexapro
#Seasonal allergies
Continue home Zyrtec
#Essential tremor
Hold propranolol for now in the setting of low blood pressure
Transitional issues
[] Apixiban 10mg PO BID through ___, then transition to 5mg PO
BID for life
[] recommend bilateral diagnostic mammogram after discharge
given calcifications in left breast noted > ___ year ago.
[] Pap/HPV testing normal in ___. Next due ___
[] Hypercoagulable workup with Heme (scheduled ___
[] Outpatient PFTs to further characterize lung disease seen on
CT
Greater than 40 mins were spent on discharge planning and
coordination of care. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hemturia, lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ with recent admission from ___ to ___ for
MRSA bacteremia, UTI/prostatitis, ___, and subdural hematoma,
presenting with persistent gross hematuria from foley and
lethargy. Pt was discharged with the foley on ___ per urology
and has a history of traumatic foley placements. Urology opted
to keep foley in rather than risk failed voiding trial and
necessitating potentially traumatic replacement. The foley has
been draining cranberry colored urine since its original
placement. Color has been stable and without clots. He had an
appt with urology today for foley removal; due to continued
hematuria urologist decided to schedule cystoscopy for ___
however, urologist noted pt appeared lethargic and requested he
come to ___ for medical work up prior to cystoscopy. The family
notes he was fine before today and the lethargy is new.
Yesterday he was alert, talkative, and reading to family. No
fevers/chills/sweats, no CP, no SOB, no N/V, no change in BM, no
blood in stool, no rashes. Admits to new c/o left leg and knee
pain beginning today. Also has had an occasional "rattly" but
non-productive cough recently. Pt states he has not been eating
well but this is due to not being given enough food, he does
have an appetite. He denies any urinary symptoms and was unaware
that he has hematuria. Denies recent falls though states his
left elbow is slightly tender. Daughter says patient not
drinking fluid like he needs to.
.
In the ED, initial vs were: 97.7 54 129/52 16 99% ra. On exam
patient alter but not oritend to time/yr/place, stool guiaic
negative. Labs were remarkable for hematocrit of 28.7 (up from
27.8 at discharge on ___, creatinine of 1.9 (was 1.6 at
discharge on ___, troponin indeterminant at 0.05. EKG per
report was SR at 56, LAD (LAFB), prolonged QTc (469ms), TWF in
III, no ST changes (overall ekg c/w prior). Head CT with no new
ICH, stable 4mm R frontal subacute to chronic SDH, age related
involution and small vessel ischemic disease. CXR with stable
cardiomegaly and no acute process. Blood and urine culture
obtained. UA with blood, positive ___, WBC, bacteria - blood and
urine culture obtained. ED spoke w/ patient's ID fellow (___)
who thought likely asymptomatic bacteruria (just completed
course of meropenem). ID recommended continue vanc for MRSA
bacteremia, repeat UA on floor, do not treat w/ additional ABX
unless develops fever or symptoms. No medications given in ED.
Access if PICC in left arm, giving 1L NS infusing at 125cc/hr.
Vitals on Transfer: HR:65, RR: 32, BP: 156/64, O2Sat: 100%RA.
Admit to medicine for ___ w/ plan to recheck creatinine after
IVF, hematuria w/ plan to trend HCT, indeterminate troponin w/
plan to trend biomarkers. ED resident updated patient's
daugther.
.
Review of sytems:
Per HPI
Past Medical History:
HTN
Prostate cancer
Spinal stenosis
Depression
GERD
BPH
Left olecranon ORIF ___, complicated by MRSA bacteremia d/t
hardware infection
Social History:
___
Family History:
Noncontributory. Both parents lived to be quite old - late
___, early ___.
Physical Exam:
Vitals: T: 97.6 BP: 159/70 P: 72 R: 18 O2: 99% RA
General: Alert, cachectic, pale, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, left lower
eyelid erythematous but no exudates
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses on LLE, unable to palpate on
right ___, no clubbing, cyanosis or edema
Skin: papery, no rashes
Neuro: CN2-12 intact, LTSI bilaterally, Strength ___ in UE and
___
DISCHARGE EXAM:
97.3, 105/50, 70, 19, 98% RA
General: AAOx1, cachectic, pale, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, left lower
eyelid erythematous but no exudates
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: no clubbing, cyanosis or edema
Skin: papery, no rashes
GU: foley draining very slightly pink-tinged urine
Pertinent Results:
ADMISSION LABS:
___ 03:12PM BLOOD WBC-7.0 RBC-2.89* Hgb-9.1* Hct-28.7*
MCV-99*# MCH-31.4 MCHC-31.7 RDW-14.3 Plt ___
___ 03:12PM BLOOD Neuts-68.8 ___ Monos-5.1 Eos-1.7
Baso-0.6
___ 03:12PM BLOOD ___ PTT-29.5 ___
___ 03:12PM BLOOD Glucose-82 UreaN-22* Creat-1.9* Na-138
K-4.0 Cl-105 HCO3-26 AnGap-11
___ 03:12PM BLOOD CK-MB-2
___ 03:12PM BLOOD cTropnT-0.05*
___ 06:00AM BLOOD CK-MB-2 cTropnT-0.06*
___ 03:12PM BLOOD CK(CPK)-30*
___ 06:00AM BLOOD CK(CPK)-28*
___ 03:12PM BLOOD Calcium-8.5 Phos-3.1 Mg-2.2
___ 03:35PM BLOOD Lactate-1.9
IMAGING:
CT HEAD: 1. No acute intracranial process.
2. Stable 4 mm right frontal chronic subdural hematoma,
unchanged.
3. Age-related involution and small vessel ischemic disease.
CXR: No acute cardiopulmonary process such as pneumonia. Stable
cardiomegaly.
DOPPLER ___: No evidence of DVT in left lower extremity.
DISCHARGE LABS:
___ 09:00AM BLOOD WBC-5.4 RBC-2.84* Hgb-8.8* Hct-28.1*
MCV-99*# MCH-30.9 MCHC-31.3 RDW-16.8* Plt ___
___ 09:00AM BLOOD Glucose-106* UreaN-22* Creat-1.7* Na-140
K-4.2 Cl-114* HCO3-20* AnGap-10
___ 09:00AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.9
___ 05:39AM BLOOD PSA-1.8
___ 07:47AM BLOOD Vanco-28.6*
Medications on Admission:
- Lupron Depot (4 Month) 30 mg Syringe Kit Intramuscular
- cholecalciferol (vitamin D3) 800 units PO DAILY.
- docusate sodium (100) mg PO BID
- multivitamin (1) Tablet PO DAILY
- omeprazole 20 mg Capsule, Delayed Release(E.C.)(1) PO BID
- calcium carbonate 500 mg calcium (1,250 mg) (1) Tablet PO BID
- senna 8.6 mg Tablet (1) Tablet PO HS
- cranberry 450 mg Tablet (2) Tablet PO twice a day.
- citalopram (20) mg PO DAILY
- polyvinyl alcohol 1.4 % Drops Sig: ___ Drops Ophthalmic TID
- erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) drop BID
to left eye
- Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) PO
once a day as needed for constipation.
- bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day
as needed for constipation.
- Fleet Enema ___ gram/118 mL Enema Sig: One (1) enema Rectal
once a day as needed for constipation.
- doxazosin 1 mg Tablet (2) Tablet PO HS
- levetiracetam 100 mg/mL Solution Sig: (500) mg PO BID
Discharge Medications:
1. Lupron Depot (4 Month) 30 mg Syringe Kit Sig: One (1) syringe
Intramuscular every 4 months.
2. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. cranberry 450 mg Tablet Sig: One (1) Tablet PO once a day.
8. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. erythromycin 5 mg/gram (0.5 %) Ointment Sig: 0.5 inch
Ophthalmic BID (2 times a day): LEFT eye.
10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
11. Calcium 500 500 mg calcium (1,250 mg) Tablet Sig: One (1)
Tablet PO once a day.
12. polyvinyl alcohol 1.4 % Drops Sig: ___ drops Ophthalmic
three times a day.
13. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
14. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
15. Fleet Enema ___ gram/118 mL Enema Sig: One (1) enema Rectal
once a day as needed for constipation.
16. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
17. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
18. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
19. vancomycin 500 mg Recon Soln Sig: Seven Hundred Fifty (750)
mg Intravenous Q48H (every 48 hours) for 6 days: last dose
___.
Disp:*2250 mg* Refills:*0*
20. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Urinary tract infection
Dehydration
Hematuria
Secondary Diagnoses:
BPH
History of MRSA bacteremia
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: ___ male with altered mental status and hematuria.
Question infectious process.
FINDINGS: Single frontal view of the chest demonstrates stable cardiomegaly
and mild unfolding of the thoracic aorta, with associated arch calcifications.
The lungs are clear, and apical thickening unchanged. There is no
pneumothorax, vascular congestion, or pleural effusion. Angulated right
proximal humeral fracture and distal right clavicular irregularity appear
longstanding.
IMPRESSION: No acute cardiopulmonary process such as pneumonia. Stable
cardiomegaly.
Radiology Report
INDICATION: ___ male with altered mental status and hematuria.
Question interval change in known history of subdural hematoma.
COMPARISON: ___.
TECHNIQUE: Contiguous non-contrast axial images were acquired through the
brain with multiplanar reformations.
FINDINGS: There is no change in the 4 mm right frontal chronic subdural
hematoma as previously noted on ___. Prominent bifrontal
extra-axial CSF spaces are also stable as compared to prior exams. There is
no new hemorrhage, mass effect, edema, or shift of normally midline
structures. Ventricles and sulci are prominent, consistent with age-related
involution. Mild ventricular asymmetry is longstanding and unchanged.
Periventricular and subcortical white matter hypoattenuation is compatible
with small vessel ischemic disease. Tiny foci of hypodensity in the basal
ganglia particularly on the right may represent small lacunes, unchanged.
Suprasellar and basilar cisterns are patent. Paranasal sinuses and mastoid
air cells are well aerated. Vascular calcifications are seen in the
cavernous, carotid and vertebral arteries. Globes and orbits are intact.
Right frontal burr hole is noted.
IMPRESSION:
1. No acute intracranial process.
2. Stable 4 mm right frontal chronic subdural hematoma, unchanged.
3. Age-related involution and small vessel ischemic disease.
Radiology Report
INDICATION: New onset lethargy and left leg/knee pain. Evaluate for DVT.
COMPARISON: None.
TECHNIQUE: Unilateral lower extremity venous ultrasound (left).
FINDINGS: Gray-scale, color and spectral Doppler sonograms were acquired of
the left common femoral, superficial femoral, and popliteal veins. Color
Doppler images of the posterior tibial and peroneal veins were also obtained.
There is normal compressibility, flow, and augmentation throughout.
IMPRESSION: No evidence of DVT in left lower extremity.
Radiology Report
HISTORY: PICC placement.
FINDINGS: In comparison with study of ___, the tip of the PICC line again
appears to be in the upper to mid portion of the SVC. Low lung volumes but
otherwise little change in the appearance of the heart and lungs.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ?ABN LABS, HEMATURIA
Diagnosed with HEMATURIA, UNSPECIFIED, RENAL & URETERAL DIS NOS, ANEMIA NOS, HYPERTENSION NOS, HX-PROSTATIC MALIGNANCY
temperature: 97.7
heartrate: 54.0
resprate: 16.0
o2sat: 99.0
sbp: 129.0
dbp: 52.0
level of pain: unable
level of acuity: 3.0 | The patient is a ___ with recent admission from ___ to ___ for
MRSA bacteremia, UTI/prostatitis, ___, and subdural hematoma,
presenting with persistent gross hematuria from Foley and
lethargy with necrotic tissue at the bladder neck, possibly
advanced prostate cancer, seen on cystoscopy.
# Hematuria: Onset of hematuria appears to have coincided with
traumatic foley placement during prior hospitalization, but has
persisted. Ddx included infection vs malignancy vs trauma vs all
of the above. U/A positive as below and pt treated with cipro.
Pt continued to have hematuria which progressively worsened,
ultimately requiring 3 units of PRBC during LOS to stabilize
Hct. pt had plan for cystoscopy on ___ with urology, so this was
pursued in house. On cystoscopy, necrotic tissue was seen at the
bladder neck consistent with advanced prostate cancer invading
the bladder was seen and areas of bleeding were cauterized,
however, no biopsies were performed and PSA is within normal
limits at 1.8 which would argue against an advanced prostate
cancer. A three way foley was placed and continuous bladder
irrigation was performed until urine was clear, then the CBI was
capped. Pt's Hct remained stable after cystoscopy and CBI.
Discussion was held with family that pt would likely rebleed
unless some treatment of prostate cancer was attempted, such as
focal XRT. They will discuss this as an outpatient. Of note,
during last hospitalization, prostatitis was considered and he
was treated with 2 weeks of meropenem before discontinuing abx
due to low suspicion for this diagnosis.
# Urinary tract infection: U/A was positive x 2 for >182 WBC and
RBC, + ___, + nitrites, + bacteria. Awaited UCx results before
starting abx and pseudomonas grew out; started pt on oral cipro
based on sensitivities. He was continued on cipro for a 7 day
course starting from replacement of the foley during cystoscopy.
UTI during this hospitalization was attributed to indwelling
foley rather than seeding from prostatitis, however, due to
recurrent nature of the infection a plan was made to get repeat
U/A after completion of cipro --> if positive pt may require
suppressive antibiotic therapy.
# Lethargy: thought to be multifactorial ___ volume depletion,
as pt has had poor po intake, elevated creatinine elevated,
anemia ___ chronic hematuria, and infection upon admission.
DVT/PE was considered, since the pt developed the complaint of
new left lower extremity pain on the same day that the lethargy
was noted, but ___ was negative. CXR neg but U/A floridly
positive as described above. Head CT was stable - no change in
subdural. EKG also stable. Pt give IVF and reported feeling
improvement on HD2. He was also given blood transfusions as
above and treated for this infection.
# Acute on Chronic Kidney Disease: pt with Cr 1.9 on admission,
slightly up from 1.6 at last D/C on ___. Suspected prerenal
on admission due to h/o poor po intake but only mild improvement
s/p IVF. FeNa was 11% which was consistent with intrarenal
pathology. He stabilized around 1.9 for several days but slowly
trended down to 1.7 after cystoscopy. Suspect this is a new
baseline.
# Hypernatremia: pt developed hypernatremia to 150 during
hospitalization, though to be ___ volume depletion due to poor
po intake. Resolved with D5W and free water repletion.
# h/o MRSA bacteremia: followed by ___ OPAT for MRSA
bacteremia thought to be ___ retained hardware from ___ ORIF
(organism matches the C&S from that hospitalization). Continued
current regimen of Vancomycin 1g IV q48 hours but vanc trough
elevated to 26 so dose was decreased to 750mg IV q48h. Last dose
___.
# Indeterminate troponin: trop minimally increased to 0.06 from
0.05 on admission with stable CK-MB and CPK. no sx of chest
pain, SOB, etc, EKG unchanged, and tele unremarkable. likely
this is ___ CKD (also could have been ___ zosyn which pt got in
ED). no further action taken.
# Leg pain: no trauma history. exam unremarkable. ruled out DVT
with ___ due to onset of complaint at the same time as lethargy
but it was negative. no further action taken.
# h/o Subdural hematoma: continued keppra
# HTN: continued doxazosin
# Depression: continued citalopram
# GERD: continued omeprazole |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Trazodone
Attending: ___.
Chief Complaint:
shoulder and chest pain
Major Surgical or Invasive Procedure:
attempted closed reduction of R anterior glenohumeral
dislocation
History of Present Illness:
___ year old lady with complex past medical history most notable
for COPD (FEV1 59% ___, schizoaffective disorder, R
glenohumeral osteoarthritis, and chronic pain on opioid
contract,
who presents with 3 days of worsening R shoulder pain and
substernal intermittent chest pain.
Patient noted to be a poor historian from notes dating back to
___.
For the past three days, patient has had trouble moving her R
arm. Per review of outpatient notes, appears that patient has
known history of R shoulder pain thought secondary to R
glenohumeral osteoarthritis that has been treated conservatively
with injections, most recently ___.
To me, she reports that her brother ___ (___) tells her
that she twisted her R shoulder/arm several days ago but she
does
not recall this. She also does not recall any fall or injury, or
any assault. Her main complaint is that she has pain in her R
shoulder as well as chest, described as sharp and stabbing. She
notes that for the past three days she has been unable to raise
her R arm up to comb her hair (although has ___ who helps her
with this). She has also been having some worsening R chest pain
which is non radiating, which she is unable to localize with one
finger, but notes that this pain is worse with deep breaths and
with activity. She says that she has been walking to the
bathroom
and also to the kitchen and has noticed that she has been a
little more short of breath requiring her to stop and catch her
breath. She denies any orthopnea. Notes that her leg swelling is
at baseline. No palpitations.
She has been taking her pain pills (hydrocodone-acetaminophen
___ BID which has helped with the pain. She denies any fevers
or chills. Has chronic cough productive of white sputum.
Endorses
maybe some urinary frequency starting today, such that she has
to
go to bathroom q15 minutes, which she also thinks is new.
Regarding history of falls, it appears that at least at recent
PCP visit in ___ there was report of no falls x ___ year.
Review of prior discharge summaries patient did reveal one fall
requiring hospitalization in ___ with left sided low anterior
column acetabular fracture after a table fell over when she was
leaning against it.
In the ED, initial VS were: 97.7 68 141/73 20 100% RA
Exam notable for:
Gen: Obese elderly woman
Pulm: CTAB no WRR, unlabored breathing
CV: RRR no MRG, no JVD
Per ED, patient became hypoxic on ambulation to the bathroom to
87% on room air, no previous history of O2 dependence.
EKG per my read: Sinus rate 70, normal axis, normal intervals,
TWI in V1-V2, T wave flattening in V3. Early R wave transition.
Baseline artifact.
Labs showed:
WBC 7.5, Hb 14.1, Plt 194 (All lines within recent baseline)
INR 1.1
144 | 104 | 10
---------------
3.8 | 26 | 0.7 (baseline 0.8-1.0)
Trop-T: <0.01
proBNP: 30
UA: Moderate leukocyte esterase, 17 ___
Imaging showed:
CTA chest:
1. Acute fractures of the right anterolateral second and third
ribs with small adjacent extrapleural hematoma. No evidence of
pulmonary contusion, laceration, or pneumothorax in the setting
of rib fractures.
2. Redemonstration of right anterior glenohumeral dislocation.
Tiny ossific densities adjacent to the dislocated right humeral
head suggests small fracture fragments.
3. No evidence of pulmonary embolism or aortic abnormality.
4. Unchanged mild narrowing of the bilateral mainstem bronchi,
right middle lobe bronchus and bronchus intermedius which again
may represent bronchomalacia.
5. Mild dilatation of the main pulmonary artery to 3.3 cm,
unchanged, and could reflect pulmonary arterial hypertension.
XR R shoulder
Right glenohumeral anterior dislocation without fracture.
XR R shoulder (post attempted reduction):
No substantial interval change in right anterior glenohumeral
joint
dislocation. Redemonstration of fractures of the right second
and
third anterolateral ribs.
Consults:
(1) Orthopedics:
Failed closed reduction of shoulder. Consented and added-on for
closed vs open reduction of the right shoulder
- Admit to medicine
- NPO Midnight
- AAT, sling to RUE for comfort if necessary
- Hold am anticoagulation
(2) Trauma surgery
Recommend Excellent pain control, frequent I/S,DVT prophylaxis,
and O2 sat monitoring. X-ray btl knees and pelvic x-ray please.
Admit to medicine for further management of hypoxia and agree
with ortho consultation for reduction of right shoulder.
Patient received:
PO Acetaminophen 1000 mg
IV CefTRIAXone 1 g
IV Morphine Sulfate 4 mg
Past Medical History:
- Moderately Severe COPD
- Schizoaffective Disorder
- CAD
- Hypertension
- Hyperlipidemia
- Chronic dysarthria of unclear etiology
- Osteoathritis of the knees s/p left TKL
- Osteopenia
- Glaucoma
- Extirpated L orbit with prosthesis and L ptosis
- Mild tracheobronchomalacia
- Urinary Incontience
- ___
- gallstone pancreatitis s/p successfully ERCP with removal of
sludge and sphincterotomy (___)
- acute cholecystitis s/p perc chole placement (___)
- acute cholecystitis s/p ERCP, lap CCY complicated by
intraabdominal abscesses requiring ___ drainage and antibiotics
(___)
Social History:
___
Family History:
T2DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
___ ___ Temp: 97.6 PO BP: 140/80 L Lying HR: 69 RR: 18
O2 sat: 96% O2 delivery: Ra
GENERAL: NAD, obese lady lying in bed comfortably
HEENT: Prosthetic L eye, MMM
NECK: supple, no LAD, JVP difficult to appreciate ___ habitus
CV: RRR, S1/S2, no murmurs, gallops, or rubs. R chest wall pain.
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles, no flail chest, respirations
shallow, no obvious hematoma visible
GI: abdomen soft, nondistended, +suprapubic tenderness, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, bilateral knees TTP, TTP
over
R tib/fib, grossly no deformity. Edema in bilateral ___ to level
of knee with venous stasis changes but not significantly
pitting.
R arm inferiorly displaced. 2+ radial pulses bilaterally.
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, EOMI on right eye without nystagmus, L prosthetic
eye, no facial droop, question of ptosis of L eyelid per patient
not new, tongue midline. Moves all four extremities with purpose
but ROM in shoulder limited ___ pain.
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
======================
VS: ___ ___ Temp: 98.3 PO BP: 135/77 HR: 68 RR: 18 O2 sat:
92% O2 delivery: Ra
GENERAL: NAD, obese lady lying in bed comfortably
HEENT: Prosthetic L eye, MMM
CV: RRR, S1/S2, no murmurs, gallops, or rubs. R chest wall pain.
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably on
RA without use of accessory muscles
GI: NABS. abdomen soft, ND, NT. No rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: RUE sling. Bilateral ___ edema to knees with venous
stasis changes. R arm inferiorly displaced. 2+ radial pulses
bilaterally.
NEURO: Alert and interactive. No focal neurologic deficits.
Moves
all four extremities with purpose but ROM in shoulder limited
___
pain.
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
==============
___ 01:59PM ___ PTT-29.6 ___
___ 01:59PM PLT COUNT-194
___ 01:59PM NEUTS-65.2 ___ MONOS-5.0 EOS-2.0
BASOS-0.4 IM ___ AbsNeut-4.87 AbsLymp-2.01 AbsMono-0.37
AbsEos-0.15 AbsBaso-0.03
___ 01:59PM WBC-7.5 RBC-4.57 HGB-14.1 HCT-44.7 MCV-98
MCH-30.9 MCHC-31.5* RDW-13.0 RDWSD-46.1
___ 01:59PM CALCIUM-9.8 PHOSPHATE-3.5 MAGNESIUM-2.0
___ 01:59PM proBNP-30
___ 01:59PM cTropnT-<0.01
___ 01:59PM GLUCOSE-86 UREA N-10 CREAT-0.7 SODIUM-144
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-26 ANION GAP-14
___ 04:00PM URINE MUCOUS-RARE*
___ 04:00PM URINE RBC-1 WBC-17* BACTERIA-NONE YEAST-NONE
EPI-3 TRANS EPI-<1
___ 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD*
___ 04:00PM URINE COLOR-Straw APPEAR-Clear SP ___
MICROBIOLOGY:
============
__________________________________________________________
___ 4:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION
IMAGING:
=======
___ CXR
IMPRESSION:
1. Congestion with probable mild interstitial pulmonary edema,
difficult to exclude a subtle superimposed pneumonia.
2. Better assessed on right shoulder radiograph is right
glenohumeral dislocation.
___ R Glenohumeral Xray
IMPRESSION: Right glenohumeral anterior dislocation without
fracture.
___ R Glenohumeral xray
IMPRESSION: No substantial interval change in right anterior
glenohumeral joint dislocation. Redemonstration of fractures of
the right second and third anterolateral ribs.
___ CTA Chest
IMPRESSION:
1. Acute fractures of the right anterolateral second and third
ribs with small adjacent extrapleural hematoma. No evidence of
pulmonary contusion, laceration, or pneumothorax in the setting
of rib fractures.
2. Redemonstration of right anterior glenohumeral dislocation.
Tiny ossific densities adjacent to the dislocated right humeral
head suggests small fracture fragments.
3. No evidence of pulmonary embolism or aortic abnormality.
4. Unchanged mild narrowing of the bilateral mainstem bronchi,
right middle lobe bronchus and bronchus intermedius which again
may represent bronchomalacia.
5. Mild dilatation of the main pulmonary artery to 3.3 cm,
unchanged, and could reflect pulmonary arterial hypertension.
___ L Pelvis and Femur Xray
IMPRESSION:
1. No evidence of acute fracture or dislocation.
2. Bony callus formation at the left superior and inferior pubic
rami are compatible with old healed fractures.
3. Extensive degenerative changes, as described above.
___ R Knee Xray
IMPRESSION:
1. No evidence of fracture or dislocation.
2. Severe degenerative changes, as described above.
___ Shoulder Xray
IMPRESSION:
Single axillary view is very limited and the glenoid is not
fully seen. Assessment for persistent anterior shoulder
dislocation is suboptimal. There are chronic degenerative
changes with irregularity of the glenoid, better assessed on the
recent chest CT. If there is high concern for persistent
anterior shoulder dislocation, would recommend dedicated right
shoulder CT.
___ R Tib/Fib Xray
IMPRESSION: No acute osseous injury of the right tibia or
fibula.
DISCHARGE LABS:
==============
No labs on day of discharge
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO BID
2. FLUoxetine 20 mg PO DAILY
3. Simvastatin 40 mg PO QPM
4. Omeprazole 20 mg PO DAILY
5. Methazolamide 25 mg PO BID
6. Lisinopril 10 mg PO DAILY
7. Gabapentin 300 mg PO BID
8. Furosemide 10 mg PO DAILY
9. ARIPiprazole 10 mg PO DAILY
10. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
11. Pilocarpine 4% 1 DROP BOTH EYES Q6H
12. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of
breath/wheezing
13. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
unknown
14. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Lidocaine 5% Patch 1 PTCH TD QPM
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of
breath/wheezing
4. ARIPiprazole 10 mg PO DAILY
5. FLUoxetine 20 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Furosemide 10 mg PO DAILY
8. Gabapentin 300 mg PO BID
9. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO BID
10. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation
inhalation unknown
11. Lisinopril 10 mg PO DAILY
12. Methazolamide 25 mg PO BID
13. Omeprazole 20 mg PO DAILY
14. Pilocarpine 4% 1 DROP BOTH EYES Q6H
15. Simvastatin 40 mg PO QPM
16. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Right anterior-inferior glenohumeral dislocation
Possible fall
Rib fracture
Pleuritic chest pain
SECONDARY DIAGNOSES:
Osteoporosis
Sterile pyuria
Schizoaffective disorder
COPD
Tracheobronchomalacia
Hypertension
Hyperlipidemia
Glaucoma
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with atraumatic right shoulder substernal chest pain//
Fractures?
COMPARISON: Prior exam from ___
FINDINGS:
Three views of the right shoulder provided. There is right glenohumeral
dislocation with anterior and inferior dislocation of the right humeral head
relative to the glenoid fossa. No definite acute fracture is seen.
Degenerative changes at the right AC joint noted. The imaged right upper ribs
appear intact.
IMPRESSION:
Right glenohumeral anterior dislocation without fracture.
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: ___ with atraumatic right shoulder substernal chest pain//
Fractures?
COMPARISON: Prior exam is dated ___
FINDINGS:
AP portable upright view of the chest. Right shoulder dislocation better
assessed on same-day shoulder radiograph. There is pulmonary vascular
congestion and likely mild pulmonary edema. Slightly irregular opacities in
the lungs likely reflect edema though difficult to exclude a subtle
superimposed pneumonia. No large effusion or pneumothorax. Cardiomediastinal
silhouette appears stable. No fracture seen.
IMPRESSION:
1. Congestion with probable mild interstitial pulmonary edema, difficult to
exclude a subtle superimposed pneumonia.
2. Better assessed on right shoulder radiograph is right glenohumeral
dislocation.
Radiology Report
EXAMINATION: CTA chest with and without contrast
INDICATION: History: ___ with substernal chest pain hypoxia// PE?
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
2) Spiral Acquisition 3.7 s, 29.3 cm; CTDIvol = 27.1 mGy (Body) DLP = 793.5
mGy-cm.
Total DLP (Body) = 806 mGy-cm.
COMPARISON: CT chest with without contrast dated ___, right
shoulder radiographs ___ at 14:16
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main pulmonary artery is mildly dilated
to 3.3 cm, unchanged. There is no evidence of right heart strain. Heart size
is mildly enlarged. Diffuse coronary artery calcifications are present.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid gland appears unremarkable. There is a small hiatal hernia.
There is no evidence of pericardial effusion. There is no evidence of
hemothorax or pneumothorax.
There is no evidence of pulmonary contusion or laceration in the setting of
rib fractures. The bilateral mainstem bronchi, right middle lobe bronchus and
bronchus intermedius are narrowed and again may reflect the sequela of
bronchomalacia, unchanged when compared to most recent prior CT. There is
moderate depended bibasilar atelectasis.
Limited images of the upper abdomen are unremarkable.
The right humerus is anteriorly and inferiorly dislocated relative to the
glenoid fossa with tiny adjacent osseous fragmentation suggestive of a small
fracture fragment (02:32). Acute fractures of the anterolateral right second
and third ribs with adjacent extrapleural hematoma is demonstrated. Mild
multilevel degenerative changes are demonstrated in the visualized thoracic
spine.
IMPRESSION:
1. Acute fractures of the right anterolateral second and third ribs with small
adjacent extrapleural hematoma. No evidence of pulmonary contusion,
laceration, or pneumothorax in the setting of rib fractures.
2. Redemonstration of right anterior glenohumeral dislocation. Tiny ossific
densities adjacent to the dislocated right humeral head suggests small
fracture fragments.
3. No evidence of pulmonary embolism or aortic abnormality.
4. Unchanged mild narrowing of the bilateral mainstem bronchi, right middle
lobe bronchus and bronchus intermedius which again may represent
bronchomalacia.
5. Mild dilatation of the main pulmonary artery to 3.3 cm, unchanged, and
could reflect pulmonary arterial hypertension.
Radiology Report
INDICATION: History: ___ with R shoulder dislocation// s/p reduction trial
TECHNIQUE: Right shoulder, three views
COMPARISON: Right shoulder radiographs ___ at 14:16, CT chest
___ at 17:46
FINDINGS:
Re-demonstrated is a right anterior glenohumeral joint dislocation with
anterior, inferior and medial displacement the humeral head relative to the
glenoid fossa. Findings appear unchanged from the prior exam. Tiny fracture
fragments adjacent to the humeral head seen on the prior CT are not well
visualized on the current radiograph. The acromioclavicular joint
demonstrates moderate degenerative changes. The imaged right lung
demonstrates mild pulmonary vascular congestion. Fractures of the right
second and third anterolateral ribs are re-demonstrated.
IMPRESSION:
No substantial interval change in right anterior glenohumeral joint
dislocation. Redemonstration of fractures of the right second and third
anterolateral ribs.
Radiology Report
EXAMINATION: DX PELVIS AND FEMUR
INDICATION: History: ___ with fall, pain. Evaluation for fracture
TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and
frog-leg lateral views of the left hip. Frontal and lateral views of the left
knee.
COMPARISON: Comparison to radiograph from CT scan of the abdomen pelvis from
___
FINDINGS:
There is no acute fracture or dislocation. Bony callus formation at the left
superior and inferior pubic rami are compatible with chronic fractures were
present on the ___ study. There are extensive degenerative changes
involving the bilateral hip joints, including joint space narrowing and
osteophytosis. Degenerative change of the partially visualized lumbar spine.
Heterotopic calcification along the left hip is similar to prior studies.
There is no suspicious lytic or sclerotic lesion. Contrast material is noted
within the urinary bladder.
There is a left total knee arthroplasty with no evidence of fracture or
hardware complication. No evidence of joint effusion.
IMPRESSION:
1. No evidence of acute fracture or dislocation.
2. Bony callus formation at the left superior and inferior pubic rami are
compatible with old healed fractures.
3. Extensive degenerative changes, as described above.
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) RIGHT
INDICATION: History: ___ with fall, pain. Evaluation for fracture.
TECHNIQUE: Frontal and cross-table lateral view radiographs of the right
knee.
COMPARISON: Comparison to radiograph from ___.
FINDINGS:
No fracture or dislocation is seen. There is significant tricompartmental
degenerative changes, including joint space narrowing most severe at the
medial compartment, as well as subchondral sclerosis and osteophytosis. There
is an enthesophyte noted at the superior pole of the patella. There is no
knee joint effusion. There is normal osseous mineralization. No suspicious
lytic or sclerotic lesions are identified.
IMPRESSION:
1. No evidence of fracture or dislocation.
2. Severe degenerative changes, as described above.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) RIGHT
INDICATION: ___ year old woman with R leg TTP after likely fall// r/o fracture
r/o fracture
TECHNIQUE: Frontal and lateral view radiographs of the right tibia and fibula
COMPARISON: Radiographs of the right knee dated ___
FINDINGS:
No fracture is detected in the tibia or fibula. No suspicious lytic lesion,
sclerotic lesion, or periosteal new bone formation is detected. No soft tissue
calcification or radio-opaque foreign bodies are detected. Severe
degenerative changes of the right knee, better evaluated on yesterday's
radiograph.
IMPRESSION:
No acute osseous injury of the right tibia or fibula.
Radiology Report
INDICATION: Shoulder pain. Closed reduction.
COMPARISON: Compared to radiographs and chest CT from ___
IMPRESSION:
Single axillary view is very limited and the glenoid is not fully seen.
Assessment for persistent anterior shoulder dislocation is suboptimal. There
are chronic degenerative changes with irregularity of the glenoid, better
assessed on the recent chest CT. If there is high concern for persistent
anterior shoulder dislocation, would recommend dedicated right shoulder CT.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain, R Shoulder pain
Diagnosed with Pain in right shoulder, Hypoxemia, Chest pain, unspecified
temperature: 97.7
heartrate: 68.0
resprate: 20.0
o2sat: 100.0
sbp: 141.0
dbp: 73.0
level of pain: 7
level of acuity: 3.0 | BRIEF HOSPITAL COURSE:
======================
Ms. ___ is a ___ year old woman with complex past medical
history most notable for COPD (FEV1 59% ___, schizoaffective
disorder, R glenohumeral osteoarthritis, and chronic pain on
opioid contract, who presented with 3 days of worsening R
shoulder pain and substernal intermittent chest pain found to
have a R anterior-inferior glenohumeral dislocation as well as
acute fractures of the right anterolateral second and third
ribs, s/p attempted closed reduction of shoulder dislocation but
ultimately thought to be chronic in nature. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
cefepime
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___ R PCN and ___ R abscess drain
___ R PCN-->PCNU replacement
___ R power midline placement
History of Present Illness:
This is a ___ year old female with
history of multiple kidney stones who underwent attempted right
PCNL and then right ureteroscopy with laser lithotripsy on
___. She had been discharged after an uncomplicated post-op
stay on a course of PO Bactrim. She developed flank pain on
___, POD#8 that worsened overnight into severe diffuse
abdominal pain prompting her to present to the ER.
Past Medical History:
-recurrent UTIs: recently admitted ___ for Proteus UTI
and again ___, and ___
She has multiple urine cultures positive for Proteus and E coli
with resistance.
-Nephrolithiasis: s/p Cystoscopy, left ureteroscopy, laser
lithotripsy, left ureteral stent placement ___.
-h/o urinary retention
-sickle cell trait, HTN
-cholecystectomy
-sCHF with LVEF 35-45%
Social History:
___
Family History:
-Mother: DM, died at age ___ from diabetes complications
-Father: CAD, heart failure, died at age ___
-Brother: colon cancer
Physical Exam:
24 HR Data (last updated ___ @ 338)
Temp: 98.5 (Tm 99.1), BP: 129/79 (124-152/57-79), HR: 63
(62-80), RR: 18, O2 sat: 98% (96-98), O2 delivery: RA
Gen: Awake, alert, NAD
Pulm: non-labored breathing, no respiratory distress
Abd: obese, soft, right flank JP drain continues with thin
purulent yellow drainage
GU: right PCNU draining clear yellow, some tenderness around
drain site without drainage
L/e: no edema.
Pertinent Results:
___ 06:05AM BLOOD WBC-11.6* RBC-3.33* Hgb-8.5* Hct-26.4*
MCV-79* MCH-25.5* MCHC-32.2 RDW-18.2* RDWSD-53.0* Plt ___
___ 06:00AM BLOOD Glucose-74 UreaN-12 Creat-1.2* Na-141
K-4.0 Cl-107 HCO3-20* AnGap-14
___ 9:15 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH
___ 8:30 am ABSCESS Source: Urinoma.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
FLUID CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
ANAEROBIC CULTURE (Final ___:
BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH.
BETA LACTAMASE POSITIVE.
___ 8:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000 CFU/mL.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 1 S
Radiology Report
INDICATION: ___ year old woman with recent ureteral stent placement.//
Evaluate for free air, ureteral stent location
COMPARISON: Abdominal CT from ___
FINDINGS:
Supine and upright views of the abdomen pelvis were provided. A right
ureteral stent is noted with the proximal coil in the expected region of the
right renal pelvis. The catheter extends inferiorly though the inferior
extent is not clearly visualized. Radiopaque stones are seen within the
kidneys. Bowel gas pattern notable for extensive fecal loading of the colon.
No free air seen below the right hemidiaphragm. Clips in the right upper
quadrant reflect prior cholecystectomy. Imaged lung bases are clear.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with recurrent nephrolithiasis and urinary
tract infections s/p recent ureteral stent placement p/w flank pain/diffuse
abdominal pain.// Evaluate for hydronephrosis, infection, free peritoneal
fluid.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Renal ultrasound dated ___
FINDINGS:
The right kidney measures 11.9 cm. There is mild to moderate hydronephrosis,
and 2 nonobstructing calculi measuring up to 1.3 and 1.6 cm are demonstrated
in the inferior pole. A poorly assessed fluid collection is demonstrated
medial and inferior to the right kidney, measuring approximately 14 x 3.3 x
4.0 cm. The left kidney measures 11.4 cm. There is mild hydronephrosis. Two
nonobstructing calculi in the lower pole measure up to 1.1 and 1.2 cm. Normal
cortical echogenicity and corticomedullary differentiation are seen
bilaterally.
Several bladder calculi are noted. These measure 1.3 cm and 0.7 cm.
IMPRESSION:
1. Moderate right and mild left hydronephrosis with nonobstructing calculi
demonstrated bilaterally.
2. Apparent fluid collection adjacent to the right kidney for which CT is
recommended to further assess.
3. Bladder stones.
Radiology Report
EXAMINATION: CT urogram
INDICATION: ___ with recent ureteral stent placement and failed PCNL p/w
severe flank pain, peritoneal signs on exam.
TECHNIQUE: CT through the abdomen pelvis performed without and with IV
contrast. Postcontrast imaging utilized a split bolus technique. No oral
contrast was administered. Coronal and sagittal reformations were performed
and reviewed on PACS.
DOSE: Total DLP (Body) = 2,567 mGy-cm.
COMPARISON: Prior CT abdomen pelvis from ___
FINDINGS:
LOWER CHEST: The imaged lung bases are clear aside from mild right basal
atelectasis in the setting of a right hemidiaphragmatic eventration. The
imaged portion of the heart is unremarkable.
ABDOMEN:
HEPATOBILIARY: Tiny hypodensities are again noted primarily within segment 7,
too small to characterize though appear unchanged. There is mild intrahepatic
biliary ductal dilation, unchanged likely reflecting prior cholecystectomy.
Main portal vein is patent. CBD appears normal in caliber.
PANCREAS: The pancreas enhances normally. No acute findings.
SPLEEN: The spleen appears intact and normal in size.
ADRENALS: A left adrenal nodule is unchanged, measuring 3.0 x 2.2 cm,
previously characterized as an adenoma. A second small nodule is seen arising
from the lateral limb, also unchanged. The right adrenal gland appears
normal.
URINARY: Left greater than right renal cortical scarring is again seen with
large stones again seen within lower pole calices. There is mild left
hydronephrosis, more conspicuous than on prior. No signs of a left ureteral
stone. There is a large right retroperitoneal fluid collection with
peripheral enhancing rim extending along the psoas inferiorly to the right
hemipelvis. This lobulated collection, concerning for an abscess, measures
approximately 21.6 cm in craniocaudal dimension. At its widest transverse
dimension, this collection measures 13.7 cm, series 3, image 53. The maximal
AP dimension is approximately 6.7 cm, series 3, image 54. This collection
also extends medially inferior to the third and fourth segments of the
duodenum. There is moderate right hydronephrosis with prominence of the right
ureter also with urothelial thickening. The possibility of a urine leak and
urinoma is difficult to exclude.
GASTROINTESTINAL: The stomach and duodenum appear grossly unremarkable. Small
bowel loops demonstrate no signs of ileus or obstruction. The appendix is
clearly visualized and is normal. The colon contains a moderate fecal load
and is without signs of inflammation or obstruction. There is no
intraperitoneal free air or free fluid.
PELVIS: The urinary bladder is markedly thickened and contains several small
stones. No definite stone is seen in the distal ureters or UVJ. There is
dilation of the right distal ureter with urothelial thickening and hyper
enhancement suggesting ureteritis. No pelvic free fluid is seen.
REPRODUCTIVE ORGANS: The uterus appears normal. The right ovary is not
clearly visualized as it abuts right pelvic sidewall collection. The left
adnexal region is normal. There is no adenopathy in the pelvis or inguinal
region.
LYMPH NODES: No definite lymphadenopathy in the abdomen or pelvis.
VASCULAR: There is no abdominal aortic aneurysm. No significant
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Degenerative changes are noted at L5-S1 with loss of disc space and prominent
posterior disc osteophyte complexes.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Large rim enhancing fluid collection in the right retroperitoneal space,
most concerning for an abscess. However, given history of recent
interventions, difficult to exclude urinoma.
2. Moderate right hydroureteronephrosis without obstructing stone. Urothelial
thickening and hyperemia likely reflects ureteritis/infection.
3. Mild left hydronephrosis without obstructing stone.
4. Additional nonemergent findings as described above.
RECOMMENDATION(S):
-Follow up abdominal radiograph or CT may be performed to assess for presence
of excreted contrast within these collections as urinoma not excluded.
-Percutaneous drainage may be considered.
NOTIFICATION: Initial findings/recommendations discussed with Dr. ___.
Radiology Report
EXAMINATION: CT abdomen/pelvis, excretory phase
INDICATION: ___ year old woman with recent ureteral stent placement now with
flank pain and peritoneal signs. CT showed abscess. Repeat CT to evaluate for
contrast moving in to the abscess.// Further evaluate intraabdominal abscess
TECHNIQUE: Excretory phase CT: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration with split
bolus technique performed approximately 50 minutes prior.Oral contrast was not
administered. Coronal and sagittal reformations were performed and reviewed
on PACS.
DOSE: Total DLP (Body) = 1,418 mGy-cm.
COMPARISON: CTU with and without contrast performed approximately 50 minutes
prior
FINDINGS:
URINARY: Bilateral renal contrast excretion is noted. However, on the right
side, contrast extravasation is noted at the level of the right ureteropelvic
junction, with contrast enhanced urine extending into the right
retroperitoneal collection detailed on prior CT. Findings are consistent with
large urinoma with probable superinfection.
Interval placement of a Foley catheter into the bladder with associated
intravesicular gas. Left greater than right renal cortical scarring, bilateral
lower pole stones, and moderate right and mild left hydronephrosis are again
seen.
OTHER: All other abdominopelvic findings are better assessed on the preceding
CTU.
IMPRESSION:
Contrast excreted by the right kidney enters a large right retroperitoneal
fluid collection, consistent with urinoma. Site of urinary tract disruption
at the right UPJ. Superinfection remains a concern.
RECOMMENDATION(S): Percutaneous drainage of collection, right nephrostomy
tube.
NOTIFICATION: Findings were discussed with ___ staff at the time of
initial review.
Radiology Report
INDICATION: ___ year old woman with infected urinoma// Urinary drainage
COMPARISON: CT Abdomen and Pelvis ___
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
150 mcg of fentanyl and 2.5 mg of midazolam throughout the total intra-service
time of 95 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: Fentanyl, Midazolam, Lidocaine
CONTRAST: 20 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 8.2 min, 263 mGy
PROCEDURE: 1. Right ultrasound guided renal collecting system access.
2. Right nephrostogram.
3. Right ___ Fr nephrostomy tube placement.
4. ___ Fr abscess catheter placement using Cone Beam CT guidance
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
prone on the exam table. A pre-procedure time-out was performed per ___
protocol. The right flank was prepped and draped in the usual sterile fashion.
After the injection of 15 cc of 1% lidocaine in the subcutaneous soft tissues,
the right renal collecting system was accessed through a posterior lower pole
calyx under ultrasound guidance using a 21 gauge Cook needle. Ultrasound
images of the access were stored on PACS. Prompt return of urine confirmed
appropriate positioning. Injection of a small amount of contrast outlined a
dilated renal collecting system. Under fluoroscopic guidance, a Nitinol wire
was advanced into the renal collecting system. After a skin ___, the needle
was exchanged for an Accustick sheath. Once the tip of the sheath was in the
collecting system; the sheath was advanced over the wire, inner dilator and
metallic stiffener. The wire and inner dilator were then removed and diluted
contrast was injected into the collecting system to confirm position. A ___
wire was advanced through the sheath and coiled in the collecting system. The
sheath was then removed and a 8 ___ nephrostomy tube was advanced into the
renal collecting system. The wire was then removed and the pigtail was formed
in the collecting system. Contrast injection confirmed appropriate
positioning. The catheter was then flushed, 0 silk stay sutures applied and
the catheter was secured with a Stat Lock device and sterile dressings. The
catheter was attached to a bag.
Then, attention was turned to the fluid collection inferior to the right
kidney, suspected of being infected urinoma. A cone beam CT was done to
delineate the anatomy. Imaging was reviewed on a separate workstation and 3D
reformats were created, overseen by Dr. ___. A needle trajectory was
planned on CT and the image detector was rotated to a bulls eye orientation.
After the injection of 15 cc of 1% lidocaine in the subcutaneous soft tissues,
a 21 G needle was advanced towards the collection. The image detector was
rotated to the orthogonal plane to monitor progression towards the target.
Prompt return of pus confirmed appropriate positioning. Injection of a small
amount of contrast outlined the fluid collection. Under fluoroscopic
guidance, a Nitinol wire was advanced into the collection. After a skin ___,
the needle was exchanged for an Accustick sheath. Once the tip of the sheath
was in the collection, the sheath was advanced over the wire, inner dilator
and metallic stiffener. The wire and inner dilator were then removed and
diluted contrast was injected into the collecting system to confirm position.
A ___ wire was advanced through the sheath and coiled in the collection.
The sheath was then removed and a 10 ___ APDL tube was advanced into the
collection. The wire was then removed and the pigtail was formed. Contrast
injection confirmed appropriate positioning. The catheter was then flushed, 0
silk stay sutures applied and the catheter was secured with a Stat Lock device
and sterile dressings. The catheter was attached to a bag. A sample of the
fluid was sent to microbiology.
FINDINGS:
1. Ultrasound demonstrating moderate right hydronephrosis.
2. Ultrasound and cone beam CT demonstrating moderate fluid collection
inferior to the right kidney, with aspiration of pus status post needle
access.
3. Appropriate position of right 8 ___ PCN tube and right 10 ___ APDL
tube in the infected fluid collection.
IMPRESSION:
1. Successful placement of 8 ___ nephrostomy on the right.
2. Successful placement of a 10 ___ APDL tube in the infected fluid
collection inferior to the right kidney.
Radiology Report
INDICATION: ___ s/p attempted right PCNL and then right ureteroscopy
with laser lithotripsy who presents with acute, severe abdominal pain,
leukocystosis with bandemia and CT findings consistent with infected
urinoma.// Assess for interval change, fluid collection, abscess
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.5 s, 48.9 cm; CTDIvol = 25.6 mGy (Body) DLP =
1,233.5 mGy-cm.
Total DLP (Body) = 1,234 mGy-cm.
COMPARISON: Multiple prior CT abdomen pelvis dated back to ___ with
the most recent CT abdomen pelvis from ___.
FINDINGS:
LOWER CHEST: Lung bases are clear.
ABDOMEN:
HEPATOBILIARY: The liver is unremarkable. The gallbladder surgically absent
PANCREAS: Unremarkable.
SPLEEN: Unremarkable.
ADRENALS: Unremarkable except for a 2.7 cm left adrenal adenoma.
URINARY: Right hydronephrosis has improved with only residual hydronephrosis
in the upper pole. There are a right percutaneous nephrostomy tube and a
right retroperitoneal drain. Mild left hydronephrosis is stable. Again seen
are unchanged bilateral renal calculi measuring up to 2.5 cm in the right
upper pole.
The superior portion of the urinoma not drained by the catheter has not
significantly changed measuring approximately 3.9 cm, previously 4 cm (series
3, image 32). Midportion of the urinoma has significantly decreased in size
measuring 6.6 cm (series 3, image 48), seen where the catheter was present.
The inferior portion of the urinoma has also decreased in size measuring 6.3
cm (series 3, image 58). No new fluid collection.
GASTROINTESTINAL: No bowel obstruction. No ascites. No free air.
PELVIS: A Foley catheter is noted. No pelvic free fluid. The uterus is
unremarkable. No adnexal mass.
LYMPH NODES: No abdominal or pelvic lymphadenopathy.
VASCULAR: No abdominal aortic aneurysm.
BONES: No suspicious osseous lesions.
SOFT TISSUES: Mild soft tissue stranding is noted along the course of the
percutaneous nephrostomy tube.
IMPRESSION:
1. Marked interval improvement of the right retroperitoneal urinoma as
detailed above.
2. Improved right and stable left hydronephrosis.
3. Bilateral nephrolithiasis.
Radiology Report
INDICATION: ___ year old woman with recent ureter stent placement now with
intra-abdominal abscess.// PCN to PCNU
COMPARISON: CT from ___
TECHNIQUE: OPERATORS: Dr. ___,
performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
75mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 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: As above
CONTRAST: 10 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 1.2 min, 3 mGy
PROCEDURE:
1. Right diagnostic antegrade nephrostogram.
2. Right 8 ___ nephrostomy exchange for PCNU.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient.The patient was then brought to the angiography suite and placed prone
on the exam table. A pre-procedure time-out was performed per ___ protocol.
The right flank was prepped and draped in the usual sterile fashion.
Diluted contrast was injected into the right nephrostomy to confirm catheter
position. The image was stored on PACS. Local anesthesia was administered with
instillation of lidocaine jelly and 1% subcutaneous lidocaine injection. The
catheter was cut. A ___ wire was advanced into the left nephrostomy tube
and advanced into the distal ureter. The stay sutures were cut and the
catheter was removed over the wire. A 6 ___ sheath was placed. Then over
___ wire Kumpe catheter was placed. Utilizing the ___ wire and
Kumpe catheter access was gained to the ureter and eventually to the bladder.
The wire was removed and injection confirmed the catheter was in the bladder.
Then, the wire was readvanced. The catheter and sheath were removed and a new
8 ___ by 24 cm PCNU tube were advanced. The pigtail was formed. The
catheter was attached to a bag for drainage. Final image was saved. StatLock
and sterile dressings were applied.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Right antegrade nephrostogram shows flow into the ureter. No definitive
disruption seen at this time. Initial tube was pulled back into a calyx.
2. Appropriate final position of Right PCNU tube.
IMPRESSION:
Technically successful Right 8 ___ PCN to PCNU conversion
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: R Flank pain
Diagnosed with Other retroperitoneal abscess
temperature: 98.1
heartrate: 112.0
resprate: 16.0
o2sat: 94.0
sbp: 146.0
dbp: 76.0
level of pain: 10
level of acuity: 3.0 | The patient was admitted to the Urology service on ___. She was
septic on admission. She was started on Zosyn. A foley was
placed and drains were placed by interventional radiology in the
urinoma and kidney for urinary drainage.
Her WBC began to downtrend and her fever curve decreased. She
was re-imaged on ___ and on ___ returned to ___ for conversion
of PCN to PCNU after which her foley was removed. Her abscess
drain was felt to be in good position so it was not manipulated.
Infectious diseases was consulted after the patient's cultures
resulted who recommended outpatient daily ertapenem
administration and repeat imaging to ensure resolution of
abscess prior to discontinuing antibiotics. A midline was placed
on ___ for outpatient antibiotic therapy.
Endocrinology was also consulted for patient's
hyperparathyroidism and non-compliance with outpatient follow up
who recommended vitamin D supplementation.
The patient was deemed stable for discharge home on ___ with
PCNU and abscess drain to bulb suction. At the time of discharge
the patient was hemodynamically stable, tolerating a regular
diet, pain was controlled on an oral pain regimen and she was at
her baseline mobility. Post-discharge restrictions, warning
signs and follow up was reviewed extensively with the patient
and all questions were answered. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Seroquel / Erythromycin Base /
Reglan
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
dophoff placement
Gtube replacement
History of Present Illness:
___ yo F with hx of eating disorder s/p G/J tube placement,
bipolar disorder, GERD, gastroparesis who presents with pain at
GJ tube site.
She was recently admitted at the end of ___ for abdominal pain.
Her GJ tube was replaced on ___. She is now here again with
abdominal pain. She says pain feels similar to prior episodes of
when here tube was malpositioned. Her pain is predominately
around the ring of the J tube for the last 24 hours. She has
minimal nausea which is her baseline. She denies diarrhea. She
had a bowel movement yesterday and has been passing gas. Prior
to yesterday she was tolerating tube feeds and minimal po
intake. She initially presented to ___ and then was
transferred here for further management. She was given dilaudid
prior to transfer.
In the ED, initial VS: 97.7 53 107/65 16 98%. A bedside
ultrasound showed no abscess. She was given IV dilaudid for pain
and subsequently admitted for pain control and evaluation of the
tube by ___. VS prior to transfer: 98.0, 106/78, 58, 18, 100%
Currently, she still has pain around her tube but improved after
medication.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, vomiting, diarrhea, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
h/o Eating disorder/laxative abuse, patient reports is in
remission and that she remains in outpatient therapy
Chronic constipation
Bipolar disorder
GERD
Gastroparesis
Social History:
___
Family History:
Pertinent for mother with breast cancer and a half sister with
type 1 diabetes and a cousin with ___ disease.
Physical Exam:
VS - Temp 98.2F, BP 89/61, HR 58, R 16, O2-sat 99% RA
GENERAL - well-appearing female in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, slightly dry MM,
OP clear
NECK - supple, no cervical lymphadenopathy, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft. tender around GJ tube site. non
distending. no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
admission labs
___ 06:06AM BLOOD WBC-10.2# RBC-4.17* Hgb-13.2 Hct-39.2
MCV-94 MCH-31.6 MCHC-33.6 RDW-12.3 Plt ___
___ 06:06AM BLOOD Neuts-69.2 ___ Monos-3.7 Eos-2.0
Baso-0.5
___ 06:06AM BLOOD ___ PTT-29.0 ___
___ 06:06AM BLOOD Glucose-93 UreaN-11 Creat-0.7 Na-141
K-3.8 Cl-107 HCO3-25 AnGap-13
.
discharge labs
___ 07:50AM BLOOD WBC-7.3 RBC-4.22 Hgb-12.7 Hct-40.5 MCV-96
MCH-30.2 MCHC-31.4 RDW-12.2 Plt ___
.
imaging
G/GJ/GI tube check:
FINDINGS: Initial scout AP view of the abdomen demonstrates
gastrojejunostomy tube coiled in the stomach. Following the
hand injection of Gastrografin through the patient's
percutaneous gastrojejunostomy tube, contrast material is noted
in the stomach as well as in the proximal duodenum. A third AP
view of the abdomen demonstrates contrast moving distally
throughout the remainder of the duodenum. There are clips noted
in the left upper quadrant. There is a nonspecific bowel gas
pattern with no evidence of obstruction.
IMPRESSION: The gastrojejunostomy tube again appears coiled in
the stomach with the tip located at the fundus of the stomach.
.
PERC G/J TUBE CHECK/REPLACE (preliminary)
-Uncomplicated exchange of old 16 ___ MIC GJ tube with a new
16 ___
G-tube, with its tip in the gastric lumen. It may be used.
-Uncomplicated placement of a ___ nasoduodenal tube
via the
left nostril, with its tip in the distal duodenum. It may be
used
Medications on Admission:
1. amphetamine-dextroamphetamine 10 mg Tablet Sig: One (1)
Tablet PO twice a day.
2. clonazepam 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. lithium citrate 8 mEq/5 mL Solution Sig: Three Hundred (300)
mg PO qAM and at 2PM.
4. lithium citrate 8 mEq/5 mL Solution Sig: Six Hundred (600) mg
PO QHS (once a day (at bedtime)).
5. calcium carbonate Oral
6. domperidone (bulk) Powder Sig: Ten (10) mg Miscellaneous
three times a day.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
8. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
9. ondansetron HCl 8 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for nausea.
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
12. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. vitamin D
Discharge Medications:
1. amphetamine-dextroamphetamine *NF* 10 mg Oral BID Reason for
Ordering: Wish to maintain preadmission medication while
hospitalized, as there is no acceptable substitute drug product
available on formulary.
2. Clonazepam 2 mg PO QHS
hold for oversedation, RR<12
3. Lithium Oral Solution 300 mg PO BID
give qAM and at 2 pm
4. Lithium Oral Solution 600 mg PO QHS
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO BID
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Thiamine 100 mg PO DAILY
10. Vitamin D 400 UNIT PO DAILY
11. traZODONE 50 mg PO HS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
primary 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: Evaluation of patient with pain at gastrojejunostomy site.
COMPARISON: Percutaneous gastrojejunostomy tube replacement on ___,
and portable abdominal radiograph from ___.
FINDINGS: Initial scout AP view of the abdomen demonstrates gastrojejunostomy
tube coiled in the stomach. Following the hand injection of Gastrografin
through the patient's percutaneous gastrojejunostomy tube, contrast material
is noted in the stomach as well as in the proximal duodenum. A third AP view
of the abdomen demonstrates contrast moving distally throughout the remainder
of the duodenum. There are clips noted in the left upper quadrant. There is
a nonspecific bowel gas pattern with no evidence of obstruction.
IMPRESSION: The gastrojejunostomy tube again appears coiled in the stomach
with the tip located at the fundus of the stomach.
Radiology Report
EXCHANGE OF INDWELLING GJ TUBE FOR A G-TUBE AND PLACEMENT OF POST-PYLORIC
NASODUODENAL TUBE.
INDICATION: ___ woman with eating disorder and gastroparesis with
existing GJ tube that is coiled within the stomach.
OPERATORS: Drs. ___ (fellow) and ___ (attending
physician). Dr. ___ was present during key moments of the procedure.
CONTRAST: Sterile 20 mL Optiray 320 in the stomach and proximal small bowel.
SEDATION: Moderate sedation with divided doses of intravenous ___ mcg
fentanyl and 2 mg Versed over 41 minutes, during which patient's hemodynamic
status was continuously monitored by a trained radiology nurse.
PROCEDURE AND FINDINGS: Consent was obtained from the patient after
explaining the benefits, risks, and alternatives. She was placed supine on
the imaging imaged in the interventional suite. Timeout was performed as per
___ protocol.
Initial scout fluoroscopic image demonstrated indwelling tube coiled in the
left upper abdomen. Under aseptic conditions, a small amount of sterile
contrast material was injected through the jejunal port of the tube, which
opacified the gastric lumen. After deflating the retention balloon, a 0.035
___ wire was advanced through the jejunal porAfter removing the wire, a
small amountt and coiled within the stomach. The old tube was removed to
place a new ___ MIC G-tube. of sterile contrast material was injected
through the port to confirm position. About 5 mL of diluted contrast was
injected to inflate the balloon, which was then apposed against the inner
gastric wall. External disc was apposed against the skin. Patient tolerated
the procedure well and no immediate post-procedure complication was seen.
A ___ tube was placed via the left nostril and advanced under
intermittent fluoroscopic guidance into the stomach. However, it was not
possible to advance it beyond the pylorus. Hence, the tube was removed over a
0.035 Glidewire. A 100-cm C1 catheter was placed, and after insufflating the
stomach with gas via the percutaneous G-tube, the catheter-wire combination
was negotiated into the distal duodenum. Catheter was then removed to place
the ___ tube. While its tip was at the level of the pylorus, it
was further advanced into the duodenum with the help of 0.035 stiff Glidewire.
Eventually, the tube tip was left in the distal duodenum. The wire was
removed. A small amount of sterile contrast material was injected to confirm
position. The tube was then secured. Patient tolerated the procedure well
and no immediate post-procedure complication was seen.
IMPRESSION:
1. Uncomplicated exchange of old 16 ___ MIC GJ tube with a new 16 ___
G-tube, with its tip in the gastric lumen. It may be used.
2. Uncomplicated placement of a ___ nasoduodenal tube via the
left nostril, with its tip in the distal duodenum. It may be used.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: PAIN AT J TUBE SITE
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, COLOSTOMY COMP NOS, EATING DISORDER NOS
temperature: 97.7
heartrate: 53.0
resprate: 16.0
o2sat: 98.0
sbp: 107.0
dbp: 65.0
level of pain: 3
level of acuity: 3.0 | ___ yo F with hx of eating disorder s/p GJ tube placement,
bipolar disorder, GERD, gastroparesis who presents with
abdominal pain found to have GJ tube coiled in her stomach.
# Abdominal Pain - most likely related to malpositioned GJ tube
as demonstrated on imaging. She was given IV narcotics in the ED
and pain was subsequently treated with with tylenol and oral
oxycodone on the floor. Given that patient has had similar
problems in the past, both ___ and surgery were consulted to
discuss alternative options. Ultimately after discussion with
the patient, ___, and surgery, the decision was made to place a
dobhoff post pyloric and exchange her GJ tube for a G tube. She
tolerated the procedure well. She was discharged with plans to
follow up with her surgeon Dr. ___ to discuss J tube
placement and with her GI physician.
# Bipolar disorder - continued home medications including
lithium, clonazepam, and amphetamine-dextroamphetamine.
# chronic constipation - docusate, senna, miralax
# GERD - continued omeprazole
Transitional Issues
- no labs pending at time of discharge
- patient will need to follow with her gastroenterologist and
her surgeon Dr. ___ to discuss J tube placement. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic cholecystectomy
History of Present Illness:
___ with IBS and pancreatic insufficiency is now presented in
the
ED for RUQ pain.
Patient reports he started noticing churning abdominal pain in
his RUQ 5 days prior to presentation, few hours after dinner.
Pain was severe that he could not sleep. It resolved a few hours
later. On ___, it recurred, and is associated with nausea,
although he reports no emesis. It lasted more than 6 hours. He
has loss of appetite. He last ate yesterday ___ and took a few
bites of pasta salad. Given RUQ, he stopped eating. Today he
decided to come to the ED for evaluation.
At the ED, he was found AVSS. WBC was remarkable at 14.8 with
left shift PMN of 82%. LFTs and lipase are normal. During RUQUS,
technician reported sonographic ___ sign. Gallbladder wall
thickening with stones and sludge while CBD normal. Surgery thus
was consulted for surgical management.
He denies fever, chills, vomiting, constipation, diarrhea,
BRBPR,
hematemesis, cough, shortness of breath, chest pain, heart
palpitation.
Past Medical History:
Past Medical History:
-IBS
-pancreatic insufficiency
Past Surgical History:
-R inguinal hernia repair, open, with mesh
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission Physical Exam:
Vitals: 99.0 108 134/89 16 100% RA
Gen: AAO3, NAD
HEENT: Normocephalic. PERRLA, EOMI. Sclerae anicteric. Hearing
grossly intact. No ear drainage. Patent nares. MMM.
NECK: Supple without lymphadenopathy.
HEART: RRR, normal S1/S2, no m/r/g
LUNGS: CTAB. No crackles/wheezes/rhonchi. No respiratory
distress.
ABDOMEN: Soft, RUQ TTP, no ___ sign in the setting of
recent pain meds, nondistended, with good bowel sounds heard. No
mass palpated. Well healed R groin hernia scar.
BACK: There is no costovertebral angle tenderness
EXTREMITIES: Without cyanosis, clubbing or edema
NEUROLOGICAL: Gross nonfocal
SKIN: Warm and dry without any rash
Discharge Physical Exam:
VS: 98.1, 99/56, 72, 18, 97 Ra
Gen: A&O x3. ambulatory.
CV: HRR
Pulm: LS ctab
Abd: soft, mildly TTP around incisions, nondistended. Lap sites
CDI, bruising around umbilical port site.
Ext: WWP no edema
Pertinent Results:
___ 05:35AM BLOOD WBC-11.5* RBC-3.92* Hgb-11.5* Hct-35.1*
MCV-90 MCH-29.3 MCHC-32.8 RDW-12.5 RDWSD-40.7 Plt ___
___ 05:27PM BLOOD WBC-11.8* RBC-4.12* Hgb-12.3* Hct-36.4*
MCV-88 MCH-29.9 MCHC-33.8 RDW-12.4 RDWSD-40.9 Plt ___
___ 05:35AM BLOOD WBC-11.4* RBC-4.49* Hgb-13.3* Hct-40.3
MCV-90 MCH-29.6 MCHC-33.0 RDW-12.5 RDWSD-41.4 Plt ___
___ 02:35PM BLOOD WBC-14.8* RBC-5.16 Hgb-15.4 Hct-45.0
MCV-87 MCH-29.8 MCHC-34.2 RDW-12.4 RDWSD-39.6 Plt ___
___ 05:35AM BLOOD Glucose-136* UreaN-13 Creat-0.9 Na-142
K-4.6 Cl-102 HCO3-27 AnGap-13
___ 05:35AM BLOOD Glucose-83 UreaN-10 Creat-0.9 Na-142
K-4.0 Cl-101 HCO3-26 AnGap-15
___ 02:35PM BLOOD Glucose-113* UreaN-10 Creat-1.0 Na-137
K-4.0 Cl-98 HCO3-24 AnGap-15
___ 05:35AM BLOOD ALT-49* AST-40 AlkPhos-68 TotBili-0.7
___ 05:35AM BLOOD ALT-24 AST-19 AlkPhos-71 TotBili-0.9
___ 02:35PM BLOOD ALT-29 AST-20 AlkPhos-68 TotBili-1.2
___ 05:35AM BLOOD Calcium-9.2 Phos-2.0* Mg-2.0
___ 05:35AM BLOOD Albumin-3.9 Calcium-9.0 Phos-1.5* Mg-2.0
___ 02:35PM BLOOD Albumin-4.5 Calcium-9.6 Phos-2.0* Mg-2.0
RUQUS: ___ sign. stones and sludge in a mildly
distended gallbladder with associated gallbladder wall
thickening. CBD 5mm.
Medications on Admission:
LIPASE-PROTEASE-AMYLASE [ZENPEP] - Zenpep 20,000 unit-68,000
unit-109,000 unit capsule,delayed release. 2 capsule(s) by mouth
with meals one with snacks
OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1
Capsule(s) by mouth daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*7 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
4. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*11 Tablet Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*3 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 packet(s) by mouth once a
day Disp #*7 Packet Refills:*0
7. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth once a day Disp #*5
Capsule Refills:*0
8. Omeprazole 20mg PO daily
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis
Urinary retention
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT
INDICATION: History: ___ with right upper quadrant pain radiating to the
back, subjective fevers, anorexia // Evaluate for acute gallbladder pathology
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Liver gallbladder ultrasound from ___.
CT urogram with and without contrast from ___
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 3 mm
GALLBLADDER: There are stones and sludge in the mildly distended gallbladder
with gallbladder wall thickening. No definite pericholecystic fluid is
identified.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Not visualized.
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 12.3 cm
Left kidney: 11.1 cm.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Stones and sludge in a mildly distended gallbladder with associated
gallbladder wall thickening, can be seen in acute cholecystitis, in the
appropriate clinical setting.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Acute cholecystitis
temperature: 99.0
heartrate: 108.0
resprate: 16.0
o2sat: 100.0
sbp: 134.0
dbp: 89.0
level of pain: 7
level of acuity: 3.0 | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal ultra-sound revealed a mildly distended
gallbladder with stones and associated gallbladder wall
thickening. The patient underwent laparoscopic cholecystectomy,
which went well without complication (reader referred to the
Operative Note for details). After a brief, uneventful stay in
the PACU, the patient arrived on the floor tolerating sips, on
IV fluids, and oral analgesia for pain control. The patient was
hemodynamically stable. He was placed on 4 days of antibiotics
for intra-op gallbladder content spillage.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
experienced urinary retention POD0 and was started on tamsulosin
with good effect. By POD1, he was voiding without problem.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay.
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: MEDICINE
Allergies:
Reclast / Fosamax
Attending: ___.
Chief Complaint:
Eye burning and blurriness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ yo woman with PMH of temporal arteritis on
steroids and DM2 who is transferred to the ___ ED with concern
for temporal arteritis flare.
Patient was recently admitted to ___ from ___t home. Workup was unrevealing aside from
hyponatremia which was corrected with IVF's and she was
discharged to ___ rehab on ___. There, she has continued
to be very weak with poor excercise tolerance. ESR was noted to
be 75, well above her normal baseline. Prednisone was
empirically increased to 20mg from 10mg with some initial
improvement of subjective symptoms. However, over the past week
she has experienced progressive burning sensation in her eyes,
right worse than left, initially associated with mild
conjuctival erythema and discharge. She was started on
erythromycin opthalmic ointment without improvement, followed by
lubricating opthalmic ointment without benefit. Over the past
___, she noted worsening vision in her right eye. Her
primary rheumatologist Dr. ___ ___ was consulted and
recommended urgent opthamologic evaluation in the setting of
known giant cell arteritis and she was transferred to ___ for
further evaluation.
In the ED intial vitals were T 97.7, HR 95, BP 148/45, RR 16, O2
100%. Initial labs were notable for Na of 125, CRP 80.4, ESR 63,
and HCT 29.9 with plt 576. Remainder of Chem7 and CBC were
unremarkable. Opthalmology was consulted who recommended
admission with rheum consult for IV steroids. IOP was 10 and
visual acuity was documented at L Eye = ___ Eye = ___ Both
= ___. Patient was then admitted to medicine for further
management.
On the floor, patient reports bilateral eye burning and
blurriness as above. She denies any headache. She also denies
recent fevers or chills. No CP or SOB. No nausea, vomiting or
diarrhea. She does note poor appetite and constipation x4 days.
No new rashes or joint pains. Remainder of ROS is unremarkable.
Past Medical History:
-HLD
-Nephrolithiasis
-Migraine
-Pseudphakia
-Vitreous degeneration
-Macular degeneration
-Blepharatis
-Ptosis
-GERD
-Hiatal hernia
-Basal cell carcinoma
-Actinic Keratoses
-DM2
-BPV
-PMR
-HTN
-Temporal arteritis
-Osteoporosis
-Iron def anemia
-Adrenal insuffeciency
Social History:
___
Family History:
No known history of autoimmune disease.
Physical Exam:
=============================
ADMISSION PHYSICAL EXAM:
=============================
Vitals- 98.4 165/63 99 16 100%RA
General- Alert, pleasant, orientedx4, no acute distress
HEENT- Sclera anicteric, dry MM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Nonlabored on RA. Slightly decreased BS at right lung
base.
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext- warm, well perfused, no edema
Neuro- AAOx4, CNs2-12 intact, moving all extremities equally
.
.
=============================
OPHTHALMOLOGIC EXAM:
=============================
EXAMINATION
Visual Acuity;
OD (sc): ___ cc near chart
OS (sc): ___ cc near chart
Mental status: Alert and oriented x 3
Pupils (mm) PERRL
Relative afferent pupillary defect: [ X ] none [ ] present
OD: 3mm --> 2mm
OS: 3mm --> 2mm
Extraocular motility: Full ___
Visual fields by confrontation: Full to counting fingers ___
Color Vision (___ pseudo-isochromatic plates):
OD: ___
OS: ___
Intraocular pressure (mm Hg):
OD: 10.3
OS: 10.3
External Exam: [ X] NL
No V1 or V2 hypesthesia
Orbital rim palpation: No point-tenderness, deformities, and
step-offs ___
Anterior Segment (Penlight or portable slitlamp)
Lids/Lashes/Lacrimal:
OD: Normal
OS: Normal
Conjunctiva:
OD: White and quiet
OS: White and quiet
Cornea:
OD: Clear, no epithelial defects
OS: Clear, no epithelial defects
Anterior Chamber:
OD: Deep and quiet
OS: Deep and quiet
___:
OD: Flat
OS: Flat
Lens:
OD: PCIOL trace PCO
OS: PCIOL trace PCO
Fundus (Indirect Ophthalmoscopy using 20D lens): Dilation
approved by patient
PLEASE NOTE, PUPILS WILL REMAIN DILATED FOR AT LEAST ___ HRS
Media/Vitreous:
OD: Clear
OS: Clear
Discs:
OD: pink, sharp margins
OS: pink, sharp margins
Maculae:
OD: multiple soft ___
OS: multiple soft ___
Periphery
OD: PRP laser scars
OS: PRP laser scars
.
.
=============================
DISCHARGE PHYSICAL EXAM:
=============================
Vitals- 97.9 142/46 95 16 99/RA
General- Alert, pleasant, orientedx3, no acute distress ,
somewhat tearful when talking about her family
HEENT- Sclera anicteric, dry MM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Nonlabored on RA. Slightly decreased BS at right lung
base.
CV- Regular rhythm, tachycardic. normal S1 + S2, no murmurs,
rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext- warm, well perfused, no edema
Neuro- CNs2-12 grossly intact, moving all extremities equally.
Bilateral upper extremity tremors
Pertinent Results:
=============================
ADMISSION LABS:
=============================
___ 08:30PM BLOOD WBC-8.2 RBC-3.47* Hgb-9.3* Hct-29.8*
MCV-86 MCH-26.9* MCHC-31.3 RDW-13.3 Plt ___
___ 08:30PM BLOOD Neuts-70.3* ___ Monos-5.7 Eos-0.7
Baso-0.4
___ 08:30PM BLOOD ___ PTT-26.5 ___
___ 08:30PM BLOOD ESR-63*
___ 08:30PM BLOOD Glucose-184* UreaN-18 Creat-0.6 Na-125*
K-4.6 Cl-90* HCO3-25 AnGap-15
___ 08:30PM BLOOD LD(LDH)-137 TotBili-0.2
___ 08:30PM BLOOD Iron-17*
___ 08:30PM BLOOD CRP-80.4*
.
=============================
DISCHARGE LABS:
=============================
___ 07:00AM BLOOD WBC-8.8 RBC-3.72* Hgb-10.0* Hct-32.0*
MCV-86 MCH-27.0 MCHC-31.4 RDW-13.3 Plt ___
___ 07:00AM BLOOD Glucose-169* UreaN-26* Creat-0.8 Na-133
K-4.5 Cl-98 HCO3-24 AnGap-16
___ 07:00AM BLOOD Calcium-9.0 Phos-2.3* Mg-2.2
___ 07:00AM BLOOD CRP-34.0*
.
=============================
IMAGING:
=============================
CT HEAD W/O CONTRAST Study Date of ___ 10:24 ___
FINDINGS: There is no acute hemorrhage, edema, mass, mass
effect, or acute large vascular territorial infarction. The
ventricles and sulci are prominent which suggest normal
age-related involutional changes. There are periventricular
white matter hypodensities consistent with the sequela of
chronic small vessel ischemic disease. The basal cisterns are
patent, and there is preservation of gray-white matter
differentiation.
No fracture is identified. The paranasal sinuses and mastoid
air cells are clear. The globes are unremarkable.
IMPRESSION: No acute intracranial process.
.
.
=============================
URINE:
=============================
___ 10:20PM URINE Color-Yellow Appear-Clear Sp ___
___ 10:20PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 10:20PM URINE RBC-6* WBC-15* Bacteri-FEW Yeast-NONE
Epi-<1
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE XL 2.5 mg PO DAILY
2. Sodium Chloride 1 gm PO BID
3. Docusate Sodium 100 mg PO BID
4. Vitamin D 1000 UNIT PO DAILY
5. Denosumab (Prolia) Dose is Unknown SC Frequency is Unknown
6. Ocuvite with Lutein (vit A,C & E-lutein-minerals) 1,000
unit-200 mg-60 unit-2 mg oral daily
7. PredniSONE 20 mg PO DAILY
8. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
9. krill oil ___ ___ unknown
10. Omeprazole 20 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Bisacodyl ___AILY:PRN constipation
13. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES BID
14. Fleet Enema ___AILY:PRN constipation
Discharge Medications:
1. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone [Mepron] 750 mg/5 mL 10 ml by mouth daily Disp
#*3000 Milliliter Refills:*0
2. PredniSONE 50 mg PO DAILY
RX *prednisone 50 mg 1 tablet(s) by mouth daily Disp #*28 Tablet
Refills:*0
3. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
4. Docusate Sodium 100 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO BID
7. Sodium Chloride 1 gm PO BID
8. Vitamin D 1000 UNIT PO DAILY
9. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*0
10. Bisacodyl ___AILY:PRN constipation
11. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES BID
12. Fleet Enema ___AILY:PRN constipation
13. GlipiZIDE XL 2.5 mg PO DAILY
14. Ocuvite with Lutein (vit A,C & E-lutein-minerals) 1,000
unit-200 mg-60 unit-2 mg oral daily
15. krill oil 0 unknown ORAL Frequency is Unknown
16. Denosumab (Prolia) 60 mg SC ASDIR
17. Outpatient Lab Work
On ___: please draw CRP, ESR, Na, K, Cl, HCO3, BUN, Cr, Glu
and fax results to Dr. ___ at ___
ICD 9 Codes: Giant cell arteritis 446.5, Hyponatremia 276.1
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary diagnosis:
- Temporal arteritis
Secondary diagnoses:
- Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CLINICAL INDICATION: Blurred vision for one week.
TECHNIQUE: Multidetector CT scan through the head without the administration
of IV contrast. Coronal and sagittal reformatted images were obtained.
DLP: 1025.72 mGy-cm.
CTDI VOLUME: 58.79 mGy.
FINDINGS: There is no acute hemorrhage, edema, mass, mass effect, or acute
large vascular territorial infarction. The ventricles and sulci are prominent
which suggest normal age-related involutional changes. There are
periventricular white matter hypodensities consistent with the sequela of
chronic small vessel ischemic disease. The basal cisterns are patent, and
there is preservation of gray-white matter differentiation.
No fracture is identified. The paranasal sinuses and mastoid air cells are
clear. The globes are unremarkable.
IMPRESSION: No acute intracranial process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABNORMAL LABS
Diagnosed with GIANT CELL ARTERITIS, VISUAL DISTURBANCES NEC
temperature: 97.7
heartrate: 95.0
resprate: 16.0
o2sat: 100.0
sbp: 148.0
dbp: 45.0
level of pain: 0
level of acuity: 2.0 | =============================
PRIMARY REASON FOR ADMISSION
=============================
___ yo F with a history of biopsy-proven giant cell arteritis
admitted with elevated inflammatory markers and bilateral blurry
vision concerning for flare of arteritis.
.
=============================
ACTIVE ISSUES
=============================
#) Temporal arteritis: The patient presented with elevated
inflammatory markers (CRP 80.4, ESR 63 on admission) and blurry
vision concerning for GCA flare. She had not improved as an
outpatient even after an empiric increase in prednisone from 10
to 20mg. She received one dose of 1g solumedrol and was
evaluated by both Opthalmology and Rheumatology. After
recieiving the solumedrol pulse, her symptoms subjectively began
to improve. Because the opthalamologic exam did not find
anterior ischemic neuropathy on funduscopic examination,
Rheumatology recommended a four week course of prednisone 50mg.
She will need inflammatory markers checked q2-3 days until a
steady downtrend is noted (discharge labs:CRP 34).
.
#) Hyponatremia: The patient has had hyponatremia noted at her
ECF, with Na in the 125-130 range that improves with IV saline.
Admission Na was 125 that improved to 133 with small NS boluses,
her home salt tabs, and improved po intake.
.
#) Anemia: She has a history of iron deficiency anemia with
likely component of chronic inflammation. Normocytic during this
admission with stable blood counts.
.
=============================
TRANSITIONAL ISSUES
=============================
- Will need inflammatory markers checked q2-3 days until
downtrending
- She should have Ophthalmologic evaluation to monitor dry
AMD/diabetic retinopathy
- She should continue on prednisone 50mg x 4 weeks with
atovaquone prophylaxis
- Code status: DNR/DNI |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nucynta / Hydromet
Attending: ___
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o woman with PMH notable for NASH
cirrhosis c/b recurrent admissions for HE and grade 2 varices
s/p banding, GAVE s/p APC in ___, HFpEF, HTN, and T2DM,
presenting with 3 days of worsening weakness.
Per both patient and her husband at bedside, Ms. ___ has
been quite weak for sometime now with her chronic medical
problems, namely cirrhosis. However, about 3 days ago, her
husband noted that she was unable to get up, even with
assistance. She began endorsing pain in her bilateral upper
thighs long the lateral aspects and almost fell multiple times,
including on day of admission due to her weakness. Her husband
comments that she may be a little more confused than usual, but
has been making about 3 BM's per day. She has been taking her
home rifaximin and lactulose as instructed.
Otherwise, the patient was sick with a cold about 2 weeks ago,
which has resolved. She denies any infectious symptoms of
fevers, chills, lingering cough, N/V, abdominal pain, rash, or
dysuria/urinary frequency. Her husband does note that her UTI's
in the past have been asymptomatic. She also denies any
hematochezia, but states that he stool is always dark with iron.
Recent medication changes include decrease in her dose of Lasix
from 20mg to 10mg PO daily and spironolactone from 50mg to 25mg
PO daily about 2 weeks PTA, at instruction of outpatient
hepatologist (Dr. ___. She does feel that her legs are
swollen, most from her ongoing pyoderma gangrenosum and that her
abdomen is slightly more swollen than usual. Denies any
shortness of breath or orthopnea.
At baseline, she is essentially non-ambulatory, sitting in a
sofa most of the day and not walking. This is attributed to
chronic fatigue and weakness from her liver disease and chronic
pain in her lower extremities due to PG. With regards to mental
status, the patient's husband feels that she may be slightly
more confused than usual, but they presented to the ED mostly
due to worsening of her weakness.
In the ED, initial VS were: 98.7 60 163/55 17 99% RA
Exam was notable for:
-No asterixis
-B/l ___ weakness, unable to lift up against gravity
-___ strength to upper extremities for muscle bulk, intact
cerebellar and sensory function grossly
-rectal exam showed guaiac+ dark mucous in vault without frank
melena
Hepatology was consulted and recommended RUQ ultrasound,
Hepatitis A, B, and C serologies, CK, 50g of 25% albumin,
lactulose q4h, rifaximin 550 bid, and ___ admission.
Work-up was notable for:
-Hemolyzed blood sample with K 4.7, Bicarb 14 (without AG),
BUN/Cr 35/0.8 (baseline Cr 0.9-1), CK 7758, AST 742, ALT 742, AP
364, Lipase 190, Albumin 3
-Hepatitis serologies pending
-Hgb 12, Plt 129
-lactate 1.2
-U/A showing moderate leuks, large blood, negative nitrites, 100
protein, 4 RBC, 17 WBC, few bacteria, albeit with ___ yeast
-Ucx and Blood cx x2 sent (pending)
Imaging showed:
-CXR with no acute cardiopulmonary processes but interval
vertebral body ehigh loss at level of T12
-Liver/Gallbladder U/S showing hepatic cirrhosis without focal
lesion and patient vasculature without cholelithitasis or acute
cholecystitis
Patient was given:
-500cc IVF
-50g of 25% albumin
-Ceftriaxone 1g IV x1
-Lactulose 30mg PO x1
On transfer, patient's vitals were 98.2 149/77 78 18 95RA.
On the floor, she reports the same history as above and is
without acute complaint, endorsing the same b/l leg weakness and
pain as well as leg pain overlying sites of pyoderma
gangrenosum.
Past Medical History:
- ___ cirrhosis complicated by hepatic encephalopathy and
grade 2 varices s/p banding
- HFpEF (LVEF 65%)
- Celiac disease
- Hypertension
- Diabetes mellitus type II complicated by neuropathy
- Hyperlipidemia
- Pyoderma gangrinosum
- Lumbar spondylosis
- History of compression fracture
- History of bladder surgery
- Cough-variant asthma
Social History:
___
Family History:
No history of liver disease
Physical Exam:
ADMISSION PHYSICAL EXAM
=================
VITALS: 98.2 149/77 78 18 95RA
General: chronically ill appearing, malnourished
HEENT: temporal wasting appreciated; no scleral icterus; EOMI,
PERRL, MMM, tongue midline on protrusion, no appreciable tongue
fasciculations
Neck: symmetric, supple, brisk carotid upstrokes; no bruits
appreciated b/l; JVP appears to be about 8cm with prominent
carotid pulsations
CV: RRR with ___ mid-systolic murmur, no appreciable radiation
to carotids or axilla; no r/g
Lungs: CTAB with initial crackles that clear with repeated
inspiration; no r/w
Abdomen: Soft, mildly distended, mild TTP over RUQ with negative
___ sign; no r/g;
GU: no foley
Ext: thin, warm well perfused; 1+ pitting edema up to thighs b/l
with +erythema and increased warmth surrounding b/l anterior
shins, which are bandaged over sites of PG (c/d/I); tenderness
to palpation over b/l lateral thighs from hips to knees without
tenderness appreciated in hip joints; distal pulses intact
Neuro: alert and appropriately interactive on exam; ___ strength
in b/l UE; no asterixis appreciated; on strength exam, unable to
lift b/l ___ up against gravity; sensation intact and symmetric
throughout
Skin: b/l PG wounds c/d/i
DISCHARGE PHYSICAL EXAM
=================
Vitals: 99.1 127/49 75 18 95%RA
General: NAD, malnourished
HEENT: temporal wasting appreciated; no scleral icterus; EOMI,
PERRL, MMM, tongue midline on protrusion, no appreciable tongue
fasciculations
Neck: symmetric, supple, brisk carotid upstrokes; no bruits
appreciated b/l; JVP appears to be about 8cm with prominent
carotid pulsations
CV: RRR with ___ mid-systolic murmur, no appreciable radiation
to carotids or axilla; no r/g
Lungs: CTAB, no r/w
Abdomen: Soft, mildly distended, NT
GU: no foley
Ext: thin, warm well perfused; 1+ pitting edema up to thighs b/l
with +erythema and increased warmth surrounding b/l anterior
shins, which are bandaged over sites of PG (c/d/I); tenderness
to palpation over b/l lateral thighs from hips to knees without
tenderness appreciated in hip joints; distal pulses intact
Neuro: alert and appropriately interactive on exam; ___ strength
in b/l UE; no asterixis appreciated; on strength exam, lower
extremities ___ in hip flexion, knee flexion, extension,
dorsiflexion and plantar flexion; sensation intact and symmetric
throughout
Skin: b/l PG wounds c/d/I bandaged with mild erythema but not
spreading
Pertinent Results:
ADMISSION LABS
===========
___ 11:45AM BLOOD WBC-7.9 RBC-3.34* Hgb-12.0 Hct-35.2
MCV-105* MCH-35.9* MCHC-34.1 RDW-17.3* RDWSD-66.0* Plt ___
___ 11:45AM BLOOD Neuts-68.7 Lymphs-12.6* Monos-12.9
Eos-4.3 Baso-0.9 Im ___ AbsNeut-5.45# AbsLymp-1.00*
AbsMono-1.02* AbsEos-0.34 AbsBaso-0.07
___ 11:45AM BLOOD ___ PTT-28.7 ___
___ 11:45AM BLOOD Glucose-125* UreaN-35* Creat-0.8 Na-139
K-4.7 Cl-112* HCO3-14* AnGap-18
___ 11:45AM BLOOD ALT-542* AST-742* CK(CPK)-7758*
AlkPhos-364* TotBili-0.9
___ 11:45AM BLOOD Albumin-3.0* Calcium-10.2 Phos-2.2*
Mg-2.0
NOTABLE LABS
=========
___ 06:40AM BLOOD Glucose-61* UreaN-22* Creat-0.6 Na-141
K-4.4 Cl-112* HCO3-18* AnGap-15
___ 06:43AM BLOOD ALT-319* AST-386* CK(CPK)-2207*
AlkPhos-285* TotBili-0.9
___ 06:40AM BLOOD ALT-301* AST-342* CK(CPK)-1856*
AlkPhos-276* TotBili-1.2
___ 07:04AM BLOOD WBC-5.8 RBC-2.53* Hgb-9.1* Hct-26.7*
MCV-106* MCH-36.0* MCHC-34.1 RDW-17.6* RDWSD-67.9* Plt ___
___ 07:04AM BLOOD Glucose-66* UreaN-31* Creat-0.8 Na-149*
K-4.5 Cl-122* HCO3-12* AnGap-21*
___ 09:25PM BLOOD ALT-356* AST-481* LD(___)-353*
CK(CPK)-3634* AlkPhos-249* TotBili-0.8
___ 07:04AM BLOOD ALT-333* AST-435* LD(LDH)-334*
CK(CPK)-2580* AlkPhos-248* TotBili-0.9
___ 11:45AM BLOOD HBsAg-Negative HBsAb-Negative HAV
Ab-Positive IgM HBc-Negative
___ 09:25PM BLOOD CRP-10.5*
___ 11:45AM BLOOD HCV Ab-Negative
___ 12:07PM BLOOD Lactate-1.2
___ 09:25PM BLOOD SED RATE-31
MICROBIOLOGY
==========
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 CFU/mL.
CIPROFLOXACIN SUSCEPTIBILITY REQUESTED BY ___ ___
(___) @ 1420
ON ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
CIPROFLOXACIN--------- =>8 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 64 I
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ =>32 R
IMAGING
======
___ CXR
No acute cardiopulmonary process.
Interval vertebral body height loss at T12 since ___, to
be correlated
with physical exam as acuity cannot be determined.
___ ABD ULTRASOUND
1. Hepatic cirrhosis without focal lesion. Patent hepatic
vasculature.
2. Cholelithiasis without evidence for acute cholecystitis.
DISCHARGE LABS
==========
___ 05:38AM BLOOD WBC-8.7 RBC-2.58* Hgb-9.6* Hct-26.9*
MCV-104* MCH-37.2* MCHC-35.7 RDW-17.9* RDWSD-66.8* Plt ___
___ 05:38AM BLOOD ___ PTT-89.2* ___
___ 05:38AM BLOOD Glucose-50* UreaN-33* Creat-0.8 Na-140
K-4.3 Cl-110* HCO3-17* AnGap-17
___ 05:38AM BLOOD ALT-196* AST-156* CK(CPK)-124
AlkPhos-280* TotBili-1.1
___ 05:38AM BLOOD Calcium-10.3 Phos-3.3 Mg-1.8
___ 09:25PM BLOOD CRP-10.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 10 mg PO DAILY
2. Spironolactone 25 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Omeprazole 20 mg PO DAILY
5. Nadolol 20 mg PO DAILY
6. Sertraline 50 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Vitamin D ___ UNIT PO DAILY
10. Gabapentin 200 mg PO QHS
11. Alendronate Sodium 70 mg PO QWED
12. Rifaximin 550 mg PO BID
13. Lactulose 30 mL PO TID
14. Glargine 24 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
15. Lidocaine 5% Ointment 1 Appl TP QID:PRN pain
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO DAILY Duration: 7 Days
End date ___
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth Daily Disp
#*7 Tablet Refills:*0
2. Alendronate Sodium 70 mg PO QWED
3. Aspirin 81 mg PO DAILY
4. Furosemide 10 mg PO DAILY
5. Gabapentin 200 mg PO QHS
6. Glargine 24 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Lactulose 30 mL PO TID
8. Lidocaine 5% Ointment 1 Appl TP QID:PRN pain
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Nadolol 20 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Rifaximin 550 mg PO BID
13. Sertraline 50 mg PO DAILY
14. Spironolactone 25 mg PO DAILY
15. Vitamin D ___ UNIT PO DAILY
16. HELD- Atorvastatin 40 mg PO QPM This medication was held.
Do not restart Atorvastatin until you talk to your doctor and
your blood enzymes return to normal
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Rhabdomyolysis
Urinary tract infection
Toxic metabolic encephalopathy
Hepatic encephalopathy
Secondary
Chronic diastolic heart failure
Diabetes mellitus
Pyoderma gangrenosusm
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 altered mental status // Pneumonia
TECHNIQUE: AP and lateral views of the chest.
COMPARISON: ___ chest x-ray and ___ torso CT.
FINDINGS:
The lungs are clear without consolidation, effusion, or edema. Cardiac
silhouette is mildly enlarged, unchanged. When compared to ___,
there is interval height loss T12.
IMPRESSION:
No acute cardiopulmonary process.
Interval vertebral body height loss at T12 since ___, to be correlated
with physical exam as acuity cannot be determined.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with elevated transaminase, altered mental status // Please
eval with dopplers, ? portal vein thrombosis, cholecystitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdominal ultrasound dated ___.
FINDINGS:
LIVER: The hepatic parenchyma appears coarsened. The contour of the liver is
nodular, consistent with cirrhosis. There is no focal liver mass. The main
portal vein is patent with hepatopetal flow. There is no ascites. Hepatic
arteries and hepatic veins are all patent.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm.
GALLBLADDER: Cholelithiasis without gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 7.8 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis. Right
kidney measures 10.9 cm in sagittal dimension.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Hepatic cirrhosis without focal lesion. Patent hepatic vasculature.
2. Cholelithiasis without evidence for acute cholecystitis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness, Confusion, Presyncope
Diagnosed with Hepatic failure, unspecified without coma, Urinary tract infection, site not specified, Altered mental status, unspecified
temperature: 98.7
heartrate: 60.0
resprate: 17.0
o2sat: 99.0
sbp: 163.0
dbp: 55.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ y/o woman with a PMH notable for NASH
cirrhosis c/b recurrent HE, GAVE s/p APC, PG, and brittle T2DM,
presenting with acute onset b/l ___ weakness and pain (in
proximal distribution) in setting of chronic weakness and labs
notable for transaminitis and CK >7000 and UTI now with CK and
LFT downtrending after fluid resuscitation. It is likely she
developed rhabdomyelisis in the setting of acute confusion
caused by the UTI. With volume resuscitation and treatment of
the UTI, her symptoms improved.
#Rhabdomyolysis, weakness: The patient's elevated CK >7000 on
admission. AST and ALT elevation are likely in [large] part due
to rhabdo as well. Likely etiology of immobility at home in
setting of acute confusion due to UTI. Drug-mediated causes also
possible including atorvastatin as potential trigger and statin
was held. No crush injuries or compartment syndrome suspected
based on history or exam. Inflammatory etiology investigated but
inflammatory makers low-normal at CRP 10.5, ESR 31 not
suggestive of PMR. She was given 500cc NS, 50g 25% albumin, and
total 50g 5% albumin during her hospital course in increments of
12.5g. CK trended down with level at discharge 124. Physical
therapy evaluated the patient and recommended rehab.
#UTI: Patient has positive blood and WBCs on U/A. History of UTI
and three days of confusion coming in may be reflection of
infection. She received 1 dose of Ceftriaxone in ED empirically.
Urine culture grew mixed bacterial flora. History of Klebsiella
oxytoca infection in ___ sensitive only to cipro, ___,
zosyn. E. coli resistant to cipro noted in ___. She was started
on ciprofloxacin 500mg Q12H on ___ with planned 7 day course;
however urine cultures came back as Enterococcus with multiple
resistances (Including cipro) and sensitive to doxycycline. We
therefore started doxycycline 100mg daily for 7 days (end date
___
#Transaminitis: Attributed to rhabdo with normal bilirubin with
labs remaining at baseline synthetic hepatic function would
suggest non-liver etiology.
#Metabolic and hepatic encephalopathy: Likely secondary to UTI
and reduced bowel movements prior to admission. Improved with
fluid resuscitation, continuing lactulose and rifaximin, and
treatment of UTI. She was at baseline on HD #2.
#NASH cirrhosis: History of NASH cirrhosis c/b HE and GE varices
and GAVE s/p APC in ___. Appears compensated at this time.
She was continue on home PPI, nadolol, nutritional supplements.
#HFpEF: Currently euvolemic appearing. ___ edema is likely due to
local inflammation and slight hypoalbuminemia.
-holding diuretic as above, I/s/o potential rhabdo. Furosemide
and spironolactone held with plan to restart at discharge.
#Celiac disease: gluten-free diet
#Hypertension: Held diuretics and continued home nadolol.
#T2 Diabetes mellitus complicated by neuropathy: She was
continued on home lantus, ISS, gabapentin.
#HLP: holding home statin in the setting of transaminitis and
elevated CK
#Pyoderma gangrenosum/Venous stasis uclers: Per recent
outpatient notes, patient is not on any oral therapy and is
recently s/p 10 day course of PO Keflex for ___ cellulitis.
She was given local wound care without signs of worsening or
cellulitis.
#Iron deficiency anemia: per patient she has anemia at baseline,
treated with PO iron.
#Depression: continued home sertraline
TRANSITIONAL ISSUES
==============
#NEW MEDICATIONS
- Doxycycline
#CHANGED MEDICATIONS
- None
#HELD MEDICATIONS
- Atorvastatin was STOPPED
[] Restart diuretics on discharge (held for elevated CK and
elevated LFT during admission)
[] Reassess if a lower dose of a statin or different lipid
lowering regimen as CK and LFT improve
[] Dermatology follow up for lower extremity ulcers is scheduled
for ___
[] Urogynecology follow up is scheduled for ___
#CODE: Full (confirmed with patient and husband)
#CONTACT: Husband - ___ ___
#DISCHARGE WEIGHT - 121 Pounds |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
elevated LFTS
Major Surgical or Invasive Procedure:
ERCP ___
Port ___
History of Present Illness:
Mr. ___ is a ___ male with recent
diagnosis of metastatic colon cancer who presents for elevated
LFTs.
Patient established care with Oncologist Dr. ___ at ___ on
___. Labs were notable for ALT 235, AST 190, ALP 1304, Tbili
14.6 (Dbili 8.8) as well as Na 130, WBC 9.5, H/H 12.8/37.5, and
Plt 426. He was called by his Oncologist due to concern for
biliary obstruction and instructed to present to the ___ ED.
He reports increasing pruritus and worsening rectal pain over
the
last 2 weeks. He also notes left testicular pain. He notes
worsening yellowing of the skin over past several days. He has
been taking oxycodone for the pain which has helped some. He
denies any fever, abdominal pain, and nausea/vomiting.
On arrival to the ED, initial vitals were 97.8 ___ 16
100% RA. Labs were notable for WBC 10.9, H/H 12.5/35.6, Plt 419,
Na 129, K 3.4, BUN/CR ___, INR 1.2, ALT 261, AST 252, ALP
1687,
Tbili 15.8, lipase 11, lactate 1.4, and UA negative. Patient had
RUQ US which showed scattered mild intrahepatic biliary
dilatation likely due to malignant obstruction secondary to
hepatic metastatic masses. ERCP was consulted and recommended
obtaining MRCP. Patient was given dilaudid 1mg IV x 3 and 1L NS.
Prior to transfer vitals were 98.8 102 163/90 18 97% RA.
On arrival to the floor, patient reports ___ rectal and left
testicular pain. He notes occasional shortness of breath. He
denies fevers/chills, night sweats, headache, vision changes,
dizziness/lightheadedness, weakness/numbness, cough, hemoptysis,
chest pain, palpitations, nausea/vomiting, diarrhea,
hematemesis,
dysuria, hematuria, and new rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
PAST ONCOLOGIC HISTORY:
Patient evaluated by PCP ___ ___ for symptoms including months
of passing mucousy stools streaked with blood. Also 6 months of
constipation for which he took laxatives with improvement. He
changed his diet and began to eat more fruits and vegetables and
then he began to move his bowels more easily. He developed
rectal
pain and was seen by an MD in ___ who sent him to a
colorectal surgeon at ___ who did a banding procedure about 1
month ago. He has lost 40 lbs in 6 months. He underwent CT torso
which showed innumerable pulmonary and hepatic nodules and
masses, worrisome for metastases, abdominal and pelvic
lymphadenopathy and probable left sacral metastases, and long
segment of thickened sigmoid with luminal narrowing, correlate
with colonoscopy. He underwent FNA of the supraclavicular node
which showed metastatic colorectal adenocarcinoma. On ___,
PET CT scan at ___ confirmed extensive metastatic cancer:
Colon
cancer with multiple sites of metabolically active metastatic
disease as described above involving pulmonary nodules, liver
lesions, left adrenal gland lesion, osseous lesions,
retroperitoneal lymph nodes, inguinal lymph nodes, bilateral
hilar lymph nodes, a left paratracheal lymph node, and a left
supraclavicular lymph node
Past Medical History:
- Asthma
- Hemorrhoids s/p homorrhoidectomy
- s/p right ankle surgery
Social History:
___
Family History:
Father with CAD/PVD in his father and cancer.
Physical Exam:
===ADMISSION PHYSICAL EXAM===
VS: Temp 99.3, BP 194/121, HR 102, RR 18, O2 sat 96% RA.
GENERAL: Pleasant man, appears in pain.
HEENT: Icteric scerae, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, normal bowel sounds.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
===DISCHARGE PHYSICAL EXAM===
VS: 98.8 157/100 98 18 96 RA
GENERAL: Pleasant man, appears in pain.
HEENT: Icteric scerae, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: CTAB
ABD: Soft, non-tender, non-distended, normal bowel sounds.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, no focal deficits
Pertinent Results:
===ADMISSION LABS===
___ 04:40PM BLOOD WBC-10.9* RBC-4.42* Hgb-12.5* Hct-35.6*
MCV-81* MCH-28.3 MCHC-35.1 RDW-16.4* RDWSD-47.0* Plt ___
___ 05:07PM BLOOD ___ PTT-33.7 ___
___ 04:40PM BLOOD Plt ___
___ 04:40PM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-129*
K-3.4 Cl-88* HCO3-26 AnGap-18
___ 04:40PM BLOOD ALT-261* AST-252* AlkPhos-1687*
TotBili-15.8* DirBili-12.4* IndBili-3.4
___ 04:40PM BLOOD Albumin-3.4* Calcium-10.4* Phos-3.8
Mg-2.0
===DISCHARGE LABS===
___ 07:10AM BLOOD WBC-13.0* RBC-4.21* Hgb-11.5* Hct-33.1*
MCV-79* MCH-27.3 MCHC-34.7 RDW-17.9* RDWSD-50.3* Plt ___
___ 07:10AM BLOOD Glucose-104* UreaN-7 Creat-0.7 Na-131*
K-3.5 Cl-92* HCO3-26 AnGap-17
___ 07:10AM BLOOD ALT-223* AST-212* LD(LDH)-1242*
AlkPhos-1537* TotBili-11.6*
___ 07:10AM BLOOD Calcium-9.7 Phos-3.4 Mg-2.1
===MICRO===
___ URINE URINE CULTURE-FINAL
===RADIOLOGY===
___ MRCP
1. Re-demonstration of metastatic disease involving the lungs
and liver, with retroperitoneal lymphadenopathy.
2. Extensive hepatic metastases with almost complete replacement
of the left hepatic lobe. There is severe attenuation of the
left hepatic vein and the left portal vein is not visualized.
3. The right anterior and right posterior branches of the right
hepatic duct are each obstructed by the metastatic disease at
the hilum. Additionally, extensive metastases in the left
hepatic lobe causes multiple regions of peripheral segmental
bile duct dilatation.
___ ruq us
1. Segmental intrahepatic biliary ductal dilation due to
malignant
obstruction.
2. Scattered masses are once again seen throughout the hepatic
parenchyma
consistent with known metastasis
3. Gallbladder wall is thickened and edematous which is likely
secondary to
liver disease. There is no evidence of acute cholecystitis. CBD
is within
normal limits.
___ ERCP
Limited exam of the esophagus was normal
Limited exam of the stomach was normal
Limited exam of the duodenum was normal
The scout film was normal.
The major papilla appeared normal.
The CBD was successfully cannulated with the Hydratome
sphincterotome preloaded with a 0.035in guidewire.
The guidewire was advanced into the right IHD.
Contrast injection revealed a CBD of approximately 6mm in
diameter and a tight malignant appearing 1 cm stricture at the
level of the bifurcation involving the proximal right IHD.
The left IHD system was not opacified.
A sphincterotomy was successfully performed at the 12 o'clock
position.
No post sphincterotomy bleeding was noted.
A 8mm X 80mm uncovered WallFlex metal stent (REF ___
___ was successfully placed across the stricture.
There was excellent drainage of bile and contrast at the end of
the procedure.
The PD was cannulated but not injected.
Otherwise normal ercp to third part of the duodenum.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
2. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*15 Tablet
Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*5 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Fentanyl Patch 37 mcg/h TD Q72H
RX *fentanyl 37.5 mcg/hour apply 1 patch to skin every 72 hours
Disp #*5 Patch Refills:*0
5. Lactulose 15 mL PO DAILY:PRN constipation
RX *lactulose 10 gram/15 mL (15 mL) 15 ml by mouth daily prn:
constipation Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN constpation
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*30 Packet Refills:*0
7. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*28 Tablet Refills:*0
8. Multivitamins 1 TAB PO DAILY
9. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
malignant biliary obstruction
Secondary Diagnoses:
cancer-related pain
metastatic colon cancer
hyponatremia
anemia
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 jaundice// assess for mass effect/biliary obstruction
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: PET-CT ___
FINDINGS:
LIVER: The hepatic parenchyma demonstrates scattered masses consistent with
known metastatic disease. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is scattered mild intrahepatic biliary dilatation likely due
to malignant obstruction in the setting of extensive metastatic disease. The
CBD is within normal limits measuring 3 mm.
GALLBLADDER: The gallbladder wall thickening edematous which is likely
secondary to liver disease. There is no evidence of acute cholecystitis.
IMPRESSION:
1. Segmental intrahepatic biliary ductal dilation due to malignant
obstruction.
2. Scattered masses are once again seen throughout the hepatic parenchyma
consistent with known metastasis
3. Gallbladder wall is thickened and edematous which is likely secondary to
liver disease. There is no evidence of acute cholecystitis. CBD is within
normal limits.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old man with metastatic colon cancer to the liver with
elevated bilirubin and RUQ US concerning for biliary obstruction. Evaluate for
biliary obstruction for possible ERCP.// Evaluate for biliary obstruction for
possible ERCP.
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 7 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: Ultrasound dated ___ and PET-CT from ___.
FINDINGS:
Lower Thorax: The visualized lung bases demonstrate multiple nodules
bilaterally, in keeping with metastatic disease.
Liver: Innumerable hepatic metastases are seen in the liver. The left hepatic
lobe is almost completely replaced by metastatic disease. Multiple metastases
in the right hepatic lobe are seen, the largest at the dome measuring 4.8 x
4.1 cm (17:109). At the hepatic hilum, there is mass effect on the portal
vein causing severe attenuation (16:65). The left portal vein is not
visualized and presumably thrombosed. The right and middle hepatic veins are
patent. The left hepatic vein is severely attenuated secondary to extensive
tumor in the left hepatic lobe.
Biliary: Both the anterior and posterior branches of the right hepatic duct
are obstructed by the metastatic disease at the hepatic hilum. Additionally,
there are multiple regions of peripheral segmental bile duct dilatation in the
left hepatic lobe secondary to extensive metastatic disease. The central left
hepatic and common hepatic ducts are not seen, presumably involved by tumor.
The CBD is not obstructed.
The gallbladder demonstrates diffuse wall thickening measuring up to 9 mm,
likely secondary to the diffuse hepatic disease.
Pancreas: Unremarkable.
Spleen: Unremarkable.
Adrenal Glands: The right adrenal gland is unremarkable. The previously noted
left adrenal nodule is not well visualized.
Kidneys: The kidneys are unremarkable aside for small right hepatic cyst.
Gastrointestinal Tract: No bowel obstruction. Small amount of ascites.
Lymph Nodes: Retroperitoneal adenopathy is again noted, the largest measuring
1.6 cm in the left para-aortic region (05:34)
Vasculature: There is a retroaortic left renal vein.
Osseous and Soft Tissue Structures: The patient's known osseous metastatic
disease are not imaged.
IMPRESSION:
1. Re-demonstration of metastatic disease involving the lungs and liver, with
retroperitoneal lymphadenopathy.
2. Extensive hepatic metastases with almost complete replacement of the left
hepatic lobe. There is severe attenuation of the left hepatic vein and the
left portal vein is not visualized.
3. The right anterior and right posterior branches of the right hepatic duct
are each obstructed by the metastatic disease at the hilum. Additionally,
extensive metastases in the left hepatic lobe causes multiple regions of
peripheral segmental bile duct dilatation.
Radiology Report
INDICATION: ___ year old man with colon ca// please place single chest port
for chemo thanks ___
COMPARISON: None
TECHNIQUE: OPERATORS: Dr. ___,
performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
50 mcg of fentanyl and 2 mg of midazolam throughout the total intra-service
time of 30 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 and Versed for moderate sedation as above, 1% local
lidocaine, 1% lidocaine with epinephrine,
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 0.4 min, 1 mGy
PROCEDURE
1. Right internal jugular approach chest single 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 right 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 single 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 ___
prolene 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 right internal jugular vein. Final fluoroscopic image showing port with
catheter tip terminating in the right atrium.
IMPRESSION:
Successful placement of a single lumen chest power Port-a-cath via the right
internal jugular venous approach. The tip of the catheter terminates in the
right atrium. The catheter is ready for use.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abnormal labs
Diagnosed with Nonspec elev of levels of transamns & lactic acid dehydrgnse
temperature: 97.8
heartrate: 105.0
resprate: 16.0
o2sat: 100.0
sbp: 163.0
dbp: 111.0
level of pain: 9
level of acuity: 3.0 | Mr. ___ is a ___ male with recent
diagnosis of metastatic colon cancer who presents for elevated
LFTs.
# Malignant Biliary Obstruction: Significantly elevated ALP and
bilirubin consistent with obstructive pattern. Also likely
component of extensive replacement of liver parenchyma by
metastatic disease. RUQ US showed scattered mild intrahepatic
biliary dilatation. MRCP with malignant obstruction, ERCP ___
with sphinterotomy and metal stent placed across a tight
malignant appearing 1 cm stricture at the level of the
bifurcation involving the proximal right IHD, with excellent
drainage of bile and contrast at the end of the procedure.
Patient received adequate post-ERCP hydration, and diet was
advanced as tolerated. Patient was started on ciprofloxacin
500mg BID x 5 days (___)
# Rectal Pain:
# Cancer-Related Pain: Rectal pain secondary to localized
disease. Continued oxycodone as well as IV dilaudid PRN. Patient
was started on a fentanyl patch, as patient was reluctant to
uptitrate PO medications, and pain was poorly controlled. Pain
was better controlled with this new regimen, and he was
discharged with rx for fentanyl patch as well as bowel meds prn.
# Metastatic Colon Cancer: Metastatic to liver, lung, left
adrenal gland, bone, and lymph nodes. Plan to start FOLFIRI.
Port placement ___.
# Hyponatremia: Likely hypovolemic, improved with IVF.
# Anemia: Likely secondary to colon cancer. Remained stable
during admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Biaxin / Lorabid
/ Levaquin / clindamycin / metoprolol / Beta-Blockers
(Beta-Adrenergic Blocking Agts) / carbamazepine /
Prochlorperazine / Tequin / Allopurinol / Wasp Venom / metformin
/ Crestor / Actos / Uloric / probenecid / spironolactone /
eplerenone
Attending: ___.
Chief Complaint:
fatigue, weakness and DOE
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a very pleasant ___ year old woman with a history
of treatment resistant HTN and Type II DM c/b stage IIIb CKD and
numerous medication allergies who presented to ED with fatigue,
weakness, lightheadedness found to have new mild ___.
Ms. ___ reports that over the past several weeks she has
noticed increased fatigue, lethargy and poor appetite. She
reports that she has nothing particularly to pinpoint as to a
cause but has felt just run down. She reports that she has not
been eating or drinking normally. She notes no new medications.
In this setting she has started to feel very shaky and
tremulous. She reports that on the day prior to presentation,
she fell on to her knees and struggled to get up from bed. This
AM she went to walk her poodle (___) and felt shaky and
unable to walk him. She called her PCP/HCP who told her to go to
the ER.
In the ED, initial vitals: 09:17 0 97.7 90 159/66 20 96% RA
Exam was notable for well appearing woman, with clear lungs and
no lower extremity edema. Labs were significant for Na 127,
BUN/Cr of 103/2.6 (baseline 1.6), AG 19, and HCO3 19. Tnt 0.06
and MB: 15, proBNP: 1109. UA was bland. Imaging showed CXR
without PNA or pulmonary edema. EKG showed NSR with RAD
In the ED, she received no treatment
Decision was made to admit for management of ___.
Vitals prior to transfer: 80 120/49 14 94% RA
On the floor, she reports that she is feeling well. She does not
currently feel shakey. She is hopeful we will determine cause of
___.
She reports that she has 5lbs in 5 days. Patient states that
walking makes her feel short of breath. Denies any chest pain.
No fevers or chills. Denies any abdominal pain, nausea, vomiting
or urinary symptoms. No orthopnea. Denies any lotion or
swelling. No recent travel or pleurisy. No history of DVT/PE.
Past Medical History:
- Resistant Hypertension
- Type II Diabetes Mellitus
- CKD, stage IIIb
- Gout
- Bipolar disorder
- Anxiety
- Chronic Rhinitis
- Hypothyroidism
Social History:
___
Family History:
Significant for father with diabetes and mother with colon
cancer and lung cancer.
Physical Exam:
ADMISSION EXAM:
VS: 99.2 PO 162 / 74 L Lying 88 16 93 RA
WEIGHT: 194lbs from 195.7kg (___)
GEN: Well appearing, hair buzzed, Atraumatic
HEENT: MMM
NECK: JVP not appreciable at 90 degrees
PULM: CTAB, no rales
COR: RRR, normal S1, preserved S2. II/VI holosytolic EM at ___
ABD: Soft, NT, ND. No CVAT
EXTREM: WWP. No ___ edema
NEURO: ___. Oriented x3
PSYCH: very upbeat, exuberant.
DISCHARGE EXAM:
VS: 98.2 ___ 144/80 (142-200/74-100) 18 93RA
GEN: Well appearing, hair buzzed, Atraumatic
HEENT: MMM
NECK: JVP not appreciable at 90 degrees
PULM: CTAB, no rales
COR: RRR, normal S1, preserved S2. II/VI holosytolic EM at ___
ABD: Soft, NT, ND. No CVAT
EXTREM: WWP. No ___ edema
NEURO: ___. Oriented x3
PSYCH: very upbeat, exuberant, somewhat pressured speech.
LABS: reviewed, see below
Pertinent Results:
ADMISSION LABS:
___ 09:30AM BLOOD WBC-8.1 RBC-3.27* Hgb-10.4* Hct-30.3*
MCV-93 MCH-31.8 MCHC-34.3 RDW-14.7 RDWSD-50.0* Plt ___
___ 09:30AM BLOOD Neuts-65.1 Lymphs-14.1* Monos-10.0
Eos-8.9* Baso-1.7* Im ___ AbsNeut-5.27 AbsLymp-1.14*
AbsMono-0.81* AbsEos-0.72* AbsBaso-0.14*
___ 09:30AM BLOOD ___ PTT-46.2* ___
___ 09:30AM BLOOD Glucose-103* UreaN-72* Creat-2.6*#
Na-127* K-5.1 Cl-89* HCO3-19* AnGap-24*
___ 06:40AM BLOOD ALT-35 AST-58* LD(LDH)-240 AlkPhos-172*
TotBili-0.5
___ 09:30AM BLOOD CK(CPK)-546*
___ 09:30AM BLOOD CK-MB-15* MB Indx-2.7 proBNP-1109*
___ 09:30AM BLOOD cTropnT-0.06*
___ 06:40AM BLOOD Albumin-3.8 Calcium-8.9 Phos-4.2 Mg-2.0
___ 09:30AM BLOOD Valproa-27*
PERTINENT LABS:
___ 05:30AM BLOOD calTIBC-365 VitB12-1135* Folate-12
Ferritn-88 TRF-281
___ 09:30AM BLOOD Osmolal-292
___ 09:30AM BLOOD TSH-5.2*
___ 06:40AM BLOOD Free T4-1.4
___ 09:30AM BLOOD Valproa-27*
DISCHARGE LABS:
___ 05:47AM BLOOD WBC-6.1 RBC-3.08* Hgb-9.7* Hct-28.5*
MCV-93 MCH-31.5 MCHC-34.0 RDW-15.2 RDWSD-50.4* Plt ___
___ 05:47AM BLOOD Glucose-100 UreaN-40* Creat-1.5* Na-137
K-4.1 Cl-98 HCO3-24 AnGap-19
___ 05:47AM BLOOD Calcium-8.9 Phos-4.4 Mg-2.0
MICRO:
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
CHEST PA+LAT ___
PA and lateral views of the chest provided. Minimal lower lung
atelectasis
noted. No convincing evidence for pneumonia. No effusion, or
pneumothorax.
The cardiomediastinal silhouette is normal. Imaged osseous
structures are
intact. No free air below the right hemidiaphragm is seen.
IMPRESSION: No signs of pneumonia or edema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
2. Lisinopril 80 mg PO DAILY
3. Divalproex (DELayed Release) 125 mg PO BID
4. Colchicine 0.6 mg PO BID
5. HYDROcodone Compound (hydrocodone-homatropine) 15 mg oral
TID:PRN
6. Ketoconazole 2% 1 Appl TP BID
7. Clorazepate Dipotassium 3.75 mg PO DAILY
8. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY
9. LORazepam 0.5 mg PO Q6H:PRN ativan
10. Diltiazem Extended-Release 240 mg PO DAILY
11. CloNIDine 0.1 mg PO BID
12. Fluticasone Propionate NASAL 2 SPRY NU DAILY
13. Minoxidil 2.5 mg PO BID
14. Pravastatin 40 mg PO QPM
15. Ethacrynic Acid 50 mg PO BID
16. Aspirin 81 mg PO DAILY
17. Levothyroxine Sodium 88 mcg PO DAILY
18. Nortriptyline 10 mg PO BID
19. Calcitriol 0.25 mcg PO EVERY OTHER DAY
20. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Divalproex (DELayed Release) 250 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO EVERY OTHER DAY
4. CloNIDine 0.1 mg PO BID
5. Clorazepate Dipotassium 3.75 mg PO DAILY
6. Colchicine 0.6 mg PO BID
7. Diltiazem Extended-Release 240 mg PO DAILY
8. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
9. Ethacrynic Acid 50 mg PO BID
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. HYDROcodone Compound (hydrocodone-homatropine) 15 mg oral
TID:PRN
12. Ketoconazole 2% 1 Appl TP BID
13. Levothyroxine Sodium 88 mcg PO DAILY
14. Lisinopril 40 mg PO DAILY
15. LORazepam 0.5 mg PO Q6H:PRN ativan
16. Minoxidil 2.5 mg PO BID
17. Nortriptyline 10 mg PO BID
18. Pravastatin 40 mg PO QPM
19. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
acute on chronic kidney failure
SECONDARY DIAGNOSIS
bipolar disorder
anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with sob, ESRD // eval for DOE, pulm edema
COMPARISON: None
FINDINGS:
PA and lateral views of the chest provided. Minimal lower lung atelectasis
noted. No convincing evidence for pneumonia. No effusion, or pneumothorax.
The cardiomediastinal silhouette is normal. Imaged osseous structures are
intact. No free air below the right hemidiaphragm is seen.
IMPRESSION:
No signs of pneumonia or edema.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea on exertion
Diagnosed with Acute kidney failure, unspecified
temperature: 97.7
heartrate: 90.0
resprate: 20.0
o2sat: 96.0
sbp: 159.0
dbp: 66.0
level of pain: 0
level of acuity: 2.0 | ___ year old woman with a history of HTN and Type II DM, c/b
stage IIIb CKD (f/b Dr. ___ who presented to ED with
fatigue, weakness and DOE, found to have new mild ___.
ACTIVE ISSUES:
===============
# Acute Kidney Injury on CKD:
Found to have new acute on chronic kidney disease w/ cr 2.6
(baseline 1.6) in setting of several weeks of poor PO intake and
prescyncopal symptoms. Urine lytes showed that she was partially
sodium avid and had relatively low urine osm, consistent w/
prerenal ___ in setting of baseline poor renal dilutional
ability with CKD. Initially held lisinopril and ethacrynic acid.
Resolved with IVF, and these meds were resumed. continued home
calcitriol 0.25 mcg PO EVERY OTHER DAY and Vitamin D 1000 UNIT
PO DAILY.
# Hyponatremia: Likely hypovolemic hyponatremia, resolved with
IVF administration.
# Anemia: Noted to have anemia on presentation w/ hgb 10.5 down
from 11.4 ___. Iron studies showed no iron deficiency, normal
B12/folate levels. Low retic index. Concern for anemia of
chronic disease in setting of CKD versus nutritional
deficiencies given recent dieting. remained stable.
# Concern for malnutrition: patient reported chronic intentional
weight loss, increasing fatigue, poor recent PO intake, and was
found to have significant anemia without evidence of iron, B12,
or folate deficiency and with evidence of mildly inadequate bone
marrow response. She reported eating very little, particularly
restricting her consumption of protein due to combination of
factors, including being too busy, trying to lose weight, and
having various dietary restrictions for diabetes, CKD, gout, and
hypertension. As a result, she may have an element of protein
malnutrition, possibly protein-calorie malnutrition. She
tolerated good PO while inpatient, and she was advised not to
restrict her calories or her protein as much as she had been,
and to follow-up with a nutritionist after discharge from rehab.
#Bipolar Disorder: Concern for bipolar decompensation leading to
poor self care, limited PO intake and ___ as above, presentation
consistent with hypomania, likely bipolar disorder II. Psych was
consulted, and after discussion with outpatient psychiatrist,
home depakote dose was increase to 250mg BID. ___ and OT were
consulted and recommended short term rehab stay prior to
returning home. The psychiatry team recommended close follow-up
with her primary psychiatrist for ongoing medication
optimization.
# EKG with RAD and QRS prolongation: no clear RBBB morphology.
Given ___ and TCA (Nortriptyline), c/f for possible sodium
channel blocker toxicity. Repeat EKG was stable and similar in
appearance to prior. Notritptyline was resumed.
CHRONIC ISSUES:
===============
# Resistant Hypertension: Treatment apprears to be limited by
numerous medication allergies. Continued home minoxidil,
diltizaem, ethacrynic acid and lisinopril. Per patient, has been
on high dose of lisinopril 80mg daily for many years. Decreased
dose to 40mg daily given ___ on presentation and concern for
poor PO intake. Hypertensive on day of discharge to systolic
170s. No adjustments were made, but BP should be monitored on
discharge.
# Type II Diabetes Mellitus: held metformin while inpatient,
managed w/ ISS as needed. Blood sugars remained in normal range,
only requiring insulin administration once. Given CKD and
improved sugars, as well as report of poor PO intake prior to
admission, we discussed with the patient and it was decided to
hold metformin on d/c.
# Gout: held colchicine initially for renal function, resumed on
d/c.
# Chronic Rhinitis: Fluticasone Propionate NASAL 2 SPRY NU DAILY
# Hypothyroidism: continued Levothyroxine Sodium 88 mcg PO
DAILY. Given malaise, checked TSH on admission, very mildly
elevated at 5.2 although difficult to interpret in setting of
acute illness. No changes were made to levothyroxine dosing.
Can repeat in several weeks to determine if levothyroxine dose
needs to be adjusted.
# Primary Prevention: continued Pravastatin 40 mg PO QPM,
Aspirin 81mg daily.
TRANSITIONAL ISSUES:
- increased Depakote to 250mg BID. Needs close psych f/u on
discharge. Please have someone check on her mood next week to
assess for response.
- recommend outpatient nutrition counseling given anemia,
concerns regarding low protein diet
- Noted to have borderline elevated TSH at 5.2. Should repeat
outpatient when not acutely ill, may need levothyroxine adjusted
- metformin was held on d/c given normal blood sugars,
borderline renal function. Post prandial blood sugars should be
monitored as she may require therapy with meal time insulin or
alternative agent for mild hyperglycemia.
- decreased lisinopril dosing to 40mg daily. If persistently
hypertensive, recommend uptitrating clonidine rather than
lisinopril
- continued home colchicine 0.6 mg BID, but renal function
should be monitored and dose adjusted if necessary
CODE STATUS: Full
CONTACT: ___ (PCP and HCP)
Phone: ___
Other Phone: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Codeine
Attending: ___.
Chief Complaint:
left index finger numbness, tingling, and discoloration
Major Surgical or Invasive Procedure:
___ angioplasty and stent of the left brachial artery
History of Present Illness:
___ w/ h/o upper extremity thromboembolism, including R
subclavian thrombosis s/p angioplasty and stenting in ___ and L
subclavian ___ in ___, now p/w dusky Left index
finger over the past few days. Patient reports that she has
noticed duskiness and coolness of her left index finger, as well
some numbness and tingling throughout the entire hand over the
past three days. She denies any motor weakness or dysfunction.
Past Medical History:
PMH: thromboembolic syndrome, Hep C, HLD, HTN, morbid obesity,
hypothyroidism, bipolar disease, anxiety, chronic knee pain,
migraines, vit D deficiency
PSH: R subclavian stenting, right axillary artery angioplasty
___ ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
GEN: NAD
HEENT: NC/AT, EOMI
Pulm: no increased work of breathing, nonlabored respirations
CV: RRR
Abd: soft, nontender, nondistended
Ext: bilateral upper extremities with palpable radial pulses,
bilateral dopplerable DPs, fingers non-cyanotic, sensorimotor
intact
Pertinent Results:
Admission labs:
___ 04:47PM WBC-12.5* RBC-4.24 HGB-6.9* HCT-25.6* MCV-60*
MCH-16.3* MCHC-27.0* RDW-20.0* RDWSD-42.9
___ 04:47PM GLUCOSE-105* UREA N-13 CREAT-0.7 SODIUM-137
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-26 ANION GAP-12
___ 10:06PM LACTATE-1.6
___ 04:47PM ___ PTT-36.5 ___
LUE CTA ___:
IMPRESSION:
1. Acute thrombus in the left distal subclavian artery extending
to the left axillary artery over a 2.7 cm segment with distal
reconstitution of flow and patent distal arteries.
2. Prominent left axillary lymph nodes are noted, likely
reactive.
Medications on Admission:
AMMONIUM LACTATE PRN
atorvastatin 80 mg tablet'
clonazepam 2 mg tablet''' prn
clonidine HCl 0.1 mg tablet''
Vitamin D2 50,000 unit capsule weekly
gabapentin 800 mg tablet'''
levothyroxine 200 mcg tablet'
methadone 92 mg daily
nystatin 100,000 unit/gram topical cream prn
oxycodone 5 mg tablet prn
paroxetine 40 mg tablet'
Xarelto 20 mg tablet'
verapamil ER (___) 100 mg capsule'
aspirin 81 mg tablet'
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Cilostazol 100 mg PO BID
RX *cilostazol 100 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
4. Verapamil 20 mg PO Q8H
We decreased the dose of this medication due to your low blood
pressure. Follow up with your PCP
5. Atorvastatin 80 mg PO QPM
6. ClonazePAM 2 mg PO TID:PRN anxiety
7. CloNIDine 0.1 mg PO BID
8. Gabapentin 800 mg PO TID
9. Levothyroxine Sodium 200 mcg PO DAILY
10. Methadone 90 mg PO DAILY
11. PARoxetine 40 mg PO DAILY
12. Rivaroxaban 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left subclavian thromboembolism
Left lower extremity rest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA left upper extremity
INDICATION: ___ year old woman with decreased radial and ulnar pulses in the
left wrist and with a cyanotic left index finger.// Evaluate for clot or
arterial injury
TECHNIQUE: Multidetector CT axial images were obtained of the left upper
extremity with the arm in race position within without contrast as well as
delayed phase imaging in the distal left upper extremity with coronal and
sagittal MIP reconstructions.
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.2 s, 79.5 cm; CTDIvol = 2.3 mGy (Body) DLP = 180.5
mGy-cm.
2) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 12.2 mGy (Body) DLP =
6.1 mGy-cm.
3) Spiral Acquisition 9.9 s, 77.6 cm; CTDIvol = 5.4 mGy (Body) DLP = 416.3
mGy-cm.
4) Spiral Acquisition 5.5 s, 43.4 cm; CTDIvol = 3.3 mGy (Body) DLP = 143.4
mGy-cm.
Total DLP (Body) = 746 mGy-cm.
COMPARISON: None.
FINDINGS:
VASCULATURE:
There is an acute thrombus in the left distal subclavian artery extending into
the left axillary artery measuring up to 2.7 cm and length with distal
reconstitution of flow. No significant atherosclerotic disease (602; 19).
The brachial artery, deep artery of the arm, and radial and ulnar arteries are
patent without evidence of occlusion or stenosis.
A stent is noted in the proximal right subclavian artery which appears patent.
An IV catheter is noted in the left aspect of the wrist.
MUSCLES AND SOFT TISSUES:
No fatty atrophy. No significant soft tissue stranding.
BONES: No acute fracture or dislocation. No joint effusion is noted in the
left elbow or glenohumeral joint. Mild degenerative changes are noted in the
left glenohumeral joint. No suspicious osseous lesions are identified.
VISUALIZED CHEST: Visualized bilateral lungs appear clear. Prominent left
axillary lymph node measures up to 0.9 cm in short axis (4; 20). No
supraclavicular lymphadenopathy visualized. Prominent AP window lymph node
measures 9 mm in short axis (4; 20).
VISUALIZED HEAD AND NECK: The thyroid is atrophic. Mild-to-moderate
atherosclerotic calcifications are noted in the bilateral carotid bifurcation,
right greater than left. Visualized paranasal sinuses and left mastoid air
cells are clear. No abnormalities were noted in the visualized portions of
the head.
IMPRESSION:
1. Acute thrombus in the left distal subclavian artery extending to the left
axillary artery over a 2.7 cm segment with distal reconstitution of flow and
patent distal arteries.
2. Prominent left axillary lymph nodes are noted, likely reactive.
NOTIFICATION: The findings were discussed with Dr. ___. by ___,
M.D. on the telephone on ___ at 7:24 pm, 5 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: ART EXT (REST ONLY)
CLINICAL HISTORY ___ year old woman with ___ h/o subclavian thromboembolism
s/p R subclavian stent and L subclavian ___ p/w 3 days cyanotic L
index finger, decreased radial/ulnar signals, now with LLE pain// evaluate LLE
vessel runoff evaluate LLE vessel runoff
FINDINGS:
Doppler waveform analysis reveals monophasic waveforms throughout bilateral
lower extremities. Resting ABIs are 0.9 on the right and 0.7 on the left.
Toe pressures are 50 on the right and 17 on the left.
Pulse volume recordings demonstrate somewhat dampened waveforms in the thigh
bilaterally. On the right there is appropriate calf augmentation and minimal
further dampening below this. On the left there is further dampening at the
calf level and a nearly flat trace at the ankle and metatarsal.
IMPRESSION:
Bilateral multilevel arterial occlusive disease worse on the left than the
right.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: CYANOTIC FINGER
Diagnosed with Anemia, unspecified
temperature: 98.2
heartrate: 90.0
resprate: 17.0
o2sat: 100.0
sbp: 90.0
dbp: 67.0
level of pain: 8
level of acuity: 2.0 | Ms ___ was admitted to the Vascular surgery service with
left hand and finger numbness and tingling. CTA of the upper
extremity showed acute thrombus in the L SCA extending to the
left axillary artery. She was started on a heparin drip and
pain management. She also had complained of LLE pain at rest,
for which LLE ABI/PVR studies were obtained. These revealed
monophasic signals in the legs with L toe pressure of 17. She
was continued on the heparin drip and then taken to the OR on
___ for an angiogram and axillary artery stent. Please see
the operative note for details. At the end of the procedure,
the radial artery pulse was palpable. The heparin drip was
then resumed. She was maintained on a heparin drip for POD 1,
Plavix was started and the left radial artery was once again
palpable. On POD 2, xarelto was restarted, the heparin drip was
stopped, and the patient was started on cilostazol. At the time
of discharge, the patient was tolerating a diet, her pain was
well controlled, she had palpable radial pulses bilaterally, and
was able to ambulate. She will follow up with Dr. ___ in
clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
ankle pain
Major Surgical or Invasive Procedure:
ORIF right ankle fracture
History of Present Illness:
___ ___ with no known medical history presents
from assisted living s/p unwitnessed fall. She is unsure of
events, but was found seated on floor. She has been unable to
ambulate since the fall. She has no numbness or tingling, no
additional complaints.
Past Medical History:
none ___)
Social History:
___
Family History:
noncontributory
Physical Exam:
Exam on Discharge
VS: afebrile, BP 150/65, HR 80
Gen: Well appearing in no acute distress
PULM: Unlabored breathing
CV: RRR
Focused exam of RLE: Splint in place, clean, dry, and intact
fires ___. Right lower extremity SILT sural, saphenous,
superficial peroneal, deep peroneal. Right lower extremity
dorsalis pedis pulse 2+ with distal digits warm and well
perfused. Large fungating mass at posterior aspect of right leg
wrapped in ABD with ace
Pertinent Results:
___ 06:40AM BLOOD WBC-9.3 RBC-4.57 Hgb-12.5 Hct-39.4 MCV-86
MCH-27.4 MCHC-31.7* RDW-14.2 RDWSD-44.3 Plt ___
___ 04:40PM BLOOD ___ PTT-23.2* ___
___ 06:15AM BLOOD Glucose-123* UreaN-10 Creat-0.5 Na-139
K-3.7 Cl-100 HCO3-27 AnGap-16
___ 06:15AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.6
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp
#*40 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp
#*20 Tablet Refills:*0
3. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*28 Syringe
Refills:*0
4. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ to 1 tablet(s) by mouth every 6 hours
Disp #*50 Tablet Refills:*0
5. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp
#*20 Tablet Refills:*0
6. Vitamin D 400 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right bimal ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with R ankle pain s/p fall // eval for fracture/deformity
COMPARISON: None
FINDINGS:
AP, lateral, oblique views of the right ankle were provided. There is a
trimalleolar fracture with subluxation at the right ankle. An oblique
fracture through the distal fibula is present with laterally displaced distal
fracture fragment. The medial malleolar fracture appears slightly inferiorly
displaced. A tibial plafond fracture is also present. Soft tissue gas is
noted concerning for an open injury. A fracture is also noted along the
tibial plafond to.
IMPRESSION:
Trimalleolar fracture of the right ankle with associated subluxation.
Radiology Report
EXAMINATION: CHEST (PRE-OP AP AND LAT)
INDICATION: ___ with bad ankle fx, pre-op and ?chest wall injury// eval for
rib frx, structural process
COMPARISON: None
FINDINGS:
AP upright and lateral views of the chest provided. Lung volumes are quite
low limiting assessment. There is left basal opacity which could represent
atelectasis versus pneumonia. Hilar congestion is noted with mild
interstitial pulmonary edema. Heart size cannot be assessed. Mediastinal
contour is prominent likely due to technique. No large pneumothorax. No
acute bony injury.
IMPRESSION:
Limited study with mild pulmonary edema and left basal opacity concerning for
atelectasis versus pneumonia.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) LEFT
INDICATION: ___ with L tib/fib pain, evaluate for fracture
TECHNIQUE: Frontal and lateral radiographs of the left tibia and fibula.
COMPARISON: None.
FINDINGS:
No fracture is detected in the tibia or fibula. No suspicious lytic, sclerotic
lesion, or periosteal new bone formation is detected. Scattered vascular
calcifications are noted. Limited assessment of the left knee and ankle joint
is unremarkable.
IMPRESSION:
No fracture.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: History: ___ with R ankle fractures, s/p reduction // ? improved
alignmnet
TECHNIQUE: Three views of the right ankle
COMPARISON: ___ at 13:40
FINDINGS:
Overlying splint/cast obscures fine bony detail. Trimalleolar fracture is
seen in improved process that alignment. The medial ankle mortise does not
appear widened however, there is persistent widening of the anterior
tibiotalar joint.
IMPRESSION:
Overall interval improvement in alignment of multiple ankle fractures.
Persistent widening of the anterior tibiotalar joint.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT IN O.R.
INDICATION: ORIF RIGHT ANKLE
TECHNIQUE: 12 spot fluoroscopic images obtained in the OR without radiologist
present.
Radiation: 29.1 seconds fluoroscopy time
COMPARISON: Right ankle radiographs ___
FINDINGS:
The available images show steps related to open reduction internal fixation of
the bimalleolar fractures. 2 percutaneous pins, fully threaded screw of
cerclage wire transfix the medial malleolus fracture. A lateral fracture
plate with proximal and distal transfixing screws, a lag screw and a
syndesmotic screw are seen laterally. The ankle mortise appears congruent.
Please see the operative report for further details.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, R Ankle pain
Diagnosed with FX BIMALLEOLAR-OPEN, UNSPECIFIED FALL
temperature: 98.9
heartrate: 92.0
resprate: 18.0
o2sat: 93.0
sbp: 151.0
dbp: 89.0
level of pain: 5
level of acuity: 3.0 | Hospitalization Summary
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right bimalleolar ankle fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for open reduction and internal
fixation of this ankle fracture. She also underwent a surgical
biopsy of the large fungating mass at the posterior aspect of
her leg, which the patient tolerated well. For full details of
the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient opted to not know the
result of the mass biopsy as it was in conflict with her
religious views. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touchdown weight bearing in the right lower extremity, and will
be discharged on lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
egg
Attending: ___
Chief Complaint:
Nausea, abdominal pain, poor PO tolerance
Major Surgical or Invasive Procedure:
EGD on ___
Duodenal Stent Placement ___
Liver Biopsy ___
History of Present Illness:
___ year old patient with chronic back pain on opiate meds, HTN,
h/o of a SBO s/p surgery in ___, presents with nausea and
vomiting and abdominal pain.
Patient has had symptoms of intermittent nausea, vomiting, and
abdominal beginning in ___ of this year. Also reports 20 lb
weight loss in past month. In this setting, patient had an EGD
done 2 weeks ago with Dr. ___ with Core ___ in
___. Per patient, EGD was significant for evidence of
obstruction with food remaining in stomach as well as gastric
ulcers, and patient reports pathology came back positive for
cancer, though though he does not recall which type. Over the
last ___ days patient has had worsening burning pain, nausea,
and vomiting, with last meal 2 days ago. Reports that he has
been able to tolerate pills. Last ___ yesterday AM, during which
he noted dark red blood per rectum. Denies fevers/chills, chest
pain, SOB, dizziness, changes in urination.
He went to ___ ED today for worsening pain and
nausea. CT torso at ___ showed gastric distension but no
evidence of obstruction or masses. Transferred to ___ ED for
surgical evaluation. In the ED, initial vitals were: T 98.3 HR
70 BP 166/78 RR 16 O2 sat 99% RA
- Exam notable for: epigastric tenderness with guarding
- Labs notable for: Mild anemia (Hgb 13.1) and uremia (BUN 23),
negative UA
- Patient was given: 1L NS, 4 mg IV morphine, 100 mg thiamine,
IV pantoprazole 40 mg
Surgery evaluated patient and felt no surgical intervention
necessary; recommended admission to medicine for workup of
possible GI malignancy.
Upon arrival to the floor, patient reports improved pain since
an episode of vomiting prior to transfer to the floor. Denies
dizziness, shortness of breath, and chest pain.
Past Medical History:
Chronic pain on opioids
SBO s/p surgery in ___
HTN
Hypothyoridism
Depression
GERD
Nephrolithaisis s/p lithotripsy (___)
BPH
PVD
Open cholecystectomy (___)
TURP (___)
Throidectomy due to multi-nodular goiter
Social History:
___
Family History:
Per OMR - Father has history of diabetes. Father and mother have
history of heart disease. Paternal grandmother has history of
cancer, of unknown type.
Physical Exam:
ADMISSION EXAM:
============
VITAL SIGNS: T 97.5 BP 158 / 78 HR 69 RR 20 O2 sat 99%RA
GENERAL: Patient is sitting in bed, alert and responsive,
appearing mildly uncomfortable but not in acute distress,
occasionally retching and spitting up clear fluid
HEENT: NCAT, PERRL, sclera anicteric, moist mucus membranes
NECK: Supple, no visible JVD
CARDIAC: Normal S1S2, RRR, no murmurs
LUNGS: Clear bilaterally to auscultation without rales,
wheezes,
rhonchi
ABDOMEN: Distended but soft, non-tender to palpation, no rebound
or guarding
EXTREMITIES: Warm, well-perfused, no lower extremity edema
NEUROLOGIC: AOX3, moves extremities spontaneously
SKIN: No bruises or rashes
DISCHARGE EXAM:
============
VS: 98.1, 144/73, 72, 20, 98 RA
GENERAL: Patient is lying down in bed, not in distress. Using
suction intermittently to clear his oral secretions.
HEENT: NCAT, sclera anicteric, MMM
CARDIAC: Normal S1S2, RRR, no murmurs
LUNGS: CTAB and posteriorly without rales, wheezes, rhonchi
CHEST: Mild TTP in epigastric area over lowest rib border b/l.
ABDOMEN: Soft but obese. Mildly distended. Back pain elicited
with deep epigastric palpation, otherwise nontender. No rebound
or guarding. +BS
EXTREMITIES: warm, trace BLE edema
NEUROLOGIC: CN ___ grossly intact. Moving all extremities
spontaneously.
Pertinent Results:
LABS ON ADMISSION:
=================
___ 12:40AM BLOOD WBC-9.1 RBC-4.53* Hgb-13.1* Hct-40.1
MCV-89 MCH-28.9 MCHC-32.7 RDW-17.4* RDWSD-56.3* Plt ___
___ 12:40AM BLOOD Neuts-80.3* Lymphs-10.9* Monos-8.0
Eos-0.2* Baso-0.3 Im ___ AbsNeut-7.30* AbsLymp-0.99*
AbsMono-0.73 AbsEos-0.02* AbsBaso-0.03
___ 12:40AM BLOOD Glucose-125* UreaN-23* Creat-0.9 Na-143
K-4.2 Cl-100 HCO3-26 AnGap-17*
___ 12:40AM BLOOD ALT-24 AST-15 AlkPhos-58 TotBili-0.5
___ 12:40AM BLOOD Albumin-4.3
___ 07:37AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.1
LABS AT DISCHARGE:
=================
___ 05:28AM BLOOD WBC-6.4 RBC-3.21* Hgb-9.2* Hct-29.0*
MCV-90 MCH-28.7 MCHC-31.7* RDW-17.2* RDWSD-57.1* Plt ___
___ 05:28AM BLOOD Glucose-94 UreaN-20 Creat-0.6 Na-139
K-4.2 Cl-102 HCO3-28 AnGap-9
___ 05:28AM BLOOD ALT-107* AST-52* LD(___)-167 AlkPhos-299*
TotBili-0.5
___ 11:11AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:28AM BLOOD Albumin-3.2* Calcium-8.5 Phos-3.4 Mg-1.9
NOTABLE LABS
=============================
___ 05:06AM BLOOD CEA-2.3
___ 05:35AM BLOOD Triglyc-104
___ 05:35AM BLOOD calTIBC-241* TRF-185*
___ 05:28AM BLOOD ALT-107* AST-52* LD(___)-167 AlkPhos-299*
TotBili-0.5
___ 06:33AM BLOOD ALT-112* AST-79* AlkPhos-206* TotBili-0.6
___ 06:00AM BLOOD ALT-59* AST-50* AlkPhos-154* TotBili-0.4
___ 12:40AM BLOOD ALT-24 AST-15 AlkPhos-58 TotBili-0.5
MICROBIOLOGY:
=================
Urine Culture (___): < 10,000 CFU/mL.
TISSUE (___) Source: liver lesion.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
PATHOLOGY:
=================
___ EGD Biopsies Results: (DONE AT ___)
FINAL DIAGNOSIS
A. Duodenum, bulb, biopsy: Adenocarcinoma
B. Stomach, antrum, biopsy: Chronic gastritis, inactive. IHC
staining for H. pylori negative.
IHC staining on duodenum biopsy:
MIB-1 positive in approximately 40% nuclei
CD56, Chrmogranin, Synaptophysin negative
___ (repeat exam at BI from OSH)
A) Duodenum, bulb, biopsy:
- Adenocarcinoma. See note.
- Background chronic active duodenitis.
Note: Tumor cells are immunoreactive for CK7 (focal), negative
for CK20 and CDX-2. Provided immunostains are evaluated, tumor
cells are negative for Synaptophysin, chromogranin, CD56 and
Mib-1 proliferation index is approximately 40%. Imaging and
endoscopic correlation recommended.
B) Stomach, antrum biopsy:
- Antral and corpus mucosa with chronic inactive gastritis.
- The provided immunostain for H. pylori is negative.
TOUCH PREP OF CORE, LIVER SEGMENT (___) 3:
NEGATIVE FOR MALIGNANT CELLS.
Reactive, benign-appearing hepatocytes with scant inflammatory
cells including neutrophils and
lymphocytes. See also surgical pathology report # ___ and
microbiology report ___.
IMAGING:
=================
___ CT Chest with contrast
IMPRESSION:
1. 10 mm nonspecific semisolid pulmonary nodule in the right
upper lobe, could be infectious or inflammatory however in the
setting of malignancy, a short-term follow-up chest CT is
recommended.
2. Additional smaller pulmonary nodules measuring up to 5 mm,
can also be evaluated at the time of follow-up examination.
RECOMMENDATION(S): Chest CT in 3 months.
___ CT Abd/Pelvis with contrast
IMPRESSION:
1. Mild interval improvement of gastric dilation with abrupt
transition at the level of the second portion of the duodenum.
Possible mass at the site of transition, better evaluated on
prior CT.
2. 1.7 cm lesion in hepatic segment III as well as multiple
subcentimeter hypodense liver lesions, described above, in the
setting of possible malignancy, correlation with more remote
imaging is recommended if available.
If no imaging is available, a liver MRI can be obtained for
further
characterization.
3. No lymphadenopathy.
4. Right adrenal adenoma.
RECOMMENDATION(S): Correlation with remote imaging to evaluate
for stability of liver lesions otherwise, MRI of the liver is
recommended.
___ Liver MRI: FINAL
IMPRESSION:
1. Multiple rim enhancing hepatic lesions, the largest measuring
1.4 cm in hepatic segment III, with multiple other subcentimeter
lesions some which are clustered in the periphery of segment
VI/VII. While findings could represent metastatic disease, in
the setting of moderate biliary duct dilation and with the
clustered appearance of many of these lesions, hepatic
microabscesses related to cholangitis would need to be
considered. ERCP could be considered to evaluate biliary ductal
dilation and for any underlying cholangitis.
2. Focal soft tissue involving the first portion of the
duodenum, consistent with primary malignancy.
3. Bilateral adrenal adenomas.
4. 7 mm gastrohepatic lymph node, attention on follow-up
imaging.
___ EGD:
Impression:Mass in the duodenal bulb (biopsy)
Erythema in the stomach body and fundus
Otherwise normal EGD to duodenal bulb
Recommendations:The findings account for the symptoms
___ Lower extremity veins U/S
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
___ EGD
Impression:
A malignant appearing mass was seen starting at the proximal
second part of the duodenum. The scope did not traverse the
lesion.
Under fluoroscopic guidance, a standard biliary extraction
balloon preloaded with a 0.35in guidewire was passed through the
therapeutic upper endoscope into the duodenum traversing the
stenosis.
As contrast was injected a tight stenosis was seen as well as an
unobstructed bowel loop distal to the stenosis.
The balloon catheter was removed and the guidewire was left in
place within the proximal jejunum.
A 22 mm by 120 mm uncovered duodenal metal stent (WallFlex
duodenal stent REF ___ ___ was slowly advanced
over the guidewire through the stenosis under fluoroscopic
visualization.
Final deployment position of the stent was from the prepyloric
antrum to the distal duodenum.
Final fluoroscopic views showed adequate luminal patency.
___
IMPRESSION:
1.5 cm hepatic segment III nodule is considered feasible for
ultrasound-guided target biopsy.
___ KUB
IMPRESSION:
No radiographic evidence of bowel obstruction. No free air.
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS WITH CONTRAST.
INDICATION: ___ year old patient with chronic back pain on opiate meds, HTN,
h/o of a ___ s/p surgery in ___, presents with nausea, vomiting, and
abdominal pain and report of recently diagnosed abdominal malignancy of
unknown origin.
TECHNIQUE: Oncology 3 phase: Multidetector CT of the abdomen and pelvis was
done as part of CT torso without and with IV contrast. Initially the abdomen
was scanned without IV contrast. Subsequently a single bolus of IV contrast
was injected and the abdomen and pelvis were scanned in the portal venous
phase, followed by a scan of the abdomen in equilibrium (3-min delay) phase.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.4 s, 37.7 cm; CTDIvol = 20.4 mGy (Body) DLP = 767.4
mGy-cm.
2) Spiral Acquisition 5.0 s, 78.7 cm; CTDIvol = 20.3 mGy (Body) DLP =
1,594.3 mGy-cm.
3) Spiral Acquisition 2.3 s, 36.7 cm; CTDIvol = 20.4 mGy (Body) DLP = 746.9
mGy-cm.
4) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 36.3 mGy (Body) DLP =
18.2 mGy-cm.
Total DLP (Body) = 3,127 mGy-cm.
COMPARISON: Reference CT torso ___
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver is normal in morphology. There is an 1.7 x 1.4 cm
hypodense lesion in segment III of the liver, which demonstrates possible low
level enhancement on post contrast imaging (series 3, image 61). Additional
subcentimeter hypodensities in the periphery of segment VII (series 3, image
53, 54, 58) and in segment V (series 3, image 63), are incompletely
characterized. Patient is post cholecystectomy. Mild central intrahepatic
and extrahepatic biliary duct dilation, likely reflects post cholecystectomy
status. There is no ascites. 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: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The left adrenal gland is thickened without discrete nodules. There
is a 1.6 x 1.2 cm right adrenal adenoma (series 2, image 27).
URINARY: The kidneys are symmetric in size. There are subcentimeter
hypodensity in the left lower and right upper pole (series 3, image 87, 77),
statistically likely simple cysts. Note is made of an extrarenal pelvis in
the right lower pole. There are no suspicious renal lesions.
GASTROINTESTINAL: A nasoenteric tube ends in the gastric body. Again seen, is
gastric dilation, overall mildly improved compared to hospital CT from 1 day
prior. There is an abrupt transition to normal caliber duodenum in the
proximal second portion. There is suggestion of a soft tissue mass at the
site of caliber change seen best on the pre contrast CT and coronal image from
outside hospital CT (series 2, image 38).
There is no small bowel obstruction. Large bowel is notable for mild
diverticulosis of the sigmoid colon. Appendix is normal. There is no
intra-abdominal free air.
PELVIS: The bladder is decompressed. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Prostate contains coarse calcifications but is not
enlarged.
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. Hepatic arterial anatomy is conventional.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Mild interval improvement of gastric dilation with abrupt transition at the
level of the second portion of the duodenum. Possible mass at the site of
transition, better evaluated on prior CT.
2. 1.7 cm lesion in hepatic segment III as well as multiple subcentimeter
hypodense liver lesions, described above, in the setting of possible
malignancy, correlation with more remote imaging is recommended if available.
If no imaging is available, a liver MRI can be obtained for further
characterization.
3. No lymphadenopathy.
4. Right adrenal adenoma.
RECOMMENDATION(S): Correlation with remote imaging to evaluate for stability
of liver lesions otherwise, MRI of the liver is recommended.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ?gastric outlet obstruction, now with NGT
placed.// please obtain film to confirm NGT placement with view of diaphragm
and partial view of the abdomen. please obtain film to confirm NGT
placement with view of diaphragm and partial view of the abdomen.
IMPRESSION:
No prior chest radiographs available for review.
Single frontal view of the chest shows top-normal size heart. Clear lungs.
No pleural abnormality. There is no anatomic detail in the upper abdomen.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ man with chronic back pain, presenting with nausea,
vomiting, and abdominal pain and report of recently diagnosed abdominal
malignancy of unknown origin.
TECHNIQUE: MDCT axial views were obtained through the chest after the
uneventful administration of intravenous contrast. Coronal and sagittal as
well as axial MIPS reformatted images were acquired.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.4 s, 37.7 cm; CTDIvol = 20.4 mGy (Body) DLP = 767.4
mGy-cm.
2) Spiral Acquisition 5.0 s, 78.7 cm; CTDIvol = 20.3 mGy (Body) DLP =
1,594.3 mGy-cm.
3) Spiral Acquisition 2.3 s, 36.7 cm; CTDIvol = 20.4 mGy (Body) DLP = 746.9
mGy-cm.
4) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 36.3 mGy (Body) DLP =
18.2 mGy-cm.
Total DLP (Body) = 3,127 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: Reference Torso CT ___
FINDINGS:
Thyroid is surgically absent. There is no supraclavicular, axillary,
mediastinal, or hilar adenopathy.
Heart size is normal. There is no pericardial effusion. The main pulmonary
trunk is not dilated. Although not optimized for evaluation, no central
embolus is identified. The thoracic aorta is normal in caliber, with mild
atherosclerosis of the arch. There are no significant aortic valvular
calcifications. There is no pericardial effusion.
The airways are patent and normal to the subsegmental level bilaterally.
There is no pleural effusion or pneumothorax. There is a 10 mm semisolid
pulmonary nodule in the right upper lobe (series 302, image 125). Other
nodules include a 5 mm solid right upper lobe pulmonary nodule (series 603,
image 12) and smaller 2 and 3 mm left lower lobe pulmonary nodules (series
302, image 125, 135). A millimetric nodule in the right posterior upper lobe
in continuity with the pleural surface, likely represents an intrapulmonary
lymph node (series 302, image 103). There is no focal consolidation.
A nasoenteric tube enters the stomach. Thoracic esophagus is otherwise
unremarkable. Please see dedicated abdominal and pelvic CT from same day for
intra-abdominal details.
OSSEOUS STRUCTURES/SOFT TISSUES: Superficial soft tissues are notable for mild
bilateral gynecomastia. There are no suspicious bony lesions.
IMPRESSION:
1. 10 mm nonspecific semisolid pulmonary nodule in the right upper lobe, could
be infectious or inflammatory however in the setting of malignancy, a
short-term follow-up chest CT is recommended.
2. Additional smaller pulmonary nodules measuring up to 5 mm, can also be
evaluated at the time of follow-up examination.
RECOMMENDATION(S): Chest CT in 3 months.
Radiology Report
EXAMINATION: Portable chest.
INDICATION: ___ year old man with SBO likely ___ gastric cancer with NG tube
in place, feeling that has pill stuck in throat, evaluate for pill in
esophagus
TECHNIQUE: Chest PA and lateral
COMPARISON: Same-day Chest CT
FINDINGS:
Nasoenteric tube seen in the esophagus, tip not visualized. No radiopaque
foreign body is seen. Cardiomediastinal silhouette is normal. Lungs are
clear. No pleural effusion or pneumothorax.
IMPRESSION:
No radiopaque foreign body.
Radiology Report
EXAMINATION: MRI of the Abdomen
INDICATION: ___ who presents as transfer from ___ for surgical
evaluation of adenocarcinoma discovered on EGD on ___. CT on ___ showed
lesions in liver c/f mets.// Liver lesions seen on CT on ___. C/f mets in
setting of known cancer. Please evaluate.
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 8 mL Gadavist.
COMPARISON: Reference CT ___, CT abdomen and pelvis ___
FINDINGS:
Lower Thorax: There is no pleural effusion. Lung bases are clear.
Liver: The liver is normal in signal intensity.
There are multiple rim enhancing T2 intermediate intensity hepatic lesions
including the largest measuring 1.4 cm in hepatic segment III (series 8, image
48). There are at least 7 or 8 additional sub centimeter T2 intermediate
intensity rim enhancing lesions, in the periphery of the lobe liver but most
apparent and clustered in periphery of hepatic segments VII and VI (series 8,
image 29, 37). There is no ascites.
Biliary: The gallbladder is surgically absent. Moderate primarily left-sided
intrahepatic as well as extrahepatic biliary duct dilation has mildly
progressed compared to prior CT. No ductal stone is identified. Primary
lesion appears separate from the biliary confluence.
Pancreas: Pancreas is normal in signal intensity. There is a tiny 4 mm cystic
lesion in the pancreatic head.
Spleen: Spleen is normal in size and signal intensity.
Adrenal Glands: There is a 1.6 cm right adrenal adenoma. 1.7 cm left adrenal
nodule is also noted, likely additional adenoma.
Kidneys: There are bilateral peripelvic renal cysts with the largest in the
right lower pole measuring 2.5 cm. There is no suspicious renal lesion.
There is no hydroureteronephrosis.
Gastrointestinal Tract: No hiatal hernia. Compared to prior, gastric
distension has normalized. There is increased enhancing soft tissue involving
the first portion of the duodenum which is consistent with the primary
malignancy (series 19, image 33; series 17, image 19). Lesion appears
separate from the biliary duct insertion.
Lymph Nodes: There are no enlarged lymph nodes. There are small gastrohepatic
lymph nodes measuring up to 7 mm (series 19, image 23).
Vasculature: There is no abdominal aortic aneurysm. Hepatic arterial anatomy
is conventional. The portal vein is patent.
Osseous and Soft Tissue Structures: There is no superficial soft tissue
abnormality. There is no suspicious bony lesion.
IMPRESSION:
1. Multiple rim enhancing hepatic lesions, the largest measuring 1.4 cm in
hepatic segment III, with multiple other subcentimeter lesions some which are
clustered in the periphery of segment VI/VII. While findings could represent
metastatic disease, in the setting of moderate biliary duct dilation and with
the clustered appearance of many of these lesions, hepatic microabscesses
related to cholangitis would need to be considered. ERCP could be considered
to evaluate biliary ductal dilation and for any underlying cholangitis.
2. Focal soft tissue involving the first portion of the duodenum, consistent
with primary malignancy.
3. Bilateral adrenal adenomas.
4. 7 mm gastrohepatic lymph node, attention on follow-up imaging.
RECOMMENDATION(S): Consider ERCP to evaluate for underlying cholangitis.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 10:12 am, 5 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: Frontal chest radiograph.
INDICATION: ___ year old man with right arm 44cm DL power PICC. ___ ___//
Right arm 44cm DL PICC. Contact name: ___: ___
TECHNIQUE: Single portable frontal chest radiograph.
COMPARISON: Chest radiograph ___
CT chest ___
FINDINGS:
The lungs are moderately well inflated with mild right lower lobe atelectasis
and otherwise clear. No pleural effusion or pneumothorax. Heart size,
mediastinal contour, and hila are unremarkable.
A right PICC tip is entering into the right atrium. An enteric feeding tube
is seen coursing midline with tip out of field of view.
IMPRESSION:
1. Right PICC tip in right atrium. Consider withdrawing 2-2.5 cm for better
positioning.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 5:37 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS
INDICATION: ___ year old man with suspected small bowel adenocarcinoma now
with asymmetric LLE swelling.// please evaluate for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Radiology Report
EXAMINATION: Limited ultrasound of the liver
INDICATION: ___ year old man with recently diagnosed duodenal adenocarcinoma
now with ?mets in liver. (segment III largest).// Please perform "feasibility"
ultrasound to assess if biopsy possible for suspected mets.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the liver was
obtained.
COMPARISON: MRI dated ___.
FINDINGS:
Focused evaluation of the liver demonstrated a 1.5 x 1.2 x 1.1 cm oval-shaped
hypoechoic nodule in the inferior aspect of segment III, corresponding to the
lesion seen on the most recent MRI.
During real-time scanning, this lesion was deemed to be amenable to
ultrasound-guided targeted biopsy.
IMPRESSION:
1.5 cm hepatic segment III nodule is considered feasible for ultrasound-guided
target biopsy.
Radiology Report
EXAMINATION: Ultrasound-guided targeted liver biopsy
INDICATION: ___ year old man with duodenal adenocarcinoma with ?mets to liver.
S/p feasibility u/s indicating that 1.5cm mass in segment III may be amendable
to biopsy.// as request per oncology, consult for possible biopsy of liver
lesion.
COMPARISON: Ultrasound dated ___
PROCEDURE: Ultrasound-guided targeted liver biopsy.
OPERATORS: Dr. ___ fellow and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
FINDINGS:
Limited preprocedure grayscale and Doppler ultrasound imaging of the liver was
performed. The lesion for biopsy was identified in the left hepatic lobe. A
suitable approach for targeted liver biopsy was determined.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
Based on the preprocedure imaging, an appropriate skin entry site for the
biopsy was chosen. The site was marked. The skin was then prepped and draped
in the usual sterile fashion. The superficial soft tissues to the liver
capsule were anesthetized with 10 mL 1% lidocaine.
Under real-time ultrasound guidance 18 gauge core biopsy simple was obtained.
The lesion became difficult to visualize after the first pass. 2 additional
18 gauge samples were obtained and sent for cytology. In addition, a fourth
simple was also obtained and sent for microbiology evaluation.
The skin was then cleaned and a dry sterile dressing was applied. There were
no immediate complications.
SEDATION: Moderate sedation was provided by administering divided doses of
1.5 mg Versed and 100 mcg fentanyl throughout the total intra-service time of
50 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
IMPRESSION:
Uncomplicated 18-gauge targeted liver biopsy x 4, with specimens provided to
the cytologist and an additional simple sent for microbiology evaluation.
Biopsy was technically challenging. Short-term follow-up imaging is
recommended if biopsy results are not concordant.
Radiology Report
INDICATION: ___ year old man with history of SBO, transfer for surgical eval,
found to have stomach adeno, partially obstructing, status post ___ duodenal
stent, now complaining of worsening abdominal pain, burping, bloating.
Concerned for obstruction
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
There is a prominent gas-filled loop of small bowel. Air is seen within the
colon. Nonspecific air-fluid levels are likely within the colon. There is no
free intraperitoneal air.
Osseous structures are notable for degenerative changes of the lumbosacral
spine. There are cholecystectomy clips in the right upper quadrant. There is
a duodenal stent seen.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
No radiographic evidence of bowel obstruction. No free air.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, N/V, Transfer
Diagnosed with Unspecified abdominal pain, Nausea with vomiting, unspecified
temperature: 98.3
heartrate: 70.0
resprate: 16.0
o2sat: 99.0
sbp: 166.0
dbp: 78.0
level of pain: 9
level of acuity: 2.0 | ___ with chronic back pain on opioids, HTN, h/o SBO s/p surgery
in ___, who presented as transfer from ___ with
adenocarcinoma discovered on ___ EGD, found to have e/o
obstruction by mass on imaging. He originally required
decompression with NG tube, and required repletion of nutrients
with TPN. He was tolerating clears, until his diet was slowly
advanced after a stent placement. He was weaned off TPN by the
time of discharge. Throughout this admission he was afebrile and
HDS. Notably, he tolerated a greatly reduced pain regimen (from
his home dose) during this stay, which likely contributed to
better urinary output. His HTN medication was also titrated up. |
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Verapamil / Percocet / Lupron
/ Chloral Hydrate Analogues / Restoril / Percodan /
Ciprofloxacin / Clinoril / Flagyl / Advair Diskus / Abilify /
Lexapro / Zyprexa / Seroquel / Codeine / Aspirin / Ibuprofen /
Sucralfate / Depakote / Topamax / Risperdal / Lisinopril /
Tramadol / Provigil / Nuvigil / Focalin / Lithium / Lyrica /
modafinil / morphine / prochlorperazine / Xopenex / pravastatin
/ Tegaderm Transparent Dressing / pramipexole / Linzess /
hyoscyamine / prednisone / ondansetron / granisetron / baclofen
/ Soma
Attending: ___
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ female with history of MS,
HTN, PTSD, and chronic pain disorder presenting with acute on
chronic pain and increasing subjective weakness.
Reports whole body pain and cramping since 0200 this morning (12
hours PTA) with difficulty with ambulation associated with some
lightheadedness and nausea. Follows with Dr. ___ MS. ___
chest pain, shortness of breath, abdominal pain. Pt reports she
started a new medication: Granisetron x2 days ago for gi
problems, decreased appetite, and feels she is having a reaction
to the medication. Pt reports the pain is similar to prior MS
flares. Pt also reports that she had a tooth extraction recently
and is continuing to have pain at the site of the extraction and
is concerned that "maybe there is an infection even though I've
been on the prophylactic antibiotics". seen by neuro. neuro
unconvinced that this is ms flare, but patient still unable to
walk and endorsing inability to tolerate pos.
In the ED:
VS: 97.4 62 148/74 16 96% RA
PE: Pain to light touch over all of her legs, arms, back, and
head.
[X] Dr. ___ ___ cell): This happens right before
every renewal of her dilaudid.
[ ] Labs - unremarkable
[ ] CXR - neg
[ ] neuro consult
Labs: AST 58, otherwise normal / unremarkable CBC/CMP, UA
Imaging: CXR ___ acute cardiopulmonary abnormality. Moderate to
large hiatal hernia.
Interventions: 2L NS, dilaudid 0.5mg IV x2, dilaudid 2mg po x1
Consults: Neurology: Completed ___ 18:58
"Discussed case with outpatient Neurologist as already done by
ED
and as suggested by protocol highlighted in Dash. Presents today
with disequilibrium, forced flexor posturing of the extremities,
and allodynia; ___ recent infectious symptoms to raise concerns
for exacerbation of underlying MS. ___ and examination
findings similarly not suggestive of coherent underlying
neurologic process. Accordingly, ___ indication for further
neurologic evaluation or management. As already extensively
documented in records, there is appreciable risk for harm in
unnecessary inpatient management and overmedication,
particularly
in context of outpatient attempts to manage opioid use; would
therefore urge consideration of outpatient management and
follow-up with well-established providers.
- ___ indication for further neuroimaging
- Would avoid unnecessary opioid administration
- Agree with supportive symptom management as completed
- Outpatient follow-up with established neurologist
Plan discussed with attending physician ___
Impression/Course: "Patient with a history of MS coming in with
whole body pain and weakness. Patient was evaluated by neurology
who felt like this was not consistent with her multiple
sclerosis. There is a significant functional component to her
presentations. However, the patient is unable to ambulate or
eat.
She is refusing a physical therapy consult and rehab placement.
She was told that she would not receive any additional
medications other than her home medications. She will require
admission safety concerns at home and inability to ambulate."
On arrival to the floor patient complaining of new pain in the
back of the neck as well as headache that started about 2 hours
ago, though she fell asleep shortly after and was comfortable
appearing.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
DSM 5 DIAGNOSES:
Borderline personality disorder
PTSD
Somatic symptom disorder, anxiety disorder
Unspecified mood disorder (some notes label her as MDD, others
appear to attribute her melancholic affect to her other
conditions)
MEDICAL HISTORY
Secondary progressive MS- very questionable diagnosis, has
lesions on MRI but ___ convincing clinical symptoms
Question of a cognitive disorder, although evaluation is heavily
confounded by her other issues.
Asthma
Iron deficiency
B12 deficiency
Migraines
IBS
Upper GI bleed
Social History:
___
Family History:
grandfather with ___.
Uncle with ___ cancer
Father w/ polio, lung mass, died of PsA infectious
mother with superficial skin cancer
mother with a chronic hematological malignancy "version that
doesn't kill you," either leukemia or lymphoma
little sister with breast cancer and bile duct cancer
Physical Exam:
ADMISSION EXAM
VS: Temp: 98.3 PO BP: 153/72 HR: 59 RR: 20 O2 sat: 96% O2
delivery: RA
Gen - NAD, non-toxic appearing
Eyes - anicteric
ENT - MMM, OP clear
Heart - RRR, ___ r/m/g
Lungs - CTAB, breathing unlabored
Abd - soft, nontender, nondistended, ___ guarding or rebound
Ext - ___ pedal edema
Skin - ___ obvious skin rashes
Vasc - WWP
Neuro - A&OOx3, moving all extremities, ___ gross sensorimotor
deficits
Psych - pleasant, calm, cooperative
DISCHARGE EXAM
Constitutional: VS reviewed, lying in bed and flat with quiet
voice and very unactivated and lying fairly flaccid in bed but
when I mention Tylenol as a treatment for her HA she somewhat
dramatically moves to argue that what she was requesting was her
triptan and Tylenol doesn't work for her migraine; later in the
day when she is ready to leave to see her dentist she is again
very activated
HEENT: eyes almost closed and not opening to my exam but appear
equal, nose unremarkable, MMM without exudate; later in the day
her eyes are wide open
CV: RRR ___ mrg
Resp: CTAB
GI: diffusely ttp to even the lightest touch but much less so
with my stethoscope, NABS, soft
GU: ___ foley
MSK: ___ obvious synovitis
Ext: wwp, neg edema in BLEs
Skin: ___ rash grossly visible
Neuro: A&O grossly, as above is lying without a lot of
activity/motion most of the interview but activates physically
when discussing medications, ___ BLEs but increases with
increasing resistance and giveway weakness, + hoover's sign on
___ strength testing, diffuse tenderness to light touch
Psych: flat and annoyed affect initially but then later when
wants to see dentist as o/p is much more pleasant and
interactive
Pertinent Results:
ADMISSION RESULTS
___ 03:15PM BLOOD WBC-5.3 RBC-4.92 Hgb-13.0 Hct-40.1 MCV-82
MCH-26.4 MCHC-32.4 RDW-14.1 RDWSD-41.0 Plt ___
___ 03:15PM BLOOD Neuts-52.0 ___ Monos-8.1 Eos-1.3
Baso-0.4 Im ___ AbsNeut-2.77 AbsLymp-2.02 AbsMono-0.43
AbsEos-0.07 AbsBaso-0.02
___ 03:15PM BLOOD Glucose-95 UreaN-13 Creat-0.7 Na-141
K-5.6* Cl-102 HCO3-22 AnGap-17
___ 03:15PM BLOOD ALT-27 AST-58* AlkPhos-96 TotBili-0.3
___ 03:15PM BLOOD Albumin-4.7 Calcium-10.0 Phos-4.2 Mg-2.0
___ 04:23PM BLOOD K-3.8
CXR
IMPRESSION:
___ acute cardiopulmonary abnormality. Moderate to large hiatal
hernia.
EKG SB at 57, old anterior infarct, ___ significant change from
previous EKG
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 400 mg PO QID
2. amLODIPine 10 mg PO DAILY
3. OXcarbazepine 300 mg PO TID
4. HYDROmorphone (Dilaudid) 2 mg PO TID:PRN BREAKTHROUGH PAIN
5. melatonin 10 mg oral QHS:PRN insomnia
6. Sumatriptan Succinate 100 mg PO ONE TABLET(S) BY MOUTH AT
ONSET OF MIGRAINE, MAY REPEAT IN 2 HOURS IF MIGRAINE STILL
PRESENT
7. Cyanocobalamin 1000 mcg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line
10. esomeprazole magnesium 40 mg oral BID
11. Calcium Carbonate 500 mg PO BID
12. Penicillin V Potassium 500 mg PO Q6H
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Calcium Carbonate 500 mg PO BID
3. Cyanocobalamin 1000 mcg PO DAILY
4. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First
Line
5. esomeprazole magnesium 40 mg oral BID
6. Gabapentin 400 mg PO QID
7. HYDROmorphone (Dilaudid) 2 mg PO TID:PRN BREAKTHROUGH PAIN
8. melatonin 10 mg oral QHS:PRN insomnia
9. OXcarbazepine 300 mg PO TID
10. Penicillin V Potassium 500 mg PO Q6H
11. Sumatriptan Succinate 100 mg PO ONE TABLET(S) BY MOUTH AT
ONSET OF MIGRAINE, MAY REPEAT IN 2 HOURS IF MIGRAINE STILL
PRESENT
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
somatoform disorder
multiple sclerosis, chronic, not actively flaring
tooth pain
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: History: ___ with MS, whole body pain, h/a, neck pain//
Infection, bleeding, MS flair
TECHNIQUE: Semi-upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___ and CT chest ___
FINDINGS:
Lung volumes are low. Heart size is mildly enlarged. The mediastinal and
hilar contours are unchanged with a moderate to large hiatal hernia again
noted. The pulmonary vasculature is normal. Lungs are clear. No pleural
effusion or pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality. Moderate to large hiatal hernia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness
Diagnosed with Weakness
temperature: 97.4
heartrate: 62.0
resprate: 16.0
o2sat: 96.0
sbp: 148.0
dbp: 74.0
level of pain: 9
level of acuity: 3.0 | ___ w MS, PTSD, sexual trauma, somatoform disorder, chronic
pain, fibromyalgia, IBS, borderline personality disorder,
frequent presentations for apparently functional pain/weakness
(often around time of renewal/expiry of her home
pain meds) presents with functional pain and weakness. Admitted
because she would not walk in the ED, decided she was ready to
leave on hospital day 1 in setting of wanting to see her
outpatient dentist. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lipitor
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ year old woman with a past medical history
significant for atrial fibrillation (on
rivaroxaban), hyperlipidemia, hypertension, hyperthyroidism,
atrial tachycardia s/p pacemaker, COPD, CVA, CHF, and
tuberculosis who presents with several days of worsening
shortness of breath, with associated productive cough, bilateral
lower extremity swelling, and generalized weakness. She was
recently hospitalized about a month ago for pneumonia, and 2
weeks ago for cellulitis. Per the patient, has not really
improved since discharge. She did complete the antibiotic
course, but continued to have significant left leg swelling,
especially over her foot although the redness resolved. Per the
patient, following her discharge, she saw her cardiologist Dr
___ recommended that she continue xarelto and lasix.
In addition, she had worsening shortness of breath with exertion
that severely limited her functionality, accompanied by sneezing
and a cough productive of yellowish brown sputum for about five
days. Denies any chest pain, palpitations, fevers, chills.
Reports her weight has remained stable since discharge, did have
a 3lb weight gain initially that appears to have resolved, last
dose of lasix yesterday. She was scheduled to see Dr ___
(cards) today, but was so short of breath came to the ED
instead.
In the ED, initial vitals were: 96.7 93 127/95 20 97%. Patient
received magnesium repletion; vanc/ceftriaxone/azithro for HCAP
coverage; she refused nebs and diuretics. Initial workup showed
elevated BNP and CXR concerning for volume overload. In
addition, she was found to have Cr elevated to 1.6 from baseline
of 1.1-1.2, 1.3 at discharge ten days ago.
On the floor, she continues to feel short of breath with minimal
exertion but is comfortable at rest.
Past Medical History:
# Asthma / COPD -- severe obstructive defect
-- last PFTs (___) FEV1 and vital capacity
0.95 and 1.8 (55 and 77% predicted respectively). FEV1 to vital
capacity ratio is 53% (72% predicted)
# Mild Pulmonary Hypertension
# Atrial fibrillation -- on rivaroxaban
# Atrial tachycardia
# Pacemaker -- ___ dual chamber PPM placed ___
-- infra-His AV block (right bundle-branch block, left anterior
fascicular block, and procainamide-induced HV prolongation to
156 milliseconds).
# Hypertension
# Hyperlipidemia
# TB History
# Right Cerebellar Stroke (___)
-- with INR 2.5, likely from small vessel disease
# Toxic Multinodular Goiter
-- s/p Iodine-131 ablation (___)
# Appendectomy
# Bilateral Hip Replacement -- ___ years ago at ___
Social History:
___
Family History:
Mother had a MI
Physical Exam:
ADMISSION
Vitals: 97.6F 156/91 100 90%2L->97%2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, mucous membranes slightly dry,
oropharynx clear
Neck: supple, JVP elevated to about 12 cm, no LAD
Lungs: Diffuse inspiratory and expiratory wheezes, mild crackles
at bases
CV: irregularly irregular
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: Warm, well perfused, palpable pulses bilaterally, 3+pitting
edema in LLE to knee, 2+ pitting edema in RLE to midcalf
Skin: hyperpigmented areas over L > R ankle
DISCHARGE
Vitals: 97.8F 130/76 86 24 94RA I/O ___ Wt 78.6 kg (79.5kg
yest, 82.6kg on admission)
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, mucous membranes moist, oropharynx
clear
Neck: supple, JVP elevated to about 11 cm, no LAD
Lungs: CTAB, no wheezes, mild crackles at bases
CV: irregularly irregular, HR in ___, no murmurs
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: Warm, well perfused, palpable pulses bilaterally, 1+pitting
edema in LLE to midcalf, 1+ pitting edema in RLE to midcalf
Skin: hyperpigmented areas over L > R ankle, no erythema
Pertinent Results:
ADMISSION LABS
___ 09:40PM CK(CPK)-61
___ 09:40PM CK-MB-3 cTropnT-0.02*
___ 09:40PM MAGNESIUM-1.5*
___ 04:50PM URINE HOURS-RANDOM CREAT-264 SODIUM-34
POTASSIUM-51 CHLORIDE-44
___ 04:50PM URINE COLOR-Yellow APPEAR-Cloudy SP ___
___ 04:50PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG
___ 04:50PM URINE RBC-24* WBC-33* BACTERIA-FEW YEAST-RARE
EPI-11
___ 04:50PM URINE HYALINE-10*
___ 04:50PM URINE URIC ACID-MANY
___ 04:50PM URINE MUCOUS-RARE
___ 10:22AM LACTATE-1.6
___ 10:15AM GLUCOSE-127* UREA N-30* CREAT-1.6* SODIUM-135
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-24 ANION GAP-15
___ 10:15AM estGFR-Using this
___ 10:15AM GLUCOSE-127* UREA N-30* CREAT-1.6* SODIUM-135
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-24 ANION GAP-15
___ 10:15AM estGFR-Using this
___ 10:15AM CK(CPK)-76
___ 10:15AM cTropnT-0.01
___ 10:15AM CK-MB-3 proBNP-5842*
___ 10:15AM CALCIUM-9.7 PHOSPHATE-2.6* MAGNESIUM-1.4*
___ 10:15AM WBC-10.4 RBC-4.03* HGB-12.3 HCT-37.6 MCV-93
MCH-30.6 MCHC-32.8 RDW-14.4
___ 10:15AM NEUTS-80.4* LYMPHS-7.7* MONOS-11.4* EOS-0.3
BASOS-0.2
___ 10:15AM PLT COUNT-203
___ 10:15AM PLT COUNT-203
EKG ___
Atrial fibrillation with a controlled ventricular response with
probable
ventricular premature beats which are monomorphic. Conducted
complexes have
marked left axis deviation. There are inferior Q waves.
Intraventricular
conduction delay of right bundle-branch block type. ST-T wave
abnormalities.
Since the previous tracing of ___ the rate is now slightly
less. Differences
in R wave progression is probably related to lead position.
Clinical
correlation is suggested.
___ LLE US
IMPRESSION:
No evidence of deep vein thrombosis in the left lower extremity.
CXR ___
FINDINGS:
Left-sided dual-chamber pacemaker device is noted with leads
terminating in
right atrium and right ventricle. Severe cardiomegaly with
marked left atrial
enlargement is re- demonstrated. There is mild pulmonary
vascular congestion.
The mediastinal and hilar contours are relatively unchanged,
with mild
atherosclerotic calcification of the thoracic aorta noted. The
lungs are
hyperinflated which suggests underlying COPD. No pleural
effusion, focal
consolidation or pneumothorax is present. There are mild
multilevel
degenerative changes in the thoracic spine.
IMPRESSION:
Mild pulmonary vascular congestion.
ECHO ___
Conclusions
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. There is
mild global left ventricular hypokinesis (LVEF = 40-45%). The
right ventricular cavity is mildly dilated with mild global free
wall hypokinesis. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. The
branch pulmonary arteries are dilated. Abnormal flow consistent
with a patent ductus arteriosus is identified (cine loops
___. There is no pericardial effusion.
IMPRESSION: Mild global biventricular systolic function. Mild
mitral regurgitation. Moderate tricuspid regurgitation. Moderate
pulmonary hypertension. Small patent ductus arteriosus.
Compared with the prior study (images reviewed) of ___, a
small PDA is seen. Biventricular systolic function has
deteriorated. There is more MR and TR; pulmonary hypertension is
seen.
___ CXR PA AND LAT
IMPRESSION: PA and lateral chest compared to ___ and ___:
Severe cardiomegaly has improved. Between ___ and ___,
a large
cluster of ring shadows developed in the right mid lung, which
persists,
concerning for cavities or acute bronchiectasis. Confirmation
with chest CT
scanning is recommended.
Lateral view shows that the lung bases are generally clear and
there is no
pleural effusion.
Transvenous right atrial and ventricular pacer leads are in
standard
placements. Dr. ___ was paged.
___ CT CHEST
IMPRESSION:
1. Predominantly central, ___ bronchovascular opacification
with changing
morphology and distribution across ___ years. Findings could be
explained by
drug hypersensitivity/toxicity, pulmonary hemorrhage, including
vasculitis,
e.g., ___ or Wegener's capillerites. No cavitating
lesions,
bronchiectasis, or fibrosis.
2. Enlarged ascending aorta measuring 4.5cm
3. Pulmonary arterial hypertension.
4. Cardiomegaly.
5. Stable 2.1 cm left thyroid nodule, unchanged since ___.
DISCHARGE LABS
___ 07:10AM BLOOD WBC-9.9 RBC-3.85* Hgb-11.9* Hct-35.9*
MCV-93 MCH-31.0 MCHC-33.2 RDW-14.3 Plt ___
___ 07:10AM BLOOD Glucose-114* UreaN-40* Creat-1.2* Na-142
K-4.2 Cl-102 HCO3-28 AnGap-16
___ 07:10AM BLOOD Calcium-9.5 Phos-3.3 Mg-1.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Rivaroxaban 15 mg PO DAILY
Discharge Medications:
1. Rivaroxaban 15 mg PO DAILY
2. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Xopenex Neb *NF* 0.63 mg/3 mL Inhalation q2h PRN COPD Reason
for Ordering: tachycardic with albuterol
RX *levalbuterol HCl [Xopenex] 0.63 mg/3 mL 3 ml IH EVERY 4
hours Disp #*120 Vial Refills:*0
4. Outpatient Lab Work
Please have Chem 10 checked on ___. Results should be
sent to your PCP's office.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Shortness of breath
Diastolic heart failure
COPD 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
HISTORY: Cough and dyspnea.
TECHNIQUE: Upright AP and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
Left-sided dual-chamber pacemaker device is noted with leads terminating in
right atrium and right ventricle. Severe cardiomegaly with marked left atrial
enlargement is re- demonstrated. There is mild pulmonary vascular congestion.
The mediastinal and hilar contours are relatively unchanged, with mild
atherosclerotic calcification of the thoracic aorta noted. The lungs are
hyperinflated which suggests underlying COPD. No pleural effusion, focal
consolidation or pneumothorax is present. There are mild multilevel
degenerative changes in the thoracic spine.
IMPRESSION:
Mild pulmonary vascular congestion.
Radiology Report
HISTORY: Left lower extremity swelling.
COMPARISON: None.
FINDINGS:
Grayscale color and spectral Doppler evaluation was performed of the left
lower extremity veins.
There is normal compressibility, flow, and augmentation of the left common
femoral, proximal femoral, mid femoral, distal femoral, and popliteal veins.
Normal color flow is demonstrated in the left posterior tibial and peroneal
veins. There is normal respiratory variation of the common femoral veins
bilaterally.
IMPRESSION:
No evidence of deep vein thrombosis in the left lower extremity.
Radiology Report
PA AND LATERAL CHEST, ___
HISTORY: ___ woman with COPD and CHF. Worsening cough despite
therapy.
IMPRESSION: PA and lateral chest compared to ___ and ___:
Severe cardiomegaly has improved. Between ___ and ___, a large
cluster of ring shadows developed in the right mid lung, which persists,
concerning for cavities or acute bronchiectasis. Confirmation with chest CT
scanning is recommended.
Lateral view shows that the lung bases are generally clear and there is no
pleural effusion.
Transvenous right atrial and ventricular pacer leads are in standard
placements. Dr. ___ was paged.
Radiology Report
HISTORY: History of tuberculosis, shortness of breath, COPD, and right heart
failure with findings on chest x-ray concerning for bronchiectasis or
cavitation. Please assess.
TECHNIQUE: Volumetric multi detector CT acquisition of the chest was
performed without intravenous contrast. Images are presented for review in
the axial plane at 5 mm and 1 mm collimation. Coronal reformations are
submitted for review.
COMPARISON: Comparison is made to chest radiographs most recently dated ___ and CT chest performed ___.
FINDINGS:
Evaluation of the thoracic inlet is limited due to artifact from a left-sided
pacemaker. Within this limitation, there is a 2 cm left thyroid lobe nodule,
unchanged compared to ___. No supraclavicular, axillary, mediastinal or
hilar lymphadenopathy is identified.
Artherosclerotic disease is noted throughout the visualized vasculature,
including the coronary arteries and aortic valve. The ascending aorta is
enlarged measuring 4.5 cm compared to a descending thoracic aorta diameter of
2.6 cm of the at the same level. In addition, the pulmonary artery is
enlarged measuring 4.3 cm suggestive of pulmonary arterial hypertension. The
heart demonstrates multichamber enlargement. There is no pericardial effusion
identified. Pacemaker leads are positioned within the right atrium and
ventricle.
Airways are normal to the subsegmental level; specifically, no bronchiectasis
identified. No cavitary lesions are present. Predominantly central
ground-glass peribronchovascular opacifications are noted, right greater than
left, with minimal if any with septal thickening. Of note abnormal lung
findings, right greater than left, have been present since ___, but always
with different configurations. Specifically, compared to the most recent
chest CT on ___, opacifications are less dense and smaller but more
numerous and with a greater distribution. No pleural effusion or pneumothorax
evident.
Limited assessment of the visualized aspects of the upper abdomen are
unremarkable. No osseous abnormality evident.
IMPRESSION:
1. Predominantly central, ___ bronchovascular opacification with changing
morphology and distribution across ___ years. Findings could be explained by
drug hypersensitivity/toxicity, pulmonary hemorrhage, including vasculitis,
e.g., ___ or Wegener's capillerites. No cavitating lesions,
bronchiectasis, or fibrosis.
2. Enlarged ascending aorta measuring 4.5cm
3. Pulmonary arterial hypertension.
4. Cardiomegaly.
5. Stable 2.1 cm left thyroid nodule, unchanged since ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: DYSPNEA, CELLULITIS
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, PNEUMONIA,ORGANISM UNSPECIFIED, CHRONIC AIRWAY OBSTRUCTION, HYPERTENSION NOS
temperature: 96.7
heartrate: 93.0
resprate: 20.0
o2sat: 97.0
sbp: 127.0
dbp: 95.0
level of pain: 6
level of acuity: 3.0 | ___ year old woman with a past medical history significant for
atrial fibrillation (on rivaroxaban), hyperlipidemia,
hypertension, hyperthyroidism, atrial tachycardia s/p pacemaker,
COPD, CVA, CHF, and tuberculosis who presents with several days
of worsening shortness of breath, with associated productive
cough, bilateral lower extremity swelling, and generalized
weakness, now improved:
#.Shortness of breath: Appears to be multifactorial etiology,
with elevated BNP, elevated JVP and ___ edema worsened from
recent discharge concerning for acute congestive heart failure.
In addition, cough productive of sputum, wheezing and chest xray
concerning for COPD exacerbation. Patient diuresed with IV lasix
and given IV solumedrol and xopenex nebs; she adamantly refused
all other meds. Also completed a five day course of
azithromycin. Repeat CXR concerning for cavitations is worrisome
given history of TB and persistent cough, CT scan done to r/o
further pathology. At the time of discharge, was 4kgs down, had
significantly reduced ___ edema.
#.Positive UA: No symptoms of dysuria or lower abdominal pain at
present, positive UA incidental finding in the absence of fever
or leukocytosis. Held off antibiotics for now, patient did
receive ceftriaxone in ED.
#.Atrial fibrillation: Rate controlled during hospitalization
with HR in ___ per tele. Continued xarelto renally dosed at 15mg
daily. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
penicillin G / ACE Inhibitors / ampicillin / ceftaroline fosamil
/ daptomycin
Attending: ___.
Chief Complaint:
Stroke/Seizure
Major Surgical or Invasive Procedure:
___
1. Redo sternotomy.
2. Redo aortic valve replacement with a 23 ___
Ease pericardial tissue valve serial number is ___, model
number is ___.
3. Removal of pacemaker.
4. Removal of pacemaker leads.
5. Placement of right ventricular epicardial leads.
History of Present Illness:
Mr. ___ is a ___ year old man with a history of prior GBS AV
endocarditis with
aortic root abscess status post aortic valve replacement on
___. His history is also notable for cerebrovascular
accident status post right carotid endarterectomy, complete
heart block status post permanent pacemaker placement. He was
recently hospitalized with a recent E. gallinarum bacteremia
with definitive prosthetic valve endocarditis s/p PPM
explantation f/b re-implantation on ___ and completion of 6
weeks of oritavancin for recurrent E. gallinarum bacteremia who
presents with seizure and concern for stroke.
He has a complicated infectious disease and cardiology history.
In brief, in ___ he developed GBS aortic valve endocarditis
complicated by an aortic root abscess which was treated with an
aortic valve replacement with a bioprosthetic valve. His post
operative course was complicated by AFib which was treated with
Amiodarone and resolved. In ___, the patient had multiple
episodes of syncope, at which time he was diagnosed with
intermittent complete heart block which was treated with a
pacemaker implantation. In ___, the patient was admitted with
E. Gallinarum bacteremia, with a TEE showing prosthetic valve
endocarditis. His pacemaker was extracted at this time and a
temporary screw was placed. He was originally treated with
ampicillin which resulted in eosinophila, and was then
discharged on Daptomycin and Ceftaroline for a planned ___eftaroline resulted in ___, and the patient completed
his 6 week course on Linezolid. On ___, the patient had
positive blood cultures suggesting relapsed E. Gallinarum
bacteremia. He was admitted at this time with high grade
bacteremia, and was treated Daptomycin and Ceftriaxone.
ID advocated for removal of his pacemaker and mechanical AV
given multiple recurrences of bacteremia, however an
interdisciplinary meeting was held with CT surgery and the
primary team, and the final plan was to complete treatment with
antibiotics and if there was relapse, to consider surgery at
that time. CT CAP, TEE, US of pacer leads, full body PET-CT, and
flexible sigmoidoscopy, all of which were non-revealing of a AVR
vs PPM vs occult source of infection. The patient completed the
course of Daptomycin and Ceftriaxone, however a second
morphology of E. Gallinarum was isolated which demonstrated
resistance to Daptomycin, and the patient was given an
additional course of Oritivancin therapy from ___.
On this admission, the patient was transferred from ___
___ for seizures and concern for CVA.
Today, the patient woke up and ate breakfast, after which point
he vomited and reported feeling unwell. He went back to sleep
and slept most of the day. He was waking up easily however,
responding to his wife, and his language was fluent. At 6pm, the
patient woke up to take a shower when he suddenly yelled for his
wife to come upstairs. When she came up, the patient was unable
to speak. According to reports from the OSH, he seemed to
recognize his wife but was not forming words. EMS was called and
the patient was taken to ___ in ___
where a code stroke was called.
The patient was about to have his CT/CTA head and neck done when
he had a witnessed GTC lasting ___ minutes, which aborting on
its own.
He was given 2mg of IV Ativan afterwards. He desaturated to the
___ and was somnolent. Intubation was attempted x2 but was
esophageal, after which the patient woke up, was tachcyardic to
the 100's, and speaking/awake, alert, so the patient was not
intubated. He had his CT which showed evidence of an old
infarct, but no acute bleed and was transferred to ___ for
further evaluation.
A code stroke was initiated when the patient arrived here. He
was
seen to be rigoring, febrile to 102.8, and vomiting bilious
fluid.
The patient was then transported to ___ where he was found to
have RUE pronator drift, altered mental status, temp of 102.8
and vomiting bilious emesis. A code stroke was called in the ED,
however an MRI was not obtained given the patient's pacemaker.
Neurology saw the patient and believed that seizures were likely
secondary to decreased threshold in the setting of an acute
infection. They recommended Keppra load of 1G, ASA 81, EEG
monitoring, MRI and if no evidence of stroke or aneurism on MRI,
to start a Heparin drip for concern of cardioembolic stroke in
the setting of AFib.
Cardiac surgery was reconsulted due to recurrent bacteremia
after
completion of antibiotics. Surgery and replacement of the AVR
was recommended.
Past Medical History:
- ___ GBS endocarditis with aortic root abscess secondary to
osteomyelitis infection, s/p AVR (23-mm SJM Trifecta tissue
valve) with moderate patient prosthesis mismatch.
-AF in the setting of AVR surgery.
- ___ Symptomatic carotid stenosis c/b R embolic CVA s/p R CEA
- Complete heart block with ___ pause s/p PPM ___.
- ?CHF
- Gallstone pancreatitis/cholangitis s/p CCY ___
- ___ Cervical Spine Decompression/Fusion
- ___ L5-S1 discectomy
Social History:
___
Family History:
Father - esophageal cancer
Mother - died at age ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: See MetaVision
GENERAL: Alert, oriented to person and place, but difficulty
remembering the date. No acute distress.
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, trace rales at the
bases. No wheezes
CV: Regular rate and rhythm. Normal S1 S2, systolic crescendo
decrescendo murmus, no rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No lesions.
NEURO: Alert and oriented to person and place, with some
difficulty remembering the date. Cranial nerves intact. Strength
and sensation intact in bilateral upper and slower extremities.
No pronator drift.
DISCHARGE PHYSICAL EXAM:
Vital signs
Neuro: PERRL, non focal, A&O x 3
Lungs: CTA decreased bases
CV: S1S2, no JVD, no murmur
Abd: soft + BS, +BM
ext: warm, +___dema, + pulse
Wounds: CDI
Pertinent Results:
ADMISSION LABS:
=================
___ 11:05PM BLOOD ___ PTT-24.0* ___
___ 11:05PM BLOOD Glucose-122* UreaN-19 Creat-1.6* Na-138
K-4.0 Cl-95* HCO3-22 AnGap-21*
___ 11:05PM BLOOD ALT-46* AST-93* AlkPhos-167* TotBili-1.2
___ 11:05PM BLOOD cTropnT-<0.01
___ 11:05PM BLOOD Glucose-112* Na-139 K-3.7 Cl-101
calHCO3-21
___ 11:34PM BLOOD Lactate-5.7*
IMAGING:
==========
Transesophageal Echocardiogram ___
Well-seated bioprosthetic AVR with mild-moderate paravalvular
regurgitation near the left coronary cusp. No vegetations or
abscess seen.
PET CT ___
1. New left greater than right inferior rectus muscle
heterogeneous fluid collections with focal FDG avidity
concerning for superinfection. Ultrasound could further
evaluate for drainable collection.
2. Post aortic valve replacement with nonspecific surrounding
FDG avidity.
3. Stable trace bilateral pleural effusions.
Abdominal Ultrasound ___
Redemonstrated left rectus muscle heterogeneous complex fluid
collection with increased central lignification which could
represent evolving hematoma or abscess.
Cardiac CT ___
1. No drainable fluid collection.
2. Approximately 1.8 cm pseudoaneurysm with peripheral
calcification, located between the RVOT and sinuses of Valsalva,
is grossly similar in retrospect to non ECG gated chest CT from
___.
3. Somewhat unusually turbulent flow of intravenous contrast
bolus in the
right atrium with question of central filling defect raises the
question of thrombus in the right atrium adjacent to the leads,
although this imaging finding may be artifactual. Normal
contrast flow and filling in the right ventricle.
Transthoracic Echocardiogram ___
The left atrial volume index is normal. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is ___ mmHg. Mild symmetric left ventricular
hypertrophy with normal cavity size, and regional/global
systolic function (biplane LVEF = X61X %). The right ventricular
cavity is moderately dilated with borderline normal free wall
function. A bioprosthetic aortic valve prosthesis is present.
The prosthetic aortic valve leaflets are thickened. The
transaortic gradient is higher than expected for this type of
prosthesis. The effective orifice area/m2 is severely depressed
(0.3; nl >0.9 cm2/m2) No masses or vegetations are seen on the
aortic valve. Moderate (2+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. No mass or vegetation is seen on the mitral
valve. Mild (1+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of tricuspid regurgitation may be
significantly UNDERestimated.] There is borderline pulmonary
artery systolic hypertension. No vegetation/mass is seen on the
pulmonic valve. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Bioprosthetic AVR with thickened leaflets and
elevated gradients. Moderate paravalvular aortic regurgitation.
No definite valvular endocarditis identified. Normal left
ventricular wall thickness, cavity size, and regional/global
systolic function. Mild mitral regurgitation. In the setting of
moderate paravalvular regurgitation, a trans-esophageal
echocardiogram is reasonable if clinically indicated to exclude
abscess. If clinically suggested, the absence of a vegetation by
2D echocardiography does not exclude endocarditis.
Carotid Ultrasound ___
Moderate homogeneous and heterogeneous atherosclerotic plaque in
the left
common carotid artery and bulb. However, no hemodynamically
significant
stenosis bilaterally (less than 40% on left, 0% on right).
Cardiac Catheterization ___
Dominance: Right
LMCA: normal
LAD: normal
LCX: normal
RCA: normal
Transesophageal Echocardiogram ___
PRE-BYPASS:
The left atrium is mildly dilated. No spontaneous echo contrast
is seen in the left atrial appendage. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The right
ventricular cavity is mildly dilated with normal free wall
contractility. There are focal calcifications in the aortic
arch. The prosthetic aortic valve leaflets are thickened. The
transaortic gradient is higher than expected for this type of
prosthesis. Aortic valve VTI = 70.3 cm. The effective orifice
area/m2 is severely depressed (0.5; nl >0.9 cm2/m2) A
paravalvular jet of mild aortic regurgitation is seen along the
left coronary cusp. No masses or vegetations are seen on the
aortic valve. The mitral valve leaflets are mildly thickened. No
mass or vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. No masses or vegetations are seen on the
tricuspid valve, but cannot be fully excluded due to suboptimal
image quality.
POST-BYPASS:
The patient is in an atrially-paced rhythm and receiving a
phenylephrine infusion.
1. Biventricular function remains preserved.
2. There has been interval replacement of the aortic valve
prosthesis (with a 23 mm ___ Ease) valve. The valve is
well-seated with normal leaflet motion. There is trivial
regurgitation (cannot ascertain intravalvular vs paravalvular).
Peak gradient across the valve is 32 mmg, mean gradient is 16
mmHg at a cardiac index of 2.7 L/min (by CCO ___). Effective
orifice area is 1.4 cm2 (0.7 cm2/m2, LVOT VTI = 24.6 cm, pAoV
VTI = 55 cm)
3. Remaining valvular function is unchanged.
4. The thoracic aorta is intact following decannulation.
___ PA&lat
Stable small bilateral pleural effusions with bibasilar
atelectasis most
likely related to congestive heart failure.
Stable position of the left-sided pacemaker
Dischage labs:
___ 02:54AM BLOOD WBC-15.2* RBC-2.78* Hgb-8.0* Hct-24.8*
MCV-89 MCH-28.8 MCHC-32.3 RDW-14.6 RDWSD-47.0* Plt ___
___ 04:04AM BLOOD WBC-13.1* RBC-2.79* Hgb-8.2* Hct-25.0*
MCV-90 MCH-29.4 MCHC-32.8 RDW-15.0 RDWSD-48.9* Plt Ct-93*
___ 04:10AM BLOOD Neuts-65.2 Lymphs-10.4* Monos-12.9
Eos-10.3* Baso-0.2 NRBC-0.5* Im ___ AbsNeut-8.53*
AbsLymp-1.36 AbsMono-1.69* AbsEos-1.35* AbsBaso-0.03
___ 04:30AM BLOOD Neuts-69.2 Lymphs-7.7* Monos-12.0
Eos-10.1* Baso-0.3 Im ___ AbsNeut-9.30* AbsLymp-1.04*
AbsMono-1.61* AbsEos-1.36* AbsBaso-0.04
___ 04:04AM BLOOD ___ PTT-29.4 ___
___ 02:54AM BLOOD Glucose-100 UreaN-10 Creat-1.1 Na-139
K-4.5 Cl-98 HCO3-31 AnGap-10
___ 03:59AM BLOOD Glucose-114* UreaN-10 Creat-1.0 Na-139
K-4.4 Cl-97 HCO3-31 AnGap-11
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Metoprolol Succinate XL 150 mg PO DAILY
3. Multivitamins 1 TAB PO BID
4. Omeprazole 20 mg PO BID
5. Pancrelipase 5000 2 CAP PO TID W/MEALS
6. Gabapentin 100 mg PO BID
7. Gabapentin 600 mg PO QHS
8. oritavancin 1200 mg intravenous Q48H
9. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Ampicillin 2 g IV Q4H
2. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
3. CefTRIAXone 2 gm IV Q12H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 grams every
twelve (12) hours Disp #*60 Intravenous Bag Refills:*0
4. Docusate Sodium 100 mg PO BID Duration: 30 Days
RX *docusate sodium [Docuprene] 100 mg 1 tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*0
5. Furosemide 40 mg PO BID
RX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*1
6. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
7. Metoprolol Tartrate 37.5 mg PO TID
RX *metoprolol tartrate 25 mg 1.5 tablet(s) by mouth three times
a day Disp #*150 Tablet Refills:*1
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN
BREAKTHROUGH PAIN
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
hold for loose stool
RX *polyethylene glycol 3350 [Purelax] 17 gram/dose 1 powder(s)
by mouth daily Disp #*30 Each Refills:*0
10. Potassium Chloride 20 mEq PO BID Duration: 7 Days
RX *potassium chloride 20 mEq 1 tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*1
11. Senna 17.2 mg PO DAILY
RX *sennosides [Senna Laxative] 8.6 mg 2 by mouth daily Disp
#*60 Tablet Refills:*1
12. Tamsulosin 0.4 mg PO QHS Duration: 1 Month
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
13. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
14. Atorvastatin 80 mg PO QPM
15. Gabapentin 600 mg PO QHS
16. Multivitamins 1 TAB PO BID
17. Omeprazole 20 mg PO BID
18. Pancrelipase 5000 2 CAP PO TID W/MEALS
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
==================
Seizure
S. viridens bacteremia
Stroke
History of AV endocarditis s/p Bioprosthetic Aortic Valve
Secondary Diagnosis:
====================
Hyperlipidemia
Gastroesophageal Reflux Disord
Discharge Condition:
Alert and oriented x3 non-focal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema 2+
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with endocarditis, stroke// mycotic aneusryms?
stroke?
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 8 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: Prior CTA done ___ at 19:03
FINDINGS:
Motion artifact degrades the diagnostic quality of the imaging.
There is a 3 mm foci of slow diffusion in the left cerebellar hemisphere
(series 6, image 7). No associated T2 or FLAIR hyperintensity.. Evidence of
old wedge-shaped infarct in the posterior left parietal area with cortical
laminar necrosis as well as associated blooming artifact resulting on
artifactual increase in signal on the DWI sequence. A couple of 2 mm round
foci of blooming artifact the right frontal superior and middle gyri.
Periventricular and deep white matter and pontine T2 and FLAIR
hyperintensities are nonspecific, but most likely sequela of microangiopathy.
The intracranial arteries demonstrate normal T2 flow void. The mild mucosal
thickening involving the paranasal sinuses. The orbits appear normal. There
is no abnormal enhancement after contrast administration.
IMPRESSION:
1. There is a 3 mm focus of slow diffusion in the left cerebellar hemisphere
(series 6, image 7). No associated T2 or FLAIR hyperintensity suggesting this
is a hyperacute infarct (but please note that small infarcts may sometimes be
difficult to see on the T2 and FLAIR images).
2. Left parietal chronic infarction.
3. White matter hyperintensities most likely reflecting sequela of
microangiopathy.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 5:33 pm, 3 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: SECOND OPINION CT NEUROPSO1CT
INDICATION: History: ___ with stroke, endocarditis// CTA HEAD and Neck,
?mycotic aneursyms
TECHNIQUE: CTA head and neck performed at outside institution
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: Prior CT chest done ___
FINDINGS:
Motion artifact degrades the diagnostic quality of the imaging.
CT HEAD WITHOUT CONTRAST:
There is no evidence of acute infarction, hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration. Wedge-shaped
hypodensity in the posterior left parietal lobe most likely representing a
chronic infarct.
Mucous retention cyst present in the right frontal and right maxillary sinus.
Mild mucosal thickening involving the ethmoid air cells.. The visualized
portion of the orbits are unremarkable.
CTA HEAD and neck:
Mild atherosclerotic changes of the aortic arch. Three-vessel arch.
The vessels of the circle of ___ and their principal intracranial branches
are patent with no evidence of stenosis, occlusion, or aneurysm. Mild to
moderate atherosclerotic changes of the carotid siphons. Fetal origin of the
right PCA. The left vertebral artery terminates as the ___. The dural
venous sinuses are patent.
Calcific atherosclerotic changes involving the carotid bulbs bilateral (left
more than right) but no significant stenosis according to NASCET criteria/less
than 50%.
Evidence of prior sternotomy. Right prepectoral pacemaker in situ. Evidence
of prior C4 to C6 posterior cervical spine decompression. Nasogastric tube
terminates in the hypopharynx. Retained secretions present in the trachea.
No suspicious pulmonary nodules or masses. No suspicious thyroid nodules.
IMPRESSION:
1. Mild atherosclerotic changes of the carotid bulbs, but this is not
significant by NASCET criteria.
2. Mild to moderate atherosclerotic changes involving the carotid siphons.
3. No intracranial aneurysm.
4. Wedge-shaped hypodensity in the posterior left parietal lobe most likely
representing a chronic infarct.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with GNR sepsis, likely endocarditis, presenting
with weakness, SOB// Concern for volume overload Concern for volume
overload
IMPRESSION:
Comparison to ___. Stable alignment of the sternal wires. Stable
position of the pacemaker leads. Borderline size of the cardiac silhouette.
No pulmonary edema. No pleural effusions. No pneumonia.
Radiology Report
INDICATION: ___ year old man with pacemaker, history of endocarditis,
presenting with seizures// H12 series
TECHNIQUE: Portable supine abdominal radiographs
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
Air is seen throughout the small and large bowel in a nonspecific pattern.
There are no abnormally dilated loops of large or small bowel. A small amount
of stool is seen within the rectum.
Multiple round densities are seen in the right lower quadrant, likely ingested
pills.
Supine assessment limits evaluation for free intraperitoneal air, although no
gross pneumoperitoneum is seen.
There are mild degenerative changes of the lumbar spine.
A small phlebolith is seen in the lower right hemipelvis. Moderate
atherosclerotic calcification is seen in the aortoiliac distribution. There
are no unexplained soft tissue calcifications or radiopaque foreign bodies.
The partially imaged lower lungs are grossly clear without pleural
abnormalities. The 4 inferior-most sternotomy wires are midline and intact.
The leads of the cardiac defibrillator device terminate within the right
atrium and right ventricle.
IMPRESSION:
1. Nonspecific, nonobstructive bowel gas pattern.
2. Multiple round densities in the right lower quadrant likely represent
ingested pills.
Radiology Report
EXAMINATION: US ABDOMINAL WALL, SOFT TISSUE LEFT
INDICATION: ___ year old man with h/o endocarditis and strep viridians blood
stream infection with PET positive for rectus abdominus muscle fluid
collection concerning for infection.// scouting scan of the rectus abdominus
muscles to look for tapable pocket-- planning scan per ___ team ___,
___ ___.
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the anterior abdominal and pelvic wall.
COMPARISON: PET-CT from ___
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
anterior abdominal and pelvic wall.
Heterogeneous expansion of bilateral rectus abdominus muscles are identified
below the umbilicus, left larger than the right. No fluid collection is
identified. Rectus abdominus muscle is expanded to thickness measuring 1.8 cm
on the right and 2.8 cm on the left.
IMPRESSION:
Heterogeneous expansion of bilateral rectus abdominus muscles below the
umbilicus, left larger than the right, likely reflects intramuscular
hematomas. No drainable fluid collection is identified.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new picc// L picc 50cm Contact name: sal,
___: ___ L picc 50cm
IMPRESSION:
Compared to a chest radiographs ___.
Left PIC line passes as far asm level of the superior cavoatrial junction
where it is partially obscured by indwelling transvenous right atrial right
ventricular pacer leads.
Normal cardiomediastinal and hilar silhouettes. Pleural effusions small on
the left if any. No pneumothorax. Lungs well expanded and clear.
Radiology Report
EXAMINATION: US ABDOMINAL WALL, SOFT TISSUE RIGHT
INDICATION: ___ year old man with PET with uptake of FDG in rectus muscle and
prior US demonstrating likely hematoma with ongoing, unimproved abdominal
pain.// interval changes in hematoma
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the a left abdominal wall.
COMPARISON: Abdominal ultrasound from ___.
PET-CT from ___.
FINDINGS:
Again seen in the left rectus muscle is a heterogeneous complex fluid
collection which measures approximately 5.7 x 2.7 x 2.6 cm, difficult to truly
compare based on differences in scan plane and measurement. There is interval
increased central cystic component. No significant peripheral hyperemia
noted.
IMPRESSION:
Redemonstrated left rectus muscle heterogeneous complex fluid collection with
increased central lignification which could represent evolving hematoma or
abscess.
Radiology Report
EXAMINATION: CARDIAC STRUCTURE/MORPH, 3D, FUNCTION
INDICATION: ___ year old man with history of aortic root abscess and
endocarditis in past with persistent bacteremia concerning for ongoing
endocarditis/aortic root abscess// ECG gated CT; evaluation of aortic root
abscess
TECHNIQUE: 320-slice multi-detector CT angiogram of the heart and aorta was
obtained from below the aortic arch to the upper abdomen using ECG gating,
with 80 cc Omnipaque contrast administered intravenously. Multiplanar
reformatted images were created on a separate workstation and reviewed.
The patient's heart rate was continuously monitored by a nurse. Prior to this
study, the heart rate was 74 beats per min and the blood pressure was 146/73
mm Hg.
Procedure complications/allergic reactions: none
DOSE: Total DLP: 268.83 mGy-cm
COMPARISON: CT chest ___
FINDINGS:
MEDIASTINUM: No mediastinal mass or lymphadenopathy identified.
HILA: No hilar lymphadenopathy.
Imaged portion of the lungs:
1. PARENCHYMA: No focal consolidation.
2. AIRWAYS: The airways are patent to subsegmental levels.
3. VESSELS: The great vessels are normal caliber.
PLEURA: Left pleural effusion is trace. No right pleural effusion. No
pneumothorax.
CHEST CAGE: No concerning lytic or sclerotic lesion. No acute fracture.
Patient is status post median sternotomy.
CHEST WALL: Imaged soft tissues are unremarkable.
IMAGED UPPER ABDOMEN: Unremarkable.
CARDIAC: There is a right chest cardiac device with lead tips in the right
atrium and right ventricle. There is somewhat unusually turbulent flow of
intravenous contrast bolus in the right atrium with question of central
filling defect. The right atrium is dilated. The right ventricle is normal.
The left atrium is mildly dilated. The left ventricle is normal. The
pericardium is normal and there is no pericardial effusion. The aortic valve
is is tricuspid with leaflet thickening. Approximately 1 x 1.8 cm
pseudoaneurysm with peripheral calcification, located between the RVOT and
sinuses of Valsalva (2:106), is grossly similar in retrospect to ___.
Dominance of the coronary artery system is left with normal origins and
course. Coronary artery calcification is moderate.
PULMONARY ARTERIES: The main, right, and left pulmonary arteries are normal
and appear patent to the segmental level without filling defects.
AORTA: The imaged portion of the thoracic aorta is normal.
IMPRESSION:
1. No drainable fluid collection.
2. Approximately 1.8 cm pseudoaneurysm with peripheral calcification, located
between the RVOT and sinuses of Valsalva, is grossly similar in retrospect to
non ECG gated chest CT from ___.
3. Somewhat unusually turbulent flow of intravenous contrast bolus in the
right atrium with question of central filling defect raises the question of
thrombus in the right atrium adjacent to the leads, although this imaging
finding may be artifactual. Normal contrast flow and filling in the right
ventricle.
RECOMMENDATION(S): Echocardiogram for evaluation of the right atrium adjacent
to the leads.
NOTIFICATION: The impression and recommendation were discussed with ___
___, M.D. by ___, M.D. on the telephone on ___ at 2:44 pm, 25
minutes after discovery of the findings.
Radiology Report
INDICATION: ___ year old man with endocarditis going for valve replacement and
epicardial lead placement on ___// Pre op xray Surg: ___
(Valve replacement)
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
IMPRESSION:
Right-sided pacemaker is unchanged.Small left pleural effusion is stable.
Cardiomediastinal silhouette is unchanged. No pneumothorax is seen Left-sided
PICC line projects to the SVC. There is no evidence of pulmonary edema
Radiology Report
EXAMINATION: Carotid Doppler Ultrasound
INDICATION: ___ year old man with presumed AV endocarditis with plan for AV
replacement. Preop carotid study
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: None
FINDINGS:
RIGHT:
The right carotid vasculature has no atherosclerotic plaque.
The peak systolic velocity in the right common carotid artery is 61 cm/sec.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 76, 92, and 101 cm/sec, respectively. The peak end
diastolic velocity in the right internal carotid artery is 33 cm/sec.
The ICA/CCA ratio is 1.7.
The external carotid artery has peak systolic velocity of 62 cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has moderate heterogeneous atherosclerotic plaque
in common carotid artery and moderate heterogeneous plaque in the left carotid
bulb.
The peak systolic velocity in the left common carotid artery is 103 cm/sec.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 96, 105, and 74 cm/sec, respectively. The peak end
diastolic velocity in the left internal carotid artery is 30 cm/sec.
The ICA/CCA ratio is 1.0.
The external carotid artery has peak systolic velocity of 100 cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
Moderate homogeneous and heterogeneous atherosclerotic plaque in the left
common carotid artery and bulb. However, no hemodynamically significant
stenosis bilaterally (less than 40% on left, 0% on right).
Radiology Report
EXAMINATION: Portable x-ray
INDICATION: ___ year old man with s/p Redo AVR// cardiac surgery fast track.
eval for ptx, effusions. call ___ house officer at ___ if there is any
concern with findings Contact name: ___ house officer, ___: ___
TECHNIQUE: Portable chest x-ray
COMPARISON: Comparisons include chest x-ray done on ___.
FINDINGS:
There is a left-sided PICC which terminates in the proximal to mid SVC.
However the distal catheter appears kinked in the SVC. Unchanged position
monitoring and supportive devices which include chest tubes and Swan-Ganz
catheter. Comparing to prior chest x-ray done on ___ the
defibrillator has been removed lung volumes of low. There is increased
pulmonary vascular congestion and mild pulmonary edema. There is bibasal
atelectasis. Cardiomediastinal silhouette is stable. Sternal wires are
intact and aligned. There are no new opacifications. There are several
radiopaque lines overlying the patient.
IMPRESSION:
The left-sided PICC which terminates in the proximal to mid SVC and appears
kinked at the distal end.
Unchanged position of monitoring and support devices which include chest tube,
Swan-Ganz catheter, ET tube.
There is increased pulmonary vascular congestion and mild pulmonary edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p redo sternotomy, tiss AVr, PPM removal new
lead placement// eval for pneumothorax s/p CT removal eval for
pneumothorax s/p CT removal
IMPRESSION:
All monitoring and support devices have been removed, with the exception of
the left PICC line. The tip of the line is likely coiled in the azygos vein.
There is no evidence of pneumothorax. Small left pleural effusion with
retrocardiac atelectasis. Minimal fluid overload but no overt pulmonary
edema.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with malpositioned PICC.// PICC pulled back
2cm/power flushed to get out of azygous. Please read for tip position.
___ ___
IMPRESSION:
In comparison with the earlier study of this date, the tip of the PICC line is
now in the lower SVC.
Otherwise little change.
Radiology Report
INDICATION: ___ year old man PPM implant// lead and generator position
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are low volume with small bilateral effusions with bibasilar
atelectasis. Cardiomediastinal silhouette is stable. Left-sided PICC line
projects to the cavoatrial junction. A left-sided pacemaker has been placed
in the interim with the lead projecting to the right ventricle. No
pneumothorax is seen. There is mild pulmonary vascular congestion and
bibasilar atelectasis
Radiology Report
EXAMINATION: The chest radiograph AP and lateral.
INDICATION: ___ year old man with AVR/pacer// interval change in vol overload
TECHNIQUE: Chest AP and lateral
COMPARISON: Comparison included study done on ___.
FINDINGS:
Low lung volumes and stable, bibasilar atelectasis. Small bilateral pleural
effusions with bibasilar atelectasis are unchanged. Cardiomediastinal
silhouette is unchanged. Hilar and mediastinal contours are normal. There is
no pneumothorax. Left pacer lead terminates at the right atrium.
IMPRESSION:
Stable small bilateral pleural effusions with bibasilar atelectasis most
likely related to congestive heart failure.
Stable position of the left-sided pacemaker
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CVA, Seizure, Transfer
Diagnosed with Oth generalized epilepsy, not intractable, w/o stat epi, Altered mental status, unspecified
temperature: 99.3
heartrate: 109.0
resprate: 24.0
o2sat: 96.0
sbp: 129.0
dbp: 86.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a ___ year old man with a complicated past medical
history. He was recently treated for gallinarum bacteremia. He
presented to an OSH with seizure and concern for stroke. He was
noted to have a generalized tonic clonic seizure at the OSH and
again on presentation to ___. He was evaluated by Neurology
and Keppra was initiated for seizure management. CT head
completed at the OSH was negative for acute hemorrhage but
notable for an area of old infarct. An MRI on presentation was
notable for hyper acute left cerebellar hemisphere. Due to
concern for respiratory compromise, he was transferred to the
ICU. He was febrile on admission and given his significant
infectious history an echocardiogram was obtained and
demonstrated concerns for a paravalvular abscess. Per ID
recommendation, he was initiated on Linezolid. He was
subsequently transferred to the ___ service for
further valvular evaluation. A transesophageal echocardiogram on
___ revealed no paravalvular abscess. LP completed ___ was
without obvious signs of infection. Given concern for patient's
persistently altered mental status an EEG was initiated on ___
which demonstrated no further seizure activity. Further
infectious work up yielded s. viridens bacteremia and he was
treated for this. An echocardiogram on ___ was significant
for moderate paravalvular aortic regurgitation. with no definite
valvular endocarditis identified. Cardiac surgery was consulted
and he underwent routine preoperative testing and evaluation. He
was evaluated by the dental service and underwent simple
extraction of tooth #5 on ___. He was cleared for
surgery. He was taken to the operating room on ___ and
underwent redo sternotomy, redo aortic valve replacement, and
placement of new epicardial leads. Please see operative note for
full details. He tolerated the procedure well and was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
Pt was weaned from sedation, awoke neurologically intact, and
was extubated on POD1. He was not started on betablocker due to
CHB history and absence of PPM. Epicardial wires remained in
place. He was diuresed toward his preoperative weight. He
remained hemodynamically stable and was transferred to the
telemetry floor for further recovery on POD1. He was followed
closely by the cardiology service. Patient underwent PPM om
___ and was started on Lopressor. He was evaluated by the
physical therapy service for assistance with strength and
mobility. Foley was re-inserted and Flomax initiated for urinary
retention. He subsequently passed a void trial. ID continued to
follow and the patient transitioned to Ampicillin/Ceftriaxone
regimen post-op. He is to continue antibiotic therapy though
___. PICC in place. Will need CBC with diff/chem 7/LFTs/CRP
twice a week per ID.
By the time of discharge on POD 7 pt was ambulating freely, all
wounds were healing, and pain was controlled with oral
analgesics. Pt was discharged to home in good condition with
appropriate follow up instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Motrin / morphine / codeine / Penicillins / Ativan
Attending: ___.
Chief Complaint:
fever, confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with history of asthma presents with temp of 101 and
concern for confusion. Two days prior to admission, patient
developed a sore throat and became fatigued. She stayed at her
mother's house and notably slept a lot. She had a fever to 100.3
at the time which did not resolved with tylenol. She developed
joints pains and aches all over. She was unable to tolerate food
or drink on ___. Her mother noted that she was not herself
and was speaking slowly and asking where she was. She developed
a fever to 101 the day prior to admission. She also developed
yellow/bloody rhinorrhea and a cough. The patient has not had
any sick contacts. She had a recent GI illness with N/V/D for
three days last weekend and many people at work had the same
symptoms. No N/V/D currently. She attended a concert with a
friend ___ night and felt well.
In the ED, initial vitals were:
00:16 T 99.7 HR 90 BP 143/81 RR 20 O2 98% 0; Tmax 100 while in
ED.
- Labs were signfiicant for wbc 9.9 with lactate 1.0.
- CXR showed no acute process and imaging of soft tissues of
neck was unremarkable
- LP was performed showing 3wbc, 92 lymphs, 29 protein, 61glc.
- Patient was given 1g vanc, 1g po tylenol, and 25mcg IV
fentanyl.
On the floor, initial vitals were:
Today 05:54 0 98.5 84 142/57 16 98% RA
Patient described feeling tired and achey but otherwise okay.
She was alert and oriented x 3. Throat is painful with
swallowing only. Denies any palpitations, CP, SOB. Mild frontal
headache at times. She is not sexaully active. No tobacco, ETOH,
or drug use.
ROS:
(+) Per HPI
(-) Denies recent weight loss or gain. 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:
Asthma
Congenital deformity of left arm
Fracture of left arm s/p surgical fixation
Social History:
___
Family History:
Mother with sjogrens
Physical Exam:
ADMSSION PHYSICAL EXAM:
VS: T: 98.9 BP 136/58 HR 66 RR 20 O2 100RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD, tenderness all anterior
neck
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, left arm short
SKIN: no rashes
NEURO: pupils equally reactive but R>L, EOMI, face symmetric,
strength intact, follows commands
DISCHARGE PHYSICAL EXAM:
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD, tenderness all anterior
neck
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, left arm short
SKIN: no rashes
NEURO: pupils equally reactive but R>L, EOMI, face symmetric,
strength intact, follows commands, visual fields intact, visual
acuity intact
Pertinent Results:
ADMISSION LABS:
___ 02:00AM BLOOD WBC-9.9 RBC-4.46 Hgb-12.7 Hct-38.0 MCV-85
MCH-28.5 MCHC-33.4 RDW-12.4 RDWSD-38.7 Plt ___
___ 02:00AM BLOOD Neuts-78.5* Lymphs-11.8* Monos-8.8
Eos-0.2* Baso-0.4 Im ___ AbsNeut-7.75* AbsLymp-1.17*
AbsMono-0.87* AbsEos-0.02* AbsBaso-0.04
___ 02:00AM BLOOD ___ PTT-28.0 ___
___ 02:00AM BLOOD Glucose-94 UreaN-8 Creat-0.7 Na-135 K-3.4
Cl-101 HCO3-21* AnGap-16
___ 02:19AM BLOOD Lactate-1.0
DISCHARGE LABS:
___ 07:20AM BLOOD WBC-5.4 RBC-4.54 Hgb-12.8 Hct-39.9 MCV-88
MCH-28.2 MCHC-32.1 RDW-12.7 RDWSD-40.5 Plt ___
___ 07:20AM BLOOD Glucose-80 UreaN-8 Creat-0.7 Na-135 K-4.6
Cl-102 HCO3-22 AnGap-16
___ 07:20AM BLOOD Calcium-9.3 Phos-3.1 Mg-1.9
MICRO:
___ 02:00AM URINE Color-Yellow Appear-Clear Sp ___
___ 02:00AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-80 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 02:00AM URINE RBC-1 WBC-3 Bacteri-FEW Yeast-NONE Epi-<1
___ 02:00AM URINE UCG-NEGATIVE
___ 02:57AM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1* Polys-0
___ ___ 02:57AM CEREBROSPINAL FLUID (CSF) TotProt-29 Glucose-61
___ 2:57 am CSF;SPINAL FLUID LP TUBE # 3.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
___ 2:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
IMAGING:
Neck Xray:
No tracheal narrowing or thickening of the prevertebral soft
tissues is noted.
CXR:
No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Acetaminophen 1000 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: viral illness
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: NECK SOFT TISSUES
INDICATION: History: ___ with sore throat // eval for rpa
COMPARISON: No comparison
IMPRESSION:
No tracheal narrowing or thickening of the prevertebral soft tissues is noted.
Radiology Report
INDICATION: Evaluate for pneumonia in a patient with fever.
COMPARISON: None available.
FINDINGS:
Frontal and lateral chest radiographs demonstrate a normal cardiomediastinal
silhouette and fairly well-aerated lungs which are without focal
consolidation, pleural effusion, or pneumothorax. The visualized upper
abdomen is unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness, Sore throat
Diagnosed with FEVER, UNSPECIFIED, ALTERED MENTAL STATUS
temperature: 99.7
heartrate: 90.0
resprate: 20.0
o2sat: 98.0
sbp: 143.0
dbp: 81.0
level of pain: 13
level of acuity: 2.0 | ___ female with history of asthma admitted with temp to 101,
mild confusion, and body aches. She had an LP in the ED due to
concern for confusion which was unremarkable. Patient was A&Ox3
while inpatient. She had a mild fever, sore throat, rhinorrhea,
cough, fatigue and body aches which was likely secondary to a
viral illness. She was starting to feel better and tolerating a
regular diet on day of discharge. Has a history of asthma but no
symptoms during admission. She was discharged to stay with her
mother. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Amoxicillin / metformin
Attending: ___.
Chief Complaint:
right abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ female with history of
ulcerative colitis, tracheomalacia s/p tracheobronchoplasty,
COPD
on home O2, and aortic regurgitation who presents with abdominal
pain and diarrhea for 3 days. Four weeks ago, she reports onset
of diffuse achy lower back and abdominal pain that was
intermittent for several weeks. However, starting three days
ago,
she reports onset of a new, diffuse abdominal cramping that
started in the lower abdomen subsequently migrating to the upper
abdomen. She reports associated multiple bouts of non-bilious,
non-bloody emesis as well as melena after eating cabbage and
beans. The pain has evolved to a constant achy pain worst on the
right side at time of evaluation today. She labels the pain a 5
out of 10 of severity. She has not vomited since ___ and has
since been able to tolerate a regular diet. She reports some
dysuria and a possible "orange"-colored urine. No history of
kidney stones. No fevers or chills. She reports this episode is
unlike her usual UC flares when she instead has high-frequency
of
loose stools with bright red blood, which she currently denies.
Past Medical History:
COPD (on 2L home O2)
Asthma
Allergic rhinitis
Atopic dermatitis
HTN
AoRegurgitation
Major Depressive Disorder with Psychotic Features
History of Polysubstance Abuse, primarily Cocaine
Anxiety Disorder NOS with Situationally Bound Panic Attacks with
Agoraphobia
Polysubstance abuse hx
Ulcerative colitis
menorrhagia
GERD
OSA
Narcolepsy
Right humerus fx
Social History:
___
Family History:
No family hx of cancer or CAD or DVT/PE. Mother with DM and
emphysema + tobacco use. She died of carbon monoxide poisoning.
She doesn't know what diseases her father had. Her brother is in
good health.
Physical Exam:
General- well-appearing, obese, NAD, not jaundiced
HEENT- PERRL, EOMI, sclera anicteric, moist mucus membranes
Cardiac- RRR
Chest- CTAB
Abdomen- No bowel sounds, soft, diffuse mild tenderness to deep
palpation, worst in RLQ, positive Rovsing sign. No rebound or
guarding. Negative psoas or obdurator sign.
Back- Bilateral mild CVA tenderness
Ext- WWP, 1+ edema
Discharge Physical:
VS: 98.0PO 120 / 71 93 18 97 2L
Gen: sitting at edge of bed, dressed, NAD
Pulm: faint wheeze
Card:HRR
Abd: soft, obese, mild TTP in LLQ
Ext: baseline pedal edema
Pertinent Results:
___ 04:00AM BLOOD WBC-6.3 RBC-3.88* Hgb-10.6* Hct-33.3*
MCV-86 MCH-27.3 MCHC-31.8* RDW-14.8 RDWSD-45.8 Plt ___
___ 04:04AM BLOOD WBC-5.8 RBC-3.64* Hgb-10.0* Hct-31.3*
MCV-86 MCH-27.5 MCHC-31.9* RDW-14.7 RDWSD-46.7* Plt ___
___ 03:55AM BLOOD WBC-6.6 RBC-3.81* Hgb-10.3* Hct-32.9*
MCV-86 MCH-27.0 MCHC-31.3* RDW-14.8 RDWSD-47.2* Plt ___
___ 03:42AM BLOOD WBC-7.0 RBC-3.84* Hgb-10.4* Hct-33.3*
MCV-87 MCH-27.1 MCHC-31.2* RDW-14.9 RDWSD-47.7* Plt ___
___ 06:05PM BLOOD WBC-8.1 RBC-4.59 Hgb-12.4 Hct-39.4 MCV-86
MCH-27.0 MCHC-31.5* RDW-14.7 RDWSD-46.1 Plt ___
___ 04:00AM BLOOD Glucose-144* UreaN-9 Creat-0.7 Na-141
K-4.2 Cl-102 HCO3-28 AnGap-11
___ 04:04AM BLOOD Glucose-114* UreaN-10 Creat-0.7 Na-142
K-4.4 Cl-103 HCO3-28 AnGap-11
___ 03:55AM BLOOD Glucose-127* UreaN-8 Creat-0.7 Na-141
K-3.8 Cl-101 HCO3-28 AnGap-12
___ 03:42AM BLOOD Glucose-105* UreaN-9 Creat-0.7 Na-143
K-3.9 Cl-105 HCO3-28 AnGap-10
___ 06:05PM BLOOD Glucose-190* UreaN-13 Creat-0.9 Na-141
K-4.9 Cl-103 HCO3-22 AnGap-16
___ 04:00AM BLOOD ALT-113* AST-45* AlkPhos-199* TotBili-0.2
___ 09:50AM BLOOD ALT-129* AST-42* AlkPhos-209* TotBili-0.3
___ 04:04AM BLOOD ALT-128* AST-41* AlkPhos-200* TotBili-0.2
___ 03:55AM BLOOD ALT-162* AST-31 AlkPhos-221* TotBili-0.4
___ 03:42AM BLOOD ALT-216* AST-54* AlkPhos-241* TotBili-0.4
___ 04:00AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.8
___ 04:04AM BLOOD Calcium-8.5 Phos-4.1 Mg-2.0
___ 03:55AM BLOOD Calcium-8.6 Phos-4.5 Mg-2.2
Imaging:
___ Liver US:
1. Echogenic liver consistent with steatosis. Other forms of
liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot
be excluded on the basis of this examination.
2. No evidence of biliary pathology.
___ CT A/P:
Acute uncomplicated appendicitis.
___ MRCP:
1. Cholelithiasis. No evidence of choledocholithiasis.
2. No focal liver lesions or abnormal hepatic parenchymal
signal.
Medications on Admission:
1. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl
[Cipro] 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp
#*24 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO TID RX *metronidazole 500 mg 1
tablet(s) by mouth three times a day Disp #*42 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheeze
5. Atorvastatin 20 mg PO QPM
6. FLUoxetine 60 mg PO DAILY
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. Lisinopril 20 mg PO DAILY
10. Mesalamine ___ 1600 mg PO TID
11. Modafinil 100 mg PO DAILY
12. Montelukast 10 mg PO DAILY
13. Omeprazole 20 mg PO BID
14. Theophylline SR 300 mg PO BID
15. Tiotropium Bromide 1 CAP IH DAILY
16. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*24 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*42 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheeze
5. Atorvastatin 20 mg PO QPM
6. FLUoxetine 60 mg PO DAILY
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. Lisinopril 20 mg PO DAILY
10. Mesalamine ___ 1600 mg PO TID
11. Modafinil 100 mg PO DAILY
12. Montelukast 10 mg PO DAILY
13. Omeprazole 20 mg PO BID
14. Theophylline SR 300 mg PO BID
15. Tiotropium Bromide 1 CAP IH DAILY
16. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ hx ulcerative colitis, tracheomalcia s/p
tracheobronchoplasty, aortic regurg, COPD (home O2) p/w 3 days of abdominal
pain, new transaminitis, CT c/f acute appendicitis for reason of
transaminitis.
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 13 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
Lower Thorax: The lung bases are clear.
Liver: The liver is normal in morphology and signal intensity. There is no
significant drop of signal on out-of-phase imaging to suggest steatosis. No
focal liver lesions are seen. There is no ascites.
Biliary: There is cholelithiasis. No MR evidence of acute cholecystitis.
There is no intra or extrahepatic biliary duct dilation. No evidence of
choledocholithiasis.
Pancreas: The pancreas is normal in morphology and signal intensity. There are
no focal pancreatic lesions. There is no pancreatic duct dilation.
Spleen: The spleen is normal in size. Note is made of a small accesory
spleen.
Adrenal Glands: The right and left adrenal glands are unremarkable.
Kidneys: The kidneys are symmetric in size. No focal renal lesion is seen.
Gastrointestinal Tract: There is no hiatal hernia. Views of the small and
large bowel are unremarkable.
Lymph Nodes: There is no mesenteric or retroperitoneal adenopathy.
Vasculature: There is no abdominal aortic aneurysm. Hepatic arterial anatomy
is conventional. Portal vein is patent.
Osseous and Soft Tissue Structures: There is no suspicious bony lesion. Note
is made of asymmetric atrophy of the right greater than left body wall
musculature.
IMPRESSION:
1. Cholelithiasis. No evidence of choledocholithiasis.
2. No focal liver lesions or abnormal hepatic parenchymal signal.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with Unspecified acute appendicitis
temperature: 98.9
heartrate: 118.0
resprate: 16.0
o2sat: 98.0
sbp: 122.0
dbp: 72.0
level of pain: 6
level of acuity: 3.0 | The patient is a ___ female with history of ulcerative
colitis, tracheomalacia s/p tracheobronchoplasty, COPD on home
O2, and aortic regurgitation who presented with abdominal pain
and diarrhea for 3 days consistent with appendicitis. Her
appendicitis was treated non operatively with cipro and flagyl.
An MRCP was done for concern for PSC in the setting of
ulcerative colitis. GI was also consulted for elevated LFTs.
They recommended an MRCP which showed a normal liver,
cholelithasis, and no choledocholithiasis. Hepatitis panel which
was also negative. On day of discharge, the patient was not
having any nausea, vomiting. She was tolerating PO pain meds and
LFTs were downtrending. The patient was discharged from the
hospital in stable condition on 2 weeks of antibiotics. She was
scheduled for follow up in ___ clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain, fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with a history of hypertension, GERD,
dyslipidemia, remote bowel resection for colonic lipoma and
peptic ulcer disease s/p vagotomy (in ___ who presents with
abdominal pain. 2 weeks ago, the patient developed gradual
onset
abdominal pain which is been waxing and waning but overall
constant per report. He says it is been nonradiating. The pain
is intermittently on the left, right and center, but typically
is
around the umbilical level. The pain is not associated with
p.o.
intake or improved by p.o. The pain is not improved or worsened
by movement or exercise. The pain is typically dull but gets
sharp when he presses and he occasionally has sharp pains that
have woken him from sleep. He has had nausea without vomiting.
He intermittently has small bowel movements which are at his
baseline and he denies any hematochezia or melena. He has also
had intermittent fevers for the past 3 days up to 38.5 °C
yesterday. He has had no difficulty with urination or blood in
his urine. Denies chest pain, shortness of breath,
palpitations,
cough, or lightheadedness. He denies any headache or double
vision. He denies any testicular pain or penile discharge. No
recent travel and no sick contacts. He has been taking Aleve
for
the pain, which is mildly effective.
His prior encounters at ___ are notable for an admission to
general surgery in ___ for abdominal cramping and blood per
rectum for 6 weeks. He had a laparoscopy sigmoid colectomy with
removal of sigmoid mass. Pathology revealed that the mass was a
lipoma. He also presented to ___ ED in ___ with rectal
bleeding. His evaluation was benign and he was discharged to the
care of his PCP.
- In the ED, initial vitals were:
T 95.8F HR 104 BP 142/83 RR 20 100% RA
- Exam was notable for:
"Diffuse abd ttp wo peritonitic signs, worse on R."
- Labs were notable for:
WBC 18 Hgb 12.9 Plt 355
BMP overall unremarkable
ALT 59 Alk phos 156 AST 37 T bili 0.4
INR 1.3
UA w/ small ketones, urobil, and RBCs
- Studies were notable for:
CT Abd/Pelv w/ contrast:
Significant wall thickening of the terminal ileum, cecum, and
proximal
ascending: With surrounding fat stranding and prominent
ileocolic
lymph nodes, suggestive of terminal ileitis; however, an
underlying mass cannot be excluded. The appendix is normal.
Recommend follow-up CT or colonoscopy once the acute process
resides to ensure resolution and exclude an underlying mass.
- The patient was given:
3L LR
IV Morphine Sulfate 4 mg
IV Ampicillin-Sulbactam 3 g
PO Acetaminophen 1000 mg
On arrival to the floor, he reports some continued abdominal
pain
around his umbilicus and in the right lower quadrant. There is
some radiation to the back from this. He thinks that some of
his
nausea was attributable to the NSAIDs and Tylenol he was taking.
He otherwise does not have any current symptoms.
Past Medical History:
Hypertension
GERD
Peptic ulcer disease s/p vagotomy
Sigmoid lipoma s/p partial sigmoid colectomy (___)
Dyslipidemia
Social History:
___
Family History:
CAD, HTN
Physical Exam:
ADMISSION PHYSICAL EXAM
==========================
VITALS:
___ 2335 Temp: 98.1 PO BP: 134/82 HR: 89 RR: 18 O2 sat: 92%
O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Somewhat hyperactive bowel sounds, non distended,
mildly
tender to deep palpation throughout, more so in the right lower
quadrant. No peritoneal signs.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE PHYSICAL EXAM
==========================
VITALS:
24 HR Data (last updated ___ @ 1855)
Temp: 99.5 (Tm 99.5), BP: 137/90 (125-139/87-90), HR: 88
(84-94), RR: 18 (___), O2 sat: 97% (95-97), O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowel sounds, non distended, mildly tender to
deep palpation throughout, more so in the right lower quadrant.
No peritoneal signs.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
Pertinent Results:
ADMISSION LABS
=================
___ 12:00PM BLOOD WBC-18.0* RBC-4.59* Hgb-12.9* Hct-39.7*
MCV-87 MCH-28.1 MCHC-32.5 RDW-14.0 RDWSD-44.5 Plt ___
___ 12:00PM BLOOD Neuts-84.9* Lymphs-4.7* Monos-9.6
Eos-0.2* Baso-0.2 Im ___ AbsNeut-15.24* AbsLymp-0.85*
AbsMono-1.73* AbsEos-0.04 AbsBaso-0.03
___ 12:00PM BLOOD ___ PTT-41.0* ___
___ 12:00PM BLOOD Glucose-111* UreaN-14 Creat-0.9 Na-142
K-4.8 Cl-103 HCO3-25 AnGap-14
___ 12:00PM BLOOD ALT-59* AST-37 AlkPhos-156* TotBili-0.4
___ 12:00PM BLOOD Albumin-3.7
___ 12:00PM BLOOD CRP-179.0*
PERTINENT LABS
=================
___ 05:10AM BLOOD ALT-88* AST-91* AlkPhos-176* TotBili-0.6
___ 05:02AM BLOOD ALT-61* AST-31 LD(LDH)-189 AlkPhos-152*
TotBili-0.3
___ 05:10AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.8 Iron-20*
___ 05:10AM BLOOD calTIBC-264 Ferritn-477* TRF-203
___ 05:02AM BLOOD Hapto-510*
___ 05:10AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG IgM HAV-NEG
___ 08:10PM BLOOD CMV IgG-POS* CMV IgM-POS* CMVI-In the app
EBV IgG-POS* EBNA-POS* EBV IgM-PND EBVI-PND
___ 08:10PM BLOOD CMV VL-NOT DETECT
___ 08:10PM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY
IGM-PND
___ 08:10PM BLOOD YERSINIA ENTERCOLITICA ANTIBODIES
(IGG,IGA)-PND
DISCHARGE LABS
=================
___ 06:43AM BLOOD WBC-10.2* RBC-4.33* Hgb-12.2* Hct-37.8*
MCV-87 MCH-28.2 MCHC-32.3 RDW-14.3 RDWSD-46.3 Plt ___
___ 06:43AM BLOOD Glucose-106* UreaN-13 Creat-1.0 Na-142
K-5.4 Cl-102 HCO3-25 AnGap-15
IMAGING
=================
CT A/P ___
IMPRESSION:
1. Marked wall thickening of the terminal ileum in very distal
ileum and wall
thickening to a lesser extent involving the cecum and proximal
ascending
colon. 5 x 4.0 cm region of likely phlegmon superior to the
thickened
terminal ileum. Numerous associated mildly prominent likely
reactive right
abdominal ileocolic lymph nodes. Consultation of findings most
compatible
with terminal ileitis and associated phlegmonous change.
Differential
diagnosis includes inflammatory bowel disease, including Crohn's
disease,
other inflammatory process, versus infectious ileitis. No free
air or
extraluminal oral contrast seen. No drainable collection.
2. Normal caliber appendix.
RECOMMENDATION(S): Recommend follow-up CT or colonoscopy once
the acute
process resides to ensure resolution and exclude an underlying
mass.
RUQUS ___
IMPRESSION:
1. Normal appearance of the liver parenchyma. No focal liver
lesions are
identified.
2. Nondistended gallbladder with trace wall edema versus
pericholecystic
fluid. Findings may be related to third spacing. No other
sonographic
findings to suggest cholecystitis.
MICROBIOLOGY
================
___ 10:26 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
Medications on Admission:
None
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO BID Duration: 7 Days
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*14 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*21 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
===================
Terminal Ileitis
SECONDARY DIAGNOSIS
======================
Peptic Ulcer Disease
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 hx bowel resection here w fevers, diffuse abdominal pain
worst on RLQ/RUQ.//eval bowel obstruction vs appy vs biliary infection vs
other infectious process
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP =
8.4 mGy-cm.
2) Spiral Acquisition 6.4 s, 50.1 cm; CTDIvol = 10.7 mGy (Body) DLP = 537.5
mGy-cm.
Total DLP (Body) = 546 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: 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. There is marked wall
thickening of the terminal and very distal ileum and wall thickening to a
lesser extent involving the cecum and proximal ascending colon. A 5 x 4.0 cm
region likely phlegmonous changes seen superior to the thickened terminal
ileum, series 601, image 28. Numerous associated mildly prominent and likely
reactive right lower quadrant ileocolic lymph nodes are seen. No free air or
drainable fluid collection is seen. The appendix is normal in caliber.
Patient is status post partial sigmoid resection, with anastomosis seen.
PELVIS: The urinary bladder and distal ureters are unremarkable.
LYMPH NODES: Prominent right ileocolic lymph nodes, likely reactive.
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: Bilateral fat containing inguinal hernias are seen.
IMPRESSION:
1. Marked wall thickening of the terminal ileum in very distal ileum and wall
thickening to a lesser extent involving the cecum and proximal ascending
colon. 5 x 4.0 cm region of likely phlegmon superior to the thickened
terminal ileum. Numerous associated mildly prominent likely reactive right
abdominal ileocolic lymph nodes. Consultation of findings most compatible
with terminal ileitis and associated phlegmonous change. Differential
diagnosis includes inflammatory bowel disease, including Crohn's disease,
other inflammatory process, versus infectious ileitis. No free air or
extraluminal oral contrast seen. No drainable collection.
2. Normal caliber appendix.
RECOMMENDATION(S): Recommend follow-up CT or colonoscopy once the acute
process resides to ensure resolution and exclude an underlying mass.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with transaminitis and abdominal pain of unclear
etiology// eval for cause of transaminitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis performed ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 4 mm
GALLBLADDER: The gallbladder is not distended. There is trace wall edema
versus pericholecystic fluid, possibly related to third spacing.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 9.2 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 11.2 cm
Left kidney: 11.2 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Normal appearance of the liver parenchyma. No focal liver lesions are
identified.
2. Nondistended gallbladder with trace wall edema versus pericholecystic
fluid. Findings may be related to third spacing. No other sonographic
findings to suggest cholecystitis.
Gender: M
Race: WHITE - RUSSIAN
Arrive by WALK IN
Chief complaint: Abd pain, Fever
Diagnosed with Crohn's disease of small intestine without complications
temperature: 95.8
heartrate: 104.0
resprate: 20.0
o2sat: 100.0
sbp: 142.0
dbp: 83.0
level of pain: 4
level of acuity: 3.0 | SUMMARY
===============
___ male with a history of GERD, peptic ulcer s/p vagotomy, and
sigmoid lipoma s/p partial sigmoid colectomy (___) who
presented with fevers and abdominal pain with features of
enterocolitis noted on imaging. He was started on ciprofloxacin
and flagyl with improvement in his symptoms. He was seen by
gastroenterology, who recommended outpatient colonoscopy for
further follow up.
TRANSITIONAL ISSUES
=====================
[] At time of discharge, patient did not have an outpatient
colonoscopy scheduled but had been ordered. Please confirm with
patient that this has been scheduled for the next few weeks
after he completes course of antibiotics.
[] Patient with " Marked wall thickening of the terminal ileum
in very distal ileum and wall thickening to a lesser extent
involving the cecum and proximal ascending
colon. 5 x 4.0 cm region of likely phlegmon superior to the
thickened terminal ileum." found on CT A/P. Recommend that
patient has a follow up CT or colonoscopy once the acute process
resides to ensure resolution and exclude underlying mass.
[] Patient discharged on ciprofloxacin and flagyl for a 10 day
course scheduled to end ___.
[] Patient found to be CMV IGM and IGG positive. Per GI, there
was no indication for antiviral treatment or colonoscopy at this
time because patient is immunocompetant. GI will follow with
outpatient colonoscopy.
[] Recommend outpatient vaccination for hepatitis.
ACUTE ISSUES
=================
# Terminal ileitis
He presented with 2 weeks of abdominal pain and intermittent
fevers and was found on imaging to have findings consistent with
terminal ileitis. This is typically associated with Crohn's
disease although there are other associated conditions such as
ulcerative colitis, infection or less likely NSAID ileitis. CRP
at admission was elevated to 179. He was started on cipro and
flagyl with improvement in his abdominal pain. GI was consulted
and recommended sending off serologies. At the time of
discharge, patient was noted to be CMV IgM positive, IgG
positive, EBV IgG positive. Per GI, since patient was
immunocompetant, they believed this was likely infectious and
recommended continuing antibiotics and setting up an outpatient
colonoscopy once the infection resolved.
# Mild normocytic anemia
Suspect reactive from illness however pt has prior hx of BRBPR
iso lipoma. Low iron. Hemolysis labs negative. No evidence of
active bleeding.
# Mild transaminitis
Initially presented with transaminitis that improved by
discharge. RUQUS negative for biliary process. Likely secondary
to infection as above. Hepatitis panels negative. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Doxycycline / erythromycin base / Penicillins
Attending: ___.
Chief Complaint:
rash
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ year old F with breast cancer with mets to the liver, spine,
and brain who is on Herceptin/Pertuzumab/Paclitazel and on
dexamethasone daily s/p prior whole brain radiation who presents
with painful rash in the R leg. Per family, rash developed about
a week ago and has been painful and itchy. Pt brought to the ED
where the rash was concerning for disseminated Zoster, so she
was
admitted for further care.
On arrival to the floor, pt is not a good historian, but reports
symptoms from rash for about a day w/ burning pain. No fevers or
chills. No vision changes. No headache or neck stiffness. No
auditory changes or dizziness. No cough or dyspnea.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___ Liver biopsy
Pathology: Metastatic carcinoma with focal necrosis, consistent
with a breast origin, focally positive for mammoglobin and
GCDFP, and negative for TTF-1 and Napsin, ER-/PR-/Her2+
___ Right mastectomy Pathology: Invasive ductal carcinoma
(palliative for extensive lesion of right chest wall with
ulcerations Dr. ___
___ Trastuzumab
___ Trastuzumab
___ Paclitaxel-trastuzumab at 60% dosing ___ elevated LFTs
and jaundice. Continued weekly trastuzumab + paclitaxel with
gradual escalation to 80mg/m2.
___ Paclitaxel-trastuzumab
___ Paclitaxel-trastuzumab
___ Trastuzumab
___ Brain MRI negative
___ Paclitaxel-trastuzumab
___ Trastuzumab
___ Poor balance and fatigue started
___ Fall
___ Brain MRI showed many lesions
___ - ___ Whole brain radiation-C2 5x4 Gy
___ - ___ XRT to T8-L2 5x4 Gy
___ Trastuzumab
___ Trastuzumab
___ Brain MRI improved
___ Trastuzumab
___ Taxol/Pertuzumab
PAST MEDICAL HISTORY:
Painful bladder syndrome s/p DMSO instillations
Recurrent UTIs
HTN
DM2
HBV on entecavir
Social History:
___
Family History:
No history of malignancy or bleeding disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM
======================
Vitals: 97.7 154/90 66 18 100 RA
GENERAL: NAD
HEENT: no conjunctival injection, pupils equal and reactive
NECK: supple neck
LUNGS: faint bibasilar rales
CV: regular
ABD: soft, nontender, nondistended
EXT: no edema
SKIN: vesicular rash in different stages of evolution w/ few
vesicles present on inner thigh on erythematous background w/
other crusted vesicles present throughout proximal thigh, above
the knee and up to the groin - crossing L1-L3 dermatome
ACCESS: R port
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 97.9 (afebrile overnight) 119 / 70 79 18 99 RA
I/O: residual of 33cc following urinating
GENERAL: Sitting comfortably in chair, NAD, appears alert
HEENT: Anicteric sclera, MMM, OP clear, no sign of thrush,
round
face
NECK: supple, no LAD
LUNGS: CTAB, no wheezes/crackles, breathing comfortably on RA
CARD: RRR, S1 + S2 present, no m/r/g
ABD: soft, non-distended, mild TTP in central lower abdomen,
+BS,
no HSM
EXT: WWP, no ___ edema, PPP
SKIN: R thigh zoster lesions healing well with no purulence. R
thigh has superficial erosion c/w skin breakdown, with no
purulence.
Back: Mepilex in place
ACCESS: Port c/d/1, no erythema or tenderness around port. No
drainage.
Pertinent Results:
ADMISSION LABS
====================
___ 06:05PM BLOOD WBC-5.3 RBC-3.22* Hgb-10.8* Hct-34.6
MCV-108* MCH-33.5* MCHC-31.2* RDW-16.9* RDWSD-67.4* Plt ___
___ 06:05PM BLOOD Neuts-88* Bands-2 Lymphs-5* Monos-4*
Eos-0 Baso-0 ___ Metas-1* Myelos-0 AbsNeut-4.77
AbsLymp-0.27* AbsMono-0.21 AbsEos-0.00* AbsBaso-0.00*
___ 06:05PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-1+* Microcy-NORMAL Polychr-NORMAL
___ 06:05PM BLOOD Plt Smr-NORMAL Plt ___
___ 06:05PM BLOOD Glucose-227* UreaN-17 Creat-0.4 Na-141
K-4.1 Cl-103 HCO3-24 AnGap-14
___ 06:05PM BLOOD ALT-41* AST-21 AlkPhos-69 TotBili-0.4
___ 06:05PM BLOOD Albumin-3.6
___ 05:00AM BLOOD HBV VL-NOT DETECT
___ 02:11AM BLOOD Type-CENTRAL VE Temp-37.8 pO2-70*
pCO2-53* pH-7.33* calTCO2-29 Base XS-0 Comment-GREEN TOP
___ 02:11AM BLOOD Lactate-2.6*
MICROBIOLOGY
============
Blood culture (___): Negative
Skin scraping VZV culture (___): Negative
URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000
CFU/mL.
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-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING
=======
CT Head (___):
1. Study is mildly degraded by motion.
2. No evidence of hemorrhage or definite acute large territorial
infarct.
3. Vasogenic edema in the left occipital lobe related to known
metastatic lesion is grossly unchanged in comparison with MRI
from ___.
4. Known metastatic lesions are better evaluated on brain MRI
from ___.
5. Probable posttreatment changes in the subcortical white
matter, as
described, with differential consideration of vasogenic edema.
Allowing for difference in technique, finding is grossly similar
to ___ prior brain MRI.
6. Left maxillary periodontal disease, as described.
CXR (___)
In comparison with the study of ___, the cardiac silhouette
is at the upper limits of normal in size and there is mild
tortuosity of the descending aorta. No evidence of appreciable
pulmonary vascular congestion. Mild atelectatic changes are
seen at the bases with blunting of the right costophrenic angle.
No evidence of acute focal pneumonia.
MRI Head (___)
1. Enlargement of innumerable enhancing cortical lesions
compatible with a history of metastatic disease.
2. Increased periventricular white matter hyperintensity that
may be treatment related.
3. Increased edema surrounding the left frontal and occipital
metastases.
DISCHARGE LABS
==============
WBC-11.2* RBC-3.06* Hgb-10.2* Hct-32.5* MCV-106* MCH-33.3*
MCHC-31.4* RDW-17.9* RDWSD-69.2* Plt ___
Neuts-74* Bands-7* Lymphs-7* Monos-3* Eos-0 Baso-0 Atyps-0
Metas-7* Myelos-2* NRBC-1* AbsNeut-9.07* AbsLymp-0.78*
AbsMono-0.34 AbsEos-0.00* AbsBaso-0.00*
Plt Smr-NORMAL Plt ___
Hypochr-NORMAL Anisocy-OCCASIONAL Poiklo-1+* Macrocy-1+*
Microcy-NORMAL Polychr-1+* Ovalocy-1+* Tear ___ UreaN-23* Creat-0.7 Na-144 K-4.6 Cl-102 HCO3-22
AnGap-20*
Calcium-9.3 Phos-4.1 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. Lidocaine 5% Patch 1 PTCH TD DAILY
3. Ondansetron ODT 8 mg PO Q12H:PRN Nausea
4. OxyCODONE SR (OxyconTIN) 30 mg PO Q12H
5. Prochlorperazine 10 mg PO Q6-8H:PRN nausea
6. Lisinopril 10 mg PO DAILY
7. OxyCODONE (Immediate Release) 15 mg PO Q4H:PRN Pain -
Moderate
8. Dexamethasone 2 mg PO DAILY
9. Entecavir 0.5 mg PO DAILY
10. Cyclobenzaprine 10 mg PO DAILY:PRN neck pain
11. Spironolactone 25 mg PO BID
12. MethylPHENIDATE (Ritalin) 5 mg PO BID
13. OxyCODONE SR (OxyconTIN) 15 mg PO NOON
14. Senna 8.6 mg PO BID
15. Docusate Sodium 100 mg PO BID
16. Multivitamins 1 TAB PO DAILY
17. Ensure (food supplemt, lactose-reduced) 1 can oral TID
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*14 Tablet Refills:*0
2. Gabapentin 200 mg PO TID
RX *gabapentin 100 mg 2 capsule(s) by mouth three times a day
Disp #*100 Capsule Refills:*0
3. LevETIRAcetam 1000 mg PO Q12H
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Metoclopramide 10 mg PO QIDACHS HA
RX *metoclopramide HCl 10 mg 1 tab by mouth twice a day Disp
#*60 Tablet Refills:*0
5. Dexamethasone 1 mg PO DAILY
RX *dexamethasone 1 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*30
Tablet Refills:*0
7. OxyCODONE SR (OxyconTIN) 30 mg PO QAM
RX *oxycodone [OxyContin] 30 mg 1 tablet(s) by mouth daily in
the morning Disp #*7 Tablet Refills:*0
8. OxyCODONE SR (OxyconTIN) 20 mg PO QPM
RX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth at night
Disp #*7 Tablet Refills:*0
9. OxyCODONE SR (OxyconTIN) 10 mg PO NOON
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth daily at
noon Disp #*7 Tablet Refills:*0
10. Citalopram 20 mg PO DAILY
11. Cyclobenzaprine 10 mg PO DAILY:PRN neck pain
12. Docusate Sodium 100 mg PO BID
13. Ensure (food supplemt, lactose-reduced) 1 can oral TID
14. Entecavir 0.5 mg PO DAILY
15. Lidocaine 5% Patch 1 PTCH TD DAILY
16. Lisinopril 10 mg PO DAILY
17. MethylPHENIDATE (Ritalin) 5 mg PO BID
18. Multivitamins 1 TAB PO DAILY
19. Ondansetron ODT 8 mg PO Q12H:PRN Nausea
20. Prochlorperazine 10 mg PO Q6-8H:PRN nausea
21. Senna 8.6 mg PO BID
22. Spironolactone 25 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Disseminated Herpes Zoster
Metastatic Breast Cancer
Hypernatremia
Oral candidiasis
Anemia
SECONDARY DIAGNOSIS
===================
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ year old woman with with metastatic breast cancer on
Herceptin, Pertuzumab, and Paclitazel who is also immunosuppressed with
chronic dexamethasone who is admitted for treatment of disseminated zoster.//
History of metastatic breast cancer. Please evaluate for interval change.
Please also evaluate for ?encephalitis/meningitis in setting of disseminated
zoster.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 6 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: Brain MR ___.
FINDINGS:
Again seen are innumerable cortical enhancing masses located in the supra and
infratentorial compartments. Most of these lesions were identified
previously. However, several are new and almost all have enlarged since the
prior study. Of course, the new lesions may have been present on the prior
study, but too small to reliably detect.
The superficial pattern of these lesions is unchanged and suggests a component
of leptomeningeal infiltration. There is no evidence of hemorrhage or
infarction.
Diffuse periventricular white matter hyperintensity appears to have progressed
since the study of ___, this may be treatment related. Left posterior
frontal and left occipital regions of edema are more prominent on the current
examination than on ___.
IMPRESSION:
1. Enlargement of innumerable enhancing cortical lesions compatible with a
history of metastatic disease.
2. Increased periventricular white matter hyperintensity that may be treatment
related.
3. Increased edema surrounding the left frontal and occipital metastases.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with metastatic breast cacner admitted with
disseminated zoster. Hypotensive and obtunded// Eval etiology of hypotension.
IMPRESSION:
In comparison with the study of ___, the cardiac silhouette is at the
upper limits of normal in size and there is mild tortuosity of the descending
aorta. No evidence of appreciable pulmonary vascular congestion. Mild
atelectatic changes are seen at the bases with blunting of the right
costophrenic angle.
No evidence of acute focal pneumonia.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with breast cancer, brain metastases. Now with
apneic periods, low RR// please eval for hemorrhage or edema
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) = 856 mGy-cm.
COMPARISON: ___ contrast brain MRI.
___ noncontrast head CT.
FINDINGS:
Study is mildly degraded by motion.
There is no evidence of acute hemorrhage. There remains vasogenic edema
within the left occipital lobe. Diffuse subcortical white matter
hypodensities corresponds to T2 and FLAIR hyperintensities on MRI. The known
innumerable metastatic lesions are not well appreciated on noncontrast CT, and
are better evaluated on brain MRI from ___. The ventricles and
sulci are grossly stable in size and configuration.
There is no evidence of fracture. Mild mucosal thickening is noted in the
maxillary sinuses and anterior ethmoid air cells, 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. Limited
imaging the teeth demonstrate left maxillary tooth periapical lucency (see
11:21; 10:20).
IMPRESSION:
1. Study is mildly degraded by motion.
2. No evidence of hemorrhage or definite acute large territorial infarct.
3. Vasogenic edema in the left occipital lobe related to known metastatic
lesion is grossly unchanged in comparison with MRI from ___.
4. Known metastatic lesions are better evaluated on brain MRI from ___.
5. Probable posttreatment changes in the subcortical white matter, as
described, with differential consideration of vasogenic edema. Allowing for
difference in technique, finding is grossly similar to ___ prior
brain MRI.
6. Left maxillary periodontal disease, as described.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Rash
Diagnosed with Rash and other nonspecific skin eruption
temperature: 98.3
heartrate: 80.0
resprate: 16.0
o2sat: 100.0
sbp: 152.0
dbp: 84.0
level of pain: 6
level of acuity: 3.0 | Ms. ___ is a ___ year-old female with metastatic breast cancer
(liver, brain, and spinal cord) previously on Herceptin,
Pertuzumab, and Paclitaxel admitted for treatment of
disseminated zoster, and found to have progressive CNS disease. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
LINQ placement by cardiac electrophysiologists
History of Present Illness:
Mr. ___ is a ___ year old male with history of HCV Cirrhosis
complicated by ascites s/p TIPS, hepatic encephalopathy who was
taken off of the transplant list in ___ due to multiple DVTs
found on his previous admission, on Fondaparinux, presents from
OSH after a fall.
He woke up in the middle of the night to go to the bathroom, and
suddenly fell. He denies lightheadedness, dizziness,
palpitations when he stood up. No prodrome symptoms. Did not
think he tripped over anything. He did not lose conciousness per
the wife who woke up when he fell. She is not sure what he hit,
but there was a drawer and the edge of a wall tha the could have
hit. He was awake right after the fall but was having difficulty
answering her questions for about a minute. She felt a large
bruise on the occipital area of the patient's head. She did not
witness any seizure like activities, stool or urine
incontinence.
He went to ___ in ___ where CT head
showed small subarachnoid hemorrhage. XR and CT of the shoulder
with right distal clavicle fracture, acromion fracture, AC joint
separation, glenoid fracture. He is transfered to BI per the
wife's request.
Of note he was discharged from rehab two weeks ago. He had
presistent cough since discharge though no fever or shortness of
breath. He saw his PCP ___ week ago and was started on Cefprozil
250mg Q12H. He hasn't felt a significant change in his cough
over the last week but he has noticed a significant increase in
his BMs. He was having ___ BM watery BMs a day up from his
baseline of ___ loose BMs a day and has been intermittently
refusing lactulose. Despite worsening diarrhea, patient denied
ever feeling lightheaded or dizzy.
After he was discharged from home, he was able to ambulate
without any assistance at home. Per the wife, he was not
unsteady.
In the ED, initial vitals: 97.2 77 100/63 16 99% RA
Labs were significant for baseline CBC, INR, BUN/Cr of ___.
T bili slighly up from discharge of 2.3.
Imaging showed stable SAH.
Currently, patient c/o of right shoulder pain but otherwise feel
well.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No cough, no
shortness of breath, no dyspnea on exertion. No chest pain or
palpitations. No nausea or vomiting. No constipation. No dysuria
or hematuria. No hematochezia, no melena. No numbness or
weakness, no focal deficits.
Past Medical History:
- HCV cirrhosis (Secondary to blood transfusion following a
stabbing in the ___ c/b ascites, hepatic hydrothorax s/p
TIPS in ___
- Upper Extremity DVT ___ L jugular and subclavian, ___ L
subclavian and R basilic, on coumadin)
- Alpha Thalessemia Minor? (Not confirmed)
- paroxysmal AFib
- Right upper extremity DVT, Left upper extremity DVT (___)
- Likely Pulmonary Embolus as evidence of right heart strain on
echocardiogram (___).
- Small left frontal subarachnoid hemorrhage following syncopal
event (___)
- Right upper extremity DVT that developed while hospitalized in
___ this DVT developed while anticoagulation was being held
___ small traumatic SAH following syncopal event (___).
- Wide-complex ventricular tachycardia noted during
hospitaliztion in ___. LINQ placed by EP.
Social History:
___
Family History:
No family hx of Colon CA, Liver CA, DM or early CAD. No known
family members with hemochromatosis.
Physical Exam:
ADMISSION PHYSICAL EXAM (___):
VS: 99.5 102/71 68 18 97%RA
GEN: Alert and oriented, lying still in bed in no acute
distress, flat affect
HEENT: MMM, OP clear, neck supple, JVP not elevated.
COR: RRR, nl s1 s2, ___ holosystolic murmur
PULM: mildly decreased in lower quadrants but otherwise clear
ABD: Soft, non-tender, non-distended, no shifting dullness, no
spider angiomas
EXTREM: Warm, well-perfused, no edema. Right arm in sling. Right
shoulder tender to palpation. able to move fingers of right
hand.
PULSES: radial and DP pulses present bilaterally
NEURO: A&Ox3. CN II-XII grossly intact (unable to do right
shoulder shrug because of pain), strength ___ in both hands. Did
not test right upper ext. stregth. LUE ___. Bilateral lower
extremities ___ strength. Sensation to soft touch throughout.
Gait defered. Positive asterixis.
DISCHARGE PHYSICAL EXAM (___):
Vitals: 98.3 BP 99/62 HR 61 R 20 O2 100% RA.
General: Alert and oriented, lying in bed w/ c-collar and right
arm sling in place, appears comfortable.
HEENT: C-collar in place, anicteric sclera.
Lungs: Clear to auscultation bilaterally.
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur, no
rubs or gallops
CHEST: Tenderness to palpation at right lower ribs, left lower
ribs.
Abdomen: Soft, non-tender, no rebound tenderness or guarding
Ext: Right arm mildly swollen, resting flexed at the elbow in
sling, range of motion limited by pain. Right forearm is
non-tender. Ecchymoses over posterior right shoulder. All
extremities are well perfused, no leg edema.
Neuro: Not moving right arm at the shoulder ___ shoulder
injuries. Sensation/motor function intact in all distal
extremities. Positive asterixis.
Skin: Tanned skin.
Pertinent Results:
ADMISSION LABS:
================
___ 08:15AM BLOOD WBC-7.7 RBC-4.63 Hgb-10.9* Hct-33.4*
MCV-72* MCH-23.5* MCHC-32.6 RDW-15.9* RDWSD-38.7 Plt Ct-88*#
___ 08:15AM BLOOD Neuts-76.2* Lymphs-10.9* Monos-11.0
Eos-0.9* Baso-0.5 Im ___ AbsNeut-5.88 AbsLymp-0.84*
AbsMono-0.85* AbsEos-0.07 AbsBaso-0.04
___ 08:15AM BLOOD ___ PTT-37.3* ___
___ 08:15AM BLOOD Glucose-226* UreaN-19 Creat-0.7 Na-133
K-5.0 Cl-99 HCO3-25 AnGap-14
___ 08:15AM BLOOD ALT-28 AST-32 AlkPhos-94 TotBili-3.0*
___ 08:15AM BLOOD Lipase-22
___ 08:15AM BLOOD cTropnT-<0.01
___ 05:43AM BLOOD cTropnT-<0.01
___ 04:10PM BLOOD cTropnT-<0.01
___ 08:15AM BLOOD Albumin-2.8* Calcium-8.9 Phos-3.0 Mg-1.6
___ 08:29AM BLOOD Lactate-2.1*
DISCHARGE LABS:
================
___ 05:25AM BLOOD WBC-5.4 RBC-4.56* Hgb-10.3* Hct-32.6*
MCV-72* MCH-22.6* MCHC-31.6* RDW-16.3* RDWSD-39.9 Plt ___
___ 05:25AM BLOOD ___ PTT-41.1* ___
___ 05:25AM BLOOD Glucose-166* UreaN-12 Creat-0.6 Na-135
K-4.0 Cl-99 HCO3-32 AnGap-8
___ 05:25AM BLOOD ALT-25 AST-21 AlkPhos-144* TotBili-1.9*
___ 05:25AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.8
MICROBIOLOGY:
==============
___ Blood culture pending
___ Urine culture negative
___ Blood culture negative
___ C. diff negative
___ Urine culture negative
___ Blood culture negative
IMAGING:
=========
CT Head (___):
IMPRESSION:
1. No evidence of new hemorrhage, infarcts, or fractures.
2. Interval improvement of layering intermediate density fluid
within the
bilateral maxillary sinuses.
Cardiac MR (___):
IMPRESSION:
Please note that this report only contains extracardiac
findings.
There is moderate gynecomastia. An enlarged 22 x 13 mm
pretracheal
mediastinal lymph node is nonspecific. There are bibasilar
opacities and a moderate-sized bilateral pleural effusions,
similar to the prior CT of the abdomen and pelvis. The right is
slightly loculated. The liver has a cirrhotic morphology with
evidence of iron deposition. A TIPSS is partially imaged. The
spleen is enlarged, but not included in the entire field of
view. There is a small amount of ascites. These findings are
better characterized on the prior CT of the abdomen.
The entirety of this Cardiac MRI is reported separately in the
Electronic
Medical Record (OMR) - Cardiovascular Reports.
CT Head (___):
IMPRESSION:
1. Stable small left frontal probable subarachnoid hemorrhage as
described. Recommend clinical correlation and attention on
followup imaging
2. No additional areas of hemorrhage.
3. Right parietal convexity soft tissue swelling, without
evidence of
underlying fracture.
4. Paranasal sinus disease as described.
CT C-Spine (___):
IMPRESSION:
1. No evidence of acute fracture or traumatic malalignment.
2. Moderate degenerative changes as described.
3. Question minimal C2 on C3 anterolisthesis. While this
finding may be
degenerative in nature, given the absence of any prior
comparison examination, ligamentous injury cannot be excluded on
the basis examination. Recommend clinical correlation for site
of tenderness. If clinically indicated, MRI of cervical spine
may be obtained for further evaluation.
RECOMMENDATION(S): Question minimal C2 on C3 anterolisthesis.
While this
finding may be degenerative in nature, given the absence of any
prior
comparison examination, ligamentous injury cannot be excluded on
the basis examination. Recommend clinical correlation for site
of tenderness. If clinically indicated, MRI of cervical spine
may be obtained for further evaluation.
MRI C-Spine (___):
IMPRESSION:
1. No evidence of epidural fluid collection or cord signal
abnormalities in the cervical spine.
2. Interspinous ligament edema at C2 through C5, suggestive of
ligamentous injury/sprain.
3. Trace prevertebral T2 signal between C2-C5, which may
represent minimal edema versus a small amount of non-specific
fluid, without evidence of ALL disruption. No airway narrowing.
4. Multilevel multifactorial degenerative changes throughout
the cervical spine, resulting in up to mild spinal canal
narrowing at C5-C6 and C6-C7.
CT A/P (___):
IMPRESSION:
1. No acute intra-abdominal or intrapelvic process.
2. Cirrhotic liver with associated varices, splenomegaly and
trace ascites is demonstrated, not significantly increased from
___. TIPS remains in unchanged position, however patency of
the hepatic vasculature is not well assessed on this single
phase examination.
3. Moderate bilateral pleural effusions and consolidative
opacities involving the bilateral lower lobes. There are
multiple hypodensities within the right lower lobe
consolidation, suggesting possible infection.
4. Minimally displaced posterior rib fractures of the ninth and
tenth ribs on the right.
RUE Ultrasound (___):
IMPRESSION:
Severely limited study due to patient positioning inability to
move the right arm. There is a nonocclusive thrombus in one of
the right brachial veins, which is not compressible.
TTE (___):
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. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systoilc
function. Moderate tricuspid regurgitation. Mild pulmonary
hypertension.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
OTHER RELEVANT LABS:
=====================
___ 05:45AM BLOOD calTIBC-105* Ferritn-408* TRF-81*
___ 05:45AM BLOOD TSH-6.7*
___ 05:45AM BLOOD T4-4.3*
___ 05:25AM BLOOD Cortsol-4.5
___ 05:10AM BLOOD 25VitD-21*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Lactulose ___ mL PO TID
3. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain
4. Spironolactone 100 mg PO DAILY
5. Rifaximin 550 mg PO BID
6. Fondaparinux 7.5 mg SC DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Bisacodyl 10 mg PR QAM constipation
9. Glargine 22 Units Breakfast
Glargine 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. cefprozil 250 mg oral Q12H
Discharge Medications:
1. Bisacodyl 10 mg PR QAM constipation
2. Fondaparinux 7.5 mg SC DAILY
3. Furosemide 20 mg PO DAILY
4. Glargine 22 Units Breakfast
Glargine 26 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Lactulose ___ mL PO TID
6. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q6h prn Disp #*15
Tablet Refills:*0
7. Rifaximin 550 mg PO BID
8. Spironolactone 50 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Lidocaine 5% Patch 2 PTCH TD QAM
11. Calcium Carbonate 1500 mg PO DAILY
12. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
===================
Syncope
Subarachnoid hemorrhage
C-spine ligamentous injury
Shoulder fractures
SECONDARY DIAGNOSES:
=====================
Cirrhosis
Atrial fibrillation
Wide-complex ventricular tachycardia
Type II diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Requires right shoulder sling for multiple right shoulder
fractures and C-collar for ligamentous injury to C-spine.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ male with syncopal episode status post fall with
noted right shoulder fracture and questioned left parietal subarachnoid
hemorrhage. Evaluate stability of hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 18.2 cm; CTDIvol = 49.0 mGy (Head) DLP =
891.9 mGy-cm.
Total DLP (Head) = 892 mGy-cm.
COMPARISON: ___ 04:04 outside noncontrast head CT.
FINDINGS:
There is right parietal convexity soft tissue swelling. There is a small
stable left frontal area of hyperdensity suggestive of subarachnoid hemorrhage
(series 2, image ___. No additional hemorrhage is identified. There is no
evidence of infarction, edema or mass. There is prominence of the ventricles
and sulci suggestive involutional changes.
There is no evidence of fracture. The visualized portion of the mastoid air
cells, and middle ear cavities are clear. The visualized portion of the
orbits are unremarkable. Bilateral maxillary and ethmoid sinus mucosal
thickening is present.
IMPRESSION:
1. Stable small left frontal probable subarachnoid hemorrhage as described.
Recommend clinical correlation and attention on followup imaging
2. No additional areas of hemorrhage.
3. Right parietal convexity soft tissue swelling, without evidence of
underlying fracture.
4. Paranasal sinus disease as described.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: The ___ male with syncopal episode status post fall with
noted right shoulder fracture and subarachnoid hemorrhage. Evaluate for
cervical spine fracture.
TECHNIQUE: Non-contrast helical multidetector CT was performed. Axial image
data was collimated to display separate 2.5 mm soft tissue and bone algorithm
axial images. Coronal and sagittal reformations were then constructed.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 5.5 s, 21.6 cm; CTDIvol = 36.8 mGy (Body) DLP = 795.0
mGy-cm.
Total DLP (Body) = 795 mGy-cm.
COMPARISON: None.
FINDINGS:
Question minimal anterolisthesis of C2 on C3, and mild reversal of the normal
cervical lordosis. No fractures are identified. A C6 vertebral body bone
island is present. At C3-4 there is a small disc protrusion resulting in at
least mild spinal canal stenosis. Moderate degenerative changes are seen
throughout the cervical spine. There is no prevertebral soft tissue
swelling.Within limits of this noncontrast examination, there is no evidence
of infection or neoplasm.
IMPRESSION:
1. No evidence of acute fracture or traumatic malalignment.
2. Moderate degenerative changes as described.
3. Question minimal C2 on C3 anterolisthesis. While this finding may be
degenerative in nature, given the absence of any prior comparison examination,
ligamentous injury cannot be excluded on the basis examination. Recommend
clinical correlation for site of tenderness. If clinically indicated, MRI of
cervical spine may be obtained for further evaluation.
RECOMMENDATION(S): Question minimal C2 on C3 anterolisthesis. While this
finding may be degenerative in nature, given the absence of any prior
comparison examination, ligamentous injury cannot be excluded on the basis
examination. Recommend clinical correlation for site of tenderness. If
clinically indicated, MRI of cervical spine may be obtained for further
evaluation.
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: History: ___ with syncope, fall, R shoulder fx, ? punctate
parietal SAH // Eval for progression of ? parietal SAH, evidence of trauma
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: 855
COMPARISON: ___
FINDINGS:
LOWER CHEST: There are small to moderate bilateral pleural effusions and
adjacent consolidative opacities at the lung bases. Of note, there are
rounded areas of hypodensity within the right lower lobe pulmonary
consolidation. Thickening of the distal esophagus is again noted, most likely
related to increased portal venous pressure. There is minimal, predominantly
right-sided cardiac enlargement.
HEPATOBILIARY: The liver is nodular in contour consistent with a known history
of cirrhosis. The patient is status post TIPS procedure. Detailed evaluation
of the hepatic vasculature is limited on this single phase exam. No focal
hepatic lesions are identified on this single phase examination. There is no
intra or extrahepatic biliary ductal dilatation. Intrahepatic varices are
again demonstrated, not significantly changed from ___.
SPLEEN: The spleen is enlarged measuring 14 cm. The spleen is homogeneous in
attenuation.
PANCREAS: The pancreas is atrophic.
ADRENALS: The adrenal glands are unremarkable bilaterally.
URINARY: The kidneys display symmetric nephrograms with no evidence of
hydronephrosis or mass lesion in either kidney. The ureters are symmetrical
in their course to the bladder.
GASTROINTESTINAL: The small bowel is normal appearing with no evidence of
obstruction. The large bowel is filled with stool and is normal. There is
trace intra-abdominal ascites.
LYMPH NODES: Multiple prominent retroperitoneal lymph nodes are again
demonstrated measuring up to 9 mm however none are pathologically enlarged by
CT size criteria. There is no mesenteric lymphadenopathy.
VASCULAR: Surgical clips are again demonstrated along the anterior abdominal
aorta just superior to the bifurcation and along the right iliac artery.
There is no aneurysmal dilatation of the abdominal aorta. Note is made of a
retroaortic left renal vein.
PELVIS: There is trace free fluid in the pelvis. The bladder is within normal
limits. The rectum and sigmoid colon are normal appearing. There is no
pelvic sidewall lymphadenopathy.
BONES AND SOFT TISSUES: No suspicious osseous lesions are identified. Mild
degenerative changes noted involving the lumbar spine. Minimally displaced
posterior rib fractures involving the ninth and tenth ribs on the right. The
patient is status post right-sided inguinal hernia repair. A small sclerotic
focus in the left ilium is unchanged from ___.
IMPRESSION:
1. No acute intra-abdominal or intrapelvic process.
2. Cirrhotic liver with associated varices, splenomegaly and trace ascites is
demonstrated, not significantly increased from ___. TIPS remains in
unchanged position, however patency of the hepatic vasculature is not well
assessed on this single phase examination.
3. Moderate bilateral pleural effusions and consolidative opacities involving
the bilateral lower lobes. There are multiple hypodensities within the right
lower lobe consolidation, suggesting possible infection.
4. Minimally displaced posterior rib fractures of the ninth and tenth ribs on
the right.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with history of HCV Cirrhosis s/p syncope and
fall with subarachoid hemorrage and question of recent PNA. // PNA?
IMPRESSION:
As compared to previous radiograph of earlier the same date, there has not
been a relevant change in the appearance of the chest when consideration is
given to differences in positioning and technique. .
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST
INDICATION: ___ year old man with HCV cirrhosis s/p fall with SAH and right
shoulder fractures. CT C-spine ? ligamentous damage. // ligamentous injury?
ligamentous injury?
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were next performed.
COMPARISON: ___ noncontrast cervical spine CT.
FINDINGS:
Please note that this study is limited by motion.
Labeling of the cervical spine is provided on series 2, image 9.
There is minimal retrolisthesis of C4 on C5 and C5 on C6. No other alignment
abnormalities are detected. There is increased T2 signal at the inferior
endplate of C3 and superior endplate of C4, likely representing ___ type 2
changes. No other marrow signal abnormalities are detected in the cervical
spine. No cord signal abnormalities are identified. No evidence of infection
or neoplasm, within the limitations of this non-contrast study.
There is trace T2 signal within the prevertebral space extending from C2
through C5 (2:9), which may represent minimal edema versus a small amount of
nonspecific fluid. No evidence of anterior longitudinal ligament (ALL)
disruption. Additional note is made of increased edema with the interspinous
ligaments between C3-C5, which is suggestive of underlying ligamentous injury.
Multilevel, multifactorial degenerative changes are noted throughout the
cervical spine, including osteophyte formation, uncovertebral hypertrophy,
loss of intervertebral disc space height and disc desiccation.
At C2-C3, there is minimal central disc bulge, without narrowing of the spinal
canal or neural foramen.
At C3-C4, there is minimal central disc bulge, without spinal canal narrowing
or neural foraminal stenosis.
At C4-C5, there is disc bulging that indents the thecal sac, without critical
spinal canal or neural foraminal narrowing.
At C5-C6, there is disc bulging with right paracentral protrusion that results
in mild spinal canal narrowing, as well as mild left neuroforaminal narrowing
(6:24).
At C6-C7, there is disc bulging and mild spinal canal stenosis. There is also
mild right neural foraminal narrowing at this level (6:27).
At C7-T1, there is no significant spinal canal or neural foraminal narrowing.
IMPRESSION:
1. No evidence of epidural fluid collection or cord signal abnormalities in
the cervical spine.
2. Interspinous ligament edema at C2 through C5, suggestive of ligamentous
injury/sprain.
3. Trace prevertebral T2 signal between C2-C5, which may represent minimal
edema versus a small amount of non-specific fluid, without evidence of ALL
disruption. No airway narrowing.
4. Multilevel multifactorial degenerative changes throughout the cervical
spine, resulting in up to mild spinal canal narrowing at C5-C6 and C6-C7.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with HCV cirrhosis and history of deep venous
thrombosis with elevated bilirubin. // Please assess for portal vein patency.
TECHNIQUE: Grey scale, color, and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON:
Abdominal ultrasound from ___ and CT abdomen pelvis from ___.
FINDINGS:
Due to the patient's inability to move his right arm, this is a limited study,
as the sonographic window was very small.
LIVER: The hepatic parenchyma is diffusely coarsened and nodular, consistent
with known cirrhosis. There is no focal liver mass. Right pleural effusion
is incompletely imaged.
The main portal vein is patent with hepatopetal flow.
The TIPS is patent and demonstrates wall-to-wall flow.
Portal vein and intra-TIPS velocities are as follows:
Main portal vein: 16.2 cm/sec, previously 18.5 cm/sec
Proximal TIPS: 34.3 cm/sec, previously 23cm/sec
Mid TIPS: 55.1 cm/sec, previously 60 cm/sec
Distal TIPS: 80 cm/sec, previously 71 cm/sec
The left portal vein is not able to be assessed on the current study.
Appropriate flow is present in the mid and left hepatic veins.
IMPRESSION:
1. Ultrasound study was limited due to the patient's inability to move his
right arm. The left portal vein was not assessed on the current study.
2. Patent TIPS, with velocities similar to those obtained on ___.
3. Cirrhotic liver with right-sided pleural effusion.
Radiology Report
EXAMINATION: VENOUS DUP UPPER EXT UNILATERAL RIGHT
INDICATION: ___ year old man with cirrhosis s/p TIPS and factor V leiden w/
history of DVTs, was on fondaparinux when he presented with syncopal event c/b
subarachnoid hemorrhage and right shoulder fractures. Anticoagulation has been
d/c'ed. // Please evaluate for right upper extremity DVT in setting of
increased swelling and pt being off anticoagulation for SAH (baseline AC with
fondaparinux for factor V leiden and h/o DVTs). Note that patient has 3 right
shoulder fractures and has severe pain with movement of RUE so if possible
please limit arm movement during exam.
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: Upper extremity Doppler from ___.
FINDINGS:
This study is severely limited, given the patient's inability to move his
right arm. Only the right axillary and right brachial veins were able to be
assessed, given patient positioning. There is nonocclusive thrombus in 1 of
the right brachial veins, which demonstrates no compressibility. Normal color
flow seen in the right axillary vein.
IMPRESSION:
Severely limited study due to patient positioning inability to move the right
arm. There is a nonocclusive thrombus in one of the right brachial veins,
which is not compressible.
NOTIFICATION: The above findings were communicated via telephone by Dr.
___ to Dr. ___ at 22:03 on ___, 5 min after discovery.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with cirrhosis s/p TIPS, factor V leiden with h/o
DVTs on fondaparinux, presenting s/p fall on anticoagulation with traumatic
SAH and right shoulder fractures x3, now with afib with RVR, right upper
extremity DVT, cough, and febrile to 100.8. Question pneumonia.
TECHNIQUE: Portable chest x-ray.
COMPARISON: Chest x-ray dated ___.
FINDINGS:
Appearance of bilateral pleural effusions and bibasilar atelectasis is
unchanged. There are no new regions of opacity. Cardiomediastinal silhouette
is unchanged.
IMPRESSION:
Unchanged bilateral pleural effusions and bibasilar atelectasis. Superimposed
infection cannot be excluded.
Radiology Report
INDICATION: History of cirrhosis, status post TIPS, with syncopal event and
wide complex ventricular tachycardia. Please evaluate.
TECHNIQUE: Cardiac MRI was performed by the Department of Cardiology.
COMPARISON: CT of the abdomen and pelvis from ___. Right upper
quadrant ultrasound from ___.
IMPRESSION:
Please note that this report only contains extracardiac findings.
There is moderate gynecomastia. An enlarged 22 x 13 mm pretracheal
mediastinal lymph node is nonspecific. There are bibasilar opacities and a
moderate-sized bilateral pleural effusions, similar to the prior CT of the
abdomen and pelvis. The right is slightly loculated. The liver has a
cirrhotic morphology with evidence of iron deposition. A TIPSS is partially
imaged. The spleen is enlarged, but not included in the entire field of view.
There is a small amount of ascites. These findings are better characterized
on the prior CT of the abdomen.
The entirety of this Cardiac MRI is reported separately in the Electronic
Medical Record (OMR) - Cardiovascular Reports.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with cirrhosis s/p TIPS, factor V leiden
presenting s/p syncopal event while on anticoagulation with traumatic SAH,
evaluate subarachnoid hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 10.0 s, 17.5 cm; CTDIvol = 52.7 mGy (Head) DLP =
921.6 mGy-cm.
Total DLP (Head) = 936 mGy-cm.
COMPARISON: Comparison is made to head CT ___
FINDINGS:
Focus of left frontal subarachnoid hemorrhage no longer seen. There are no
new areas of hemorrhage identified. The ventricles and sulci are unchanged in
size and configuration. The basal cisterns are patent and there is
preservation of gray-white matter differentiation.
There is no acute osseous abnormality. The globes are unremarkable. There is
a small amount of layering intermediate density fluid within the bilateral
maxillary sinuses, right greater than left. The remainder of the paranasal
sinuses are clear. There is fluid within the bilateral mastoid air cells.
IMPRESSION:
1. Small focus of left frontal subarachnoid hemorrhage no longer seen. No new
areas of hemorrhage.
2. Layering intermediate density fluid within the bilateral maxillary sinuses,
no fracture identified.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with DM, cirrhosis s/p TIPS, factor V Leiden with
h/o DVTs, presenting s/p syncopal event while on anticoagulation with
traumatic SAH and right shoulder fractures x3, hospital course complicated by
wide-complex VT (thought to be SVT with aberrancy) as well as afib with RVR,
right upper extremity DVT; home fondaparinux has been held ___ SAH but
re-started on heparin drip on ___ for DVT given resolved SAH, now patient is
therapeutic on heparin (PTT 117 this am) and we would like to repeat head CT
to ensure that SAH is still stable.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced
Acquisition 16.0 s, 17.5 cm; CTDIvol = 50.9 mGy (Head) DLP = 891.9 mGy-cm.
Total DLP (Head) = 892 mGy-cm.
COMPARISON: Comparison is made with prior CT head without contrast from
___.
FINDINGS:
There is no new evidence of infarction, hemorrhage, edema, or mass. There is
no midline shift or mass effect. There is no evidence of soft tissue swelling.
There is prominence of the ventricles and sulci suggestive involutional
changes.
There is no evidence of fracture. There is interval decrease in the
intermediate density fluid in the bilateral maxillary sinuses, left fluid more
prominent than the right. The other visualized portions of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No evidence of new hemorrhage, infarcts, or fractures.
2. Interval improvement of layering intermediate density fluid within the
bilateral maxillary sinuses.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SAH, R Shoulder injury, Transfer
Diagnosed with FX SCAPUL, ACROM PROC-CL, FX CLAVICL, ACROM END-CL, FX SCAP, GLEN CAV/NCK-CL, SUBARACH HEM-COMA NOS, OTHER FALL
temperature: 97.2
heartrate: 77.0
resprate: 16.0
o2sat: 99.0
sbp: 100.0
dbp: 63.0
level of pain: 8
level of acuity: 2.0 | Mr. ___ was hospitalized at ___ from ___ to ___ for
treatment of his injuries following a syncopal event, and for
workup of the etiology of his syncope. His hospital course was
complicated by a RUE DVT (noted on ___, intermittent
wide-complex ventricular tachycardia, and afib with RVR.
Anticoagulation was initially held due to the small traumatic
subarachnoid hemorrhage noted on admission, but this was
restarted for RUE DVT after confirming that a repeat
non-contrast head CT showed no evidence of SAH. EP placed a
LINQ monitor on ___ and he was transitioned back to
___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
house dust / dogs and cats / morphine
Attending: ___
___ Complaint:
superficial thrombophlebitis/cellulitis
Major Surgical or Invasive Procedure:
___ (___)
History of Present Illness:
Mr. ___ is a ___ year-old gentleman with a history of hearing
impairment and transformed DLBCL currently on R-CHOP (___)
who presents with fever and worsening superficial
thrombophlebitis/cellulitis which reportedly has not responded
to oral antibiotics.
He was evaluated on ___ in the ___ clinic treatment area for
left forearm pain found to have a superficial thrombophlebitis
with mild cellulitis. He received vancomycin 1g and was sent
home with plan to complete 5-day course of ASA325 and SMX/TMP DS
bid. It is unclear per records whether he started SMX/TMP but he
called the clinic on ___ reporting chills, worsening pain and
erythema. He was seen at ___ and discharged on
doxycycline. On ___ he called his oncologist's office due to
fever to 101.6 and was advised to go to nearest ED for broad
spectrum antibiotics and transfer to ___. ED initial vitals
were 99.3 116 117/72 16 99% RA Tmax: 101.2 Prior to transfer
vitals were 99.2 98 109/63 16 98% RA
Exam in the ED showed : No exam ED work-up significant for:
-CBC: 11.6 > 9.0 < 244 -Chemistry: 137/4.0 | ___ | ___
-Lactate: 1.5 -LFTs: ___ | 158/0.5 -UA: +ket -LUE US: no DVT,
distal SVT
ED management significant for: -Medications: cefepime 2g,
vancomycin 1g, 1L NS
On arrival to the floor, patient reports via writing having a
mild headache and having significant pain in his left arm. He
has not received any pain medication since he got to the
hospital. He reports having pain in his right biceps. He is
worried about being exposed to bacteria in the hospital and
requests not having a room mate.
Past Medical History:
PMH: deaf, asthma, recurrent diverticulitis, non-Hodgkin's
lymphoma
PSH: repair of supra-umbilical midline incisional hernia (___)
Social History:
___
Family History:
Sister: ___ (unclear type), in remission
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.8 PO 136 / 78 82 22 97 RA
GENERAL: Well-appearing gentleman in no distress lying in bed
comfortably.
HEENT: Anicteric, PERLL, Mucous membranes moist, OP clear.
CARDIAC: Regular rate and rhythm, normal heart sounds, no
murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Non-distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly.
EXT: Warm, well perfused. No lower extremity edema. Tender and
erythematous venous cord in volar aspect of left forearm,
demarcated with marker. No axillary or epitrochlear
lymphadenopathy.
NEURO: CN II-XII intact. Strength full throughout. Sensation to
light touch intact.
SKIN: No significant rashes.
DISCHARGE PHYSICAL EXAM:
VS: 97.5PO 103 / 65 87 18 97 RA
GENERAL: Well-appearing gentleman in no distress resting flat in
bed. Girlfriend at bedside.
HEENT: Anicteric sclera, Mucous membranes moist, OP clear.
CARDIAC: Regular rate and rhythm, normal heart sounds, no m/r/g
LUNG: CTAB, no crackles, wheezes, or rhonchi.
ABD: Non-distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly.
EXT: Warm, well perfused. No lower extremity edema. No axillary
or epitrochlear lymphadenopathy.
SKIN: Very mild erythema on left forearm
Pertinent Results:
ADMISSION LABS:
=========================
___ 11:44PM BLOOD WBC-11.6*# RBC-3.06* Hgb-9.0* Hct-26.0*
MCV-85 MCH-29.4 MCHC-34.6 RDW-15.5 RDWSD-45.8 Plt ___
___ 11:44PM BLOOD Neuts-75* Bands-7* Lymphs-3* Monos-9
Eos-0 Baso-1 ___ Metas-2* Myelos-3* AbsNeut-9.51*
AbsLymp-0.35* AbsMono-1.04* AbsEos-0.00* AbsBaso-0.12*
___ 11:44PM BLOOD Plt Smr-NORMAL Plt ___
___ 11:44PM BLOOD Glucose-101* UreaN-13 Creat-0.8 Na-137
K-4.0 Cl-99 HCO3-22 AnGap-16
___ 11:44PM BLOOD ALT-28 AST-24 AlkPhos-158* TotBili-0.5
___ 06:20AM BLOOD Calcium-7.8* Phos-3.1 Mg-1.9
___ 11:44PM BLOOD Albumin-3.4*
IMAGING:
==========================
___ UENI: No LUE DVT, distal superficial vein thrombus
___ B/l upper extremity US:
IMPRESSION:
1. No evidence of deep vein thrombosis in the bilateral upper
extremity veins.
2. Persistent occlusive thrombus within the distal superficial
veins in the area of erythema overlying the left wrist.
3. Likely slow flow within the left basilic vein, which
compresses well.
MICROBIOLOGY:
==========================
___: MRSA screen negative
___: Blood cx negative
___: Urine culture neg
DISCHARGE LABS:
==========================
___ 12:00AM BLOOD WBC-8.4 RBC-2.83* Hgb-8.5* Hct-24.5*
MCV-87 MCH-30.0 MCHC-34.7 RDW-16.0* RDWSD-49.6* Plt ___
___ 12:00AM BLOOD Neuts-97* Bands-1 Lymphs-1* Monos-1*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-8.23*
AbsLymp-0.08* AbsMono-0.08* AbsEos-0.00* AbsBaso-0.00*
___ 12:00AM BLOOD Plt Smr-NORMAL Plt ___
___ 12:00AM BLOOD ___
___ 12:00AM BLOOD Glucose-213* UreaN-18 Creat-0.9 Na-139
K-4.4 Cl-101 HCO3-21* AnGap-17
___ 12:00AM BLOOD ALT-20 AST-24 LD(LDH)-301* AlkPhos-125
TotBili-0.5
___ 12:00AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.0 UricAcd-4.1
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Ondansetron 8 mg PO Q8H:PRN nausea or vomiting
2. Allopurinol ___ mg PO DAILY
3. LORazepam 0.5-1 mg PO Q8H:PRN nausea or vomiting
4. Acyclovir 400 mg PO Q12H
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
6. Promethazine 25 mg PO Q6H:PRN nausea or vomiting
7. albuterol sulfate ___ puffs inhalation Q6H:PRN
8. Artificial Tears ___ DROP BOTH EYES PRN dry eye
Discharge Medications:
1. PredniSONE 100 mg PO Q24H Duration: 5 Doses
5 days total. 2 days were in hospital. 3 more days, last day is
___.
RX *prednisone 50 mg 2 tablet(s) by mouth once a day Disp #*6
Tablet Refills:*0
2. Rivaroxaban 20 mg PO DAILY
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
3. Rivaroxaban 15 mg PO BID
RX *rivaroxaban [___] 15 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*36 Tablet Refills:*0
4. Acyclovir 400 mg PO Q12H
5. albuterol sulfate ___ puffs inhalation Q6H:PRN
6. Artificial Tears ___ DROP BOTH EYES PRN dry eye
7. LORazepam 0.5-1 mg PO Q8H:PRN nausea or vomiting
8. Ondansetron 8 mg PO Q8H:PRN nausea or vomiting
9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth Every four hours Disp
#*20 Tablet Refills:*0
10. Promethazine 25 mg PO Q6H:PRN nausea or vomiting
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
====================
Superficial thrombophlebitis
Diffuse large B cell lymphoma
Secondary diagnoses:
====================
anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: History: ___ with left arm pain, swelling, concern for deeper
blood clot// DVT or superficial thrombophlebitis
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None available.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
vein.
The right internal jugular and axillary veins are patent, show normal color
flow and compressibility. The right brachial, basilic, and cephalic veins are
patent, compressible and show normal color flow and augmentation.
Targeted ultrasound at the area of erythema at the left wrist demonstrates a
an occlusive thrombus in the superficial vein.
IMPRESSION:
1. No evidence of deep vein thrombosis in the left upper extremity.
2. Occlusive thrombus in the distal superficial vein in the area of erythema
in the left wrist.
Radiology Report
EXAMINATION: BILAT UP EXT VEINS US
INDICATION: ___ year old man with diffuse large B cell lymphoma on chemo with
superficial thrombophlebitis of the L distal upper extremity. This area is now
much more indurated than before; erythema has not expanded. Complaining of
some R arm pain now as well.// ?DVT in R arm? Progression/change in L arm
thrombophlebitis.
TECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral
upper extremity veins.
COMPARISON: Ultrasound from ___
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
As previously noted, occlusive thrombus within the distal superficial veins in
the area of erythema overlying the left wrist is grossly unchanged in
appearance. The most distal portion of the left basilic vein demonstrate
echogenic debris along the wall, which may represent slow flow. The vein
compresses without expansile echogenic clot.
The bilateral internal jugular and axillary veins are patent, show normal
color flow and compressibility.
The bilateral brachial, and cephalic and right basilic veins are patent,
compressible and show normal color flow and augmentation.
IMPRESSION:
1. No evidence of deep vein thrombosis in the bilateral upper extremity veins.
2. Persistent occlusive thrombus within the distal superficial veins in the
area of erythema overlying the left wrist.
3. Likely slow flow within the left basilic vein, which compresses well.
NOTIFICATION: The findings were discussed with ___ , M.D. by
___, M.D. on the telephone on ___ at 12:29 pm, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with new line. Evaluate right PICC placement.
TECHNIQUE: Frontal view of the chest.
COMPARISON: Chest x-ray ___.
FINDINGS:
The right PICC terminates in the lower SVC.
The heart size is normal. The right lateral chest and costophrenic angle are
not imaged. With this in consideration, the lungs are clear. No left pleural
effusion or pneumothorax. Surgical clips in the mid upper abdomen.
IMPRESSION:
The right PICC terminates in the lower SVC.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Fever, unspecified
temperature: 99.3
heartrate: 116.0
resprate: 16.0
o2sat: 99.0
sbp: 117.0
dbp: 72.0
level of pain: 8
level of acuity: 2.0 | Mr. ___ is a ___ year-old man with a history of deafness and
transformed DLBCL currently on R-CHOP (___) who presents
with fever and worsening superficial thrombophlebitis/cellulitis
which reportedly did not responded to oral antibiotics. |
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:
___ past medical history includes HTN, diabetes, depression,
reflux and ? history of cerbrovascular ischemia vs. demylination
per MRI in ___ who presents with acute on sub-acute abdominal
pain.
.
Was well untill 1 month ago when started experiencing
periumbilical and RUQ pain accompanied by loose non-bloody
stools X 2 per day and per his report 15kg weight loss. Over the
past 4 days gradual worsening of RUQ pain now with radiation to
the mid back. Pain is constant and waxes and wanes from ___ in
intensity. Not related to food. Patient also sees been nauseous
no vomiting. No other exacerbating or relieving factor. He does
say that about a year ago he stopped taking alcohol due to
similar pains which were related to dringing ETOH. Before that
he would dring ___ glasses of rum per day for many years. He is
also a current smoker of 1 PPD > ___ years. Current pain is not
similar to reflux symptoms he had before. Also noticed some
diarrhea. No chest pain, no shortness of breath.
Past Medical History:
- HTN
- HLD
- DM II
- GERD/Reflux ?
- ___: investigated for headaches with MRI scan showing white
matter hyperintensities suggestive of either ischemia or
demyelinating disease.
- s/p LLE # ___ years ago.
Social History:
___
Family History:
___
Physical Exam:
Admission:
Vital Signs: 98.2 131/84 68 18 99RA
GEN: Alert, comfortable, NAD
EYE: EOMI, PERRL, no conjuctival pallor or irritation.
ENT: MMM, no oral lesions
Neck: no LAD, no nuchal rigidity, JVP WNL
CV: RRR, no M/R/G
RESP: CTAB, no wheezes or crackles
GI: Soft, NTND, no HSM, Normal Bowel Sounds
EXT: No cyanosis, clubbing or edema. No signs of DVT.
SKIN: no rash, no Pressure Ulcers
NEURO: A+OX3, Non-Focal, Fluent Speech, Normal concentration
PSYCH: Calm and Appropriate
Discharge:
98.0 150/68 68 18
GEN: Alert, comfortable, NAD
EYE: EOMI, PERRL, no conjuctival pallor or irritation.
ENT: MMM, no oral lesions
Neck: no LAD, no nuchal rigidity, JVP WNL
CV: RRR, no M/R/G
RESP: CTAB, no wheezes or crackles
GI: Soft, NTND, no HSM, Normal Bowel Sounds
EXT: No cyanosis, clubbing or edema. No signs of DVT.
SKIN: no rash, no Pressure Ulcers
NEURO: A+OX3, Non-Focal, Fluent Speech, Normal concentration
PSYCH: Calm and Appropriate
Pertinent Results:
___ 06:24AM BLOOD WBC-7.2 RBC-4.19* Hgb-12.8* Hct-39.9*
MCV-95 MCH-30.6 MCHC-32.1 RDW-13.3 Plt ___
___ 12:30AM BLOOD Neuts-64.0 ___ Monos-4.7 Eos-2.7
Baso-0.2
___ 06:24AM BLOOD Plt ___
___ 06:24AM BLOOD Glucose-217* UreaN-9 Creat-0.7 Na-139
K-4.4 Cl-102 HCO3-29 AnGap-12
___ 12:30AM BLOOD ALT-20 AST-20 AlkPhos-79 TotBili-0.2
___ 06:24AM BLOOD Calcium-9.4 Phos-3.0 Mg-1.6
___ 12:30AM BLOOD WBC-9.6 RBC-4.06* Hgb-12.7* Hct-38.4*
MCV-95 MCH-31.3 MCHC-33.1 RDW-13.6 Plt ___
___ 12:30AM BLOOD Neuts-64.0 ___ Monos-4.7 Eos-2.7
Baso-0.2
___ 12:30AM BLOOD Plt ___
___ 12:30AM BLOOD Glucose-136* UreaN-16 Creat-0.7 Na-140
K-4.4 Cl-102 HCO3-27 AnGap-15
___ 12:30AM BLOOD Lipase-147*
___ 12:30AM BLOOD Albumin-4.0
EXAMINATION: CT ABD AND PELVIS W AND W/O CONTRAST, ADDL
SECTIONS
INDICATION: ___ male with past medical history of
hypertension,
diabetes, depression, reflux, alcohol use, and smoking with
acute on subacute
abdominal pain and elevated lipase. Evaluation for pancreatitis
and pancreatic
malignancy.
TECHNIQUE: Helical axial MDCT images were obtained from the
bases of the
lungs through the pubic symphysis, after the administration of
IV contrast
(130 cc of Omnipaque 350). Reformatted images in coronal and
sagittal axes
were generated.
DLP: 606 mGy-cm.
COMPARISON: None available.
FINDINGS:
The bases of the lungs are clear. There is no pleural or
pericardial effusion.
LIVER: The liver enhances homogeneously without focal lesion or
intrahepatic
biliary duct dilation. The portal vein is patent.The
nondistended gallbladder
is within normal limits, without wall thickening or
pericholecystic fluid.
SPLEEN: The spleen is homogeneous and normal in size.
PANCREAS: There is minimal haziness between the head of the
pancreas and the
duodenum. Subtle early groove pancreatitis cannot be excluded.
Please continue
to correlate clinically and biochemically. No focal lesions,
masses,
pancreatic calculi, or pancreatic ductal dilatation are
identified.
ADRENALS: The adrenal glands are unremarkable.
KIDNEYS: The kidneys demonstrate symmetric nephrograms and
excrete contrast
promptly. There is no focal lesion or hydronephrosis.
GI:The stomach is unremarkable, without obvious intraluminal
mass or wall
thickening.The small and large bowel are within normal limits,
without wall
thickening or evidence of obstruction.A normal, air-filled
appendix is
visualized.
RETROPERITONEUM: The aorta is normal in caliber, with mild
atherosclerotic
calcifications.There is no retroperitoneal or mesenteric lymph
node
enlargement by CT size criteria.
CT PELVIS: The urinary bladder appears normal.No pelvic wall or
inguinal lymph
node enlargement by CT size criteria is seen.There is no pelvic
free fluid.
OSSEOUS STRUCTURES:No focal lesion suspicious for malignancy
present.
IMPRESSION:
1. Minimal haziness noted between the head of the pancreas and
the duodenum.
Subtle early groove pancreatitis cannot be excluded. Both
clinical and
biochemical correlation are recommended.
2. No focal pancreatic lesions or masses identified. No
pancreatic ductal
dilatation or pancreatic calculi noted.
NOTIFICATION: The above findings were communicated on the phone
by Dr.
___ to Dr. ___ at 16:01 on ___, 10
min after
discovery.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___
___: WED ___ 4:40 ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 30 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. GlipiZIDE 10 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Lisinopril 30 mg PO DAILY
3. GlipiZIDE 10 mg PO BID
4. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Mild Acute Pancreatitis
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: ___ male with past medical history of hypertension,
diabetes, depression, reflux, alcohol use, and smoking with acute on subacute
abdominal pain and elevated lipase. Evaluation for pancreatitis and pancreatic
malignancy.
TECHNIQUE: Helical axial MDCT images were obtained from the bases of the
lungs through the pubic symphysis, after the administration of IV contrast
(130 cc of Omnipaque 350). Reformatted images in coronal and sagittal axes
were generated.
DLP: 606 mGy-cm.
COMPARISON: None available.
FINDINGS:
The bases of the lungs are clear. There is no pleural or pericardial effusion.
LIVER: The liver enhances homogeneously without focal lesion or intrahepatic
biliary duct dilation. The portal vein is patent.The nondistended gallbladder
is within normal limits, without wall thickening or pericholecystic fluid.
SPLEEN: The spleen is homogeneous and normal in size.
PANCREAS: There is minimal haziness between the head of the pancreas and the
duodenum. Subtle early groove pancreatitis cannot be excluded. Please continue
to correlate clinically and biochemically. No focal lesions, masses,
pancreatic calculi, or pancreatic ductal dilatation are identified.
ADRENALS: The adrenal glands are unremarkable.
KIDNEYS: The kidneys demonstrate symmetric nephrograms and excrete contrast
promptly. There is no focal lesion or hydronephrosis.
GI:The stomach is unremarkable, without obvious intraluminal mass or wall
thickening.The small and large bowel are within normal limits, without wall
thickening or evidence of obstruction.A normal, air-filled appendix is
visualized.
RETROPERITONEUM: The aorta is normal in caliber, with mild atherosclerotic
calcifications.There is no retroperitoneal or mesenteric lymph node
enlargement by CT size criteria.
CT PELVIS: The urinary bladder appears normal.No pelvic wall or inguinal lymph
node enlargement by CT size criteria is seen.There is no pelvic free fluid.
OSSEOUS STRUCTURES:No focal lesion suspicious for malignancy present.
IMPRESSION:
1. Minimal haziness noted between the head of the pancreas and the duodenum.
Subtle early groove pancreatitis cannot be excluded. Both clinical and
biochemical correlation are recommended.
2. No focal pancreatic lesions or masses identified. No pancreatic ductal
dilatation or pancreatic calculi noted.
NOTIFICATION: The above findings were communicated on the phone by Dr.
___ to Dr. ___ at 16:01 on ___, 10 min after
discovery.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 99.0
heartrate: 74.0
resprate: 16.0
o2sat: 97.0
sbp: 127.0
dbp: 77.0
level of pain: 6
level of acuity: 3.0 | ___ past medical history includes HTN, diabetes, depression,
reflux, ETOH and smoking who presented with acute on subacute
abdominal pain and elevated lipase. Also reported chronic mild
diarrhea over the past month and significant weight-loss. Bed
side US in ED did not show evidence of bile/gallbladder issues.
CT contrast of his abdomen showed minimal haziness between the
head of the pancreas and the duodenum which may be consistent
with subtle early groove pancreatitis. In discussion on day of
discharge with the radiology attending ___. ___ the
findings are not concerning for malignancy and no further
imaging is indicated.
Mr. ___ did very well clinically throughout his admission.
Abdominal pain resolved without any specific intervnetion. Did
not require analgesia. Diet was advanced and tolerated well.
problem summary:
- Acute on Subacute RUQ pain: likely ___ mild acute ___,
___ have a mild chronic pancreatitis in the backround. Also has
history of EGRD which may explain some of his more chronic
abdominal pain and discomfort.
- Diarrhea 1 month: etiology is unclear, most of his pancreatic
tissue appears normal on imaging so exocrine failure seems
unlikely.
- significant weight loss: as reported by patient. this will
require further work-up in the out-patient setting.
- elevated lipase - likely ___ to mild acute pancreatitis.
- normocytic anemia - further work-up including iron profile and
B12 should be pursued following discharge.
- h/o of alcohol and tobbaco consumptions.
- HTN, DM - oral diabetic meds were held and restarted on
discharge. Other meds were continued.
Transitional Issues:
- follow-up with PCP and GI for health maintnance and further
work-up of diarrhea, chronic abdominal dyscomfort and
weightloss.
- please also check Triglyceride levels to r/o
hypertriglyceridemia as a cause of pancreatitis.
- normocytic anemia - further work-up including iron profile and
B12 should be pursued following discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___, ___ edema, chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with CAD s/p PCI ___ (unknown details), CKD (recent
baseline ___, evaluated last admission with renal ultrasound,
consistent with longstanding kidney disease, likely secondary to
microvascular changes from HTN), HTN, former smoker, ___ (EF
>55%), recently discharged from ___ ___ for acute on
chronic diastolic heart failure here from ___ office with
increased peripheral edema worsening over past few months
markedly worse past week, also c/o chest pain since ___ worse
past 2 weeks.
Patient reports that he came today to the ED because his PCP
told him that his kidney function was worse. He endorses that
his ankles have gotten more swollen. Chronic chest pain has
become more frequent. Chest pain is a dull pain over his chest
that radiates to the neck and left side of his face which
happens after walking approximately 20 feet. He stops when the
chest pain starts and rests and after 15 minutes rest the chest
pain goes away. However the severity of the chest pain has
increased over the past 2 weeks compared to before. He sleeps
with 2 pillows which is unchanged and he denies any orthopnea or
PND. He noticed decreased urine output for the last 4 or 5 days.
Notes he's gained ~5lbs over the past week.
Denies any diet changes, actually has had decreased appetite
and been eating smaller portions. No increased salt intake. Has
been adherent to his torsemide at home.
Denies fevers/chills, dizziness, cough, abdominal pain.
+chronic constipation. Does not endorse other associated
symptoms with his chest pain.
In the ED, initial vitals: 97.6 100 173/67 18 100% RA
- Exam notable for: JVD to ear at 45 degrees in bed. decreased
breath sounds throughout, no crackles. 2+ pitting edema b/l and
chronic skin changes. - Labs notable for: cr 5.7 (recent
baseline ___, Na 138, proBNP: 1227, trop neg, H/H ___
(baseline ___ - ECG: sinus rhythm with no ST changes
- Imaging notable for: CXR: Possible minimal pulmonary vascular
congestion with top-normal to mildly enlarged cardiac
silhouette. - Patient given: Furosemide 40 mg IV x 1
- Vitals prior to transfer: 98.3 77 151/61 16 100% RA On arrival
to the floor, pt denies any shortness of breath, chest pain.
Past Medical History:
- CAD s/p 1x stent (placed in ___ in ___
- Hypertension
- CKD (unknown baseline)
Social History:
___
Family History:
No family history of early MI or history of heart failure.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.6 176/85 88 20 97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, no
LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops. JVP to midneck at 30 degrees. Abdomen: obese, soft,
non-tender, mildly distended, bowel sounds present, no rebound
tenderness or guarding, no organomegaly Ext: Warm, well
perfused, no cyanosis or edema
Skin: Without rashes or lesions Neuro: A&Ox3. Face symmetric.
DISCHARGE PHYSICAL EXAM:
General: Alert, no acute distress
Lungs: CTAB
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops. JVP at 12cm
Abdomen: obese, soft, non-tender, mildly distended
Ext: Warm, well perfused, no cyanosis or edema
Pertinent Results:
ADMISSION LABS:
___ 05:35PM BLOOD WBC-6.3 RBC-2.63* Hgb-7.6* Hct-23.0*
MCV-88 MCH-28.9 MCHC-33.0 RDW-12.3 RDWSD-38.7 Plt ___
___ 05:35PM BLOOD Neuts-81.0* Lymphs-9.7* Monos-5.4 Eos-3.3
Baso-0.3 Im ___ AbsNeut-5.11 AbsLymp-0.61* AbsMono-0.34
AbsEos-0.21 AbsBaso-0.02
___ 05:35PM BLOOD ___ PTT-30.2 ___
___ 05:35PM BLOOD Glucose-113* UreaN-83* Creat-5.7*# Na-138
K-4.8 Cl-103 HCO3-21* AnGap-19
___ 05:35PM BLOOD proBNP-1227*
___ 05:35PM BLOOD Albumin-3.5 Calcium-8.2* Phos-5.2* Mg-2.1
STUDIES:
___ Cardiac Cath:
Right dominant
LM: No disease.
LAD: Patent stent, no significant disease.
LCx: Small true LCx is subtotally occluded, distal vessel fills
via R to L collaterals. RCA: Mid vessel 30% disease. PDA with
80% proximal stenosis. Interventional Details After discussion
with the patient and the referring team, we elected to pursue
PCI of the LCx. Attempts to wire the vessel were made with a
Prowater and ___ XT. The ___ XT went subintimal. The
lesion was behaving more like a CTO with continued passage of
the wire into the subintimal space. Due to not wanting to embark
on a complex CTO reentry given the patient's renal failure, we
elected to stop at this point, and consider staged intervention
of the PDA lesion instead. TR band to right radial. Impressions:
Subtotally occluded LCx, behaving as a chronic lesion. Unable to
wire luminally with conservative attempt given renal failure.
PDA 80% disease.
___ Cardiac Cath:
Interventional Details
AL0.75 guide catheter engaged the RCA. The vessel was wired with
a Prowater wire. IVUS was
performed to size the lesion and to minimize contrast use.
Angioplasty followed by placement of a 2.5 x
24 mm Promus Premier DES. Post-dilated after IVUS using a 3.0 NC
balloon and a 3.75 NC balloon
proximally. IVUS confirmed excellent stent expansion and
apposition throughout. TIMI III flow, 0% residual.
Impressions:
Successful IVUS-guided PCI of the RCA using a single DES.
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-8.5 RBC-2.98* Hgb-8.6* Hct-27.2*
MCV-91 MCH-28.9 MCHC-31.6* RDW-12.8 RDWSD-41.3 Plt ___
___ 10:30AM BLOOD ___ PTT-26.6 ___
___ 03:33PM BLOOD Glucose-121* UreaN-89* Creat-4.9* Na-142
K-4.8 Cl-106 HCO3-21* AnGap-20
___ 07:00AM BLOOD Calcium-8.4 Phos-5.9* Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Calcitriol 0.25 mcg PO 3X/WEEK (___)
3. Cephalexin 250 mg PO Q8H
4. HydrALAZINE 25 mg PO Q8H
5. Isoniazid ___ mg PO DAILY
6. Pyridoxine 50 mg PO DAILY
7. sevelamer CARBONATE 1600 mg PO TID W/MEALS
8. Sodium Bicarbonate 650 mg PO BID
9. Torsemide 20 mg PO BID
10. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Atorvastatin 80 mg PO QPM
Discharge Medications:
1. Carvedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Clopidogrel 75 mg PO DAILY
Please do not stop taking without discussing with your
cardiologist
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. HydrALAZINE 50 mg PO Q8H
RX *hydralazine 50 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
4. Torsemide 40 mg PO BID
RX *torsemide 20 mg 2 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
5. amLODIPine 10 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Calcitriol 0.25 mcg PO 3X/WEEK (___)
9. Isoniazid ___ mg PO DAILY
10. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
11. Pyridoxine 50 mg PO DAILY
12. sevelamer CARBONATE 1600 mg PO TID W/MEALS
13. Sodium Bicarbonate 650 mg PO BID
14.Outpatient Lab Work
E87.5- Hyperkalemia
Please check chem7 and fax results to ___ clinic ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Acute exacerbation of heart failure with preserved ejection
fraction
Secondary Diagnoses:
Acute gout
coronary artery disease
chronic kidney disease
latent TB
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with CHF w/ increased DOE, chest pain // eval for
pulmonary edema
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
The lungs show no focal consolidation. No pleural effusion or pneumothorax is
seen. Cardiac silhouette is top-normal to mildly enlarged. Mediastinal
contours are unremarkable. Minimal pulmonary vascular congestion may be
present.
IMPRESSION:
Possible minimal pulmonary vascular congestion with top-normal to mildly
enlarged cardiac silhouette.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: ___ year old man with R ankle pain, tender posterior to medial
malleolus, unable to ambulate. no trauma hx. ongoing diuresis in pt with h/o
gout // ?fx
TECHNIQUE: Right ankle three views
COMPARISON: None
FINDINGS:
There are prominent calcaneal plantar, Achilles bone spurs, with chronic
discontinuity of the Achilles bone spur. No acute fractures. Mild soft
tissue swelling about ankle. Mild degenerative arthritis right ankle.
IMPRESSION:
No acute fractures.
Gender: M
Race: ASIAN
Arrive by WALK IN
Chief complaint: Chest pain, Dyspnea on exertion, Leg swelling
Diagnosed with Other chest pain
temperature: 97.6
heartrate: 100.0
resprate: 18.0
o2sat: 100.0
sbp: 173.0
dbp: 67.0
level of pain: 3
level of acuity: 2.0 | Mr. ___ is a ___ with CAD s/p PCI ___ (unknown details), CKD
(unknown
baseline), HTN, former smoker, dCHF (EF >55%), recently
discharged from ___ on ___ for acute on chronic
diastolic heart failure presenting with acute on chronic DOE and
___ edema concerning for CHF exacerbation vs worsening renal
failure, also with chest pain with ambulation. Underwent PCI of
PDA on with DES ___.
#Acute on Chronic Diastolic Heart Failure: Increased ___ edema w/
pulm vascular congestion on CXR was concerning for exacerbation
of diastolic heart failure. Unclear precipitating factor, no
obvious dietary indiscretion or medication nonadherence. He was
managed as below:
- PRELOAD: Torsemide 40 BID
- AFTERLOAD: continue amlodipine and imdur, increased
hydralazine to 50mg TID,
- NHBK: Started carvedilol
#Chest pain/CAD: s/p 1x stent in ___ in ___, unknown artery.
Reports increased frequency of pain. Trop neg, no acute changes
on ecg. Exertional, likely stable angina in setting of known
CAD. Trop was x 2 negative. He was continued ASA 81mg, atorva
80mg, imdur. He underwent a pmibi without areas of ischemia, but
symptoms were concerning for stable angina so patient underwent
cardiac cath which demonstrated a subtotal occlusion of the mid
LCx and a 80% distal RCA stenosis. Initially attempt was made to
the stent the LCx, but this lesion behaved like a chronic total
occlusion so PCI was aborted. To avoid excessive contrast load,
the patient was brought back the next day for PCI of the distal
RCA lesion with ___ 1 and a good angiographic result.
Following the PCI, the patient reported that his exertional
chest pain had resolved.
#Gout flare
Likely in setting of diuresis in patient with h/o gout. NSAIDs,
colchicine limited due to CKD. Ankle xray without fx. Finished a
Prednisone taper.
# CKD: Unclear etiology, baseline cr unknown, now stage 5 w/
reported decreased urine output. No urgent indications for
initiating HD. He was evaluated by renal during a recent
admission, USG with small echogenic kidney s/o longstanding
kidney disease. Likely due to microvascular changes from HTN w/
possible contribution from cardiorenal syndrome. Continued
calcitriol, sodium bicarb, sevelemar. Was supposed to have AV
graft placed ___ but deferred due to PCI and Plavix.
Hyperkalemia was managed by restarting diuretic and a dose of
kayexylate.
# Latent TB: H/o pos TST, born in ___ BGC status unknown. INH
300 mg initiated ___ (___voiding rifampin due to
drug interaction with statins). Continued INH, pyridoxine
# HTN: elevated BP on arrival to the floor after not receiving
home meds. He was continued on home amlodipine, hydralazine, and
imdur |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amitiza / Oxybutynin / Bactrim
Attending: ___.
Chief Complaint:
multidrug resistant uti treatment
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is an ___ year old man with a hypotonic bladder, BPH,
chronic indwelling foley and multiple recent multidrug resistant
urinary tract infections who was sent to the ED by his PCP for
admission and iv antibiotics for a UTI. He has multiple other
chronic medical problems (see below). He was last admitted to
___ from ___ to ___ for treatment of a UTI. He was
treated with meropenem initially then narrowed to po
ciprofloxacin on which he was discharged home.
Patient denies fevers or chills, but he complains of a dull
suprapubic ache which has worsened over the course of the last
three days. He does not have back pain.
In the ED, initial VS were:97.6, hr 88, bp 86/47, rr 20, sat
95%. His subsequent blood pressures ranged from 108-118/71-76,
even before he recieved fluid. He was given NS x 1 Liter and
cefepime 2g iv once.A #20 right EJ was inserted.
Transfer vitals were 97.2 oral, HR 79, BP 108/74, RR ___, O2
sat 2L NC.
On arrival to the floor, he had mild suprapubic discomfort.
Past Medical History:
1. Hypotonic bladder with incomplete emptying, s/p indwelling
foley since ___ c/b frequent Multidrug resistent UTIs, incl
MRSA and ESBL E Coli
2. BPH
3. CAD s/p CABG x 3 in ___
- CABG anatomy: LIMA to LAD, SVG to OM, and SVG to RCA
- s/p stenting ___ of mid RCA, PTCA of proximal RCA and PDA
- redo single vessel CABG in ___ with Dr. ___.
4. Bovine AVR in ___. Type 2 Diabetes Mellitus: diet controlled
6. Hypertension
7. Hx of Chronic constipation
8. Hyperlipidemia
9. Depression /Anxiety
10. Asbestosis
11. Spinal stenosis
12. R kidney mass - Followed by urology w/ serial imaging,
likely RCC
13. Osteoarthritis
14. Carotid stenosis - chronic occlusion of ___, ___ with 40%
Social History:
___
Family History:
Daughter- died at ___,breast cancer.
Father- died from MI in his ___.
Physical Exam:
Admission exam:
VS - Temp 97.9 F, BP 105/76, HR 76, R 20, O2-sat 97% 3LNC
GENERAL - NAD, comfortable
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MM dry, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat except for fine crackles in the bases
bilaterally, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/ND, no masses or HSM, no rebound/guarding.
There is mild ttp in the suprapubic area.
BACK: no cva tenderness
EXTREMITIES - There is moderate edema in both lower extremities
with discoloration and erythema especially in the left leg--it
is not warm nor tender, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ on flexion of r hip, 4- on flextion of left hip, upper
extremity strength is ___ bilaterally, sensation grossly intact
throughout, gait was not assessed.
Discharge exam:
VS - Temp 97.7 F, BP 110-130/60-64, HR 78-86, R 20, O2-sat
92-94%/RA
GENERAL - NAD, comfortable
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat except for fine crackles in the bases
bilaterally, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/ND, no masses or HSM, no rebound/guarding.
Non-tender.
BACK: no cva tenderness
EXTREMITIES - There is moderate edema in both lower extremities
with discoloration and erythema especially in the left leg--it
is not warm nor tender, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ on flexion of r hip, 4- on flextion of left hip, upper
extremity strength is ___ bilaterally, sensation grossly intact
throughout, gait was not assessed.
Discharge exam:
T 97.9 112-142/61-70 ___ 94%/RA 20
GENERAL - elderly man, lying in bed in no apparent distress
LUNGS - CTA bilat
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - soft, non-tender, non-distended
BACK: no cva tenderness
EXTREMITIES - trace edema in both lower extremities with
discoloration and erythema especially in the left leg--it is not
warm nor tender
Skin: Rash on right check with crusted blood, erythematous rash
on face.
NEURO - A&Ox3.
Pertinent Results:
Admission labs:
___ 11:30PM BLOOD WBC-6.6 RBC-4.15* Hgb-12.3* Hct-36.0*
MCV-87 MCH-29.7 MCHC-34.2 RDW-17.6* Plt ___
___ 11:30PM BLOOD Neuts-66.0 ___ Monos-6.8 Eos-5.8*
Baso-0.4
___ 05:32AM BLOOD ___ PTT-31.5 ___
___ 10:15PM BLOOD Glucose-126* UreaN-25* Creat-1.0 Na-138
K-4.3 Cl-101 HCO3-28 AnGap-13
___ 08:00PM BLOOD CK-MB-6 cTropnT-0.09*
___ 05:25AM BLOOD CK-MB-6 cTropnT-0.08*
___ 10:15PM BLOOD Calcium-9.2 Phos-4.5 Mg-2.2
Microbiology:
___ 7:25 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
FOSOMYCIN Susceptibility testing requested by ___.
___
PAGER ___.
.
ZONE SIZE FOR FOSOMYCIN IS 27 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-------------- 4 S
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ =>16 R
___ 11:05 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
SENSITIVITIES PERFORMED ON CULTURE # ___-___
___.
___ 9:01 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
___ PARAPSILOSIS. >100,000 ORGANISMS/ML..
IDENTIFICATION REQUESTED BY ___ ___ ___
___.
___ 5:19 pm DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS
**FINAL REPORT ___
DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Final
___:
Negative for Varicella zoster by immunofluorescence.
Refer to culture results for further information.
___ 5:19 pm
Direct Antigen Test for Herpes Simplex Virus Types 1 & 2
**FINAL REPORT ___
Direct Antigen Test for Herpes Simplex Virus Types 1 & 2
(Final
___:
Negative for Herpes simplex by immunofluorescence.
Refer to culture results for further information.
Imaging:
___ CXR:
As compared to the previous radiograph, there is unchanged
evidence
of elevation of the left hemidiaphragm and subpleural partly
calcified scars. Status post CABG. Minimal atelectasis at the
right lung base but no evidence of current pneumonia or fluid
overload. Unchanged appearance of the cardiac silhouette.
___ Abdominal X-ray:
There is moderate colonic fecal load with minimally dilated
cecum. Air is seen in scant loops of nondilated small bowel.
This is a nonobstructive bowel gas pattern. Remnant contrast
material is seen in the large bowel. There is no supine
radiographic evidence of pneumoperitoneum or pneumatosis.
IMPRESSION:
Moderate colonic fecal load. Nonobstructive bowel gas pattern.
CXR ___ Cardiac size is top normal. The main pulmonary
arteries are larger as before. Elevation of the left
hemidiaphragm is longstanding. There are low lung volumes.
Bibasilar atelectases have increased. Bilateral calcified
pleural plaques are again noted. There are probably small
bilateral pleural effusions. There is no pneumothorax.
Kidney ultrasound ___:
The right kidney measures 10.2 cm. The left kidney measures
10.4 cm.
Bilateral kidneys are without evidence of hydronephrosis or
stones. The
vascular right upper pole tumor is again noted measuring 3.3 x
3.6 x 2.9 cm. The bladder is decompressed and not evaluated.
There is no evidence of distinct collections.
IMPRESSION:
No evidence of distinct collections. Right upper pole solid
tumor is again identified measuring 3.3 x 3.6 x 2.9 cm.
Abdominal X-ray ___
There is a nonobstructing bowel gas pattern. There is air in
the ascending and transverse colon. There is fecal material in
the descending colon. There is no air in the rectum. There are
few air fluid levels in the small bowel loops that are
nondistended. There are severe degenerative changes in the
lumbar spine. There are vascular calcifications.
CXR ___
Elevated left hemidiaphragm is redemonstrated. No definitive
opacity except for minimal bibasilar atelectasis is
demonstrated. Pulmonary nodules seen in the left mid lower lung
are demonstrated and might represent at least in part pleural
calcifications. No pneumothorax is seen.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Calcium Carbonate 500 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Duloxetine 30 mg PO DAILY
7. Furosemide 40 mg PO DAILY
8. Lactulose 30 mL PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
hold for HR<55, bp<95
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. Senna 1 TAB PO BID
14. traZODONE 100 mg PO HS:PRN insomnia
15. Vitamin D 800 UNIT PO DAILY
16. Milk of Magnesia 30 mL PO Q6H:PRN constipation
17. Naproxen 500 mg PO Q8H:PRN pain
18. Lidocaine Jelly 2% 1 Appl TP DAILY: PRN penile pain/foley
pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Furosemide 20 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
hold for HR<55, bp<95
6. Milk of Magnesia 30 mL PO Q6H:PRN constipation
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 1 TAB PO BID
11. Vitamin D 800 UNIT PO DAILY
12. Acetaminophen 650 mg PO Q6H:PRN pain
13. Lidocaine Jelly 2% 1 Appl TP DAILY: PRN penile pain/foley
pain
14. Bisacodyl 10 mg PR HS constipation
15. Bisacodyl 10 mg PO DAILY constipation
16. Atorvastatin 40 mg PO DAILY
17. CefePIME 2 g IV Q12H
18. Fluconazole 200 mg PO Q24H Duration: 5 Days
19. Mirtazapine 7.5 mg PO HS
20. Lactulose 30 mL PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Complicated urinary tract infection
Hypotonic bladder
Constipation
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
CHEST RADIOGRAPH
INDICATION: Chronic heart failure, evaluation for edema and effusion.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, there is unchanged evidence
of elevation of the left hemidiaphragm and subpleural partly calcified scars.
Status post CABG. Minimal atelectasis at the right lung base but no evidence
of current pneumonia or fluid overload. Unchanged appearance of the cardiac
silhouette.
Radiology Report
HISTORY: ___ man with UTI, chronic constipation presents with severe
abdominal pain, not passing gas.
COMPARISON: Abdominal radiograph, ___.
FINDINGS:
There is moderate colonic fecal load with minimally dilated cecum. Air is
seen in scant loops of nondilated small bowel. This is a nonobstructive bowel
gas pattern. Remnant contrast material is seen in the large bowel. There is
no supine radiographic evidence of pneumoperitoneum or pneumatosis.
IMPRESSION:
Moderate colonic fecal load. Nonobstructive bowel gas pattern.
Wet read was entered into the system by Dr. ___ on ___
at 22:33.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Increased lethargy, assess for pneumonia.
Comparison is made with prior study, ___.
Cardiac size is top normal. The main pulmonary arteries are larger as before.
Elevation of the left hemidiaphragm is longstanding. There are low lung
volumes. Bibasilar atelectases have increased. Bilateral calcified pleural
plaques are again noted. There are probably small bilateral pleural
effusions. There is no pneumothorax.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Assess line.
Right PICC tip is in the low SVC. The patient is very rotated. Assessment of
the cardiomediastinum is very limited. There is a probable new large opacity
in the left lower lobe that would correspond to a large area of atelectasis.
A conventional frontal radiograph without rotation is recommended for further
and better evaluation. There is no evident pneumothorax.
Radiology Report
ABDOMEN
REASON FOR EXAM: Increasing abdominal pain and distention. Assess for
obstruction.
There is a nonobstructing bowel gas pattern. There is air in the ascending
and transverse colon. There is fecal material in the descending colon. There
is no air in the rectum. There are few air fluid levels in the small bowel
loops that are nondistended.
There are severe degenerative changes in the lumbar spine. There are vascular
calcifications.
Radiology Report
HISTORY: Right renal tumor and indwelling Foley with positive urine culture.
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
The right kidney measures 10.2 cm. The left kidney measures 10.4 cm.
Bilateral kidneys are without evidence of hydronephrosis or stones. The
vascular right upper pole tumor is again noted measuring 3.3 x 3.6 x 2.9 cm.
The bladder is decompressed and not evaluated. There is no evidence of
distinct collections.
IMPRESSION:
No evidence of distinct collections. Right upper pole solid tumor is again
identified measuring 3.3 x 3.6 x 2.9 cm.
Radiology Report
REASON FOR EXAMINATION: PICC line placement and assessment of left lower lobe
opacity.
AP radiograph of the chest was reviewed in comparison to ___ and
___.
Elevated left hemidiaphragm is redemonstrated. No definitive opacity except
for minimal bibasilar atelectasis is demonstrated. Pulmonary nodules seen in
the left mid lower lung are demonstrated and might represent at least in part
pleural calcifications. No pneumothorax is seen.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: UTI COMPLAINTS
Diagnosed with URIN TRACT INFECTION NOS, HYPERTENSION NOS
temperature: 97.6
heartrate: 88.0
resprate: 20.0
o2sat: 95.0
sbp: 86.0
dbp: 47.0
level of pain: 7
level of acuity: 1.0 | Acute issues:
# Urinary tract infection: Patient with BPH and hypotonic
bladder with incomplete emptying, s/p indwelling foley since
___ c/b frequent multidrug resistent UTIs, including MRSA, ESBL
E Coli, Pseudomonas, and Klebsiella. Had multiple ED visits the
week of admission, initially treated with Cipro then switched to
Keflex when culture grew Klebsiella resistant to Cipro. Repeat
culture grew Pseudomonas, so patient admitted to the hospital
for IV antibiotics and was started on cefepime. He was trialed
on fosfomycin, but deteriorated clinically so cefepime was
resumed. Patient continued to complain of suprapubic pain,
repeat UA suggestive of infection and culture grew yeast
___ PARAPSILOSIS) and patient was started on fluconazole to
complete a ___onstipation: Patient with significant abdominal pain and
distension, abdominal X-ray on ___ showed large amount of
dense stool. Patient disimpacted without significant success,
given MoviPrep with good result. Bowel regimen up-titrated, but
patient with no bowel movements for next 3 days. MoviPrep given
again, again with good success.
# Tremors: Patient with intermittant somnolence and tremor of
chin and hands in the context of possibly worsening UTI. Patient
had similar tremors on hospitalization in ___, which were
thought to be myoclonus secondary to infection. Neurology
consulted, recommended discontinuing duloxetine, trazodone,
oxycodone and starting clonazepam, as that seemed to help
previuosly. However, clonazepam then held due to patient
lethargy.
# Depression: Patient's duloxetine held due to tremors. Patient
with decreased appetite, tearfulness, hopelessness. Started on
low dose ___ likely need uptitration on an
outpatient basis.
# Delirium/acute encephalopathy: patient with waxing and waning
mental status throughout hospitalization. UTI and constipation
thought to be main contributing factors, treated as above. EKG
repeatedly unchanged from baseline, electrolytes and LFTs
normal, CXR normal.
# Hypoxia: patient with intermittant desats into the high
___ on room air. No signs of acute pulmonary process on
multiple chest x-rays, improved with deep breathing/incentive
spirometry.
# Facial rash: patient with crusted rash on right side of face,
DFA negative for zoster or HSV. Also with erythematous rash on
forehead. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lower extremity swelling, EKG changes
Major Surgical or Invasive Procedure:
Blood transfusion
History of Present Illness:
The patient is a ___ with HTN, CKD (baseline creatinine of
3.3-3.8) , and anemia of CKD. Had a routine visit with Dr. ___
___ and was noted to have new deep TWI in V3-V6 so was
referred to ED for further evaluation. Notes new bilateral lower
extremity edema since 2d prior, denies hx of edema. Denies
chest pain/pressure/tightness, SOB, palpitations, either at rest
or with exertion. Is still able to climb his 5 steps at home
without having to rest. Sleeps on 1 pillow and is able to sleep
flat, denies PND or orthopnea.
.
In the ED, initial vs were:97 50 130/64 16 100%. On exam, he was
guiaic negative, JVP elevated, 1+ pedal edema, faint bibasilar
rales but poor respiratory effort, a/a/o x3, hard of hearing,
independent. Labs were remarkable for HCT of 21.3 (baseline
___, creatinine of 4.2 (baseline 3.3-3.8) with BUN of 94, BNP
3404 (no prior), troponin-T 0.3. EKG per report showed sinus
brady at 53, NA, QRS 116, QTc 498, TWI in II/III/AVF (old) and
TWI in V3-V6 (new and deeper). CXR obtained and showed findings
suggestive of pulmonary vascular engorgement without frank
pulmonary edema. He was given aspirin 325mg. Vitals on Transfer:
70, RR: 18, BP: 125/49, O2Sat: 99, Pain: 0.
Past Medical History:
-Hypertension
-chronic kidney disease (baseline 3.3-3.8) due to chronic IgA
nephropathy(biopsy proven) followed by nephrology
-Anemia due to chronic kidney disease
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.2 147/62 68 18 97RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP ~2-3cm above clavicle @45 degrees, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi but poor inspiratory effort
CV: Regular rate and rhythm, s4 appreciated, -m/r.
Abdomen: soft, non-tender, mildly distended (baseline per pt),
bowel sounds present, no rebound tenderness or guarding.
+hepatojugular reflex. Liver not pulsatile.
Ext: Warm, well perfused. 1+ pitting edema to mid shin
bilaterally. 2+ pulses, no clubbing, cyanosis.
Neuro: AOx3, CN grossly intact
DISCHARGE PHYSICAL EXAM:
O:PHYSICAL EXAM:
Vitals: 98.0 148/60 64 18 98RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP flat while upright, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi but poor inspiratory effort
CV: Regular rate and rhythm, s4 appreciated, -m/r.
Abdomen: soft, non-tender, mildly distended (baseline per pt),
bowel sounds present, no rebound tenderness or guarding.
+hepatojugular reflex. Liver not pulsatile.
Ext: Warm, well perfused. trace to 1+ pitting edema to mid shin
bilaterally. 2+ pulses, no clubbing, cyanosis.
Neuro: AOx3, CN grossly intact
Pertinent Results:
___ 11:45AM BLOOD WBC-6.6 RBC-2.27* Hgb-7.6* Hct-21.7*
MCV-96 MCH-33.3* MCHC-34.8 RDW-14.4 Plt ___
___ 06:00AM BLOOD WBC-6.1 RBC-2.13* Hgb-7.0* Hct-20.1*
MCV-95 MCH-32.7* MCHC-34.5 RDW-14.4 Plt ___
___ 11:45AM BLOOD Neuts-71.0* ___ Monos-6.5 Eos-2.3
Baso-0.5
___ 11:45AM BLOOD ___ PTT-30.9 ___
___ 11:45AM BLOOD Glucose-104* UreaN-94* Creat-4.2* Na-140
K-4.6 Cl-105 HCO3-23 AnGap-17
___ 06:00AM BLOOD Glucose-89 UreaN-95* Creat-4.1* Na-143
K-4.8 Cl-109* HCO3-20* AnGap-19
___ 11:45AM BLOOD CK(CPK)-33*
___ 07:28PM BLOOD CK(CPK)-31*
___ 06:00AM BLOOD CK(CPK)-32*
___ 11:45AM BLOOD CK-MB-3 proBNP-3404*
___ 11:45AM BLOOD cTropnT-0.03*
___ 07:28PM BLOOD CK-MB-3 cTropnT-0.03*
___ 06:00AM BLOOD CK-MB-2 cTropnT-0.02*
___ 07:28PM BLOOD Iron-64
___ 07:28PM BLOOD calTIBC-189* Ferritn-343 TRF-145*
CXR ___: IMPRESSION: Findings suggestive of pulmonary
vascular engorgement without frank pulmonary edema. Trace
bilateral pleural effusions.
Medications on Admission:
-Aranesp 60 mcg once a month (gets in ___ clinic)
-Calcitriol 0.25 mcg once a week (started in ___
-nifedipine 60mg daily
-carvedilol 3.125 BID
-calcium acetate 667mg BID
Discharge Medications:
1. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
3. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
week.
5. Aranesp (polysorbate) 60 mcg/mL Solution Sig: One (1)
Injection once a month.
6. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. Outpatient Lab Work
Please get your bloodwork drawn at ___ clinic tomorrow (___).
There is a standing order in the system. Show up to the lab at
any time. Dr ___ will follow-up on the lab result.
Discharge Disposition:
Home
Discharge Diagnosis:
non-specific EKG changes
Acute on chronic renal failure
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS: ___
HISTORY: ___ man with lower extremity swelling, question CHF.
FINDINGS: Frontal and lateral views of the chest are compared to previous
exam from ___.
There is no confluent consolidation identified. There is however engorgement
of central vasculature with indistinct pulmonary vascular markings seen
particularly at the bases. There are also trace bilateral pleural effusions.
Cardiac silhouette is slightly enlarged but stable. Osseous and soft tissue
structures are stable.
IMPRESSION: Findings suggestive of pulmonary vascular engorgement without
frank pulmonary edema. Trace bilateral pleural effusions.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABNORMAL EKG
Diagnosed with ABNORM ELECTROCARDIOGRAM, ANEMIA IN END-STAGE RENAL DISEASE, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED, CHRONIC KIDNEY DISEASE, UNSPECIFIED
temperature: 97.0
heartrate: 50.0
resprate: 16.0
o2sat: 100.0
sbp: 130.0
dbp: 64.0
level of pain: 0
level of acuity: 3.0 | ___ hx worsening CKD, HTN who presents with EKG changes from
PCPs office, asymptomatic.
.
#EKG changes: New deep TWI in V3-V6 with new AV nodal delay. No
hx suggestive of coronary disease although on exam appears with
volume overload (JVD, edema, S4 from ?longstanding HTN).
Cardiac risk factors include hypertension, age. Has no hx of
DM2, previous remote smoking hx. DDx includes ischemia
(although no s/s, no hx), LV strain (anemia below baseline
although not symptomatic), neurogenic T waves (although neuro
exam and hx reassuring), memory T waves (does have new AV nodal
delay on EKG but no evidence for RBBB/LBBB). Other more chronic
etiologies such as ___ syndrome less likely due to
previously normal EKG in ___. He was ruled out for MI
with serial CE x3 (all negative). TTE was deferred to the
outpatient setting. It is unclear what these EKG changes were
due to.
.
#Volume overload: evidence of edema, JVD with +HJR, lung
vasculature engorged but no signs of pulmonary edema on CXR or
clinically. Etiology likely secondary to worsening renal
failure although cardiac etiology cannot be ruled out. TTE was
deferred to the outpatient setting as the patient was quite
stable. His volume status was managed with IV lasix; to 40IV
lasix he only put out approximately 250-300cc, so he was
discharged with 80mg PO with close follow-up and labwork the day
after discharge to evaluate electrolytes and renal function.
His dose of lasix will likely have to be altered as an
outpatient.
.
#Anemia: HCT 21 on admission, below baseline of 25, secondary to
CKD. On aranesp as outpt. Hemodynamically stable and
asymptomatic. Unlikely to be causing his EKG changes, however he
was transfused 1 unit RBCs due to HCT 20 on HD2. He tolerated
this well, receiving 40IV lasix before and after the transfusion
for volume management. He will have a repeat HCT drawn the day
after discharge.
.
#AOCKD: baseline Cr rising from mid 3.5 to now 4.2. BUN near
his recent baseline. Etiology secondary to progressive chronic
IgA nephropathy. Initially pt declined HD/PD. In further
discussion with patient, he is going to weigh the risks/benefits
of the various options tomorrow at his appointment with his
nephrologist. There were no urgent indications for dialysis
during this admission.
.
#HTN: Maintained on his home medications. Added lasix on this
admission.
. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. ___ is a ___ female with multiple
myeloma with adverse cytogenetics who has had progressive
disease
through multiple treatment regimens, most recently treated with
D-PACE and bortezomib/pomalidomide. Patient now presents with
fever 100.4 at home and chills from OSH.
Infectious workup at OSH unrevealing thus far but CXR consistent
with interval improvement in PNA but noted progressive disease.
Patient was initiated on cefepime. Urine and blood cultures NTD,
admitted for further management.
Past Medical History:
PAST ONCOLOGIC HISTORY:
DIAGNOSIS: Multiple myeloma, ISS stage II, Durie-Salmon stage
III, high risk cytogenetics
Multiple numerical and structural abnormalities, including
6q deletion, gain of 1q, monosomy 13 and a possible t(14;16)
most likely resulting in an IGH/MAF rearrangement.
TREATMENT HISTORY:
On clinical trial ___, randomized to arm B (early
transplant): RVD = lenalidomide 25 mg daily D1-14, bortezomib
1.3 mg/m2 D1,4,8,11, dexamethasone 20 mg D1,2,4,5,8,9,11,12
3 cycles ___ - ___
Found to have disease progression (new plasmacytoma) on ___
and taken off treatment on ___
Dexamethasone 40 mg PO x4 on ___, Cytoxan 1000 mg/m2 IV on
___, Bortezomib 1.3 mg/m2 D1,4,8,11 on ___ -> stable
M-protein
RCVD (Cytoxan 300 mg/m2 + Dex ___ mg + bortexomib 1.5 mg/m2 on
D1,8,15,22 and lenalidomide 25 mg D1-21 in a 28 day cycle)
CyBorD started on ___, All 4 drugs started on ___
-C1 Carfilzomib/dex/revlmid Starting ___
-C2 Carfilzomib/dex/revlmid Starting ___
- D-PACE since ___
PAST MEDICAL HISTORY:
-Multiple Myeloma as above
-HSV-2
-Asthma
Social History:
___
Family History:
In terms of family history, there is a fairly substantial family
history of malignancy. Her oldest sister had some sort of
cancer of the spine. A different sister had lung cancer. A
brother died from leukemia. Another brother had prostate
cancer. She has three other siblings who are well. She is the
youngest of eight children. Her father died at age ___ of an
unknown cause and her mother passed away at age ___. Her
children and grandchildren are healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
GEN: Chronically appearing female in no distress, cachetic
VS: Tc 98.2 HR 96 BP 112/60 Resp 19 spO2 96%RA
Pain (___): 0
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary LAD
CV: RRR. Normal S1 and S2. No S3/S4. No M/R/G
PULM: Crackles on LLL. Otherwise, CTA. No increased WOB,
wheezing
or rhonchi. Tenderness over L ribs, chronic
ABD: Multiple bruising from lovenox injections. Hypoactive BS,
soft, mild distention, no tenderness, Left abdominal wall
induration
LIMBS: No edema/inguinal adenopathy
SKIN: Bruising as noted above. No rashes or skin breakdown
NEURO: Grossly non-focal, alert and oriented x 3
DISCHARGE PHYSICAL EXAM:
GEN: Chronically appearing female in no distress, cachetic
VS: Tc 98.7 HR 101 BP 108/60 Resp 101 spO2 97%RA
Pain (___): 0
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary LAD
CV: RRR. Normal S1 and S2. No S3/S4. No M/R/G
PULM: Crackles on LLL, diminished at bilateral bases. Otherwise,
CTA. No increased WOB, wheezing or rhonchi. Tenderness over L
ribs, chronic
ABD: Multiple bruising from lovenox injections. Hypoactive BS,
soft, mild distention, no tenderness, 4 subcutaneous nodules,
remain assumed to be plasmocytoma no pain
LIMBS: No edema/inguinal adenopathy
SKIN: Bruising as noted above. No rashes or skin breakdown
NEURO: Grossly non-focal, alert and oriented x 3
Pertinent Results:
___ 07:52AM BLOOD WBC-2.8* RBC-2.67* Hgb-7.9* Hct-24.2*
MCV-91 MCH-29.6 MCHC-32.6 RDW-18.8* RDWSD-59.4* Plt Ct-24*
___ 12:02PM BLOOD WBC-3.0* RBC-2.36* Hgb-7.2* Hct-21.8*
MCV-92 MCH-30.5 MCHC-33.0 RDW-19.1* RDWSD-62.9* Plt Ct-20*#
___ 07:52AM BLOOD Neuts-66 Bands-0 Lymphs-4* Monos-29*
Eos-0 Baso-0 ___ Metas-1* Myelos-0 NRBC-2* AbsNeut-1.85
AbsLymp-0.11* AbsMono-0.81* AbsEos-0.00* AbsBaso-0.00*
___ 12:02PM BLOOD Neuts-77* Bands-10* Lymphs-3* Monos-6
Eos-0 Baso-1 ___ Metas-3* Myelos-0 AbsNeut-2.61
AbsLymp-0.09* AbsMono-0.18* AbsEos-0.00* AbsBaso-0.03
___ 07:52AM BLOOD Glucose-147* UreaN-9 Creat-0.5 Na-129*
K-4.2 Cl-100 HCO3-23 AnGap-10
___ 12:02PM BLOOD UreaN-12 Creat-0.7 Na-131* K-4.8 Cl-100
HCO3-24 AnGap-12
___ 07:52AM BLOOD ALT-37 AST-17 LD(LDH)-174 AlkPhos-91
TotBili-0.4
___ 12:02PM BLOOD ALT-40 AST-25 LD(LDH)-165 AlkPhos-84
TotBili-0.4
___ 07:52AM BLOOD Albumin-2.8* Calcium-8.1* Phos-2.5*
Mg-1.7
___ 12:02PM BLOOD Calcium-8.9 Phos-4.3 Mg-1.8 UricAcd-2.3*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Clotrimazole 1 TROC PO TID
3. Gabapentin 300 mg PO QHS
4. Lorazepam 0.5 mg PO QHS:PRN insomnia
5. Lorazepam 0.5 mg PO Q4H:PRN nausea/vomiting
6. Metoprolol Succinate XL 25 mg PO DAILY
7. OLANZapine 2.5-5 mg PO BID:PRN nausea/vomiting
8. Omeprazole 20 mg PO BID
9. Ranitidine 300 mg PO QHS
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. Bisacodyl 10 mg PO DAILY:PRN constipation
12. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
13. Docusate Sodium 100 mg PO BID
14. Magnesium Oxide 400 mg PO DAILY
15. Senna 8.6 mg PO BID
Discharge Medications:
1. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
2. Senna 8.6 mg PO BID
3. Ranitidine 300 mg PO QHS
4. Omeprazole 20 mg PO BID
5. OLANZapine 2.5-5 mg PO BID:PRN nausea/vomiting
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Magnesium Oxide 400 mg PO DAILY
8. Lorazepam 0.5 mg PO QHS:PRN insomnia
9. Gabapentin 300 mg PO QHS
10. Docusate Sodium 100 mg PO BID
11. Clotrimazole 1 TROC PO TID
12. Bisacodyl 10 mg PO DAILY:PRN constipation
13. Lorazepam 0.5 mg PO Q4H:PRN nausea/vomiting
14. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
15. Acyclovir 400 mg PO Q8H
16. Levofloxacin 500 mg PO Q24H Duration: 5 Days
RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*5
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
MM
fever of unknown origin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with progressive MM // febrile at home, R/o
PNA febrile at home, R/o PNA
IMPRESSION:
In comparison with the study of ___ from an outside hospital, there is
continued enlargement of the cardiac silhouette with some indistinctness of
engorged pulmonary vessels consistent with elevated pulmonary venous pressure.
Continued left pleural effusion with compressive atelectasis at the base.
Probable atelectatic changes are also seen on the right.
Continued irregular pleural opacifications about the border of the left
hemithorax, consistent with the pleural myeloma circumferentially involving
the left lung on the CT of ___.
Radiology Report
INDICATION: ___ woman with a history of multiple myeloma, now with
fever and abdominal pain. Evaluate for obstruction.
TECHNIQUE: Supine abdominal radiograph.
COMPARISON: Abdominal radiograph from ___.
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
Small phlebolith in the left pelvis.
IMPRESSION:
No evidence of obstruction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ yo woman with multiple myeloma here with fever and now with
new abdominal pain // Please evaluate for free air.
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, no relevant change is seen. No
evidence of free intra-abdominal air. Extensive pleural left-sided changes,
combined to a left pleural effusion, are constant. Moderate cardiomegaly,
signs of mild pulmonary edema and bilateral apical thickening, accompanied by
apical fibrosis is constant.
Gender: F
Race: WHITE - BRAZILIAN
Arrive by AMBULANCE
Chief complaint: Fever, Pneumonia, Transfer
Diagnosed with FEVER, UNSPECIFIED, OTHER PANCYTOPENIA, PNEUMONIA,ORGANISM UNSPECIFIED, MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
temperature: 98.5
heartrate: 81.0
resprate: 18.0
o2sat: 96.0
sbp: 100.0
dbp: 61.0
level of pain: 0
level of acuity: 2.0 | Mrs. ___ is a ___ female with adverse
cytogenetics and an aggressive multiple myeloma. She has had
multiple prior lines of therapy outlined in the treatment
history
above. She was transfered from OSH where she presented with
fever
and chilss. She is currently ___ s/p C8 D-PACE
#Abdominal cramping: Resolved. most likely due to constipation,
received
multiple stool medication as no BM x 4 days. Had 3 stools since
yesterday. -KUB neg
-Lactate 1.1
-oxycodone prn
-continue bowel regimen
#Fever/PNA: transferred from OSH ___ to ___ due to fever +
chills. Was febrile 100.4 at home and OSH. Patient has been
afebrile since admission. CXR at OSH showed interval improvement
of lung aeration, with decreased perihilar interstitial and
alveolar opacities compared to previous CXR on ___. However,
concerning for progressive disease. Previous Chest CT ___ at
OSH
was consistent with right infiltrate vs metatases
-d/c IV ABX after afebrile 48hrs, changed to po levaquin x 5
days
-blood culuture ___ NTD
-urine culture ___ neg
-will continue to monitor closely outpatient
#Pericardial Effusion: Was noted to have a small pericardial
effusion on ___ at OSH. Continue to monitor I/O, weights and
diurese prn.
-Last BNP 114 on ___
-TTE ___ clinically insignificant effusion per CARDs
#Progressive Multiple Myeloma: Initiated C8 D-PACE per Br J
Haematol. ___ Jul;138(2):176-85 on ___. However, has had
temporary benefit from each cycle in terms of symptomatic
improvement and decrease in LDH.
-Received 1 dose of Marizomib on ___ as part of the ___
clinical trial but pt currently not enrolled due to progressive
disease
-IgG ___, repeat ___ IgG 5702, IgG 6700 ___
-free kappa ___: 39 -> ___: 306 -> ___: 455 -> ___: 330
-C9 D-PACE due end of this week but may be on hold due to
infectious w/u, plan for ___
-f/u with Dr ___, aware to call with any
persistent fevers at home.
#SIADH: Most likely due to pseudohyponatremia from paraprotein.
Will consider repeating paraproteins. could be SIADH but ___
s/p
D-PACE
-urine osmo 407/serum 275
-NA+ 129 today
-continue trending lytes outpatient
#Anemia and thrombocytopenia: Due to extensive marrow
involvement by myeloma, compounded by recent chemotherapy with
C8 D-PACE/POM/Bortezimib. Platelet 24K today. Hgb 6.8, received
1
unit prbcs ___. Will continue to monitor for sxs of
bleeding/anemia. Completed neupogen prior to admission.
-transfuse for hgb <7 and/or plt <20K outpatient
#History of DVT (in the setting of lenalidomide, despite
prophylactic ASA) - diagnosed on ___. Held lovenox per Dr.
___ note on ___. Re-started on 60mg daily on
previous
admission
-holding lovenox on admission due to thrombocytopenia (plts 37)
-monitor for sxs of bleeding
#Hypertension: Hx of PAF, received amiodarone gtt ___ at OSH
during previous admission. will continue home metoprolol BID
#Constipation: +hypoactive BS. No BM x 4 days upon admission.
Had
1 stool this AM. Maximizing stool regimen, pt has had poor-fair
appetite.
- currently on senna, colace, dulcolax ATC and miralax prn
- will continue to monitor closely
#Electrolyte imbalance (hypokalemia): may be related to
infectious lung process. will be repleting prn, continue to
monitor lytes closely
# Infectious prophylaxis:
- PCP: ___
- HSV/VZV: Acyclovir |
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, vomitting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ male with Hx of diverticulitis and
IBS, s/p multiple abdominal surgeries, most recently ex lap with
ileostomy takedown and end descending colostomy on ___, who
was discharged ___ from ___ and now presented on ___ with
nausea, bilious vomiting and increased abdominal pain. Patient
was discharged yesterday, at which point he was tolerating a
regular diet without nausea or vomitting. When he got home
yesterday he was able to have a small meal (spaghetti) with
minimal discomfort. Late on the night prior to admission,
patient starting having diffuse abdominal pain and green/bilious
vomiting, with 3L of total emesis volume (measured by wife). He
continued to vomit this morning so they called Dr. ___
recommended he come to the ED. He denies hematemesis, coffee
ground emesis, fever, or chills. He has received 1L of normal
saline and IV zofran in the ED. Currently, denies active N/V.
Colostomy continues to have output although patient estimates
that total output is slightly less and stool appears more
dehydrated.
Past Medical History:
Past Medical History: psoriasis (previously on methotrexate),
diverticulitis, OSA, depression, IBS
Past Surgical History: sigmoid colectomy (OSH, ___ c/b leak,
diverting ileostomy (OSH, ___, ileostomy reversal (___)
c/b leak ___ foreign body, resection of prior colorectal
anastomosis/VAC placement (___), washout/open abdomen
(___), washout/partial closure of abdomen (___), ex
___ separation closure w/ SurgiMend
(___), colostomy takedown/primary repair of
colostomy/LOA/diverting double-barrel ileostomy
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission PE ___:
Temp: 98.5 HR: 74 BP: 122/90 Resp: 18 O(2)Sat: 99 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: diffusely tender with packing in 2 abscesses,
normal colostomy outpt
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent
Discharge PE: ___
Vitals: 98.3, HR: 70, BP: 95/58, RR: 18, 95% on RA
General: comfortable appearing man
Lungs: CTAB, diminished at the bases
CV: RRR, no murmurs, rubs or gallops
Amdominal: soft, non tender, non distended, colostomy with well
perfused stoma and brown stool. Healing midline incision, lower
portion of the incision epithealizing well, no packing required.
Extremities: warm, well perfused, +PP
Neuro: Alert and oriented X3, MAE to command, PERRL
Pertinent Results:
___ 04:28AM PLT COUNT-507*
___ 04:28AM NEUTS-45.0* LYMPHS-44.4* MONOS-6.1 EOS-4.0
BASOS-0.5
___ 04:28AM WBC-3.2* RBC-3.42* HGB-9.5* HCT-30.7* MCV-90
MCH-27.8 MCHC-31.0 RDW-14.5
___ 04:28AM GLUCOSE-89 UREA N-21* CREAT-0.7 SODIUM-138
POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15
___ 07:45AM ___ PTT-35.1 ___
___ 07:45AM PLT COUNT-713*
___ 07:45AM NEUTS-60.0 ___ MONOS-9.8 EOS-1.0
BASOS-1.0
___ 07:45AM WBC-3.3* RBC-4.13* HGB-11.4* HCT-36.5* MCV-88
MCH-27.6 MCHC-31.2 RDW-14.5
___ 07:45AM ALBUMIN-4.7
___ 07:45AM LIPASE-67*
___ 08:08AM LACTATE-2.4*
___ 04:48AM BLOOD WBC-1.8* RBC-3.11* Hgb-8.5* Hct-27.5*
MCV-89 MCH-27.4 MCHC-31.0 RDW-14.3 Plt ___
___ 07:45AM BLOOD Neuts-60.0 ___ Monos-9.8 Eos-1.0
Baso-1.0
___ 04:48AM BLOOD Glucose-108* UreaN-18 Creat-0.7 Na-138
K-4.3 Cl-106 HCO3-26 AnGap-10
___ 04:48AM BLOOD Calcium-9.1 Phos-2.5* Mg-2.0
___: CT ABD/Pelvis:IMPRESSION:
1. Further slight decrease in size of the known abdominal and
pelvic fluid collections. No new collections identified.
2. Findings raising concern for partial small-bowel obstruction
at the level of a proximal small bowel anastomosis in the
jejunum.
___: CXR: Left PICC with the tip in the mid to low SVC.
Medications on Admission:
1. Acetaminophen 1000 mg PO Q8H
2. Duloxetine 90 mg PO DAILY
3. Gabapentin 800 mg PO Q8H
4. Daptomycin 300 mg IV Q24H
5. Fentanyl Patch 25 mcg/h TD Q72H chronic pain
6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
7. Meropenem 1000 mg IV Q8H
8. Pantoprazole 40 mg PO Q24H
9. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
10. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP TID:PRN
psoriasis
11. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Duloxetine 90 mg PO DAILY
4. Fentanyl Patch 25 mcg/h TD Q72H
5. Gabapentin 800 mg PO Q8H
6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
7. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP TID:PRN
psorisis
8. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
partial small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Recent surgery with 3 L of bilious vomiting.
TECHNIQUE: Upright PA and supine AP views of the abdomen.
COMPARISON: CT abdomen pelvis ___ and abdominal radiographs ___.
FINDINGS:
A nonobstructive bowel gas pattern is demonstrated. No air-fluid levels are
seen on the upright view. Multiple chain sutures are seen within the abdomen.
A left lower quadrant colostomy is present. There is no free intraperitoneal
air identified. No acute osseous abnormalities are seen.
IMPRESSION:
Nonobstructive bowel gas pattern without free intraperitoneal air. No
significant air-fluid levels are present.
Radiology Report
CT OF THE ABDOMEN AND PELVIS WITH IV CONTRAST
INDICATION: ___ man with complicated surgical history, assess for
fluid collection or ileus.
CT OF THE ABDOMEN AND PELVIS WITH IV CONTRAST TECHNIQUE: Multidetector
scanning is performed from the diaphragm through the symphysis during dynamic
injection of Omnipaque.
Comparison is made to ___.
DLP: 672 mGy-cm.
CT OF THE ABDOMEN WITH IV CONTRAST: There is mild atelectasis at the lung
bases, not significantly changed. The liver is without focal lesions. The
gallbladder is unremarkable. The spleen is normal in size. An NG tube is
identified in the stomach and oral contrast is seen in the small bowel and can
be followed into the pelvis. The pancreas enhances homogeneously and there is
no dilatation of the pancreatic duct. The adrenal glands are normal. The
kidneys enhance homogeneously. There is no evidence for hydronephrosis.
There is no retroperitoneal lymphadenopathy. The aorta is normal in caliber.
Some focal dilatation of jejunal loops in the left upper quadrant proximal to
an anastomosis contrast is seen distally to this, however, and the distal
loops are normal in caliber. Proximal loops measure up to 5.1 cm. This is a
new finding from prior examination. The previously identified fluid
collection immediately underneath the abdominal wall is decreased in size.
Previously, it measured approximately 8.4 cm in length, currently only 4.7 cm.
Its depth is relatively unchanged measuring 0.7 cm.
There is a 1.4 x 1.0 cm fluid collection in the left upper quadrant (series 2,
___ 31) which contains a small focus of air. This is slightly decreased in
size, previously measuring 1.5 x 1.3 cm.
CT OF THE PELVIS WITH IV CONTRAST: A ___ pouch is identified and
immediately above the suture line, there is a 3.2 x 2.8 x 1.2 cm fluid
collection. This is slightly decreased in size, previously measuring 3.6 x
2.9 x 1.4 cm. No new collections are identified. There is no free fluid in
the pelvis. There is no pelvic or inguinal lymphadenopathy. The prostate
gland is normal in size.
On bone windows, there are no concerning osteolytic or osteosclerotic lesions.
IMPRESSION:
1. Further slight decrease in size of the known abdominal and pelvic fluid
collections. No new collections identified.
2. Findings raising concern for partial small-bowel obstruction at the level
of a proximal small bowel anastomosis in the jejunum.
Radiology Report
HISTORY: Chronic TPN requirements, admitted with PICC line. Evaluate
placement.
COMPARISON: Chest radiograph from ___.
FINDINGS:
A portable frontal chest radiograph demonstrates a left PICC with the tip in
the mid to low SVC and a nasoenteric tube that likely enters the small bowel.
The cardiomediastinal silhouette is normal and the lungs are clear. There is
no pleural effusion or pneumothorax.
IMPRESSION:
Left PICC with the tip in the mid to low SVC.
Radiology Report
PORTABLE ABDOMEN, ___
COMPARISON: ___.
FINDINGS: A non-obstructive bowel gas pattern is visualized. Colostomy is
noted in the left lower quadrant, and surgical chain sutures present
bilaterally. Oral contrast is present within non-distended small bowel in the
left upper quadrant and within non-distended colon in the right side of the
abdomen. Recently described dilated jejunal loop on CT of one day earlier is
not evident, but additional upright or lateral decubitus views may be helpful
if warranted clinically. Residual oral contrast within bowel is related to
the recent CT.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Abd pain, N/V
Diagnosed with ABDOMINAL PAIN GENERALIZED, VOMITING
temperature: 98.5
heartrate: 74.0
resprate: 18.0
o2sat: 99.0
sbp: 122.0
dbp: 90.0
level of pain: 8
level of acuity: 3.0 | Mr ___ is a ___ year old with a history of diverticulitis and
a complex surgical history who presented to ___ with nausea,
large volume emesis, and abdominal pain on ___. He was
most recently discharged on ___ after a lengthy admission
s/p exploratory laparotomy, ileostomy reversal and end colostomy
complicated by intraabdominal collections. He had been home
less than 24 hours when he experienced diffuse abdominal with
emesis after a small meal. CT scan on admission revealed a
partial small bowel obstruction and the previous fluid
collection had decreased in size.
At this time, the patient was made NPO with IVF and a NGT was
placed to low wall suction. He continued to have ostomy output
at this time. The NGT was clamped on ___ with little residual
and was removed on ___. On admission, he was placed on TPN to
optimize his nutrition status; although, it had been
discontinued prior to his previous discharge. His diet was
advanced on ___. He was tolerating a regular diet with
supplements on the day of discharge so it was decided that his
TPN would be discontinued and his L PICC removed. He continued
to pass stool through his colostomy.
On the day of discharge, the patient was alert and oriented and
pain was controlled on his home pain regimen. He was
hemodynamically stable. He had remained afebrile. His white
blood cell count trended down to 1.8 throughout this
hospitalization which was deemed to be the effect of Meropenum.
He completed his antibiotic course of Meropenum and Daptomycin
on ___ for the intraabdominal fluid collections. He was
ambulating independently. Throughout his hospitalization he was
maintained on Heparin subcutaneously for deep vein thrombosis
prophylaxis. He will follow up on ___ in the Acute Care
Surgery Clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Mr. ___ is a ___ y/o man w/PMH FSGS s/p failed deceased donor
transplant, previously on peritoneal dialysis c/b encapsulating
peritoneal sclerosis, now on HD MWF presenting with abdominal
pain, nausea/vomiting, and inability to tolerate PO for the past
two weeks. Also with hx papillary thyroid cancer s/p
thyroidectomy, non-secretory pituitary adenoma, and eosinophilic
gastritis.
Of note, patient presented to ___ earlier this month
3
weeks ago for the same symptoms. According to patient's mother,
he had a CT scan that just showed a large amount of stool in the
colon, and he was treated supportively with morphine for pain
and
enemas for constipation. Discharged w/ persistent pain.
Pain is in left upper quadrant radiating to back. Constant, was
taking oxyocodone ___ that he was discharged with for pain
without relief. Also having daily nausea with vomiting every
time
he tried to eat. Vomiting initially bilious, last episode of
emesis was yesterday was when he tried to eat soup, vomit
consisted of undigested soup. Last bowel movement was yesterday,
only because he had a suppository, has not been able to have
regular bowel movements. Not passing gas. No fevers/chills,
chest
pain, palpitations, SOB, ___ edema, bloody stools. Anuric. Due
for
HD today, did not go since he presented to ED. Tolerated
sandwich
in ER today.
In the ED:
- Initial VS: T97.8, HR101, BP 94/63, RR18, PO2 99% RA
- Exam notable for: chronically ill, dry MM, +subcutaneous scar
tissue in LUQ, multiple well-healed scars in RUQ (peritoneal
dialysis port site), RLQ/right flank (s/p renal transplant).
+b/l
flank tenderness
- Labs were notable for: hgb 10.7, wbc 8.1, plt 349, phos 7.8,
Cr
9.6, K 4.7, LFTs wnl
- Studies performed include:
*CT A/P w/IV contrast:
1. Mildly dilated loops of small bowel in the right upper
quadrant may be consistent with early partial small bowel
obstruction.
2. Re-demonstrated extensive peritoneal calcifications likely
secondary to chronic peritoneal dialysis and compatible with
encapsulating peritoneal sclerosis.
3. Diffuse sclerotic changes to the visualized osseous
structures, compatible with renal osteodystrophy.
- Patient was given:
IV HYDROmorphone (Dilaudid) .5 mg
IV HYDROmorphone (Dilaudid) .5 mg
IV Pantoprazole 40 mg
- Consults: Renal
Upon arrival to the floor, patient is still in ___ pain in LUQ
radiating to the back. Heat packs and sitting upright somewhat
helping. Tolerated sandwich in the ER. No N/V and still not
passing gas. Feels bloated.
Past Medical History:
PITUITARY MASS
H/O THYROID CANCER
FSGS
END STAGE RENAL DISEASE
H/O RENAL TRANSPLANT
ENCAPSULATING PERITONEAL SCLEROSIS
PANCREATITIS
STROKE
HYPERPROLACTINEMIA
HYPOGONADISM
EOE/GERD
LACTOSE INTOLERANCE
CONSTIPATION/DYSMOTILITY
Social History:
___
Family History:
Maternal grandmother with diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM:
==================
VITALS: T98.4, BP 97/65, HR 101, RR 16, PO2 100 Ra
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection.
ENT: MMM. No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, firm on palpation, not bloated;
non-tender to deep palpation in all four quadrants. No
organomegaly.
MSK: No spinous process tenderness. No CVA tenderness.
SKIN: Warm. Cap refill <2s. No rash.
DISCHARGE PHYSICAL EXAM:
===================
24 HR Data (last updated ___ @ 843)
Temp: 98.3 (Tm 98.6), BP: 105/67 (93-113/54-72), HR: 76
(73-85), RR: 18 (___), O2 sat: 99% (98-100), O2 delivery: Ra
GENERAL: Alert and interactive. Lying in bed. NAD
EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection.
ENT: MMM. No cervical lymphadenopathy.
CARDIAC: RRR, no murmurs/rubs/gallops.
RESP: CTAB. No wheezes, rhonchi or rales. No increased work of
breathing.
ABDOMEN: normoactive BS+, firm on palpation particularly around
midline, no tenderness. No rebound tenderness or guarding.
SKIN: Warm. No rash noted.
Pertinent Results:
ADMISSION LABS:
============
___ 12:45PM BLOOD WBC-8.1 RBC-3.82* Hgb-10.7* Hct-36.2*
MCV-95 MCH-28.0 MCHC-29.6* RDW-15.9* RDWSD-55.1* Plt ___
___ 12:45PM BLOOD Neuts-74.3* Lymphs-13.9* Monos-9.6
Eos-1.4 Baso-0.6 Im ___ AbsNeut-5.99 AbsLymp-1.12*
AbsMono-0.77 AbsEos-0.11 AbsBaso-0.05
___ 12:45PM BLOOD Plt ___
___ 12:45PM BLOOD Glucose-73 UreaN-50* Creat-9.6*# Na-139
K-4.7 Cl-88* HCO3-23 AnGap-28*
___ 12:45PM BLOOD ALT-6 AST-10 AlkPhos-104 TotBili-0.7
___ 12:45PM BLOOD Albumin-4.1 Calcium-9.7 Phos-7.8* Mg-2.1
___ 04:42AM BLOOD calTIBC-109* Ferritn-998* TRF-84*
___ 04:42AM BLOOD PTH-14*
___ 04:42AM BLOOD 25VitD-62*
DISCHARGE LABS:
===========
___ 06:31AM BLOOD WBC-5.4 RBC-3.13* Hgb-8.9* Hct-30.1*
MCV-96 MCH-28.4 MCHC-29.6* RDW-17.2* RDWSD-58.6* Plt ___
___ 06:31AM BLOOD Glucose-75 UreaN-45* Creat-9.0*# Na-140
K-4.0 Cl-99 HCO3-23 AnGap-18
___ 06:31AM BLOOD Calcium-8.5 Phos-4.3 Mg-2.0
IMAGING:
=======
___ CT ABD/PELVIS:
1. Mildly dilated loops of small bowel in the right upper
quadrant with
collapse of the terminal ileum may be consistent with early
and/or partial
small bowel obstruction.
2. Re-demonstrated extensive peritoneal calcifications likely
secondary to
chronic peritoneal dialysis and compatible with encapsulating
peritoneal
sclerosis. Re-demonstrated low-density ascites encased by the
peritoneal
calcifications.
3. Diffuse sclerotic changes to the visualized osseous
structures, compatible
with renal osteodystrophy.
___ KUB:
Persistently dilated small bowel in the right upper quadrant
measuring up to
3.6 cm.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q12H
2. Levothyroxine Sodium 200 mcg PO 5X/WEEK (___)
3. Levothyroxine Sodium 300 mcg PO 2X/WEEK (MO,FR)
4. sevelamer CARBONATE 2400 mg PO TID W/MEALS
Discharge Medications:
1. Polyethylene Glycol 17 g PO DAILY
2. PredniSONE 30 mg PO BID
RX *prednisone 10 mg 3 tablet(s) by mouth twice a day Disp #*180
Tablet Refills:*0
3. 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
4. Levothyroxine Sodium 200 mcg PO 5X/WEEK (___)
5. Levothyroxine Sodium 300 mcg PO 2X/WEEK (MO,FR)
6. Pantoprazole 40 mg PO Q12H
7. sevelamer CARBONATE 2400 mg PO TID W/MEALS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==============
Partial small bowel obstruction
SECONDARY DIAGNOSIS:
================
FSGS s/p failed deceased donor transplant on iHD (previously on
peritoneal dialysis)
Papillary thyroid cancer s/p thyroidectomy
Hypothyroidism
Eosinophilic gastritis
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 FSGS s/p failed deceased donor transplant, formerly on
peritoneal dialysis, complicated by peritoneal sclerosis, presenting with
abdominal pain, nausea/vomiting, and inability to tolerate PO intake. Now on
hemodialysis MWF. R/o bowel obstruction, acute abdomen
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 2.5 s, 0.5 cm; CTDIvol = 12.0 mGy (Body) DLP =
6.0 mGy-cm.
2) Spiral Acquisition 5.9 s, 46.1 cm; CTDIvol = 9.0 mGy (Body) DLP = 414.2
mGy-cm.
Total DLP (Body) = 420 mGy-cm.
COMPARISON: CT abdomen and pelvis dated ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion. A hemodialysis catheter is
partially visualized.
ABDOMEN:
Re-demonstrated is diffuse, extensive peritoneal calcification encasing
multiple loops of small bowel. There is also ascites encased in
calcification.
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,
besides vicarious excretion of contrast.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Bilateral kidneys are severely atrophic and not well visualized.
GASTROINTESTINAL: The stomach is unremarkable. There is mild distension of
small bowel loops measuring up to 3.6 cm in the right upper quadrant, with
collapse of the distal ileum. There is change in caliber of the bowel loops
in the right lower quadrant. The colon and rectum are within normal caliber,
with stool and air. The appendix is not definitely visualized. There is air
within the colon.
PELVIS: The urinary bladder is decompressed. There is free-fluid, slightly
decreased compared to prior.
LYMPH NODES: There is no retroperitoneal abdominopelvic lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm.
BONES: There is diffuse sclerosis throughout the visualized osseous
structures, compatible with renal osteodystrophy.
SOFT TISSUES: Focal skin thickening in subcutaneous soft tissue induration
along the bilateral gluteal clefts, right greater than left, extending into
the anal verge is again re-demonstrated.
IMPRESSION:
1. Mildly dilated loops of small bowel in the right upper quadrant with
collapse of the terminal ileum may be consistent with early and/or partial
small bowel obstruction.
2. Re-demonstrated extensive peritoneal calcifications likely secondary to
chronic peritoneal dialysis and compatible with encapsulating peritoneal
sclerosis. Re-demonstrated low-density ascites encased by the peritoneal
calcifications.
3. Diffuse sclerotic changes to the visualized osseous structures, compatible
with renal osteodystrophy.
Radiology Report
INDICATION: ___ year old man with hx of FSGS s/p failed transplant, on iHD,
presented with nausea/vomiting, constipation concerning for SBO.// SBO
TECHNIQUE: Supine abdominal radiograph was obtained.
COMPARISON: CT abdomen/pelvis dated ___. KUB dated
___.
FINDINGS:
Persistently dilated loop of small bowel in the right upper quadrant measuring
up to 3.6 cm.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum. Hyperdensities overlying the abdomen correspond to known
peritoneal calcifications, better evaluated on CT dated ___.
Osseous structures are unremarkable.
IMPRESSION:
Persistently dilated small bowel in the right upper quadrant measuring up to
3.6 cm.
Radiology Report
INDICATION: ___ year old man with SBO, now with n/v and worsening abdominal
pain.// Does this patient have perf? Worsening of obstruction?
TECHNIQUE: Supine and upright radiographs of the abdomen and pelvis
COMPARISON: Radiographs from ___
FINDINGS:
Diffuse peritoneal calcification is seen again and similar to prior.
There are several prominent loops of small bowel located centrally within the
abdomen, and on the upright images there are multiple fluid-filled level
suggestive of a small bowel obstruction.
There is no free intraperitoneal air.
Lumbar spine degenerative change.
IMPRESSION:
Prominent small bowel loops with multiple fluid-filled levels on the upright
images suggest ongoing small bowel obstruction.
Radiology Report
INDICATION: ___ y/o w/FSGS s/p failed transplant s/p peritoneal dialysis
c/bperitoneal sclerosis, now on HD presenting who is admitted with partial
bowel obstruction iso peritoneal sclerosis// Complaining of burning abdoninal
pain. getting KUB to asses SBO
TECHNIQUE: Supine abdominal radiograph
COMPARISON: Multiple prior abdominal radiographs, most recently ___.
CT abdomen and pelvis dated ___
FINDINGS:
Again seen is diffuse peritoneal calcification in keeping with known history
of encapsulating peritoneal sclerosis. Unchanged, centrally displaced
prominent loops of small bowel. Supine technique limits evaluation of free
air.
Osseous structures are unremarkable.
IMPRESSION:
1. Diffuse peritoneal calcification is unchanged and in keeping with known
history of encapsulation peritoneal sclerosis
2. Unchanged, centrally displaced prominent loops of small bowel are
suggestive of persistence/partial SBO
3. Supine view limits evaluation of free air
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, N/V
Diagnosed with Unspecified abdominal pain
temperature: 97.8
heartrate: 101.0
resprate: 18.0
o2sat: 99.0
sbp: 94.0
dbp: 63.0
level of pain: yes
level of acuity: 3.0 | BRIEF HOSPITAL COURSE:
=================
Mr. ___ is a ___ yo M with history of FSGS s/p failed
transplant s/p peritoneal dialysis s/p peritoneal sclerosis now
in iHD who presented with ongoing abdominal pain, nausea,
vomiting, and few bowel movements admitted for partial small
bowel obstruction in the setting of encapsulating peritoneal
sclerosis. He was treated conservatively with bowel rest, strict
NPO, and nausea/pain medications. We talked with the patient
about how opioid pain medication was likely prolonging this
small bowel obstruction and encouraged him to use alternative
pain medication treatments and the patient was amendable. He was
given IV tylenol and toradol and did well. His nausea and
vomiting slowly improved and he began to have bowel movements.
He was also seen by the tranpslant surgery team who did not feel
that any surgical intervention was necessary at this time. He
was evaluated by GI and he was started on steroids for treatment
of peritoneal sclerosis. His diet slowly advanced and he did
well. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Gabapentin / Bactrim
Attending: ___.
Chief Complaint:
Right ankle pain.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ yo male with history of uncontrolled diabetes with last A1C
9.2 who presents for right ankle pain and swelling. He has a
history of a right foot diabetic wound followed by podiatry s/p
debridement on last ___. Since that time, the patient
endorses fevers at home to 99-100 with right ankle pain and
swelling. He reports decreased PO intake but denies nausea or
vomiting. He denies any other symptoms. He wears a diabetic
shoe on the right foot at baseline.
On arrival to the ED, initial vitals were: pain 5 97.8 71 142/49
16 96% RA. Podiatry felt that his right foot ulcer was stable
and recommended CAM walker or aircast to restrict ankle range of
motion. They felt he could have been discharged with Bactrim DS
but the ED felt his right leg was concerning for cellulitis.
Ankle xrays were done and were without evidence of osteo. He
was not given any antibiotics or medications. Most recent
vitals prior to transfer: 98.1 67 125/62 18 99% on RA.
Currently, he reports mild pain in the right ankle.
ROS: per HPI, denies 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.
Past Medical History:
1. Hepatitis C genotype 1 (s/p interferon plus ribavirin x at
least six months and relapsed)
- Treated in the 2000s by Dr. ___ at ___. He
was treated with interferon plus ribavirin x at least six months
and was a relapser on nadolol.
2. HCV Cirrhosis with portal hypertension including grade 2
esophageal varices
- EGD (___) - varices at the lower third of the
esophagus, friability and erythema in the antrum and pre-pyloric
area compatible with gastritis, erythema in the duodenal bulb
compatible with Duodenitis
- easy to control ascites
- HE on lactulose and rifaximin
- Now followed by Dr. ___ at ___
3. Insulin dependent diabetes, with last A1C 9.2, managed by his
PCP.
4. Hypertension.
5. Hyperlipidemia.
6. BPH.
7. History of HBV exposure (core Ab positive/surface ag
negative)
8. Overweight/obese state
9. Right foot drop
10. Chronic median neuropathy at the L wrist, as in carpal
tunnel syndrome, w/associated axonal loss ___ EMG), s/p
neurolysis and release (___)
11. s/p Colonic and rectal polypectomies (___)
12. GERD
13. Recurrent herpes simplex (on acyclovir)
14. Moderate to severe AS (valve area 1.0-1.2cm2)
15. Low back pain ___ discitis
16. Right tib-fib fracture ___ with indwelling screws
Social History:
___
Family History:
Father with heart valve replacement. Mother with diabetes. Both
are deceased.
Physical Exam:
Admission exam:
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, ___ SEM best heard
RUSB that radiates to carotids
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 1+ bilateral ___ edema, 2+ peripheral pulses
(radials, DPs), erythema and mild increase in warmth on the
right medial calf and ankle, nontender to touch, no pus; right
plantar foot with small 1cm round ulcer without pus, erythema or
warmth, borders c/d/i; no pain with passive ROM of right ankle
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Discharge exam:
VS - 98.0 137/60 65 20 100% on RA 147kg
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, ___ SEM best heard
RUSB that radiates to carotids
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 1+ bilateral ___ edema, 2+ peripheral pulses
(radials, DPs), no further erythema on right medial calf, small
area of erythema on medial ankle over malleolus, nontender to
touch, no pus; right plantar foot with small 1cm round ulcer
without pus, erythema or warmth, borders c/d/i; no pain with
passive ROM of right ankle
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
Labs:
___ 03:45PM BLOOD WBC-4.0 RBC-3.49* Hgb-10.7* Hct-32.2*
MCV-92 MCH-30.5 MCHC-33.1 RDW-15.3 Plt Ct-86*
___ 03:45PM BLOOD Neuts-60.7 ___ Monos-10.0 Eos-2.0
Baso-0.4
___ 05:19AM BLOOD WBC-3.3* RBC-3.40* Hgb-10.1* Hct-30.9*
MCV-91 MCH-29.7 MCHC-32.7 RDW-15.3 Plt Ct-87*
Micro:
___ blood cxrs pending x2
Imaging:
___ Unilat Lower Ext Veins Right -- No evidence of deep
venous thrombosis in the right lower extremity.
___ Ankle (Ap, Mortise & Lat) Right / Foot Ap,Lat & Obl
Right -- No radiographic evidence for osteomyelitis. No
subcutaneous emphysema. No fracture or dislocation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Clotrimazole Cream 1 Appl TP BID feet
3. Felodipine 2.5 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Furosemide 80 mg PO DAILY
6. GlipiZIDE XL 10 mg PO DAILY
7. Glargine 42 Units Breakfast
Glargine 42 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Lactulose 30 mL PO QID
9. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN lower back pain
10. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
Do Not Crush
11. Nadolol 20 mg PO DAILY
12. Omeprazole 40 mg PO BID
13. Rifaximin 550 mg PO BID
14. Simvastatin 20 mg PO HS
15. Tamsulosin 0.4 mg PO HS
16. Calcium Carbonate 500 mg PO BID
17. cranberry *NF* 1000 mg Oral daily
18. Ferrous Sulfate 325 mg PO TID
19. Glucosamine *NF* (glucosamine sulfate) 750 mg Oral bid
20. Multivitamins 1 TAB PO DAILY
21. Fish Oil (Omega 3) ___ mg PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Calcium Carbonate 500 mg PO BID
3. Clotrimazole Cream 1 Appl TP BID feet
4. Felodipine 2.5 mg PO DAILY
5. Ferrous Sulfate 325 mg PO TID
6. Finasteride 5 mg PO DAILY
7. Fish Oil (Omega 3) ___ mg PO DAILY
8. Furosemide 80 mg PO DAILY
9. Lactulose 30 mL PO QID
10. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN lower back pain
11. Multivitamins 1 TAB PO DAILY
12. Nadolol 20 mg PO DAILY
13. Omeprazole 40 mg PO BID
14. Rifaximin 550 mg PO BID
15. Simvastatin 20 mg PO HS
16. Tamsulosin 0.4 mg PO HS
17. Doxycycline Hyclate 100 mg PO Q12H Duration: 6 Days
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*12 Tablet Refills:*0
18. cranberry *NF* 1000 mg Oral daily
19. Glucosamine *NF* (glucosamine sulfate) 750 mg Oral bid
20. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
21. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 6 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab by mouth
twice a day Disp #*12 Tablet Refills:*0
22. Glargine 42 Units Breakfast
Glargine 42 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: cellulitis, uncontrolled Type 2 diabetes,
right foot ulcer
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: Lower extremity infection.
TECHNIQUE: Right ankle, 3 views and right foot, 3 views.
COMPARISON: ___.
FINDINGS:
4 screws within the distal right tibia demonstrate no evidence of hardware
failure. No acute fracture or dislocation is present. The ankle mortise is
symmetric. No cortical destruction is noted. There is no subcutaneous gas.
Mild degenerative changes are noted within the tibiotalar joint with
osteophytic spurring. A small plantar calcaneal spur.
The patient is status post resection of the ___ metatarsal head. Hammertoe
deformities are re- demonstrated. There is degenerative spurring within the
mid foot. Deformity of the ___ metatarsal head is unchanged, likely related
to remote trauma. There are mild to moderate degenerative changes of the ___
MTP joint with joint space narrowing and osteophytic spurring. No
subcutaneous gas or radiopaque foreign body is identified. There is no
cortical destruction to suggest osteomyelitis. No suspicious lytic or
sclerotic osseous abnormalities are seen.
IMPRESSION:
No radiographic evidence for osteomyelitis. No subcutaneous emphysema. No
fracture or dislocation.
Radiology Report
HISTORY: Lower extremity swelling in the right greater than the left, here to
evaluate for deep venous thrombosis of the right lower extremity.
COMPARISON: Venous duplex ultrasound of the right lower extremity dated ___.
TECHNIQUE: Grayscale, color and spectral Doppler evaluation was performed of
the right lower extremity veins.
FINDINGS:
There is normal compressibility, flow and augmentation of the right common
femoral, right proximal, mid and distal superficial femoral, and right
popliteal veins. Normal color flow is demonstrated in the right posterior
tibial and peroneal veins. There is normal respiratory variation of the
common femoral veins bilaterally.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: FOOT SWELLING
Diagnosed with DIAB W MANIF NEC ADULT, CELLULITIS OF LEG
temperature: 97.8
heartrate: 71.0
resprate: 16.0
o2sat: 96.0
sbp: 142.0
dbp: 49.0
level of pain: 5
level of acuity: 3.0 | ___ yo male with uncontrolled diabetes and stable right plantar
foot ulcer presented with low grade fevers and right ankle
erythema admitted for right ankle cellulitis.
# right ankle cellulitis: Erythema and warmth around the right
ankle in a patient with uncontrolled diabetes. No evidence for
osteo or septic joint on exam or imaging. Area of erythema not
near ulcer and does not seem to be confluent. Prior history of
MRSA and pseudomonas but these bugs have been cultured when
patient has had a leukocytosis and pus on exam. Improved
dramatically overnight with bactrim/unasyn so was discharged on
doxycycline and augmentin for a one week course. He was
discharged with a CAM walker for control of the ankle joint with
follow up planned with his PCP, ___ and podiatry. Blood
cultures were pending at the time of discharge.
# HTN: Continued felodipine, furosemide.
# HCV cirrhosis: Currently stable. No recent hx of acsites, HE,
or bleeding varices. Continued rifaximin, lactulose, nadolol,
and furosemide.
# History of duodenitis: Continued omeprazole but encourage that
dose reduction to 40mg daily be considered as an outpatient.
# DM2: Uncontrolled with complications. He was continued on
lantus with uptitrated HISS. Metformin and glipizide were held
during admission. Only metformin was restarted prior to
discharge. He was referred back to ___ to reinitiate care
with his provider.
CHRONIC ISSUES:
# Chronic back pain: Continued lidocaine patch.
# HLD: Continued simvastatin, fish oil.
# BPH: Continued finasteride and tamsulosin.
# Med rec: Continued acyclovir for ppx, clotrimazole cream,
calcium, MVI, and iron. Glucosamine and cranberry were held
during admission but restarted on discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tetanus / Ibuprofen
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ gentleman with a history of recurrent
syncope, hypothyroidism, Waldenstrom's macroglobulinemia, CKD,
and anemia of chronic disease presented to the ED early in the
morning of ___ after a syncopal episode at home.
Patient reported that he has been in the bathroom on early
morning of ___ when he felt suddenly quite nauseous and warm,
and when he went to get a receptacle to vomit in, he felt faint
and fell forward. Since he felt that he might lose
consciousness, he was able to put his arms out to brace himself.
He denies chest pain or palpitations prior to symptoms onset.
Per ED report, he was unable to get up and called ___. He has
denied any similar symptoms since the event.
Mr. ___ and his wife were apparently having diarrhea leading
up this event. He described his stools as loose and light in
color. He denied any abdominal pain or emesis associated with
the diarrhea.
Of note, Mr. ___ has had multiple syncopal episodes in the
past several months with ___ in the past month according prior
records. He has been undergoing outpatient workup for this with
an implantable LINQ loop recorder and is followed by Dr. ___
(___). At the time of this note, no clear cardiac
source had been discovered as the cause of his syncope.
Past Medical History:
1. ___ macroglobulinemia.
2. Schatzki's ring.
3. Eyelid entropion.
4. Chronic kidney disease.
5. Anemia of chronic disease.
6. Ankle edema.
7. BPH.
8. History of lung nodule and thyroid nodule.
9. History of basal cell carcinoma.
10. History of dizziness.
11. Status post inguinal hernia surgery in ___ and ___.
Social History:
___
Family History:
His mother died of old age in her ___. His father died from a
stroke complications.
Physical Exam:
PHYSICAL EXAM:
On Admission:
Vital Signs: T 97.8 HR 59 BP 138/65 RR 20 O2 98% RA
General: Awake and Alert, oriented x4. No acute distress.
Extremely hard of hearing but does not wear hearing aids
anymore.
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI. PERRL
with appearace c/w previous cataract removal surgery.
Neck: JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2. ___ systolic
murmur best heard at sternal border.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, mildly obese. Bowel sounds present,
no organomegaly, no rebound or guarding.
Ext: Warm, well perfused. 1+ DP pulses. 1+ ___ edema. No
discoloration of skin.
Neuro: CNII-XII intact,. Intact ___ strength in upper and lower
extremities. Grossly normal sensation. Reflexes and gait exam
deferred.
On Discharge:
VITALS - Tmax 97.9 | 127-146/ ___ | 56-65 | ___ | 94-97% RA
orthostatics (from ___: Lying- 117/65, HR 66; sitting 117/66,
Hr 65; standing 143/73 HR 71
GENERAL - Sitting and eating breakfast.
HEENT - PERRL, EOMI, anictric. Mucous membrane moist
NECK - no LAD, no JVD
CARDIAC - soft heart sounds, regular rate and rhythm, grade III
holosystolic murmur best heard R ___ costal sternal border,
radiates to up the carotids.
LUNGS - CTAB
ABDOMEN - soft, non tender, non distended
EXTREMITIES - ___ strength in all extremities. 2+ ___ pulses.
bilateral ankles 2+ edema, 2+ pitting edema up to mid-tibia
SKIN - thin skin with excess laxity
NEUROLOGIC - A&Ox3, later conversational. CN II-XII intact,
though very hard at hearing and not wearing hearing aids.
Gait (assessed ___ ___- slow to start with small steps,
required multiple steps to turn. Improved slightly with longer
walks
Pertinent Results:
On Admission
___ 04:15AM BLOOD WBC-6.8 RBC-2.61* Hgb-9.2* Hct-27.9*
MCV-107* MCH-35.2* MCHC-33.0 RDW-13.1 RDWSD-50.4* Plt ___
___ 04:15AM BLOOD Neuts-85.3* Lymphs-7.5* Monos-5.3 Eos-1.3
Baso-0.3 Im ___ AbsNeut-5.84# AbsLymp-0.51* AbsMono-0.36
AbsEos-0.09 AbsBaso-0.02
___ 08:50PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL
___ 04:15AM BLOOD Plt ___
___ 04:15AM BLOOD Glucose-103* UreaN-46* Creat-1.4* Na-138
K-4.9 Cl-105 HCO3-20* AnGap-18
___ 04:15AM BLOOD ALT-12 AST-20 CK(CPK)-54 AlkPhos-172*
TotBili-0.3
___ 04:15AM BLOOD proBNP-833
___ 04:15AM BLOOD cTropnT-<0.01
___ 04:15AM BLOOD Albumin-3.7 Calcium-9.8 Phos-3.3 Mg-1.9
___ 04:46AM BLOOD Lactate-1.6
At Discharge
___ 06:49AM BLOOD WBC-3.7* RBC-2.23* Hgb-7.9* Hct-24.0*
MCV-108* MCH-35.4* MCHC-32.9 RDW-13.2 RDWSD-52.2* Plt ___
___ 06:49AM BLOOD ___ PTT-29.8 ___
___ 06:49AM BLOOD Glucose-91 UreaN-32* Creat-1.2 Na-141
K-3.9 Cl-110* HCO3-22 AnGap-13
___ 06:49AM BLOOD Calcium-9.2 Phos-3.1 Mg-1.9 Iron-49
Imaging
___ CXR:
IMPRESSION:
Retrocardiac opacity which may reflect pneumonia.
___ Non-contrast CT head:
IMPRESSION:
No acute intracranial abnormality. Specifically, no evidence of
acute infarct or hemorrhage.
___ CT C-spine without contrast
IMPRESSION:
No acute fracture, malalignment, or prevertebral soft tissue
edema.
___ TTE:
Conclusions
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
There is no left ventricular outflow obstruction at rest or with
Valsalva. There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with normal free wall
contractility. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened. There is mild aortic valve stenosis (valve
area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
Microbiology
___ Bcx: NO GROWTH.
___ Ucx: URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. magnesium chloride 71.5 mg oral DAILY
5. Aspirin 81 mg PO DAILY
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
Vasovagal Syncope
Mild Aortic stenosis
Secondary Diagnosis
Supraventricular tachycardia with aberrancy
Waldenstrom macroglobulinemia
Benign Prostate Hyperplasia
Chronic Kidney Disease
Chronic lower extremity edema
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: History: ___ with syncope// Eval for acute process
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.9 cm; CTDIvol = 47.9 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: Noncontrast CT head from ___.
FINDINGS:
There is no evidence of acute infarcthemorrhage,edema,or mass. A chronic
lacunar infarct is again noted in the right internal capsule. Prominent
ventral and sulci are suggestive of age-related involutional changes.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial abnormality. Specifically, no evidence of acute infarct
or hemorrhage.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with syncope// Eval for 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) Spiral Acquisition 5.9 s, 22.8 cm; CTDIvol = 37.1 mGy (Body) DLP = 846.8
mGy-cm.
Total DLP (Body) = 847 mGy-cm.
COMPARISON: Thyroid ultrasound from ___.
FINDINGS:
Alignment is normal. No fractures are identified. There is no evidence of
spinal canal or neural foraminal stenosis. There is no prevertebral soft
tissue swelling. There is no evidence of infection or neoplasm. A 1.6 x 1.8
cm nodule arising from the lower pole of the left thyroid lobe has been
previously evaluated on dedicated ultrasound and is similar in size compared
to ___.
IMPRESSION:
No acute fracture, malalignment, or prevertebral soft tissue edema.
Radiology Report
INDICATION: History: ___ with syncope// Eval for acute process
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs from ___.
FINDINGS:
Frontal and lateral chest radiographs demonstrate slightly low lung volumes
resulting in exaggeration of the cardiac silhouette and bronchovascular
crowding. Allowing for this, the cardiomediastinal silhouette is normal.
There is a retrocardiac opacity, better seen on lateral view, which may
reflect pneumonia. No pleural effusion or pneumothorax is seen.
IMPRESSION:
Retrocardiac opacity which may reflect pneumonia.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Diarrhea, Dizziness
Diagnosed with Syncope and collapse
temperature: 97.6
heartrate: 76.0
resprate: 14.0
o2sat: 100.0
sbp: 124.0
dbp: 73.0
level of pain: 0
level of acuity: 3.0 | ___ male with a history of CKD, anemia, mild AS, and
recurrent syncope presents after an episode of syncope at home.
ACTIVE ISSUES:
# Syncope: Patient with recurrent episodes of syncope in recent
months. Outpatient work up negative so far. ED workup negative
for acute cardiac ischemia. Echo no e/o of structural heart
disease. History most consistent with vasovagal. Orthostatics
negative, however done after 1L of fluid in ED. Pt is at high
risk for orthostatic syncope. Pt was encouraged to make
lifestyle adaptations to avoid orthostasis, such as drinking
before getting out of bed. If vasovagal syncope persist,
consider using smelling salts. ___ evaluated patient and
recommended home ___.
# Diarrhea: No recent antibiotic or other new medication
exposure per OMR history tab. C. diff and Norovirus PCR
negative. Possibly other viral enteritis/colitis. Guaiac
negative in ED. Magnesium was discontinued as it may contribute
to diarrhea. Patient did not have diarrhea while inpatient.
# Macrocytic anemia: Folate 9, B12 569. Normal ferritin with low
TIBC and low transferrin, may be consistent with "anemia of
chronic disease" though this would not typically be macrocytic.
# Hypothyroidism with thyroid nodule: Continues on home
synthroid. Most recent TSH borderline high at 4.5 with T4=6.2,
however TSH is higher in elderly. Incidentally identified
thyroid nodule, been stable and worked up as benign. Continued
home levothyroxine 25mcg daily.
CHRONIC ISSUES:
# Hypertension and H/O SVT with aberrancy: continued home
metoprolol and ASA
# GERD with Schatzki's Ring: Symptoms well-controlled with PPI.
Continued home omeprazole 40mg daily.
# ___'s macroglobulinemia: Followed by Dr. ___ in
hematology, to follow up as needed.
# CKD: Stable. Per previous note, baseline creatinine=1.5. On
admission, creatinine=1.3-1.4.
# Lower extremity edema: Chronic. No discoloration or venous
stasis changes. Encouraged elevation and compression stockings
# Aortic stenosis: No obvious heart failure or decompensation.
TTE grossly unchanged from prior. Continued home metoprolol
=============================================================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bilateral Subdural hematomas
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a vibrant ___ year-old male who underwent a
non-contrast head CT today, ___, for staging of questionable
skin cancer on his face. The images revealed bilateral subacute
subdural hematomas. The patient was transferred to ___ for
further Neurosurgical evaluation.
Mr. ___ acknowledges that he has fallen approximately 1 - 2
months ago. He takes aspirin 325mg daily due to a history of
vascular disease. He had no neurologic deficits, loss of
consciousness or further issues after that fall.
Past Medical History:
Throat polyps, hepatitis, right femoral bypass, stenting of left
leg vessel (pt unsure what vessel), right hip fracture s/p
repair
Social History:
___
Family History:
NC
Physical Exam:
On Admission:
O: T: 98.2 HR 85 BP 121/73, RR 14, O2 Sat 93% on room air
Gen: WD/WN, comfortable, NAD.
HEENT: PERRL, EOMs intact.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. 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
On Discharge:
Intact
Pertinent Results:
CT Head ___:
Stbale bialteral subdural hematomas, formal read pending at time
of discharge
Medications on Admission:
Aspirin 325', simvastatin (unknown dose) daily, iron daily,
Zantac daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Ranitidine 75 mg PO BID
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral Subdural Hematomas
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Bilateral subdural hematomas, preoperative planning.
TECHNIQUE: Frontal and lateral chest radiographs were obtained.
COMPARISON: None.
FINDINGS:
On the lateral projection, there is a posterior airspace opacity without a
definitive correlation on the PA projection, which may represent consolidation
in the appropriate clinical setting. Diffuse, coarse interstitial markings
and biapical bulla formation are compatible with interstitial lung disease.
Additionally, a band of linear atelectasis is seen within the left mid lung.
There is no evidence of frank pulmonary edema, pleural effusion, or
pneumothorax. The cardiomediastinal silhouette is stable. No bony
abnormality is detected.
IMPRESSION:
1. Posterior airspace opacity visualized on the lateral projection alone.
Recommend clinical correlation, as this may indicated and airspace
consolidation in the appropriate clinical setting.
2. Diffuse coarse interstitial lung markings and biapical bulla. These
findings may be compatible with interstitial lung disease. If there is no
evidence of acute infection, a dedicated chest CT could be obtained for
further characterization.
Radiology Report
EXAMINATION: CT HEAD WITHOUT CONTRAST
INDICATION: ___ year old man with bilateral subacute subdural hematomas. //
Assessment for interval change.
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: 54 mGy
COMPARISON: Outside non contrast head CT performed at ___ on ___ at
15:07 (18 hours earlier).
FINDINGS:
HEAD CT: There is no significant interval change in predominantly hypodense
subdural collections along the bilateral superior cerebral convexities in
comparison to the most recent prior head CT of ___, measuring up to
15 mm in thickness on the left and 10 mm in thickness on the right. The left
subdural collection appears chronically compartmentalized with layering
hyperdensity in some compartments suggesting a subacute component of
hemorrhage.
There is no edema, mass effect or shift of normally midline structures. The
gray-white matter interface is preserved without evidence of acute major
vascular territorial infarction. The ventricles and sulci are prominent,
compatible with age related global atrophy. The basal cisterns appear patent.
The orbits and globes are unremarkable. The right maxillary sinus is
completely opacified with sclerotic thickening of its lateral wall,
representing chronic osteitis. The remainder of the imaged paranasal sinuses,
middle ear cavities and mastoid air cells are clear bilaterally. The bony
calvaria appear intact.
IMPRESSION:
1. No significant interval change in predominantly hypodense bilateral
subdural collections along the cerebral convexities without evidence of an
acute hemorrhage, compared to the CT performed 18 hours earlier. The right
subdural collection may represent a true subdural hygroma or chronic hematoma.
The chronically compartmentalized left subdural collection shows evidence of
subacute on chronic hemorrhage.
2. No midline shift or evidence of herniation.
3. Right maxillary sinus chronic inflammatory disease.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, ABNORMAL CT SCAN
Diagnosed with OPEN SUBDUR HEM W/O COMA, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 98.2
heartrate: 85.0
resprate: 18.0
o2sat: 93.0
sbp: 121.0
dbp: 73.0
level of pain: 0
level of acuity: 2.0 | Patient presented to ___ for evaluation of bilateral subdural
hematomas found on work up for skin cancer. He was admitted to
the floor for observation and remained stable overnight into
___. He was NPO in case surgical intervention was required
however repeat CT head showed stable bilateral subdural
hematomas and decision was made that he was safe to discharge to
home with followup. He agreed with this plan and was given
prescriptions for required medications, instructions for
follow-up, and all questions were answered prior to discharge.
We recommended that he hold his aspirin for the time being and
discuss it with his cardiologist/PCP regarding the utility of
continuing in setting of intracranial bleed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ Left VATS decortication
___ Left chest tube place by IP
History of Present Illness:
Mr. ___ is a ___ hx prior empyema in the setting of an
aspirated macadamia nut s/p R VATS decortication and
empyemectomy w/bronchoscopy and lavage ___ with recurrent
left pleural effusion who presents with two days of dyspnea,
fever to 101 x2 days, productive cough and left chest wall pain.
Of note, in ___ pt was found to have a 3cm LLL mass c/w
abscess, s/p 2 weeks of levofloxacin, for which he underwent
thoracentesis ___, and then had a repeat thoracentesis ___
for recurrence of his pleural effusion for which he completed 2
weeks of Augmentin.
In the ED, initial vitals: 97.0 115 138/66 26 95% RA
Initial labs notable for: WBC 25.8 (87.5% polys) H/H 12.5/37.8
Plt 257
Na 130 K 4.7 Cl 95 HCO3 24 BUN 18 Cr 1.2 (baseline 0.7) Glc 85
Lactate 1.5
INR 1.5
CXR showed near complete opacification of left hemithorax due
to pleural effusion and collapse.
IP was consulted in the ED and placed a ___ chest tube and
drained 750ccs serous fluid, sent for analysis. Follow-up CXR
showed no pneumothorax.
Pleural fluid studies: pH 6.97 Protein 5.1 glucose 31 LDH 410
amylase 25 albumin 2.5 WBC 4300 (83 polys, 14 lymphos, 0 monos,
3 macros) RBC 5025.
The patient was given 1L NS, vanc/cefepime, and a total of 7 mg
IV morphine.
After chest tube drainage, the patient became more tachypneic
to the ___ and desatted to 94% on 4L NC and decision was
made to transfer to MICU for further management.
On transfer, vitals were: 91 119/73 35 92% Nasal Cannula
On arrival to the MICU, patient states that he feels crummy.
Endorses L-sided chest and back pain, mostly in the mid-axillary
line. Denies abdominal pain, nausea, vomiting, diarrhea,
constipation, dysuria, myalgias, arthralgias.
Review of systems:
(+) Per HPI
Past Medical History:
Hepatitis C - genotype 1a
h/o IVDU on Suboxone
Tobacco abuse
Obesity
Recurrent strep tonsillitis
Cleared HBV (positive HBsAb, HBcAb)
Social History:
___
Family History:
Father with diabetes, HTN, who is deceased. He also has a
brother with diabetes.
Physical Exam:
ADMISSION EXAM
Vitals: 83 104/57 17 95% 4L NC
GENERAL: speaks slowly, NAD
HEENT: eyes
NECK: supple, JVP not elevated, no LAD
LUNGS: very diminished breath sounds L side, R side is clear
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: chest tube site appears clean
NEURO: AOx4
DISCHARGE EXAM
VITALS: 97.9 (98.6) 134/74 (120-140/60-80) 69 (60-80) 18 94%RA
GENERAL: Alert, awakes and engages easily, oriented, no acute
distress.
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: Supple, JVP not elevated, no LAD
RESP: Clear right lung with crackles at bases. Diminished breath
sounds on left with transmitted bronchial sounds. Prior chest
tube site with clean dressing.
CV: Regular rhythm, systolic murmur LLSB
ABD: soft, nontender, nondistended. BS+
EXT: warm, well perfused, 2+ pulses. Hyperpigmented
discoloration of ___ distal shins, no edema.
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: site around prior L subclavian CVL site w/o overlying
erythema or pus.
Pertinent Results:
ADMISSION LABS
___ 12:09PM BLOOD WBC-25.8*# RBC-4.44* Hgb-12.5* Hct-37.8*
MCV-85 MCH-28.2 MCHC-33.1 RDW-12.9 RDWSD-40.1 Plt ___
___ 12:09PM BLOOD Neuts-87.5* Lymphs-4.5* Monos-6.7
Eos-0.0* Baso-0.2 Im ___ AbsNeut-22.58* AbsLymp-1.15*
AbsMono-1.73* AbsEos-0.00* AbsBaso-0.05
___ 12:09PM BLOOD ___ PTT-33.1 ___
___ 12:09PM BLOOD Glucose-85 UreaN-18 Creat-1.2 Na-130*
K-4.7 Cl-95* HCO3-24 AnGap-16
___ 12:09PM BLOOD Osmolal-274*
___ 03:56AM BLOOD Calcium-7.9* Phos-3.2 Mg-1.6
___ 07:32PM BLOOD Type-ART pO2-65* pCO2-35 pH-7.44
calTCO2-25 Base XS-0
IMAGES/STUDIEs
+ CXR ___
Near complete opacification of left hemithorax due to large
pleural effusion and collapse.
+ CXR ___
1. No significant interval change in near complete opacification
of the left hemithorax due to pleural effusion and collapse.
2. Interval placement of left-sided pleural drainage catheter.
No
pneumothorax identified.
CT CHEST ___:
IMPRESSION:
Recurrence of large nonhemorrhagic left pleural effusion
responsible for left lung collapse. Substantial growth since
___ in the left lower lobe abscess or necrotic mass.
Possible new small left pericardial effusion, probably secondary
to pleural
effusion. Right pleural reaction and small effusion, and
reactive right hilar and mediastinal lymph nodes have all
increased since ___. New splenomegaly. Upper esophageal
distention could be secondary to the effusion or in indication
of esophageal dysfunction and possibly a propensity to reflux
and aspiration.
CXR ___
IMPRESSION:
1. Persistent left hydropneumothorax.
2. Stable left pleural effusion and left lateral wall pleural
thickening.
3. Unchanged loculated fluid collection in the posterior left
hemithorax.
DISCHARGE LABS
___ 06:33AM BLOOD WBC-8.2 RBC-3.45* Hgb-9.6* Hct-29.8*
MCV-86 MCH-27.8 MCHC-32.2 RDW-13.5 RDWSD-41.7 Plt ___
___ 06:33AM BLOOD Plt ___
___ 06:33AM BLOOD Glucose-98 UreaN-9 Creat-0.7 Na-137 K-3.8
Cl-102 HCO3-29 AnGap-10
___ 06:33AM BLOOD Calcium-8.0* Phos-4.0 Mg-1.8
___ 06:33AM BLOOD Vanco-21.2*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 800 mg PO QID
2. ClonazePAM 2 mg PO DAILY
3. Methadone 65 mg PO DAILY
4. Promethazine 50 mg PO DAILY
5. Albuterol Inhaler 2 PUFF IH Q6H
6. Benzonatate 100 mg PO DAILY
Discharge Medications:
1. ClonazePAM 0.5 mg PO BID
2. Methadone 65 mg PO DAILY
3. Promethazine 12.5 mg PO BID
4. Albuterol Inhaler 2 PUFF IH Q6H
5. Benzonatate 100 mg PO DAILY
6. Gabapentin 800 mg PO QID
7. Acetaminophen 1000 mg PO Q8H
8. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing/dyspnea
9. Docusate Sodium 100 mg PO BID
10. Polyethylene Glycol 17 g PO DAILY
11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
12. Heparin 5000 UNIT SC BID
13. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
14. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
15. Senna 8.6 mg PO BID
16. Vancomycin 1000 mg IV Q 8H
Last day ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Left lung abscess
Left pleural effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with dyspnea // r/o infiltrate
TECHNIQUE: Portable semi-upright chest radiograph.
COMPARISON: Radiographs of the chest dated ___ through ___, and CT of the chest dated ___.
FINDINGS:
There is near complete opacification of the left hemithorax, with rightward
shift of the mediastinal structures, consistent with large pleural effusion
and collapse. A small portion of the left upper lung appears minimally
aerated. Mild blunting of the right costophrenic angle appears chronic, but
may reflect a small amount of pleural effusion. Assessment of the cardiac
silhouette is limited. No pneumothorax.
IMPRESSION:
Near complete opacification of left hemithorax due to large pleural effusion
and collapse.
Radiology Report
INDICATION: ___ year old man with new Rt sided pleural effusion // r/o PTX
TECHNIQUE: Portable semi-upright chest radiograph.
COMPARISON: Chest radiographs dated ___ through ___.
FINDINGS:
Again seen is near complete opacification of the left hemithorax due to large
pleural effusion and collapse. There has been interval placement of a
left-sided pleural drainage catheter. No pneumothorax is identified.
IMPRESSION:
1. No significant interval change in near complete opacification of the left
hemithorax due to pleural effusion and collapse.
2. Interval placement of left-sided pleural drainage catheter. No
pneumothorax identified.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with chest tube, decreasing O2 sats // Eval for
reexpantion pulmonary edema
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___ at 14:05
FINDINGS:
Again seen is near complete opacification of the left hemi thorax with slight
increase in aeration of the left upper lung. The majority of the left hemi
thorax remains opacified. A pigtail catheter is seen projecting over the
lateral left lower hemi thorax. The right lung is grossly clear.
IMPRESSION:
Near complete opacification of the left hemi thorax with slight improvement
and slight increase in aeration at the left upper lung.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with L pleural effusion/hemithorax collapse, s/p
chest tube // progression of L pleural effusion
TECHNIQUE: Multi detector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agent and reconstructed as
5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images. All images were reviewed.
DOSAGE: TOTAL DLP 5 and 5.0mGy-cm
COMPARISON: Chest CT ___. Examination is also read in conjunction
with conventional chest radiographs since ___ most recently ___ at
04:36.
FINDINGS:
Large nonhemorrhagic left pleural effusion has recurred since ___ and
interval thoracenteses, now nearly entirely collapsing the left lung, not
appreciably drained following insertion of a left basal pigtail pleural drain.
The attenuation values of the effusion range from ___ ___. At the medial
aspect of the collapsed lower lobe is a 3 x 9 cm region of relative low
attenuation, compared to the enhancing collapse lower lobe, but with
attenuation values 40-50 ___, and two small gas bubbles. This abnormality
conforms to the 27 mm wide mass or abscess seen on ___.
Most of the fluid between the left upper lobe and the heart is loculated
pleural fluid, but there may be a new very small pericardial effusion. Small
right pleural effusion with hyperemic pleural thickening or subpleural
atelectasis has increased.
Moderate distension of the upper esophagus to the level of the carina is new,
and may indicate esophageal dysfunction and a propensity to reflux and
aspiration. Mild wall thickening of the lower esophagus is chronic.
Cm size lymph nodes are numerous in the mediastinum, new at the thoracic inlet
in the left tracheoesophageal groove, 02:15 more numerous in the prevascular
station at the level of the left brachiocephalic vein, 02:21. There are
larger lymph nodes in the right hilus, 18 x 23 mm, 02:31 and in the
azygoesophageal recess.
Significant air trapping in the right lower lobe is not explained by
relatively mild narrowing of the right lower lobe basal trunk and milder right
hilar lymph node enlargement. There are no enlarged nodes in the
diaphragmatic or internal mammary or retro crural stations.
This study is not designed for subdiaphragmatic diagnosis but shows
normal-size adrenal glands and a cyst in the upper pole of the left kidney,
but significantly no sub diaphragmatic fluid collections or abscesses in the
upper abdominal organs. Spleen is newly enlarged since ___, but with no
findings to suggest splenic infection.
There are no findings in the chest cage suspicious for malignancy or
infection.
IMPRESSION:
Recurrence of large nonhemorrhagic left pleural effusion responsible for left
lung collapse. Substantial growth since ___ in the left lower lobe
abscess or necrotic mass.
Possible new small left pericardial effusion, probably secondary to pleural
effusion.
Right pleural reaction and small effusion, and reactive right hilar and
mediastinal lymph nodes have all increased since ___. New splenomegaly.
Upper esophageal distention could be secondary to the effusion or in
indication of esophageal dysfunction and possibly a propensity to reflux and
aspiration.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with L empyema s/p chest tube placement with new
L subclavian CVL placement // confirm L subclavian CVL placement Contact
name: ___: ___ confirm L subclavian CVL placement
COMPARISON: ___
IMPRESSION:
Left pigtail catheter has been placed. In unchanged position. No substantial
difference in the opacification of the left hemi thorax is seen but the
mediastinum is shifted more to the right does consistent with internal
accumulation of pleural effusion. Small amount of right pleural fluid is
seen.
Left subclavian line tip is at the level of superior SVC.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with left side pleural effusion s/p chest tube
// assess interval change assess interval change
IMPRESSION:
In comparison with the study of ___, there again is almost complete
opacification of the left hemithorax despite a pigtail catheter in place.
Little change in the degree of shift of the mediastinum to the right.
Pulmonary vascular congestion may be more prominent than on the previous
study.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p left VATS decortication // Eval for chest
tube placement, PTX Eval for chest tube placement, PTX
IMPRESSION:
In comparison with the earlier study of this date, there has been placement of
2 chest tubes following vats decortication on the left. The degree of
opacification related to pleural effusion has substantially decreased, though
some fluid and atelectasis is still seen at the left base. Specifically,
there is no evidence of pneumothorax.
Otherwise, little change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p left VATS decortication // AM rounds ___ AM rounds ___
IMPRESSION:
In comparison with the study of ___, there is little overall change.
2 chest tubes remain on the left following vats decortication. There may be
slight increase in pleural fluid along the left lateral chest wall. Continued
opacification at the left base most likely relating to pleural fluid and
volume loss in the left lower lobe.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with asthma, prior R lung empyema s/p VATS now L
sided pleural effusion s/p VATS on ___ // interval change in pleural
effusion (Please perform at 7 AM)
TECHNIQUE: Portable AP chest radiograph.
COMPARISON: Chest radiograph ___
FINDINGS:
Supportive lines and tubes are unchanged in appearance when compared to the
prior study. There is persistent pleural fluid along the lateral chest wall.
This is unchanged in extent compared to the prior study. Left lower lobe
atelectasis persists. Continued airspace opacity at the left lung base likely
due to a atelectasis.
IMPRESSION:
No significant interval change when compared to the prior study.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man s/p L VATS decortication now with apical chest
tube removed. // Assess for interval PTX.
TECHNIQUE: AP and lateral chest radiographs.
COMPARISON: Chest radiograph obtained earlier on the same date
FINDINGS:
There has been interval removal of 1 of the left-sided chest drains without
evidence of of a pneumothorax. A small amount of pleural fluid tracks along
the left chest wall. Airspace opacity in the left mid lung likely reflects
re-expansion pulmonary edema and is unchanged compared to the prior study.
Infection cannot be definitively excluded. Linear atelectasis of the right
lung base. Persistent left basilar atelectasis. A left subclavian catheter
terminates at the proximal SVC.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with recurrent pleural effusion now s/p VATS on
___ // interval change in effusion with lateral CT (please perform at 7AM)
interval change in effusion with lateral CT (please perform at 7AM)
IMPRESSION:
In comparison with the study of ___, there is little overall change.
Left chest tube remains in place without evidence of pneumothorax.
Opacification along the left lateral chest wall is consistent with pleural
fluid. The opacification in the left mid and lower zone most likely reflects
re-expansion edema combined with residual pleural fluid and atelectatic
changes. In the appropriate clinical setting, it would be impossible to
exclude superimposed pneumonia.
Cardiac silhouette again is prominent and there is mild elevation of pulmonary
venous pressure and atelectatic changes at the right base.
The left subclavian catheter is no longer seen.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with recurrent L pleural effusion s/p VATS and
posterior CT // interval change in pleural effusion
TECHNIQUE: Portable AP chest.
COMPARISON: Chest radiograph ___
FINDINGS:
A right-sided PICC is unchanged compared to the prior study, likely
terminating in the right brachiocephalic vein. A left-sided chest tube is
unchanged in appearance. There is persistent left pleural fluid with slight
improvement in the hazy in the left mid lung opacity. There is a small
loculated air within the pleural fluid at the left costophrenic angle. Left
basilar atelectasis persists. No pneumothorax seen.
IMPRESSION:
1. Slight interval improvement in the left mid lung airspace opacities.
2. Persistent left hydro pneumothorax.
3. A right-sided PICC terminates likely in the distal right brachiocephalic
vein.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new picc // R picc 55cm ___ ___
Contact name: ___: ___ R picc 55cm ___ ___
IMPRESSION:
In comparison with the earlier study of this date, this and placement of a
right subclavian PICC line that extends to the upper portion of the SVC.
Otherwise little change in the appearance of the heart and lungs.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with new line // new right PICC 60 cm ___
___ Contact name: ___: ___
TECHNIQUE: Portable AP chest radiograph.
COMPARISON: Chest radiograph ___
FINDINGS:
The previously seen right PICC has been exchanged and is now low in the right
atrium. This could be withdrawn at least 5 cm for better seating within the
SVC. 2 left-sided chest tubes are in-situ. Unchanged in appearance when
compared to the prior study. There is a persistent left pleural effusion
tracking along the lateral chest wall. Left basilar atelectasis is also
unchanged. Persistent hazy opacity in the left lung. Small amount of
loculated air in the pleural space on the left.
IMPRESSION:
The right-sided PICC is position distally in the right atrium. This should be
withdrawn at least 5 cm for better positioning in the SVC.
NOTIFICATION: The findings were discussed with ___ (IV nurse) at
14:04 on ___, within 5 min of discovery.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new line // please check PICC tip 60 cm
___ ___ Contact name: ___: ___
TECHNIQUE: Portable AP chest radiograph.
COMPARISON: Chest radiograph obtained earlier on the same date.
FINDINGS:
The right-sided PICC has been withdrawn somewhat but is still within the right
atrium. This could be withdrawn a further 5-6 cm for better seating within
the SVC. The left-sided chest drains are unchanged in position. Persistent
left pleural fluid and left basilar atelectasis. No pneumothorax seen.
IMPRESSION:
The right-sided PICC terminates in the right atrium.
NOTIFICATION: Findings discussed with ___ (IV nurse) by telephone
at 15:30, within 5 min of discovery.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new line // PICC pulled back 6 cm please
check tip ___ ___ ___ name: ___: ___
TECHNIQUE: Portable AP chest radiograph.
COMPARISON: Chest radiograph obtained earlier on the same date.
FINDINGS:
The right-sided PICC has been withdrawn further, this is likely now in the
distal SVC/cavoatrial junction allowing for low lung volumes and suboptimal
inspiration. Lungs are otherwise unchanged in appearance including the
left-sided chest drains, left hydro pneumothorax and left lung airspace
opacity.
IMPRESSION:
The right-sided PICC is likely at the distal SVC/ cavoatrial junction given
the lung volumes and is suboptimal inspiratory effort. The catheter could
safely be withdrawn a further 3 cm and still remain in the SVC.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with empyema with CT // interval change in
effusion
TECHNIQUE: Portable AP chest radiograph.
COMPARISON: Chest radiograph ___
FINDINGS:
The right-sided PICC remains in the right atrium, this could be withdrawn 5 cm
for better seating in the SVC. 2 left-sided chest tubes are unchanged in
appearance. A small left hydro pneumothorax is also unchanged. Persistent
right basilar atelectasis. Unchanged left lung airspace opacity.
IMPRESSION:
No significant interval change when compared to the prior study. The
right-sided PICC remains with the tip in the right atrium. This could be
withdrawn 5 cm for better seating in the SVC.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with empyema with CT // interval change in
effusions; s/p 1 chest tube removed on ___ interval change in
effusions; s/p 1 chest tube removed on ___
IMPRESSION:
In comparison with the study of ___, there has been removal of a chest
tube from they left with no evidence of pneumothorax. The small left hydro
pneumothorax is unchanged, as is the fluid along the left lateral chest wall.
The overall, there is little change in the opacification in the left
hemithorax. A lateral view would be necessary to assess changes in the
empyema.
Little change in the right hemithorax. The right PICC line has been pulled
back so that the tip lies in the mid portion of the SVC.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: ___ year old man with persistent bilateral pleural effusions;
please evaluate for PTX post- L-sided chest tube pull. // evaluate for
pneumothorax
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Portable chest x-ray ___
Chest PA and lateral ___
FINDINGS:
A right-sided PICC terminates at the mid to distal SVC. Left anterior
hydropneumothorax is unchanged. Pleural thickening along the left lateral
chest wall is unchanged. A loculated fluid collection contiguous with the
major fissure in the posterior left superior hemithorax appears unchanged
compared to chest x-ray from ___. Bibasilar atelectasis and left
pleural effusion are stable. No evidence of pneumothorax.
IMPRESSION:
1. Persistent left hydropneumothorax.
2. Stable left pleural effusion and left lateral wall pleural thickening.
3. Unchanged loculated fluid collection in the posterior left hemithorax.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Pleural effusion, not elsewhere classified
temperature: 97.0
heartrate: 115.0
resprate: 26.0
o2sat: 95.0
sbp: 138.0
dbp: 66.0
level of pain: 10
level of acuity: 2.0 | Mr. ___ is a ___ hx prior empyema in the setting of an
aspirated macadamia nut s/p R VATS decortication and
empyemectomy w/bronchoscopy and lavage ___ with recurrent
left pleural effusion who presents with two days of dyspnea,
fever to 101 x2 days, productive cough and left chest wall pain,
found to have a large left empyema with lung collapse,
transferred to the ICU for management of hypoxia and tachypnea,
now s/p L VATS and L-sided chest tube placement with significant
improvement on IV antibiotics.
# Left lung abscess/pleural effusion. In ___ of this
year, Mr. ___ developed a productive cough with 'salmon'
colored sputum, pleuritic chest pain, fevers and chills. A CXR
ordered by his PCP showed ___ lung lesion, which was confirmed on
a follow up chest CT as a 3cm LLL lung mass with appearance
consistent with abscess. A 2 week course of levofloxacin had no
effect on his symptoms. On ___ he underwent an ultrasound
guided thoracentesis for 720cc of serous fluid. Cytology showed
no malignant cells or organisms, but 4+ PMNs. On ___ he was
seen by Dr. ___ a CXR at that time showed a
recurrent left pleural effusion. Thoracentesis was repeated, and
he was started on a 2 week course of augmentin. He re-presented
this admission for intolerable dyspnea and fevers after
completion of the augmentin course. Chest imaging at admission
showed significant L-sided pleural effusion and LLL
abscess/necrotic mass. Thoracics Surgery placed chest tubes
bilaterally which confirmed an exudative process; pleural fluid
cultures grew Strep anginosus sensitive to IV vancomycin.
Regarding the LLL abscess/necrotic mass, Thoracics Surgery felt
that drainage would be very difficult given the significant
inflammatory changes and fibrosis of the left lung base. Both
chest tubes were discontinued prior to discharge and patient
will have follow-up with Thoracics. Last day of vancomycin will
be ___ (total 2 week course per Thoracic Surgery). Of note,
work-up for immunodeficiency syndromes including Ig levels and
HIV were negative.
# chronic stable Asthma: Receiving duonebs.
# Opiate Dependence, Chronic: Methadone replacement therapy dose
confirmed 65mg PO daily ___ clinic ___.
# Panic disorder: Home clonazepam restarted at reduced dose.
***TRANSITIONAL ISSUES***
- IV vancomycin to continue for total 2 week course (d 14 on
___
- Vancomycin level on ___. Dosing decreased to 1 gm q8h.
Please re-check vanc level on ___.
- Please check EKG to monitor QTc on ___ as patient is on
promethazine (discharge dose is lower than his home dose)
- Patient to have outpatient follow-up with Pulmonary and
Thoracics Clinics
- Patient will need CT chest in ___ weeks (after ___ with
follow up with Thoracics for LLL abscess (already scheduled) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amoxicillin / codeine / Flonase / sertraline / fluoxetine /
hydrochlorothiazide / Macrolide Antibiotics / Iodinated Contrast
Media - IV Dye / Ativan
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
___ 05:10AM BLOOD WBC-6.2 RBC-3.43* Hgb-11.8 Hct-37.3
MCV-109* MCH-34.4* MCHC-31.6* RDW-20.3* RDWSD-81.5* Plt ___
___ 05:10AM BLOOD ___ PTT-38.0* ___
___ 01:38PM BLOOD Glucose-101* UreaN-21* Creat-1.1 Na-140
K-4.2 Cl-101 HCO3-24 AnGap-15
___ 05:10AM BLOOD Calcium-8.9 Phos-2.7 Mg-2.0
HMVA BLOOD CX: GNR
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN asthma
flare
2. Enalapril Maleate 20 mg PO BID
3. ALPRAZolam 0.25 mg PO BID:PRN anxiety
4. Vitamin D 1000 UNIT PO DAILY
5. Digoxin 0.125 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO BID
7. olaparib 200 mg oral BID
8. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
9. Warfarin 2.5 mg PO DAILY16
Discharge Medications:
1. LevoFLOXacin 500 mg PO Q24H
RX *levofloxacin 500 mg 1 tablet(s) by mouth once a day Disp #*4
Tablet Refills:*0
2. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN asthma
flare
3. ALPRAZolam 0.25 mg PO BID:PRN anxiety
4. Digoxin 0.125 mg PO DAILY
5. Enalapril Maleate 20 mg PO BID
6. Metoprolol Succinate XL 100 mg PO BID
7. olaparib 200 mg oral BID
Resume dose tonight, ___
8. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
9. Vitamin D 1000 UNIT PO DAILY
10. Warfarin 2.5 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
Acute GNR bloodstream infection - E.coli
Sinusitis
h/o VTE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with history of ovarian cancer, fever, positive
blood culture // Pneumonia? Mass?
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: No prior chest radiograph available for comparison. Reference
made to chest CT from ___
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The aorta is tortuous. The cardiac silhouette is
mildly to moderately enlarged. Chronic irregularity of the posterior right
seventh rib with better assessed on prior CTs; possibly representing fibrous
dysplasia, chronic fracture not excluded radiographically.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: PORTUGUESE
Arrive by WALK IN
Chief complaint: Positive blood cultures
Diagnosed with Bacteremia
temperature: 97.4
heartrate: 91.0
resprate: 22.0
o2sat: 99.0
sbp: 177.0
dbp: 98.0
level of pain: 0
level of acuity: 3.0 | ___ w/ HTN, asthma, Afib on warfarin, remote DVT, and met high
grade serous ovarian cancer s/p TAH-BSO and chemo, now on
maintenance olaparib (follows with Dr ___ s/p ureteral
stent exchange 1 week ago for chronic hydronephrosis, who p/w
F/C, sinus pain, and positive GNR BSI from an OP blood culture.
1. E.coli blood stream infection:
Source is presumed acute Sinusitis vs Urological source given
recent stent exchange.
She was started on levaquin outpatient when her culture came
back positive but did not take any doses as she was referred to
the ER.
She was hemodynamically stable with no fevers, abnormal blood
work and so was continued on PO levaquin pending blood cultures.
Her blood cultures have been negative to date. Her blood culture
from ___ medical records show 1 out of 2 bottles positive for
E.coli, sensitive to levaquin. The other bottle was with no
growth. Possible contamination however given her
immunocompromised state and symptoms of infectious outpatient,
she was continued with levaquin for total of 10 days.
Her olaparib was held but resumed on discharge after discussion
with Dr ___.
2. She was found to have an elevated INR > 4 so her coumadin was
initially held and resumed after it was maintained within goal.
No signs of bleeding. She is to have an INR check in 2 days for
close monitoring. Her last INR was 2. She was given 3.75mg dose
day of discharge instead of her 2.5mg.
Patient has her GYN/ONC appointment on ___ and her HEME/ONC
appointment is ___.
Will monitor for inpatient finalized blood culture results and
if any changes, patient will be contacted. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Depakote
Attending: ___.
Chief Complaint:
sent from PCP with lab abnormalities (hyponatremia & ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ (given name ___ is a ___ transitioning
trans-female with a history of migraines, HTN, HLD, and
depression who is sent from PCP office with findings ___ and
hyponatremia after presenting with malaise and vomiting. Patient
was in usual state of health until the day prior to admission w/
general malaise, mild headache, one episode of nausea with
vomiting (non-bloody non-bilious). Of note, patient recently had
spironolactone increased to 100mg bid, which she is taking for
transition from male to female.
In the ED, labs were notable for Na 128, Cr 1.8 (baseline 1.0),
K 4.7, WBC 14.1. Received 1L NS.
Past Medical History:
Currently transitioning male to female on hormonal supplements
HTN, HLD
Depression, anxiety, insomnia, migraines
Social History:
___
Family History:
- Mother: Died age ___ of lung cancer
- Father: Does not know
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital signs: T 98.8, BP 148/104, P 98, RR 18, O2 93% RA
Gen: Well appearing, in no apparent distress
HEENT: NCAT, oropharynx clear
Lymph: no cervical lymphadenopathy
CV: No JVD present, regular rate and rhythm, no murmurs
appreciated
Resp: CTA bilaterally in anterior and posterior lung fields, no
increased work of breathing
GI: soft, non-tender, non-distended. No hepatosplenomegaly
appreciated.
GU: No suprapubic tenderness
Extremities: no clubbing, cyanosis, or edema
Neuro: no focal neurologic deficits appreciated. Moves all 4
extremities purposefully and without incident, no facial droop.
Psych: Euthymic, speech non-tangential, appropriate
DISCHARGE PHYSICAL
Vitals: 99.1F, HR 99, BP 127/75, RR 18, SpO2 96%
General: no acute distress, lying comfortably in bed
HEENT: moist mucus membranes, PERRL
Cardio: RRR, no murmur
Pulm: clear b/l, no wheeze
Abdomen: soft, nontender, nondistended, bowel sounds present
Extremities: no pedal edema
Neuro: no focal neurological deficits, AAOx3
Pertinent Results:
___ 06:18PM BLOOD WBC-14.1* RBC-5.32 Hgb-15.8 Hct-45.4
MCV-85 MCH-29.7 MCHC-34.8 RDW-13.8 RDWSD-42.5 Plt ___
___ 05:25PM BLOOD WBC-7.7 RBC-5.53 Hgb-16.2 Hct-46.5 MCV-84
MCH-29.3 MCHC-34.8 RDW-13.2 RDWSD-41.1 Plt ___
___ 06:18PM BLOOD Glucose-130* UreaN-33* Creat-1.8* Na-128*
K-4.7 Cl-89* HCO3-23 AnGap-21*
___ 07:55AM BLOOD Glucose-111* UreaN-17 Creat-1.1 Na-136
K-4.9 Cl-94* HCO3-26 AnGap-21*
___ 04:29PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-POSITIVE *
CXR: no acute cardiopulmonary process
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO QHS
2. Spironolactone 100 mg PO BID
3. Lisinopril 20 mg PO QHS
4. TraZODone 50 mg PO QHS:PRN insomnia
5. melatonin 3 mg oral QHS:PRN insomnia
6. Sumatriptan Succinate 50 mg PO ONCE:PRN migraine
7. Simvastatin 40 mg PO QPM
8. Estradiol Transdermal Patch (estradiol) 0.1 mg/24 hr
transdermal weekly
9. Naproxen 500 mg PO Q12H:PRN Pain - Mild
Discharge Medications:
1. OSELTAMivir 75 mg PO Q12H
RX *oseltamivir 75 mg 1 capsule(s) by mouth twice a day Disp #*8
Capsule Refills:*0
2. Aspirin 81 mg PO QHS
3. Estradiol Transdermal Patch (estradiol) 0.1 mg/24 hr
transdermal weekly
4. Lisinopril 20 mg PO QHS
5. melatonin 3 mg oral QHS:PRN insomnia
6. Naproxen 500 mg PO Q12H:PRN Pain - Mild
7. Simvastatin 40 mg PO QPM
8. Sumatriptan Succinate 50 mg PO ONCE:PRN migraine
9. TraZODone 50 mg PO QHS:PRN insomnia
10. HELD- Spironolactone 100 mg PO BID This medication was
held. Do not restart Spironolactone until you discuss restarting
this with your PCP.
Discharge Disposition:
Home
Discharge Diagnosis:
Hyponatremia, hyperkalemia, ___
Influenza B
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 man with hyponatremia and ___ now with fever.//
?pneumonia
TECHNIQUE: Chest single view
COMPARISON: None
FINDINGS:
Normal heart size, pulmonary vascularity. No effusion. Lungs are clear. No
pneumothorax.
IMPRESSION:
No acute findings.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal labs
Diagnosed with Acute kidney failure, unspecified, Hypercalcemia, Abn lev hormones in specimens from female genital organs
temperature: 98.3
heartrate: 104.0
resprate: 18.0
o2sat: 98.0
sbp: 114.0
dbp: 73.0
level of pain: 3
level of acuity: 3.0 | ___ (given name ___ is a ___ year old trans-female
with a history of migraines, HTN, HLD, and depression who is
sent from PCP office with findings ___ and hyponatremia after
presenting with malaise and vomiting.
1. ___ w/ hyponatremia and hyperkalemia
Patient initially presented with ___ and hyponatremia thought to
be due to increased dose of spironolactone. Urine studies were
somewhat conflicting: elevated sodium and osm suggesting SIADH,
FeNa 0.2% suggesting prerenal, and FeUrea (patient on
spironolactone) 43.5% suggesting intrinsic renal disease. She
appears to be euvolemic, which is more consistent with intrinsic
renal disease or SIADH. Initially
sodium worsened with NS and improved with fluid restriction, and
creatinine improved with fluids and then stabilized with fluid
restriction. Suspect that influenza may also have contributed
to abnormalities. At time of discharge sodium normalized and
creatinine at baseline; she received one dose of kayexylate with
correction of potassium. At discharge resumed lisinopril but
will continue to hold spironolactone. Patient has an
appointment with PCP ___ where BMP will be repeated and
discussion of resuming spironolactone had.
2. Sepsis due to Influenza B
SIRS (fever, tachycardia) with influenza B. Patient started on
Tamiflu the evening of ___ and will continue 75mg PO BID for
total of 5 days.
3. Transgender
Patient currently transitioning from male to female on hormonal
therapy: estradiol patch and spironolactone. Incidentally she
had a testicular torsion some yeas ago and is s/p removal of
affected testis. At this point will hold spironolactone.
Informed PCP of admission and holding of spironolactone with
plans for close follow up ___ and discussion on whether to
resume this in setting of ___. Patient
mentioned discussion of removal of remaining testicle, which she
can discuss further with PCP.
Chronic Medical Problems
1. HLD: continue simvastatin
2. Insomnia: continue trazodone
3. HTN: lisinopril and spironolactone held in setting of ___.
Plan to resume lisinopril at discharge and hold spironolactone.
>30 minutes spent on discharge planning |
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:
___ hx HTN, HL who presents with worsening exertional chest
pain.
He was in his usual health until ___ wks prior to admission,
when he notes onset of discomfort with eating; he cannot further
describe the characteristics. The pain lasted several hours and
spontaneously resolved. Since that episode he notes worsening
exertional chest pain. In the last ___ now pain is constant and
feels like chest pressure, without radiation to the neck, jaw,
or upper extremity. He has never felt this discomfort before.
Today, he ate a hamburger about 1h PTA; he thinks this
exacerbated the pain. He tool 3x ASA, so he came into the ED for
further evaluation.
In the ED, initial vitals: 98.0 44 144/67 18 100% RA
- Labs: Chemistry, CBC, and Tn were normal.
- Imaging: CXR showed no acute process. ECG was read in ED as
"NSR w/ PVCs. NANI. No STEMI."
- Interventions: ASA 81, SL NTG (apparently relieved her CP), 1L
NS.
- Consults: none
Per discussion with ED providers, this patient would usually
have remained in the ED for biomarker monitoring and stress test
on ___ however, because stress test was not available, she was
admitted to the Cardiology service for ACS rule out.
VS on transfer 97.9 48 117/62 22 98% RA.
On the floor, the patient recounts the history above.
Additionally, he reports that he has been getting very fatigued
when climbing a flight of stairs. He becomes very lightheaded
and has almost passed out. Denies orthopnea, PND, ___ edema.
He also reports significant LUTS, including weak stream,
urgency, frequency, nocturia, and occasional incontinence. Of
note, he has had this problem for years, but is on solifenacin
alone.
Otherwise, denies pain anywhere. Denies HA, visual changes,
overt syncope, dyspnea, cough, abd pain, n/v/d/c.
Past Medical History:
- HTN
- hyperlipidemia
- colonic adenoma
- osteoarthritis
- GERD
Social History:
___
Family History:
- father: CAD, HTN
- cousin: colon cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: afebrile, 136/72, (86*), 20, 100/ra
GEN: Alert, lying in bed, no acute distress
COR:
-- His VS were taken while observing the screen on the telemetry
box. Though his electrical rate is recorded as ___, he is noted
to have bigeminy, and a pulse is only palpable during the
initial QRS complex of the couplet ("morphology 1" - appears to
be native P->QRS). Heart sounds can only be auscultated during
the initial QRS complex (not the second complex, "morphology 2,"
which appears to be a non-conducted PVC). There appears to be no
cardiac activity in response to the second beat (morphology 2),
making his actual pulse ___ despite recorded electrical activity
in the ___.
-- I asked the patient to exercise through a series of about 30
"prisoner squats," which increased his HR to 100s. he did not
develop lightheadedness, syncope, or other symptoms. on
telemetry, his HR increased, and there were more native QRS
complexes and fewer non-conducted PVCs
-- Heart sounds regular, with distant S1/S2. NMRG.
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
PULM: Generally CTA b/l without wheeze or rhonchi
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: AOx3. CN II-XII grossly intact, motor function grossly
normal
DISCHARGE PHYSICAL EXAM
=======================
VS: 98.1 ___ 18 96%RA
GEN: Alert, lying in bed, no acute distress
COR: Heart sounds irregular, with distant S1/S2. NMRG.
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
PULM: Generally CTA b/l without wheeze or rhonchi
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema
NEURO: AOx3. CN II-XII grossly intact, motor function grossly
normal
Pertinent Results:
ADMISSION LABS
==============
___ 03:48PM BLOOD WBC-7.2 RBC-5.00 Hgb-15.5 Hct-46.2 MCV-92
MCH-31.0 MCHC-33.5 RDW-13.6 RDWSD-45.8 Plt ___
___ 03:48PM BLOOD Neuts-66.3 ___ Monos-6.6 Eos-3.8
Baso-0.8 Im ___ AbsNeut-4.74 AbsLymp-1.60 AbsMono-0.47
AbsEos-0.27 AbsBaso-0.06
___ 03:48PM BLOOD Glucose-115* UreaN-19 Creat-1.0 Na-142
K-4.1 Cl-105 HCO3-27 AnGap-14
___ 03:48PM BLOOD cTropnT-<0.01
___ 03:48PM BLOOD Calcium-9.0 Phos-3.6 Mg-2.1
DISCHARGE AND PERTINENT LABS
============================
___ 06:10AM BLOOD WBC-5.4 RBC-4.67 Hgb-14.4 Hct-42.4 MCV-91
MCH-30.8 MCHC-34.0 RDW-13.4 RDWSD-43.8 Plt ___
___ 06:10AM BLOOD Glucose-101* UreaN-17 Creat-0.8 Na-142
K-3.8 Cl-109* HCO3-26 AnGap-11
___ 06:10AM BLOOD CK-MB-4 cTropnT-<0.01
___ 11:20PM BLOOD CK-MB-4 cTropnT-<0.01
___ 06:10AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.1
MICROBIOLOGY
============
none
IMAGING
=======
___ CXR PA&L
FINDINGS:
The lungs are clear. There is no focal consolidation, effusion,
or edema.
The cardiomediastinal silhouette is within normal limits. No
acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. esomeprazole magnesium 20 mg oral DAILY
2. lisinopril-hydrochlorothiazide ___ mg oral DAILY
3. Simvastatin 40 mg PO DAILY
4. solifenacin 5 mg oral DAILY
5. Cetirizine 10 mg PO DAILY
Discharge Medications:
1. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
2. Cetirizine 10 mg PO DAILY
3. esomeprazole magnesium 20 mg oral DAILY
4. lisinopril-hydrochlorothiazide ___ mg oral DAILY
5. Simvastatin 40 mg PO DAILY
6. Flecainide Acetate 75 mg PO Q12H
RX *flecainide 50 mg 1.5 tablet(s) by mouth twice a day Disp
#*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- angina without acute coronary syndrome
- symptomatic PVCs
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with chest pain, cough // ?pna
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
The lungs are clear. There is no focal consolidation, effusion, or edema.
The cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: ASIAN - SOUTH EAST ASIAN
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with Other chest pain
temperature: 98.0
heartrate: 44.0
resprate: 18.0
o2sat: 100.0
sbp: 144.0
dbp: 67.0
level of pain: 5
level of acuity: 3.0 | ___ with history of HTN, HL who presented to ___ ED with
symptomatic PVCs and questionable exertional chest pain for
several days.
#Bradycardia: Most likely PVC induced concealed mechanical
bradycardia with symptomatic lightheadedness. His ECGs were
notable for ventricular bigeminy, with each native QRS
associated with a PVC. On physical exam, the PVCs seen on
telemetry did not produce palpable pulses or audible heart
sounds, and on TTE dated ___ it can be observed producing
ineffective beats. He was able to augment his sinus rate with
exercise, which decreased frequency of PVCs. He was started on
flecainide 75 mg bid to suppress the PVCs. He may benefit from
event monitoring to determine the frequency of these PVCs to
better ascertain whether they are the cause of his symptoms, and
he will follow up with Dr. ___ who ___ determine further
steps and a cardiac stress test if necessary.
#ACS Rule out: He underwent ACS rule out with nonischemic serial
ECGs and negative cardiac biomarkers x 3, and will be referred
for outpatient stress testing after he follows up with
electrophysiologist Dr. ___ as an outpatient.
#BPH: Patient described significant LUTS, but is prescribed
solifenacin (approved for overactive bladder); however, his
incontinence is most likely overflow, as it is occuring in the
setting of weak stream, urgency, frequency, and nocturia
consistent with BPH. We discontinued solifenacin and started
tamsulosin.
TRANSITIONAL
============
- Follow up appointments: PCP, ___ (not scheduled at d/c)
- Started on flecainide 75mg BID
- ___ need outpatient stress test, Holter monitoring - to be
determined at cardiology follow up
- ___ need Urology eval for lower urinary tract symptoms/BPH
- No AVN blocking agents for now given symptomatic PVCs |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
=============
___ 10:48AM BLOOD WBC-9.5 RBC-3.56* Hgb-11.2 Hct-36.2
MCV-102* MCH-31.5 MCHC-30.9* RDW-12.7 RDWSD-47.5* Plt ___
___ 10:48AM BLOOD Neuts-88.9* Lymphs-3.3* Monos-5.5 Eos-1.1
Baso-0.2 Im ___ AbsNeut-8.42* AbsLymp-0.31* AbsMono-0.52
AbsEos-0.10 AbsBaso-0.02
___ 10:48AM BLOOD ___ PTT-19.5* ___
___ 10:48AM BLOOD Glucose-165* UreaN-13 Creat-0.8 Na-143
K-5.3 Cl-104 HCO3-21* AnGap-18
___ 10:48AM BLOOD ALT-19 AST-60* AlkPhos-44 TotBili-0.4
___ 10:48AM BLOOD cTropnT-0.01 proBNP-294
___ 10:48AM BLOOD Lipase-8
___ 10:48AM BLOOD Albumin-4.2 Calcium-9.6 Phos-2.7 Mg-1.5*
___ 10:54AM BLOOD ___ pO2-27* pCO2-46* pH-7.41
calTCO2-30 Base XS-2
___ 10:54AM BLOOD Lactate-2.0
DISCHARGE LABS:
==============
___ 06:13AM BLOOD WBC-10.3* RBC-3.72* Hgb-11.8 Hct-39.3
MCV-106* MCH-31.7 MCHC-30.0* RDW-12.7 RDWSD-49.3* Plt ___
___ 06:13AM BLOOD Glucose-110* UreaN-10 Creat-0.8 Na-144
K-4.1 Cl-99 HCO3-27 AnGap-18
___ 06:13AM BLOOD Calcium-9.8 Phos-4.3 Mg-2.0
DISCHARGE PHYSICAL EXAM:
=======================
VITALS: ___ 0235 Temp: 97.8 PO BP: 155/76 HR: 94 RR: 18 O2
sat: 97%
GENERAL: Chronically ill appearing female in NAD. Lying
comfortably in bed.
HEENT: Sclera anicteric and without injection. MMM, but poor
dentition.
Neck: Supple. FROM without pain.
CARDIAC: Regular rate and rhythm with normal S1 and S2. II/VI
systolic murmur, loudest over the left sternal border. No rubs
or
gallops.
RESP: Normal respiratory effort. Scattered faint inspiratory
crackles at bilateral bases. No wheezes or rhonchi.
ABDOMEN: Normal bowels sounds, soft, NT/ND. Normoactive BS. No
guarding or masses.
MSK: Warm, well perfused. No ___ edema or erythema. TTP over
right
lumbar paraspinal muscles and SI joint. TTP over lower sacrum.
No
TTP over right greater trochanter. full active ROM of right hip,
pain with extension and abduction. full ROM of right knee,
without any pain. no ___ edema.
SKIN: Warm, dry. No rashes. no overlying skin changes @ right
hip.
NEUROLOGIC: AOx3. face symmetric, speech fluent, moving all 4
extremities purposefully. Strength exam:
Lower extremities:
L HF: ___ HE: ___ KF: ___ KE: ___ DF: ___ PF: ___
R HF: 4+/5 HE: ___ KF: ___ KE: 4+/5 DF: ___ PF: ___
L Delt: ___ EF: ___ EE: 4+/5 Int: ___ Thumb abd: ___
R Delt: ___ EF: ___ EE: 4+/5 Int: ___ Thumb abd: ___
Decreased sensation over lateral and plantar aspect of foot and
lateral lower leg. neg straight leg
Reflex 3+ in left lower extremity and 2+ in right lower
extremity. Downgoing toes bilaterally. +clonus bilaterally with
R>L.
MICRO DATA:
==========
___ 07:00PM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-18*
Polys-21 ___ Macroph-7
___ 07:00PM CEREBROSPINAL FLUID (CSF) TotProt-50*
Glucose-100
___ 04:15PM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG
___ 5:45 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___:
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
___ 7:00 pm CSF;SPINAL FLUID SOURCE: LP #3.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
___ 11:09 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 11:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
========
NCHCT ___:
1. No acute intracranial hemorrhage.
2. Prominent ventricles out of portion of sulci suggestive of
central atrophy.
3. Left frontal lobe encephalomalacia.
4. Mild periventricular white matter disease.
CTA Chest ___:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Grossly similar appearance of chronic interstitial lung
disease.
3. Small hiatal hernia.
4. Mild pulmonary artery dilation suggestive of pulmonary
hypertension.
Hip X-ray ___: Mild degenerative changes in the bilateral
hip joints
MRI Right Hip ___: Unchanged right hip MRI with a small
degenerative labral tear. No evidence of avascular necrosis,
fracture or other acute abnormality.
MRI lumbar spine with and w/o contrast ___:
1. Severe canal narrowing with compression of the cauda equina
nerve roots at L3-4 due to a disc bulge and superimposed right
paracentral disc extrusion. The extruded disc fragment also
narrows the right L4 lateral recess, displaces the traversing
nerve root, and compresses the traversing/exiting right L4 nerve
root.
2. Moderate to severe canal narrowing is also present at L4-5.
3. Other levels of severe neural foraminal narrowing including
on the left at L3-4, bilaterally at L4-5 and on the right at
L5-S1 as described above.
4. No evidence of an epidural collection. No signal abnormality
in the sacrum to explain sacral tenderness.
MRI cervical spine with and w/o contrast ___:
1. No epidural collection or evidence of discitis/osteomyelitis.
2. Multilevel degenerative changes of the cervical spine, most
prominent at C5-6 where there is moderate to severe canal
narrowing with remodeling of the cord, but no cord signal
abnormality. Evaluation of neural foramina is somewhat limited
due to motion, but is likely moderate to severe at this level.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY
3. LORazepam 0.5 mg PO BID:PRN anxiety
4. Omeprazole 20 mg PO DAILY
5. albuterol sulfate 90 mcg/actuation inhalation TID
6. Lovastatin 10 mg oral DAILY
7. AzaTHIOprine 100 mg PO DAILY
8. Baclofen 10 mg PO BID
9. ipratropium bromide 42 mcg (0.06 %) nasal TID prn
10. Lisinopril 20 mg PO DAILY
11. meloxicam 7.5 mg oral daily
12. Nystatin Oral Suspension 5 mL PO QID
13. PredniSONE 20 mg PO DAILY
14. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Atovaquone Suspension 1500 mg PO DAILY
3. Ibuprofen 400-600 mg PO Q8H:PRN Pain - Mild
4. Lidocaine 5% Patch 1 PTCH TD QAM right hip/lower back
5. Multivitamins W/minerals 1 TAB PO DAILY
6. albuterol sulfate 90 mcg/actuation inhalation TID
7. Aspirin 81 mg PO DAILY
8. AzaTHIOprine 100 mg PO DAILY
9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral daily
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
11. ipratropium bromide 42 mcg (0.06 %) nasal TID prn
12. Lisinopril 20 mg PO DAILY
13. LORazepam 0.5 mg PO BID:PRN anxiety
14. Lovastatin 10 mg oral DAILY
15. Nystatin Oral Suspension 5 mL PO QID
16. Omeprazole 20 mg PO DAILY
17. PredniSONE 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
=========
SIRS
SECONDARY:
==========
Piriformis Pain Syndrome
Degenerative Joint Disease (Hips & Lumbar Spine)
Hypokalemia
Hypomagnesemia
Severe Malnutrition
Interstitial Lung Disease
Anxiety
Hypertension
Thrush
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 confusion fever // PNA?
TECHNIQUE: Portable semi-upright AP view of the chest
COMPARISON: CT chest ___ and chest radiograph ___
FINDINGS:
Lung volumes remain low. Cardiac silhouette size is mildly enlarged,
unchanged. Mediastinal and hilar contours are similar. Redemonstrated are
chronic interstitial opacities with scattered parenchymal opacifications,
potentially in the left lung base, compatible with known chronic interstitial
lung disease. Superimposed infection in the left lung base is difficult to
exclude. There appears to be a small left pleural effusion. No pneumothorax.
Crowding of bronchovascular structures without frank pulmonary edema. No
acute osseous abnormality.
IMPRESSION:
Low lung volumes with chronic interstitial lung disease redemonstrated.
Superimposed infection in the left lung base is difficult to exclude.
Probable small left pleural effusion.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with altered mental status // Rule out bleed
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.3 cm; CTDIvol = 49.5 mGy (Head) DLP =
903.1 mGy-cm.
2) Sequenced Acquisition 2.0 s, 4.1 cm; CTDIvol = 49.5 mGy (Head) DLP =
200.7 mGy-cm.
Total DLP (Head) = 1,104 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of fracture, acute large territorial
infarction,hemorrhage,edema,or mass. The ventricles are prominent out of
portion of sulci suggestive of central atrophy. There is left frontal lobe
encephalomalacia. There is mild periventricular white matter disease.
The visualized portion of the mastoid air cells, and middle ear cavities are
clear. The visualized portion of the orbits are normal. There is mucosal
thickening in the right maxillary sinus with air-fluid level and aerosolized
secretions. Moderate atherosclerotic calcifications of the cavernous carotid
arteries..
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Prominent ventricles out of portion of sulci suggestive of central atrophy.
3. Left frontal lobe encephalomalacia.
4. Mild periventricular white matter disease.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with shortness of breath, tachycardia // Assess for
pulmonary embolism
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 12.1 mGy (Body) DLP =
6.1 mGy-cm.
2) Spiral Acquisition 3.6 s, 28.3 cm; CTDIvol = 16.0 mGy (Body) DLP = 454.2
mGy-cm.
Total DLP (Body) = 460 mGy-cm.
COMPARISON: CT chest dated ___ and ___.
FINDINGS:
HEART AND VASCULATURE: The main pulmonary artery measures 3.2 cm suggestive of
pulmonary artery hypertension. There is no filling defect visualized to the
level of subsegmental pulmonary artery suggestive of pulmonary embolism. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. There is mild atherosclerotic calcification involving
the thoracic aorta. There is mild mitral annular calcification. The heart is
mildly enlarged. Pericardium and great vessels are within normal limits. No
pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: There are multiple subcentimeter mediastinum
lymph nodes which are likely reactive. No axillary or hilar lymphadenopathy
is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: The airways are patent to the level of the segmental bronchi
bilaterally. There is grossly unchanged scattered bilateral lung
peribronchovascular ground-glass opacification and reticulation, interlobular
septal thickening and traction bronchiectasis consistent with chronic
interstitial lung disease. No new focal consolidation.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: There is a small hiatal hernia. Included portion of the upper
abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
There is mild multilevel degenerative changes of the thoracic spine.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic abnormality.
2. Grossly similar appearance of chronic interstitial lung disease.
3. Small hiatal hernia.
4. Mild pulmonary artery dilation suggestive of pulmonary hypertension.
Radiology Report
EXAMINATION: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) RIGHT
INDICATION: ___ year old woman with fever and right hip pain // Evaluate for
infection, effusion
TECHNIQUE: AP pelvis, two views right hip
COMPARISON: Pelvis and right hip radiographs ___
FINDINGS:
No fracture or dislocation seen. There are mild degenerative changes in the
bilateral hip joints as seen previously. More severe degenerative changes are
noted in the lower lumbar spine, similar to slightly progressed when compared
to the prior study. No destructive lytic or sclerotic bone lesions.
Evaluation of the sacrum is limited due to overlying bowel gas.
IMPRESSION:
Mild degenerative changes in the bilateral hip joints
Radiology Report
EXAMINATION: MR HIP ___ CONRAST RIGHT
INDICATION: ___ year old woman with long term steroid use, hx of greater
trochanteric bursitis, and piriformis pain syndrome, now with acute on chronic
right hip pain // e/o AVN or other cause for acute on chronic right hip pain?
TECHNIQUE: Multiplanar images of the right hip were performed without the
administration of intravenous contrast using a unilateral hip MR protocol.
COMPARISON: None
FINDINGS:
Dedicated right hip imaging is limited by motion artifact.
There is normal marrow signal within the proximal femurs bilaterally. There
is no evidence of avascular necrosis, fracture, stress fracture. The marrow
signal throughout the rest of the pelvis is within normal limits. There is
normal signal at the sacroiliac joints, without evidence of sacroiliitis.
Focused imaging of the right hip demonstrates no significant joint effusion.
The articular cartilage is grossly preserved. The previously seen small
degenerative labral tear is better assessed on prior MRI, but not
significantly changed. There is no greater trochanteric bursitis. The
hamstring insertion onto the ischial tuberosity is normal.
Limited assessment of intra-pelvic soft tissue structures is grossly
unremarkable.
No gross intrapelvic fluid or enlarged intrapelvic lymph nodes detected.
Limited assessment of the lower lumbar spine is grossly unremarkable.
IMPRESSION:
Unchanged right hip MRI with a small degenerative labral tear. No evidence of
avascular necrosis, fracture or other acute abnormality.
Radiology Report
EXAMINATION: MR ___ AND W/O CONTRAST
INDICATION: ___ year old woman with ILD on chronic steroids initially with
fever and with tenderness over sacrum. // ?acute infectious process
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging. This was followed by sagittal and axial T1
images obtained after the uneventful intravenous administration of ___
contrast agent.
COMPARISON: None.
FINDINGS:
There is approximately 5 mm retrolisthesis of L3 on L4. There is minimal
grade 1 anterolisthesis of L4 on L5 with bilateral spondylolysis. Vertebral
body height and signal intensity is preserved. There is disc desiccation
signal and height loss throughout the lumbar spine. The conus medullaris
terminates at L2. Post-contrast images demonstrate no abnormal enhancement
of the conus or cauda equina nerve roots.
At T12-L1 and L1-L2, there is a disc bulge with no canal or neural foraminal
narrowing.
At L2-3 there is a broad disc bulge, mild facet and ligamentum flavum
hypertrophy which results in mild canal narrowing and minimal bilateral neural
foraminal narrowing.
At L3-4, there is a broad disc bulge with superimposed central/right
paracentral disc extrusion extending inferiorly which in combination with
facet hypertrophy, ligamentum flavum hypertrophy and epidural fat results in
severe canal narrowing with compression of the cauda equina nerve roots. The
extruded disc fragment extends inferiorly into the right right lateral recess
at L4, where it likely affects the traversing right L4 nerve root. Overall,
the extrusion measures 2.3 cm cc x 1.3 cm TRV x 1.2 cm AP. Neural foraminal
narrowing is severe on the left and moderate to severe on the right.
At L4-5, there is a broad disc bulge with right central annular fissure and
superimposed left paracentral protrusion. This in combination with ligamentum
flavum thickening and facet hypertrophy results in moderate to severe canal
narrowing with crowding of the cauda equina nerve roots. The superimposed
disc protrusion on the left narrows the extraforaminal and subarticular zone.
In combination with facet joint hypertrophy, there is severe bilateral
subarticular recess and neural foraminal narrowing.
At L5-S1, there is a disc bulge and facet joint hypertrophy resulting in
moderate canal narrowing. There is severe right and moderate to severe left
neural foraminal narrowing.
Other: Cholelithiasis is partially imaged.
IMPRESSION:
1. Severe canal narrowing with compression of the cauda equina nerve roots at
L3-4 due to a disc bulge and superimposed right paracentral disc extrusion.
The extruded disc fragment also narrows the right L4 lateral recess, displaces
the traversing nerve root, and compresses the traversing/exiting right L4
nerve root.
2. Moderate to severe canal narrowing is also present at L4-5.
3. Other levels of severe neural foraminal narrowing including on the left at
L3-4, bilaterally at L4-5 and on the right at L5-S1 as described above.
4. No evidence of an epidural collection. No signal abnormality in the sacrum
to explain sacral tenderness.
PREVALENCE: Prevalence of lumbar degenerative disk disease in subjects
without low back pain:
Overall evidence of disk degeneration 91% (decreased T2 signal, height loss,
bulge)
T2 signal loss 83%
Disk height loss 58%
Disk protrusion 32%
Annular fissure 38%
Jarvik, et all. Spine ___ 26(10):1158-1166
Lumbar spinal stenosis prevalence- present in approximately 20% of
asymptomatic adults over ___ years old
___, et al, Spine Journal ___ 9 (7):545-550
These findings are so common in asymptomatic persons that they must be
interpreted with caution and in context of the clinical situation.
NOTIFICATION: The findings were discussed with ___, m.D. by ___,
M.D. on the telephone on ___ at 925 am, 30 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: MR ___ WAND W/O CONTRAST ___ MR ___ SPINE
INDICATION: ___ year old woman with ILD on immunosuppression, here with hip
pain, found to have severe lumbar DDD and also with triceps weakness. // ?
acute spinal process
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were next performed. After administration
of Gadavist intravenous contrast, sagittal and axial T1 weighted imaging was
performed.
COMPARISON: None.
FINDINGS:
There is about 2 mm anterolisthesis of C4 on C5 and about 4 mm anterolisthesis
of C5 on C6. This is appears chronic, as there is no prevertebral edema or
evidence of ligamentous injury. The spondylolisthesis results in somewhat
exaggerated cervical lordosis. Vertebral body signal intensity is within
normal limits. There is disc desiccation signal throughout the cervical
spine. Spinal cord is normal in caliber and configuration. No evidence of
infection or malignancy.
At C2-3, there is no canal or neural foraminal narrowing.
At C3-4, a posterior disc osteophyte complex results in minimal canal
narrowing. Left greater than right facet uncovertebral osteophytes result in
moderate left and mild right neural foraminal narrowing.
At C4-5, a posterior disc osteophyte complex results in mild canal narrowing
with flattening of the ventral thecal sac. Evaluation of the neural foramina
is somewhat motion limited, but is likely moderate bilaterally.
At C5-6, a central posterior disc osteophyte complex results in moderate to
severe canal narrowing with remodeling of the cord. There is no cord signal
abnormality. Once again, motion limits evaluation of the neural foramina but
narrowing is likely moderate to severe bilaterally due to facet and
uncovertebral osteophytes.
At C6-7, a small posterior disc osteophyte complex results in mild canal
narrowing with flattening of the ventral thecal sac. Complete assessment of
the neural foramina is limited due to motion, but there are facet and
uncovertebral osteophytes probably causing mild narrowing bilaterally.
C7-T1: There is no canal or neural foraminal narrowing.
The remainder of the imaged upper thoracic spine is grossly unremarkable,
without canal or neural foraminal narrowing.
IMPRESSION:
1. No epidural collection or evidence of discitis/osteomyelitis.
2. Multilevel degenerative changes of the cervical spine, most prominent at
C5-6 where there is moderate to severe canal narrowing with remodeling of the
cord, but no cord signal abnormality. Evaluation of neural foramina is
somewhat limited due to motion, but is likely moderate to severe at this
level.
3. Additional degenerative changes of the cervical spine as described above.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Confusion, Dyspnea
Diagnosed with Sepsis, unspecified organism, Fever, unspecified, Dyspnea, unspecified
temperature: 99.9
heartrate: 134.0
resprate: 28.0
o2sat: 98.0
sbp: 184.0
dbp: 114.0
level of pain: UTA
level of acuity: 2.0 | BRIEF HOSPITAL COURSE
=================================
Ms. ___ is a ___ y/o female with a history of ILD on
azathioprine/prednisone, and piriformis pain syndrome, who
presented initially with worsening hip pain and confusion. The
confusion, which was marked by word finding difficulties at
home, resolved by time pt arrived to the hospital and was
believed to be possibly ___ toxic metabolic encephalopathy in
the setting of infection vs. TIA vs. medication side effect (on
baclofen at home). Noncontrast head CT w/o evidence of bleed. In
the ED she was found to be febrile to ___. Broad infectious
workup including LP did not find cause for her fever. She was
placed on empiric abx for 48 hours which were discontinued at
that point in time as cultures remained negative and fever had
not returned. Regarding her acute on chronic right hip pain, pt
underwent x-ray and MRI imaging which revealed no evidence of
avascular necrosis or other acute process. She was provided
analgesics for sx relief and additionally worked with ___. She
also complained of focal lower back pain which given history of
immunosuppression was concerning for infection. Lumbar MRI
without evidence of abscess, but did show extensive degenerative
disc disease and possible compression of cauda equina for which
neurosurgery was consulted. Cervical spine MRI also obtained for
triceps weakness which again demonstrated degenerative disease.
Will plan for follow up with neurosurgery as outpatient.
TRANSITIONAL ISSUES:
=================================
[]Pulmonology: started Ms. ___ on atovaquone for PCP ppx
while on pred 20mg.
[]PCP: please follow up on hip and back pain
[]PCP: note that patient became confused with tramadol and
oxycodone and would avoid those medications
[]PCP: ___ to be hypertensive during admission. ___ benefit
from additional antihypertensive agent.
[]PCP: ___ weaning benzodiazepines given age.
[]Neurosurgery:
--Recommend EMG as outpatient to evaluate neuropathy; follow up
with Neuromuscular Neurology. Call ___ to schedule.
--Please follow up with Neurosurgery in 4 weeks (after EMG).
Call
___ to schedule with Dr. ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Niacin / Tape ___ / Percocet / ibuprofen / house
dust / house dust mite
Attending: ___.
Chief Complaint:
cough, shortness of breath, leg swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ with a PMG of h/o CHF (last TTE ___ showing mild
systolic and diastolic dysfunction, on Lasix 80mg QD) CAD s/p
PPM, DVT/PE not on anticoagulation, IDDM (on metformin and
insulin), asthma, OSA, CKD, lymphedema presenting from assisted
living with increased SOB and bilateral pedal edema. Of note,
patient was hospitalized at ___ in ___ for PNA.
Per repot, patient reports chronic SOB, orthopnea, ___ edema,
worsened over the past couple of days. She describes a sensation
of SOB only with bending over at the waist. When she is lying
flat or sitting upright the SOB is not present. She does not
walk
anymore given her lymphedema and lower extremity edema. She
denies any change in her Lasix dosing or dietary indiscretion.
ROS positive for non productive cough and lightheadedness over
the past several days. Does not feel like a cold. ROS negative
for LOC, CP, fever, chills, abdominal pain, N/V/D/C, dysuria.
In the ED, initial VS were: 98.9, 88, 125/63, 20, 96% RA
Exam notable for: On stretcher, in visible distress when lying
down
AOx3. RRR, no /r/g
Labs showed:
- CBC: 9.2/10.8/___.4/222
- Chem 7: K4.8, Cr 1.1
- BNP 661
- Trp 0.01 negative x2
- Lactate 3.3-4-4-2.5
Imaging showed: Bilateral US negative for DVT, CXR showing mild
pulmonary vascular congestion without frank pulmonary edema.
Received:
___ 12:47 IV Furosemide 80 mg ___
___ 12:47 IV Vancomycin ___ Started
___ 13:01 SC Insulin 30 ___
___ 14:10 IV Vancomycin 1 mg ___ Stopped (1h
___
___ 19:48 SC Insulin 8 Units ___
___ 22:33 SC Insulin 10 Units ___
___ 23:14 SC Insulin 20 UNIT ___
Transfer VS were: 93, 141/67, 20, 98% RA
On arrival to the floor, patient reports the above symptoms. She
is most bothered by the cough. Denies any SOB with lying flat in
the bed. No pain with deep inspiration. Specifically denies any
urinary symptoms aside from increased urinary frequency in the
setting of Lasix.
Past Medical History:
--complete heart block s/p PPM
--Congestive heart failure
--Cardiac history: Dilated cardiomyopathy diagnosed ___
following spine surgery, with subsequently normalized cardiac
function
--obesity
--diabetic neuropathy
--DVT-R.popliteal vein and PE ___
--Lymphedema of legs, R>L for many years
--Obstructive sleep apnea (uses CPAP)
--Gastroesophageal reflux disease
--Anemia (baseline Hct = ___
--osteoarthritis
--Sciatica
--Cervical stenosis
--Restless leg syndrome
--Cataracts s/p surgery in left eye
-allergic rhinitis
-asthma
-overactive bladder
-bilateral carpal tunnel release about ___ yrs ago
-trigger finger
- headaches
--Gout vs pseudogout ___
PAST SURGICAL HISTORY:
--Right knee replacement
--Lumbar spondylosis and disk degeneration s/p laminectomy and
fusion ___
--Tonsillectomy
--Cervical fusion
Social History:
___
Family History:
Mother with CAD
Sister with CABG in ___
Other sister with heart issues, unsure what kind
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.6, 126/80, 87 18 97 RA
GENERAL: NAD, appears fatigued
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, JVD 8 lying flat in bed
HEART: RRR, occasional extra beats, no murmurs
LUNGS: CTAB, no wheezes, rales, rhonchi, coughing with deep
breathing.
ABDOMEN: nondistended, obese, +BS, nontender in all quadrants,
no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: bilateral lymphedema, large 5cm diameter region
pretibial surface of right leg warmth and erythematous. 2+
pitting edema bilaterally to knees. Distal extremities WWP. No
open ulcerations.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
DISCHARGE PHYSICAL EXAM:
VITALS: Tm 98.2 HR 92 BP 124/81 RR 16 SPO2 96%CPAP
GENERAL: Elderly woman laying in bed in NAD
HEENT: MMM
CV: Soft heart sounds. Nl s1/s2. No m/r/g. Minimal JVD
RESP: CTAB anteriorly. No w/r/r. Not using accessory muscles.
GI: Obese. Soft. NT ND +BS
EXT: 1+ ___ edema in bilateral LEs. No calf tenderness. No
cyanosis or clubbing. No redness of LEs.
SKIN: Warm and well-perfused
NEURO: AAOx3. Able to move around in bed by herself.
Pertinent Results:
===============
Admission labs
===============
___ 11:30AM BLOOD WBC-9.2 RBC-4.06 Hgb-10.8* Hct-34.4
MCV-85 MCH-26.6 MCHC-31.4* RDW-15.4 RDWSD-46.9* Plt ___
___ 11:30AM BLOOD Neuts-70.4 Lymphs-18.6* Monos-7.8 Eos-2.4
Baso-0.4 Im ___ AbsNeut-6.45* AbsLymp-1.70 AbsMono-0.71
AbsEos-0.22 AbsBaso-0.04
___ 11:30AM BLOOD Glucose-258* UreaN-25* Creat-1.1 Na-136
K-4.8 Cl-99 HCO3-22 AnGap-15
___ 12:29AM BLOOD ALT-15 AST-15 AlkPhos-120* TotBili-0.2
___ 11:30AM BLOOD proBNP-661*
___ 11:30AM BLOOD cTropnT-0.01
___ 12:29AM BLOOD Calcium-9.5 Phos-3.6 Mg-1.9
___ 12:04PM BLOOD Lactate-3.3*
===============
Pertinent labs
===============
___ 06:15AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.2 UricAcd-7.8*
___ 02:51AM BLOOD %HbA1c-13.7* eAG-346*
===============
Discharge labs
===============
___ 07:45AM BLOOD WBC-9.3 RBC-4.25 Hgb-11.0* Hct-35.6
MCV-84 MCH-25.9* MCHC-30.9* RDW-14.8 RDWSD-45.3 Plt ___
___ 06:15AM BLOOD Glucose-184* UreaN-34* Creat-1.3* Na-139
K-4.1 Cl-92* HCO3-31 AnGap-16
===============
Studies
===============
___: ANKLE (AP, MORTISE AND LAT) LEFT
IMPRESSION: Comparison to ___. No relevant change
is noted. No fracture or dislocation. The more ties and hilar
dome are stable in appearance. Plantar and posterior calcaneal
spurs are again demonstrated. Stable moderate periarticular
soft tissue swelling.
___: Lower Extremity US
1. Limited evaluation of the calf veins bilaterally. Within
these
limitations, no evidence of deep venous thrombosis in the right
or left lower extremity veins.
2. Subcutaneous edema of the calves bilaterally.
___: CXR
IMPRESSION:
Possible mild pulmonary vascular congestion without frank
pulmonary edema.
===============
Microbiology
===============
___: blood culture pending
___: urine culture pending
___: URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- 4 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
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
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- <=1 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Allopurinol ___ mg PO DAILY
3. Cetirizine 10 mg PO DAILY
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN rhinitis
5. Gabapentin 100 mg PO TID
6. Montelukast 10 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
10. Furosemide 80 mg PO DAILY
11. Detemir 30 Units Breakfast
Detemir 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
12. Colchicine 0.6 mg PO 2X/WEEK (___)
13. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
14. Potassium Chloride 40 mEq PO DAILY
15. Ferrous Sulfate 325 mg PO DAILY
16. mometasone 50 mcg/actuation nasal DAILY
17. Multivitamins 1 TAB PO DAILY
18. Ascorbic Acid ___ mg PO DAILY
19. trospium 20 mg oral BID
20. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Medications:
1. Lidocaine 5% Ointment 1 Appl TP DAILY
2. Allopurinol ___ mg PO DAILY
3. Gabapentin 100 mg PO BID
4. Detemir 30 Units Breakfast
Detemir 20 Units Bedtime
Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
6. Ascorbic Acid ___ mg PO DAILY
7. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
8. Cetirizine 10 mg PO DAILY
9. Colchicine 0.6 mg PO 2X/WEEK (___)
10. Ferrous Sulfate 325 mg PO DAILY
11. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN rhinitis
12. Furosemide 80 mg PO DAILY
13. mometasone 50 mcg/actuation nasal DAILY
14. Montelukast 10 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. Pantoprazole 40 mg PO Q24H
17. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
18. trospium 20 mg oral BID
19. HELD- Potassium Chloride 40 mEq PO DAILY This medication
was held. Do not restart Potassium Chloride until you see your
Cardiologist
20. HELD- TraZODone 50 mg PO QHS:PRN insomnia This medication
was held. Do not restart TraZODone until you see your primary
care doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
===============
#Acute on chronic HFrEF
#Acute on chronic ___ edema
#Dyspnea
#IDDM, poorly-controlled
#Chronic
#Chronic knee pain
Secondary Diagnoses
================
#OSA
#Gout
#Hx of DVT/PE
#CKD stage III
#asthma
#seasonal allergies
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) LEFT
INDICATION: ___ year old woman with pain to palpation of left lateral ankle
and complaining of pain// r/o fracture r/o fracture
IMPRESSION:
Comparison to ___. No relevant change is noted. No fracture or
dislocation. The more ties and hilar dome are stable in appearance. Plantar
and posterior calcaneal spurs are again demonstrated. Stable moderate
periarticular soft tissue swelling.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Pedal edema
Diagnosed with Heart failure, unspecified
temperature: 98.9
heartrate: 88.0
resprate: 20.0
o2sat: 96.0
sbp: 125.0
dbp: 63.0
level of pain: 4
level of acuity: 3.0 | SUMMARY:
====================
___ with a PMH of HFrEF (EF 45%) s/p permanent pacemaker
placement, CAD, hx of DVT/PE not on anticoagulation, IDDM (on
metformin and insulin), asthma, OSA on CPAP, CKD, lymphedema
presenting from assisted living with cough x2 weeks, shortness
of breath, and ___ edema concerning for CHF exacerbation.
=======================
ACUTE MEDICAL PROBLEMS
=======================
#HFrEF exacerbation
Patient with known LVEF 45-50%, status-post placement of
permanent pacemaker. She presented with subacute cough and mild
SOB, concerning for HFrEF exacerbation. A chest x-ray showed
some mild pulmonary vascular congestion without frank edema. Her
proBNP was 661, with a history of >4000 during heart failure
exacerbations. She was treated with IV Lasix 80 mg instead of
her baseline PO Lasix 80 mg. She is not on a beta-blocker or
___ at home and follows with the heart failure clinic at
___. She diuresed net negative 7.5L during her admission. Her
discharge weight was 110.3 kg. Due to concern for aspiration
contributing to her respiratory distress, she was evaluated by
speech and swallow who recommended a heart healthy diet with
thin liquids.
# Type 2 DM - Insulin dependent
Blood sugars elevated on admission, possibly in setting of
medication
non-compliance (HbA1C 13.7). Continued Lantus 30U qAM and 20U
qPM for standing insulin and her was put on a high dose sliding
scale. There was some concern that she may not have been taking
her insulin regularly as an outpatient. Her discharge insulin
regimen was insulin glargine 30 units at breakfast and 20 units
at bedtime, and insulin Humalog 8 units at breakfast, lunch, and
dinner with sliding scale on top of it. Metformin was
discontinued given her significant HbA1C elevation and unlikely
benefit. She has an outpatient appointment with ___ Diabetes
___ to further titrate her insulin.
# Lower extremity swelling
# History of provoked DVT/PE
Patient with chronic lymphedema. Initially had concern for lower
extremity DVT due to erythema of right lower extremity but
resolved and lower extremity US negative for DVT. In addition,
she was briefly treated with vancomycin/doxycycline for presumed
cellulitis as her one legs (R) was more red than the other, but
this was stopped as the redness resolved quickly with diuresis.
# Lactatemia
Patient with initial labs showing lactate 3.3, but patient was
not hypotensive or in shock. This trended down to 2.5 and then
we stopped checking it. This may have been secondary to relative
hypoperfusion from cardiorenal syndrome.
# Asymptomatic bacteriuria
Patient had urinalysis with WBC>27, large leuks, positive
nitrates. Urine culture with Ecoli>100k. In setting of no
symptoms, fever or WBC, the decision was made to hold off on
antibiotics. A repeat urinalysis was done that showed no
abnormalities.
# Acute on chronic knee and right ankle pain
# Hx of gout
Patient complaining of bilateral knee pain for which she
received Tylenol and topical lidocaine gel for. She also had
complaints of pain on her left lateral malleolus, so an X-ray
was done of her left ankle which showed soft tissue swelling and
bone spurs, but no evidence of fracture. Due to her history of
gout, her allopurinol was increased to 150 mg PO daily based on
renal function. Uric acid was checked for purposes of titrating
outpatient medications which was 7.8. She was restarted on
colchicine on discharge as she takes it twice a week at home.
CHRONIC MEDICAL ISSUES
======================
# CKD Stage III
Cr 1.1 on admission below recent baseline 1.5-2.0. This
increased to 1.3 with diuresis, till below recent baseline.
# OSA
Continued on CPAP at night.
# Asthma/Allergies
Continued home Cetirizine, Monteleukast, Albuterol
=================
TRANSITIONAL ISSUES
=================
[] Speech and swallow recs for diet: Heart healthy, carb
consistent diet with thin liquids
[] Discharge weight: 110.3 kg (bed weight)
[] Discharge creatinine: 1.3
[] Allopurinol increased to 150 mg PO daily (uric acid 7.8),
continue to titrate as able given chronic renal disease
[] Follow up with Cardiology, ___, PCP
[] Discharge insulin: Lantus 30 units qAM, 20 units qbedtime;
Humalog 8 units qac with additional sliding scale
[] HbA1c 13.7% --> suspect she was not getting insulin at
assisted living facility, so please ensure she is receiving her
medications
[] Metformin stopped due to little relative benefit with this
degree of HbA1C elevation
[] Daily KCl was held given no issues with hypokalemia
throughout her admission despite ongoing intravenous diuresis
[] Patient complaining of L hallux pain after putting on socks
day of discharge, no concern for acute gouty flare based on
clinical exam, please continue to monitor
[] Urine culture from ___ pending
[] Blood culture from ___ pending
Advanced Care Planning
#CONTACT:
Name of health care proxy: ___
___: son
Phone number: ___
Cell phone: ___
#CODE STATUS: Full, presumed, not specifically discussed |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ativan
Attending: ___
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a medically complex ___ with PMH significant
for poorly controlled T1DM c/b retinopathy, ESRD s/p living
kidney xplant in ___, neuropathy with neurogenic bladder and
gastroparesis, CAD s/p MI in ___ and with 3 DES placed in
___, hypothyroidism and h/o multiple MDR UTIs
(Klebsiella, E.coli, Enterococcus), sclerodermda/CREST and
antiphospholipid antibody syndrome with h/o PE in ___ who
presents to the ED with intractable N/V and mechanical fall with
head strike.
Patient was in her usual state of health until one week prior
to admission when she developed nausea and vomiting. This nausea
and vomiting seemed to occur after she took an oral antibiotic
while on vacation in ___ (unclear why this was
prescribed - clinic paperwork said for inguinal ___. She became
concerned that she was not able to tolerate PO intake and
specifically that she was not keeping down her anti-rejection
meds so she went to ___ urgent care. Vitals at urgent
care were: 97.3, 127/65, 122, 97%RA. She was given 500cc NS and
IV Zofran 4mg x1. Labs were checked which showed an INR of 4.9.
Urgent care recommended that she be seen at the ___ ED for
further evaluation. Patient decided to drive herself to ___
but unfortunately fell while exiting a restaurant (she felt
better after the Zofran and stopped for food on the way to
___. She fell down some stairs and struck her head but did
not lose conciousness. At this point in time, EMS was called and
brought her to ___.
Initial vitals in the ED were: 97.2, 135, 168/69, 18, 100% RA
Exam was notable for: laceration to right forehead and right
wrist swelling.
Labs were notable for: H/H 8.4/25.1 (recent baseline 9.5/28.8
but decline is recent in last 4 months), INR 4.8, plts 292, BNP
1547, Cr 1.4 (baseline 1.2-1.4), lactate 1.4, UA grossly
positive. Blood and urine cultures were sent.
Imaging showed: No acute fractures or intracranial pathology
but with right supraorbital soft tissue hematoma. C-spine
intact. No fracture of the right wrist.
Patient was given: IV ciprofloxacin 400mg x1
Consults: transplant nephrology who recommended medicine
admission.
Vitals prior to transfer were: 98.9, 115, 153/60, 18, 95% RA
On the floor, patient reports that she feels better and only
complains of right wrist pain. She denies nausea since she
received Zofran at the urgent care clinic.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
- Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catherization) - most recent HgbA1c 12.4 in ___
- End-stage renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
- Scleroderma w/ CREST syndrome
- Antiphospholipid antibody syndrome and remote PE history on
Coumadin ___
- CAD s/p MI in ___ c/ LAD PTCA; s/p PTCA ___: one vessel
disease with LAD 60% apical lesion and 90% ___ diagonal lesion.
___ diagonal branch was treated with ballon angioplasty w/o
stenting. Final angiography demonstrated ___ residual
stenosis and improved flow down the diagonal branch.
- LVH
- Gastroparesis/GERD/Hiatal hernia
- Hypothyroidism
- Gout diagnosed ___ years ago
- Herniated disk
- OSA
- Carpal tunnel s/p release
- H/o multiple UTIs (Enterococcus vanc & amp sensitive,
Klebsiella, E. Coli)
- Hx of TIA?
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Physical Exam:
ADMISSION EXAM
VS: 98.3, 152/67, 117, 19, 97% RA wt 76.2kg.
General: well appearing Caucasian female in NAD
HEENT: NC, sclerae anicteric. Significant bruising and soft
tissue swelling of the right periorbital area. PERRL, EOMI. OP
clear without lesion or exudate.
Neck: Supple, no ___, no thyromegaly
CV: Tachycardic but regular. Normal s1/s2, no m/r/g
Lungs: CTAB posteriorly, no w/r/r
Abdomen: Distended but soft and nontender. Normal bowel sounds,
no rebound or guarding. Unable to appreciate organomegaly.
GU: no foley
Ext: WWP, DP pulses 1+ bilaterally. No cyanosis, clubbing or
edema
Neuro: CN ___ grossly intact, moving all 4 extremities with
purpose. Gait deferred.
Skin: Ecchymoses around right eye, right wrist, above right
breast and scattered throughout lower extremities.
DISCHARGE EXAM
Vitals 98.3 ___ 18 100RA
General: obese, NAD
HEENT: swollen erythematous R eye that has overall improved but
has some crusting; now L eye has some ecchymoses
Heart: borderline tachycardic, normal rhythm, no murmurs
Lungs: CTAB
Abdomen: Obese, NT, NABS, several well-healed scars
Extremities: 1+ pitting edema bilaterally
Skin: bruising on stomach, R breast, R eye
Pertinent Results:
ADMISSION LABS
___ 04:10PM BLOOD WBC-10.0 RBC-2.70* Hgb-8.4* Hct-25.1*
MCV-93 MCH-31.1 MCHC-33.5 RDW-13.8 RDWSD-45.7 Plt ___
___ 04:10PM BLOOD ___ PTT-60.1* ___
___ 04:10PM BLOOD Glucose-114* UreaN-21* Creat-1.4* Na-136
K-3.7 Cl-101 HCO3-24 AnGap-15
___ 04:10PM BLOOD ALT-16 AST-14 CK(CPK)-99 AlkPhos-85
TotBili-0.2
___ 06:41AM BLOOD Calcium-9.6 Phos-2.5* Mg-1.6
___ 06:41AM BLOOD tacroFK-7.4
DISCHARGE LABS
___ 04:42AM BLOOD WBC-5.5 RBC-2.72* Hgb-8.1* Hct-26.1*
MCV-96 MCH-29.8 MCHC-31.0* RDW-15.3 RDWSD-53.1* Plt ___
___ 04:42AM BLOOD ___ PTT-35.9 ___
___ 04:42AM BLOOD Glucose-304* UreaN-24* Creat-1.5* Na-140
K-4.0 Cl-105 HCO3-27 AnGap-12
___ 04:42AM BLOOD Calcium-9.5 Phos-3.3 Mg-1.8
___ 04:42AM BLOOD tacroFK-5.6
MICRO
___ 4:57 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 ORGANISMS/ML..
___ 8:02 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 7:37 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING
WRIST XRAY ___
Dorsal soft tissue swelling along the wrist without underlying
fracture.
Extensive vascular calcification.
CT HEAD ___. No acute intracranial hemorrhage.
2. Right frontal supraorbital superficial soft tissue hematoma.
No underlying fracture seen.
CT C-SPINE ___
No fracture or malalignment in the C-spine.
RENAL TRANSPLANT US ___
Mildly elevated intrarenal resistive indices which are slightly
higher than ___.
CT ABD/PELVIS ___. No intra or retroperitoneal or intramuscular hematoma noted
in the abdomen or pelvis.
2. Transplant kidney in the left lower quadrant demonstrates no
hydronephrosis.
3. Moderate amount of stool throughout the colon without bowel
obstruction.
CT HEAD ___. No acute intracranial hemorrhage.
2. Small, residual, supraorbital, right frontal scalp hematoma.
CXR ___
IN COMPARISON WITH THE STUDY OF ___, THERE IS LITTLE
CHANGE AND NO
ACUTE CARDIOPULMONARY DISEASE. THE CARDIAC SILHOUETTE IS
ENLARGED AND THERE IS NO EVIDENCE OF VASCULAR CONGESTION,
PLEURAL EFFUSION, OR ACUTE FOCAL PNEUMONIA.
CT HEAD ___. No evidence of fracture, infarction or intracranial
hemorrhage.
2. Minimal residual right frontal/supraorbital scalp swelling.
Radiology Report
INDICATION: ___ with pain swelling
COMPARISON: None
FINDINGS:
AP, lateral, obliques views as well as a dedicated navicular view of the right
wrist provided. Overlying IV limits assessment. There is extensive vascular
calcification noted. Carpal alignment appears preserved. The scaphoid
appears intact. Distal radius and ulna appear intact. No acute fracture or
dislocation. No significant DJD. Soft tissue swelling is seen dorsally at
the wrist.
IMPRESSION:
Dorsal soft tissue swelling along the wrist without underlying fracture.
Extensive vascular calcification.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with head trauma // head trauma on coumadin
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: CT from ___
FINDINGS:
There is no acute intracranial hemorrhage, mass, mass effect or large
territorial infarction. An old infarction is seen within the left centrum
semiovale. Bilateral basal ganglia mineralization is identified. The
ventricles and sulci are normal in size and configuration. The basilar
cisterns are patent, and there is otherwise good preservation gray-white
matter differentiation.
A right frontal supraorbital superficial soft tissue hematoma is identified.
No underlying fracture is seen. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The globes are unremarkable.
Extensive carotid calcifications are seen.
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Right frontal supraorbital superficial soft tissue hematoma. No underlying
fracture seen.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with head trauma. Please evaluate.
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) = 861 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no fracture, or alignment. There is no prevertebral soft tissue
swelling. No significant degenerative changes are seen throughout the
cervical spine. The thyroid is normal. There is no cervical lymphadenopathy.
The visualized apices of lungs are clear.
IMPRESSION:
No fracture or malalignment in the C-spine.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ year old woman with renal transplant presenting with n/v and
inability to take rejection meds // eval for evidence of rejection
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Renal transplant ultrasound ___.
FINDINGS:
The left iliac fossa transplant renal morphology is normal. Specifically, the
cortex is of normal thickness and echogenicity, pyramids are normal, there is
no urothelial thickening, and renal sinus fat is normal. There is no
hydronephrosis and no perinephric fluid collection.
The resistive index of intrarenal arteries ranges from 0.76 to 0.82, which is
mildly elevated and slightly increased since prior exam. The main renal
artery shows a normal waveform, with prompt systolic upstroke and continuous
antegrade diastolic flow, with peak systolic velocity of 59 cm/sec.
Vascularity is symmetric throughout transplant. The transplant renal vein is
patent and shows normal waveform.
IMPRESSION:
Mildly elevated intrarenal resistive indices which are slightly higher than ___.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with recent fall with INR 4.8, lots of
bruising, decreased breath sounds on R // pulmonary contusion, effusion
pulmonary contusion, effusion
IMPRESSION:
IN COMPARISON WITH THE STUDY OF ___, THERE IS LITTLE CHANGE AND NO
ACUTE CARDIOPULMONARY DISEASE. THE CARDIAC SILHOUETTE IS ENLARGED AND THERE
IS NO EVIDENCE OF VASCULAR CONGESTION, PLEURAL EFFUSION, OR ACUTE FOCAL
PNEUMONIA.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: ___ woman with a recent mechanical fall in the setting of
a supratherapeutic INR, now with increased lethargy. Evaluate for evidence of
acute intracranial hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.7 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 2.0 s, 4.0 cm; CTDIvol = 49.7 mGy (Head) DLP =
200.7 mGy-cm.
Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: ___ noncontrast head CT.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration. An old infarct is
again seen in the left centrum semiovale. Stable, bilateral basal ganglia
calcification. Mild periventricular white-matter hypodensities are
nonspecific, but likely reflect chronic microvascular ischemic disease. Dense
calcification of the carotid siphons and vertebral arteries at the V4 segments
appear unchanged.
Small, residual, supraorbital, right frontal scalp hematoma. There is no
evidence of fracture. Mild mucosal thickening in the sphenoid sinuses,
maxillary sinuses, and ethmoid air cells. Otherwise, the visualized portion
of the frontal sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Small, residual, supraorbital, right frontal scalp hematoma.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: ___ year old woman presenting after fall and recent cardiac
catheterization in setting of supratherapeutic INR, now with downtrending
Hgb/Hct concerning for bleed. // ?RP bleed
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis without
intravenous contrast administration.
Coronal and sagittal reformations were performed and submitted to PACS for
review.
Oral contrast was not administered.
IV contrast: 130ml Omnipaque
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.9 s, 53.4 cm; CTDIvol = 15.6 mGy (Body) DLP = 834.5
mGy-cm.
Total DLP (Body) = 834 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___
FINDINGS:
Optimal evaluation of organ pathology and vasculature is limited without the
benefit of intravenous contrast.
LOWER CHEST:
There is minimal bibasilar dependent atelectasis. Mild mitral valve
calcification is present. Trace pericardial fluid noted.
ABDOMEN:
GENERAL: There is no intra-abdominal free air or free fluid. No intra or
retroperitoneal hematoma identified.
HEPATOBILIARY: Within limitations of a non contrast-enhanced scan, the
hepatic parenchyma demonstrates a homogeneous attenuation. Punctate
calcification in segment 7 is likely capsular and benign.
The gallbladder is surgically absent.
PANCREAS: There is diffuse pancreatic parenchymal atrophy without main duct
dilation.
SPLEEN: No splenomegaly.
ADRENALS: No adrenal nodules.
URINARY: The native kidneys are highly at trophic with severe thinning of the
renal cortical parenchyma. In the absence of intravenous contrast presence of
any enhancing mass cannot be evaluated. No hydronephrosis.
There is a transplant kidney in the left lower quadrant with no
hydronephrosis.
GASTROINTESTINAL: There is a moderate amount of stool throughout the colon.
No bowel obstruction. There is mild hyperdense fluid within the gastric
fundus that may be related to enteric contents.
LYMPH NODES: Within limitations of a non contrast-enhanced scan, there are sub
cm retroperitoneal (para-aortic, bilateral common iliac) lymph nodes. There
are numerous small mesenteric lymph nodes measuring up to 9 mm in short axis.
VASCULAR: Extensive atherosclerotic calcification of the abdominal aorta and
its branches is noted without aneurysmal dilation.
PELVIS:
The bladder is distended, unremarkable. The uterus and adnexae are
unremarkable. There is no free fluid in the pelvis..
BONES AND SOFT TISSUES:
There are no suspicious osteolytic or blastic bone lesions.
There are scattered soft tissue nodules in the subcutaneous fat of the
anterior abdominal wall, likely related to subcutaneous injections. No
intramuscular hematoma noted in the body wall. There is a small fat
containing umbilical hernia.
IMPRESSION:
1. No intra or retroperitoneal or intramuscular hematoma noted in the abdomen
or pelvis.
2. Transplant kidney in the left lower quadrant demonstrates no
hydronephrosis.
3. Moderate amount of stool throughout the colon without bowel obstruction.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 1:15 ___, 2 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with R vision changes and worsening n/v. //
?head bleed
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.8 s, 16.4 cm; CTDIvol = 51.6 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: Noncontrast head CT ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration. Minimal bilateral
periventricular white matter hypodensities are nonspecific, but likely
represent a sequela of chronic small vessel disease.
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.
Residual right frontal/supraorbital scalp swelling is minimal.
IMPRESSION:
1. No evidence of fracture, infarction or intracranial hemorrhage.
2. Minimal residual right frontal/supraorbital scalp swelling.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: s/p Fall, Abnormal labs
Diagnosed with Abrasion of other part of head, initial encounter, Fall (on) (from) other stairs and steps, initial encounter
temperature: 97.2
heartrate: 135.0
resprate: 18.0
o2sat: 100.0
sbp: 168.0
dbp: 69.0
level of pain: 4
level of acuity: 2.0 | ___ yo F with history of T1DM and ESRD s/p living kidney
transplant ___ on MMF, tacro, prednisone, also with history of
CAD s/p multiple MI's and recent ___ 3 ___, and h/o
multiple UTI's (mostly enterococcus, Klebsiella, coag neg staph)
who presents for elevated INR and a mechanical fall down some
stairs at ___. Suffered trauma but no head bleed.
Nausea/vomiting resolved on admission. Experienced labile blood
pressures and orthostatic hypotension a/w anemia, improved after
transfusion of 1 unit of blood. INR drifted to <2 with improved
nutrition and warfarin resumed prior to d/c.
Investigations/Interventions
1. Elevated INR: patient is on coumadin for history of PE, and
she presented with INR 4.8 in setting of 1 week of nausea and
vomiting. Elevated INR likely due to poor nutrition. INR was
trended and coumadin restarted ___ when INR was 1.8. INR 1.5 on
day of discharge.
2. Fall: patient fell down some stairs at restaurant and had no
preceding symptoms. EKG on admission was at baseline. We felt
fall to be mechanical in nature due to poor vision related to
diabetic nephropathy.
3. Hypotension: patient initially presented with hypertension
sbp in 190s, then became hypotensive when working with ___ sbp in
___. She was orthostatic. Home anti-hypertensives discontinued.
In setting of fall with elevated INR there was concern for
internal bleeding so CT abd/pelvis, CT head, and CXR (PA &
lateral) were obtained which were negative for evidence of
bleeding. She refused IVF so we encouraged po intake which
resulted in stabilization of blood pressures. Discharging home
on blood pressure medication regimen of metoprolol succinate
12.5 mg daily and losartan 50 mg daily. Amlodipine discontinued
in favor of increasing losartan.
4. Anemia: pt has baseline anemia but Hgb downtrended to 6's in
house. As this was associated with hypotension, bleeding was
ruled out with imaging described above. She was transfused 1
unit PRBC's with return of her hgb to baseline. No evidence of
GI bleeding during hospitalization.
5. Vitreous, retinal hemorrhage: patient reported blurry vision
during hospitalization. Ophthalmology consulted who diagnosed
vitreous and retinal hemorrhage. Recommended to keep HOB
elevated, avoid bending over or straining. Instructed to follow
up with ___ clinic.
6. Diabetes mellitus: patient followed at ___. Home regimen
continued in house initially but patient experienced
hypoglycemia into the 70's in the morning. ___ consulted and
patient agreed to change pm Lantus from 20 units to 16 units.
She will also change her correction factor to 14.
7. History of UTI's: patient has history of many UTI's. UA on
admission c/w UTI so patient placed on ciprofloxacin. UCx grew
yeast which we did not treat. Due to her history of infection we
decided to discharge her on ciprofloxacin for 14 days, last day
being ___.
8. CKD, ESRD s/p kidney transplant: patient is s/p living donor
kidney transplant in ___. Maintained on tacro, MMF, prednisone
as outpt. Her graft has CKD, likely related to diabetic
nephropathy. Serial tacro levels were within goal range and she
was maintained on her home regimen of 1mg q12h. Home prednisone
dose changed from 6mg qd to 5mg qd. Patient also is on Bactrim
DS tab qd which was changed to SS tab qd for PCP ___.
9. CAD: patient with recent ___ 3 placed. Continued on Asa,
Plavix, statin in house. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
S/p fall, PleurX catheter management
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a pleasant ___ year old male with metastatic NSCLC
presenting s/p unwitnessed fall at rehab. He was recently
discharged on ___ for an admission for nausea, vomiting and
anion-gap metabolic acidosis. The patient states he was sitting
on the edge of his bed with the urge to urinate and fell
reaching for the urinal. He landed directly onto his face. He
denies loss of consciousness. He complains of right sided head
pain and right shoulder pain. He also notes some difficulty
moving his right arm, but denies complete weakness numbness or
tingling. He complains of a chronic cough and shortness of
breath.
In the ED, initial VS were 99.6 110 123/75 12 97% 4L.
In the ED he received albuterol 0.083% Neb Soln, morphine
sulfate 4mg IV, ipratropium bromide neb 2.5mL, GlyBURIDE 5 mg
Tab, Benzonatate 100mg Capsule, Diltiazem Extended-Release 120
mg x2, Senna 1 Tablet, Guaifenesin 200 mg / 10 mL, Morphine SR
15mg Tab, Aspirin 81mg Tab and Levofloxacin 750mg IV.
Labs significant for anion gap metabolic acidosis (AG = 19) and
slightly elevated troponin (0.03->0.04). Imaging significant for
CT C-spine w/ no fractures and severe degenerative disease; CT
Head with small subgaleal hematoma, no intracranial hemorrhage
and non-displaced left nasal and right lamina papyracea
fractures. CT Chest with lingular mass with post-obstructive
pneumonitis, chronic effusions, innumerable nodal/liver/osseous
metastases and right middle lobe inflammation or early
infection. No fractures on shoulder x-rays.
Transfer VS 97.0 100 134/79 16 96%.
On arrival to the floor, the patient reports significant right
shoulder pain. He complains of shortness of breath which has not
significantly changed over the last 24 hours. He denies
productive cough, fevers and chills. He denies chest pain. He
has a mild headache which he only admitted to on direct
questioning. His right hand function is improving; he has no
other focal weakness.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, vision changes, rhinorrhea,
congestion, sore throat, chest pain, abdominal pain, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
1. Hypertension
2. Hyperlipidemia
3. Type 2 diabetes mellitus
4. Chronic shoulder pain, arthritis
5. S/P right toe surgery for a bone cyst ___
6. S/P Pleur-X cath placement for malignant effusion
7. Admitted ___ for sepsis and pneumonia
8. Hypoxemia 88% RA, on 2L home O2
9. Cervical stenosis with radiculopathy
10. Non-small cell lung cancer
ONCOLOGY HISTORY: Mr. ___ is a ___ year-old ___
male former smoker (50 pack-years) who presented to medical care
in ___ with subacute worsening of shortness of
breath and cough productive of purulent sputum. He also had low
grade fevers. He denied prior cardio-pulmonary complaints or
constitutional symptoms. At the time of admission he was quite
hypoxemic on room air and required supplemental oxygenation. He
was admitted to ___ from ___ to ___ for evaluation.
Imaging studies with CT chest from ___ disclosed a
consolidation of the lingula, bronchial narrowing, mediastinal
lymphadenopathy, liver hypodense lesions and a large loculated
left pleural effusion. A PET/CT Scan from ___ disclosed the
presence of an extensive FDG-avid consolidative process in the
lingula, lymphangitic carcinomatosis, non-FDG avid pleural
effusion, FDG-avid lymphadenopathy involving the bilateral
supraclavicular regions, mediastinum, subcarinal stations, hilar
portacaval and retroperiotenal nodes. FDG-avid liver lesions and
FDG-avid osseous metastases. Head MRI from ___ did not
disclose evidence of lesions. The patient was symptomatically
treated with antibiotics (completed a course of cefpodoxime - 14
days), supplemental oxygen and a left-sided thoracentesis. The
patient reported significant improvement of his cardio-pulmonary
function with the pleural drainage. The malignant pleural fluid
removed on ___ disclosed a carcinoma. Immunohistochemical
stains of the tumor cells were positive for CK5/6, and CK7; and
negative for CK20, p63, and TTF-1. This immunoprofile is
nonspecific but compatible with a non-small-cell lung cancer not
otherwise specified. Since his inpatient discharge, the
patient's condition has slowly deteriorated. His dyspnea with
exertion has worsened since his diagnosis. His cough is present
but w/o significant sputum production. He is no longer smoking.
He denies much in the way of chest pain. A PleurX catheter was
recently placed to manage his chronic left pleural effusion.
Social History:
___
Family History:
Father with a stroke; mother with cancer; sister with diabetes,
hypertension.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.5 bp 123/78 HR 96 RR 20 ___ NC Wt 160 lbs
GEN: NAD, awake, alert
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP dry and
without lesion
NECK: Supple
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTA on right,
decreased breath sounds on left w/ dullness to percussion,
Pleur-X cath in place with clean dressing
ABD: Soft, NT, ND, bowel sounds present
MSK: normal muscle tone and bulk
EXT: No c/c, normal perfusion; right foot has bandage after
operation on foot ___
SKIN: No rash, warm skin
NEURO: oriented x 3, normal attention, ___ upper extremity
strength, ___ lower extremity strength, (right upper extremity
difficult to assess in detail due to recent injury and pain),
intact sensation to light touch throughout
PSYCH: appropriate
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
Admission labs:
___ 03:14AM BLOOD WBC-9.6# RBC-3.57* Hgb-9.2* Hct-28.8*
MCV-81* MCH-25.9* MCHC-32.1 RDW-16.1* Plt ___
___ 03:14AM BLOOD Neuts-81.6* Lymphs-10.8* Monos-6.4
Eos-1.1 Baso-0.2
___ 03:14AM BLOOD Glucose-165* UreaN-23* Creat-0.9 Na-135
K-4.6 Cl-96 HCO3-20* AnGap-24*
___ 03:14AM BLOOD cTropnT-0.03*
___ 09:15AM BLOOD cTropnT-0.04*
___ 03:14AM BLOOD Calcium-9.4 Phos-4.0 Mg-1.8
Discharge labs:
___ 06:05AM BLOOD WBC-12.0* RBC-3.44* Hgb-8.9* Hct-29.0*
MCV-85 MCH-26.0* MCHC-30.7* RDW-17.0* Plt ___
___ 06:05AM BLOOD Plt ___
___ 06:05AM BLOOD UreaN-37* Creat-0.9 Na-133 K-6.2* Cl-98
HCO3-15* AnGap-26*
___ 09:20AM BLOOD UricAcd-9.2*
___ 06:05AM BLOOD Calcium-9.4 Phos-4.0 Mg-2.2
___ 04:21PM BLOOD Lactate-6.6*
___ 04:21PM BLOOD ___ pH-7.39
CT SPINE ___
FINDINGS: There are no fractures or malalignments. Chronic
loss of height in the C3 through C6 vertebrae. Moderate loss of
disc height, bridging anterior osteophytes, and mild
uncovertebral/facet joint hypertrophy throughout the cervical
spine. Broad-based disc osteophyte complexes are mild at C2-3,
large at C3-4, and moderate at C4-5, C5-6, and C6-7. These
markedly efface the ventral thecal sac and obliterate the dorsal
CSF space. There is mild left neural foraminal narrowing at
C4-5 on the left, and moderate narrowing at C5-6 on the left.
Anterior osteophytes impinge on the esophagus. Visualized
posterior fossa demonstrates atrophy. Mastoid air cells, middle
ear cavities, and maxillary sinuses are clear. Note is made of
right palatine tonsillith. Retained secretions in the
oropharynx. Thyroid gland is heterogeneous. Calcifications of
the bilateral carotid artery bifurcations. No pathologically
enlarged cervical lymph nodes. Moderate
centrilobular/paraseptal emphysema and pleuroparenchymal
scarring at the lung apices. Chronic left pleural thickening
and effusion, better evaluated on accompanying chest CT.
IMPRESSION: No fractures. Severe degenerative disease with
thecal sac compression at all levels, particularly C3-4 and
C4-5.
CT HEAD ___
FINDINGS: No intracranial hemorrhage, edema, mass effect, or
vascular
territorial infarct. Ventricles and sulci are prominent,
compatible with
age-related involutional changes. Periventricular and
subcortical white
matter hypodensities reflect small vessel ischemic disease.
Calcifications in the cavernous carotid and basilar arteries.
No shift of the normally midline structures. Non-displaced nasal
bone fractures (___), with mild overlying soft tissue
swelling. There is also minimally displaced fracture of the
right lamina papyracea (3:10), with overlying focus of gas. 6
mm right frontal subgaleal hematoma and mild left frontal scalp
swelling. Mastoid air cells and middle ear cavities are clear.
IMPRESSION: 1. Small subgaleal hematoma. No intracranial
hemorrhage. 2. Non-displaced left nasal and right lamina
papyracea fractures. ATTENDING NOTE: The fractures described are
of undetermined age.
CT CHEST ___
IMPRESSION:
1. Lingular mass with post-obstructive pneumonitis,
peribronchovascular and possible lymphangitic spread.
2. Extensive left pleural and pericardial invasion, with chronic
effusions.
3. Innumerable nodal, liver, and osseous metastases.
4. Right middle lobe inflammation or early infection.
5. Innumerable osseous metastases, without pathologic fracture.
R SHOULDER XR ___
RIGHT SHOULDER, AP INTERNAL/EXTERNAL ROTATION, Y, AND AXILLARY
VIEWS: There is an oblique linear lucency along the
mid-to-distal medial humeral shaft, likely a nutrient foramen.
Mildly prominent deltoid tuberosity. No
dislocation. Mild glenohumeral joint space narrowing. Mild
cromioclavicular joint spurring. Right elbow joint is grossly
normal. The right lung apex is unremarkable. IMPRESSION: Mild
degenerative changes of the right shoulder.
BILATERAL HIP XR ___
There is no evidence of fracture. Moderate right and mild left
degenerative changes are seen with osteophytes, sclerosis of
joint surfaces, and decrease in the joint space. There are
vascular calcifications. There are surgical clips in the left
pelvis.
MR HEAD ___
FINDINGS: The study is compared with the recent NECT dated
___, and
(motion-degraded) enhanced MR examination dated ___.
There is
significant image distortion of the diffusion-weighted sequence,
particularly at the vertex and a second acquisition is even
further degraded, for unclear reasons (with no additional
notation by the MR technologist). Allowing for this artifactual
limitation, and comparing the two acquisitions, there is no
definite focus of slow diffusion to suggest acute ischemia. The
principal intracranial vascular flow voids, including those of
the dural venous sinuses are preserved, and these structures
enhance normally. Again demonstrated is both discrete and
confluent FLAIR-hyperintensity in bihemispheric, subcortical and
periventricular, as well as central pontine white matter, likely
the sequelae of chronic small vessel ischemic disease. There is
only mild bifrontal cortical atrophy, the midline structures are
in the midline, and there is no intra- or extra-axial
hemorrhage. There is no pathologic parenchymal, leptomeningeal
or dural focus of enhancement. There is no space-occupying
lesion, and the sella, parasellar region and remainder of the
skull base, and orbits are unremarkable. The mastoid air cells
and included paranasal sinuses are grossly clear. The regional
bone marrow signal is overall preserved, with no suspicious
osseous lesion. Incidentally noted is severe degenerative
disease involving the limited included upper cervical spine with
marked ventral canal narrowing at the C2-3 and C3-4 levels, and
frank compression and angulation of the cervical spinal cord at
the latter, as on the recent NECT of ___ this has likely
progressive since the MR examination of ___.
IMPRESSION:
1. The diffusion-weighted sequence is very limited, particularly
at the
cranial vertex, likely due to technical factors (unclear, at
present);
however, there is no definite large focus of slow diffusion to
suggest acute ischemia.
2. No pathologic focus of enhancement or cerebral edema to
suggest
intracranial metastatic disease.
3. Bifrontal cortical atrophy and moderately severe sequelae of
chronic small vessel ischemic disease.
4. Severe degenerative disease in the limited included upper
cervical spine, with significant compression and angulation of
the spinal cord at the C3-4 level.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Benzonatate 100 mg PO TID
3. Sildenafil 50 mg PO DAILY:PRN sex
4. urea *NF* 40 % Topical BID
Apply to affected areas of both feet
5. Insulin SC Sliding Scale Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
6. Docusate Sodium 100 mg PO BID
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
8. OxycoDONE (Immediate Release) 5 mg PO DAILY:PRN prior to
pleurx drainage
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 1 TAB PO BID
11. Simvastatin 10 mg PO DAILY
12. Megestrol Acetate 80 mg PO TID
13. Mirtazapine 15 mg PO HS
14. Morphine SR (MS ___ 15 mg PO Q12H
15. Prochlorperazine 10 mg PO Q6H:PRN nausea
16. Ondansetron 4 mg PO Q8H:PRN nausea
17. Diltiazem 15 mg PO QID
18. Dextromethorphan-Guaifenesin (Sugar Free) 5 mL PO Q6H
Discharge Medications:
1. urea *NF* 40 % Topical BID
Apply to affected areas of both feet
2. Tiotropium Bromide 1 CAP IH DAILY
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
5. Morphine Sulfate (Concentrated Oral Soln) 5 mg PO Q3H
pain/dsypnea/PleurX drainage
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 5 mg by mouth
every 3 hours Disp ___ Milliliter Refills:*0
6. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO Q2H:PRN
pain, dyspnea
concentration 20mg per mL
please dispense 30mL
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg by
mouth every 2 hours Disp ___ Milliliter Refills:*0
7. Bisacodyl ___AILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Non-small cell lung cancer
Malignant pleural effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Somnolent but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: Unwitnessed fall on face.
COMPARISON: CT head from ___ and MR brain from ___.
TECHNIQUE: Contiguous non-contrast axial images were obtained through the
brain. 5 mm soft tissue and 2.5 mm bone kernel images were generated in the
axial plane. 2 mm coronal and sagittal multiplanar reformats were created.
FINDINGS: No intracranial hemorrhage, edema, mass effect, or vascular
territorial infarct. Ventricles and sulci are prominent, compatible with
age-related involutional changes. Periventricular and subcortical white
matter hypodensities reflect small vessel ischemic disease. Calcifications in
the cavernous carotid and basilar arteries. No shift of the normally midline
structures.
Non-displaced nasal bone fractures (___), with mild overlying soft tissue
swelling. There is also minimally displaced fracture of the right lamina
papyracea (3:10), with overlying focus of gas. 6 mm right frontal subgaleal
hematoma and mild left frontal scalp swelling. Mastoid air cells and middle
ear cavities are clear.
IMPRESSION:
1. Small subgaleal hematoma. No intracranial hemorrhage.
2. Non-displaced left nasal and right lamina papyracea fractures.
ATTENDING NOTE: The fractures described are of undetermined age.
Radiology Report
INDICATION: Unwitnessed fall on face.
No prior examinations for comparison.
TECHNIQUE: Helical MDCT images were acquired through the cervical spine
without intravenous contrast. 2.5-mm axial images were generated in soft
tissue and bone kernels. 2-mm coronal and sagittal multiplanar reformats were
created.
FINDINGS: There are no fractures or malalignments. Chronic loss of height in
the C3 through C6 vertebrae. Moderate loss of disc height, bridging anterior
osteophytes, and mild uncovertebral/facet joint hypertrophy throughout the
cervical spine. Broad-based disc osteophyte complexes are mild at C2-3, large
at C3-4, and moderate at C4-5, C5-6, and C6-7. These markedly efface the
ventral thecal sac and obliterate the dorsal CSF space. There is mild left
neural foraminal narrowing at C4-5 on the left, and moderate narrowing at C5-6
on the left. Anterior osteophytes impinge on the esophagus.
Visualized posterior fossa demonstrates atrophy. Mastoid air cells, middle
ear cavities, and maxillary sinuses are clear. Note is made of right palatine
tonsillith. Retained secretions in the oropharynx. Thyroid gland is
heterogeneous. Calcifications of the bilateral carotid artery bifurcations.
No pathologically enlarged cervical lymph nodes. Moderate
centrilobular/paraseptal emphysema and pleuroparenchymal scarring at the lung
apices. Chronic left pleural thickening and effusion, better evaluated on
accompanying chest CT.
IMPRESSION: No fractures. Severe degenerative disease with thecal sac
compression at all levels, particularly C3-4 and C4-5.
Radiology Report
INDICATION: Smoker with metastatic non-small lung cancer, unwitnessed fall on
face.
COMPARISON: PET-CT from ___, CT chest from ___, CT abdomen/pelvis
from ___.
TECHNIQUE: Helical MDCT images were acquired through the chest following
uneventful administration of 75 ml of intravenous Omnipaque. 5 mm and 25 mm
axial images were generated in the soft tissue and lung kernels. 2.5 mm
coronal and sagittal multiplanar reformats, as well as 8 mm maximum intensity
projection axial images, were created.
FINDINGS: Interval PleurX catheter placement at the left lung base, with
adjacent locule of air and slight decrease in a moderate basilar pleural
effusion. There is also a large loculated anterior effusion tracking
superiorly into the lung apex. Circumferential nodular pleural thickening
throughout the left hemithorax, including the mediastinal pleura. There is
also pericardial invasion, as evidenced by obscuration of fat planes with the
heart and great vessels (2:42, 31).
Vaguely defined hypoenhancing lingular mass (602b:50) with abrupt bronchial
occlusion (2:32). Secondary chronic lingular collapse, with convex margins
and heterogeneous enhancement reflecting bronchial mucoid impaction. Volume
loss in the left hemithorax, with ipsilateral mediastinal shift.
Lingular pulmonary artery and branches are encased and narrowed, but no large
occlusion identified on this non-angiographic study. Irregular soft tissue
thickening extends along the remaining left lobar and segmental pulmonary
artery and bronchi, compatible with peribronchovascular spread of tumor.
Numerous areas of septal thickening indicate superimposed pulmonary edema,
though scattered areas of irregularity raise the question of lymphangitic
spread of tumor.
Moderate, apical-predominant centrilobular and paraseptal emphysema. Faint
ground-glass centrilobular opacities in the right middle lobe with a
___ distribution (___:19), suggesting early inflammation or
infection.
Heart is normal in size, with small pericardial effusion. Dense coronary
artery and aortic arch calcifications. Central pulmonary arteries are within
normal limits.
Again seen are numerous enlarged intrathoracic lymph nodes measuring 8 and 11
mm in the paraaortic region, 8 mm in the aortopulmonary window, 13 mm in the
superior right paratracheal region, 12 mm in the mid right paratracheal
region, 20 mm in the inferior right paratracheal region, 17 mm in the inferior
left paratracheal region, 11 mm in the precarinal region, 14 mm in the
subcarinal region, 16 mm in the right hilus, 14 mm in the right pulmonic
region, 16 mm in the left hilus, and 10 mm in the left pulmonic region.
Axillary nodes are not pathologically enlarged.
Examination is not tailored for subdiaphragmatic evaluation, but reveals
innumerable rounded, hypoenhancing metastases throughout the liver, many with
a targetoid appearance. Calcifications in the upper abdominal aorta.
Diffuse permeative mixed lysis and sclerosis throughout the vertebrae,
sternum, and ribs with multiple areas of irregular periostitis, corresponding
to known metastases. No pathologic fractures. Thoracic vertebrae and disc
spaces are preserved in height and alignment. Prominent anterior osteophytes
in the lower cervical spine.
IMPRESSION:
1. Lingular mass with post-obstructive pneumonitis, peribronchovascular and
possible lymphangitic spread.
2. Extensive left pleural and pericardial invasion, with chronic effusions.
3. Innumerable nodal, liver, and osseous metastases.
4. Right middle lobe inflammation or early infection.
5. Innumerable osseous metastases, without pathologic fracture.
Radiology Report
INDICATION: Unwitnessed fall on face.
COMPARISON: CT chest ___.
RIGHT SHOULDER, AP INTERNAL/EXTERNAL ROTATION, Y, AND AXILLARY VIEWS: There
is an oblique linear lucency along the mid-to-distal medial humeral shaft,
likely a nutrient foramen. Mildly prominent deltoid tuberosity. No
dislocation. Mild glenohumeral joint space narrowing. Mild acromioclavicular
joint spurring. Right elbow joint is grossly normal. The right lung apex is
unremarkable.
IMPRESSION: Mild degenerative changes of the right shoulder.
Radiology Report
PELVIS, BILATERAL HIPS, FIVE IMAGES.
REASON FOR EXAM: Fall and continuous pain.
There is no evidence of fracture. Moderate right and mild left degenerative
changes are seen with osteophytes, sclerosis of joint surfaces, and decrease
in the joint space. There are vascular calcifications. There are surgical
clips in the left pelvis.
Radiology Report
MR EXAMINATION OF BRAIN WITHOUT AND WITH CONTRAST, ___
HISTORY: ___ male with metastatic NSCLC, admitted from rehab after
fall, now with right-sided weakness; evidence of stroke.
TECHNIQUE: Routine ___ enhanced MR examination, including T1-weighted
sagittal MP-RAGE sequence, post-gadolinium, with axial and coronal
reformations. N.B. No axial T1-weighted SE sequence was obtained,
post-contrast, due to MR technologist error.
FINDINGS: The study is compared with the recent NECT dated ___, and
(motion-degraded) enhanced MR examination dated ___. There is
significant image distortion of the diffusion-weighted sequence, particularly
at the vertex and a second acquisition is even further degraded, for unclear
reasons (with no additional notation by the MR technologist). Allowing for
this artifactual limitation, and comparing the two acquisitions, there is no
definite focus of slow diffusion to suggest acute ischemia. The principal
intracranial vascular flow voids, including those of the dural venous sinuses
are preserved, and these structures enhance normally.
Again demonstrated is both discrete and confluent FLAIR-hyperintensity in
bihemispheric, subcortical and periventricular, as well as central pontine
white matter, likely the sequelae of chronic small vessel ischemic disease.
There is only mild bifrontal cortical atrophy, the midline structures are in
the midline, and there is no intra- or extra-axial hemorrhage. There is no
pathologic parenchymal, leptomeningeal or dural focus of enhancement. There
is no space-occupying lesion, and the sella, parasellar region and remainder
of the skull base, and orbits are unremarkable.
The mastoid air cells and included paranasal sinuses are grossly clear. The
regional bone marrow signal is overall preserved, with no suspicious osseous
lesion. Incidentally noted is severe degenerative disease involving the
limited included upper cervical spine with marked ventral canal narrowing at
the C2-3 and C3-4 levels, and frank compression and angulation of the cervical
spinal cord at the latter, as on the recent NECT of ___ this has likely
progressive since the MR examination of ___.
IMPRESSION:
1. The diffusion-weighted sequence is very limited, particularly at the
cranial vertex, likely due to technical factors (unclear, at present);
however, there is no definite large focus of slow diffusion to suggest acute
ischemia.
2. No pathologic focus of enhancement or cerebral edema to suggest
intracranial metastatic disease.
3. Bifrontal cortical atrophy and moderately severe sequelae of chronic small
vessel ischemic disease.
4. Severe degenerative disease in the limited included upper cervical spine,
with significant compression and angulation of the spinal cord at the C3-4
level.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Patient with metastatic lung cancer with new hypoxia.
Comparison is made with prior studies CT ___, chest x-ray ___.
There is almost complete white out of the left hemithorax, consistent with
almost complete collapse of the left lung. There is minimal aeration in the
left apex. Patient has known left lung cancer and large loculated effusion.
Cardiac silhouette cannot be evaluated, is obscured by the lung abnormalities.
In the right, right upper lobe opacities are better seen in prior CT. There
is no pneumothorax or effusion.
Findings were discussed with Dr. ___ by phone on ___ at 9:54 a.m.,
five minutes after discovery of the finding.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: UNWITNESSED FALL
Diagnosed with CONTUSION OF FACE, SCALP, & NECK EXCEPT EYE(S), NASAL BONE FX-CLOSED, CL SKUL BASE FX W/O COMA, FALL FROM BED
temperature: 99.6
heartrate: 110.0
resprate: 12.0
o2sat: 97.0
sbp: 123.0
dbp: 75.0
level of pain: nan
level of acuity: 2.0 | ___ year old male with metastatic NSCLC presenting s/p
unwitnessed fall at rehab. He was recently discharged on
___ for an admission for nausea, vomiting and anion-gap
metabolic acidosis.
#FALL
Mr. ___ fell off the side of his bed after reaching for the
urinal. He recalls the entire event and denies any loss of
consciousness. He was advised by nursing to call for help if he
needed to use the urinal. He ignored this advice. The fall
appears to be mechanical, however the patient reported right
upper extremity weakness after the event. His weakness was
difficult to assess initially due to pain in his right shoulder,
grip strength was decreased to ___ on presentation. He sustained
a minor amount of head trauma. CT scan in the ED revealed a
small subgaleal hematoma, no intracranial hemorrhage and
non-displaced left nasal and right lamina papyracea fractures.
His most significant complaint after the fall was right shoulder
pain. XR in the ED demonstrated no fracture or pathology of the
___ joint. He received IV morphine with good effect. He used a
sling during the early part of his hospitalization. Pain control
was provided with morphine ___ and morhpine IV PRN. After he
was unable to swallow, he was placed on morphine oral
concentrate 5q3h standing and ___ PRN.
#RIGHT ARM WEAKNESS
Mr. ___ presented with right arm weakness which was initially
difficult to assess because of his right upper extremity pain
after the fall. On the second day of his hospitalization his
strength improved, however was clearly different from the left
upper extremity. His right upper extremity strength remained at
___ and he later developed right lower extremity strength. A
facial droop was noted by the pulmonary consult team, but was
felt to be facial asymmetry with preserved function of all
facial nerves and muscles by the medicine team. An MR head was
obtain on ___ which showed no evidence of stroke and evere
degenerative disease in the upper cervical spine, with
significant compression and angulation of the spinal cord at the
C3-4 level. This was thought to be the culprit lesion. Full
C-spine MR imaging was not obtained as the patient was
subsequent made CMO, therefore a compressive metastatic lesion
could not be totally excluded. The patient responded well to
dexamethasone 10mg IV x1 followed by 4mg IV Q6hrs. His extremity
strength improved to ___. It remained unclear whether the fall
and associated neck trauma precipitated further cord compression
or if the weakness was present before the fall. Dexamethasone
was discontinued when the patient became unable to swallow.
#FACIAL FRACTURES
Non-displaced left nasal and right lamina papyracea fractures.
Case discussed with ENT; non-operative, antibiotics recommended.
Patient was started on a 7 day course of amoxicillin, which was
later discontinued with initiation of post-obstructive pneumonia
treatment.
#SHORTNESS OF BREATH
Mr. ___ complained of shortness of breath since his discharge
on ___. He was admitted on 24hr nasal cannula oxygen. He
has a chronic cough which is unchanged. He denied sputum
production, worsening chest pain, fevers and chills on
presentation. His SOB is likely related to his primary lung
cancer and large, malignant effusion on the left. The patient
received a dose of levofloxacin in the ED, which was not
continued on the floor. Chest CT noted focal RML ___
opacities suggestive of inflammation or early infection. He had
no lower extremity swelling or other evidence of DVT. The
patient developed low grade temperatures on his ___ and ___
hospital days; treatment for post-obstuctive HCAP was started
with cefepime and vancomycin. His fevers resolved, however his
shortness of breath did not significantly change. His PlearX
catheter was drained as necessary. Output was quite poor
compared to his previous admission, <250mL per 2 days. The
patient was made CMO and his IV was not replaced. Cefepime and
vancomycin were changed to levofloxacin, but this was
discontinued when the patient became unable to swallow. He was
on morphine oral concentrate as above for dyspnea as well.
#METASTATIC NSCLC
Patient presented with dyspnea, cough and community acquired
pneumonia in ___. Imaging studies included CT chest on
___ which disclosed a consolidation of the lingula,
bronchial narrowing, mediastinal lymphadenopathy, liver
hypodense lesions and a large loculated left pleural effusion. A
PET/CT Scan from ___ disclosed the presence of an extensive
FDG-avid consolidative process in the lingula, lymphangitic
carcinomatosis, non-FDG avid pleural effusion, FDG-avid
lymphadenopathy involving the bilateral supraclavicular regions,
mediastinum, subcarinal stations, hilar portacaval and
retroperiotenal nodes. FDG-avid liver lesions and FDG-avid
osseous metastases. Pleural fluid removed on ___ disclosed
a carcinoma. Immunohistochemical stains of the tumor cells were
positive for CK5/6, and CK7; and negative for CK20, p63, and
TTF-1. This immunoprofile was nonspecific but compatible with a
non-small-cell lung cancer not otherwise specified. Extensive
discussions between family, patient and primary oncologist lead
to the decision for no further cancer directed therapies,
including palliative chemo, radiation or surgery.
#AG METABOLIC ACIDOSIS
Issue on previous admission, attributed to lactic acidosis from
malignancy, and metformin. Metformin discontinued on previous
admission. Lactate on ___ 6.6. Anion gap stable, no
improvement with IVFs.
#TYPE II DIABETES MELLITUS
Metformin and glyburide discontinued during previous
hospitalization due to reports of hypoglycemia and lactic
acidosis. Insulin sliding scale continued during hospitalization
in the setting of dexamethasone administration. Aspirin
discontinued after CMO decision was made.
#HYPERTENSION
Blood pressures well controlled this admission. Diltiazem 15 mg
PO/NG QID continued until CMO decision was made.
#PROLAPSED HEMORRHOIDS
Stable issue. Outpatient follow up suggested during prior
admission. Patient ordered for an aggressive bowel regimen.
TRANSITIONAL ISSUES
*******************
-PleurX catheter care, drainage PRN
-Continue concentrated morphine solution for dyspnea and pain,
may increase to 5mg q5min as needed
-Continue inhaler for shortness of breath |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ lady with hypothyroidism and h/o Afib
s/p cardioversion and pacemaker a few months ago who presented
to the ED due to shortness of breath and chest discomfort.
.
At her baseline, she has exertional dyspnea with limited
exercise capacity. No wheezing but she does have a cough with
whitish sputum that is worse at night. She began to feel
constant dull left-sided chest discomfort on the morning of
presentation so she decided to go to the ED. The pain is dull,
pleuritic, nonradiating. Not related to exertion. Not at the
site of her pacemaker.
.
In the ___ ED, initial VS were: T 97.3, HR 71, BP 106/81, RR
18, POx 100%RA. Received ASA 325mg. EKG was not concerning for
ischemia and troponin was negative. CXR was unchanged from
prior. CTA ruled out PE. Bedside ultrasound showed no
pericardial effusion. She received 1L normal saline, IV Morphine
and NTG paste; her pain was relieved. She was given IV steroids
and duonebs. She was admitted to Medicine to rule out MI with
imaging stress. VS prior to transfer were: T 97.1, HR 70, BP
121/63, RR 18, POx 97%RA.
.
Currently, she feels great. She is at her baseline SOB. Her pain
is present, worsened by pressing on the left side of her chest.
She states this is the pain she has been having
.
Past Medical History:
hypothyroidism
atrial tachycardia/atrial fibrillaton ___
---s/p cardioversion ___
Tachy-Brady Syndrome
---s/p PPM ___
Dobutamine stress echo ___ with no active ischemia (B+W)
plantar fasciitis
hysterectomy
tachycardia-induced CM (EF 49% prior to cardioversion and pacer
placement).
Social History:
___
Family History:
Father died of MI at ___. Mother had a valve replacement, pt
unsure what valve or underlying diagnosis.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
PE:
VS - Temp 96 117/53 70 18 92%RA, Standing weight 191 lbs
GENERAL: Well appearing in NAD
HEENT: Poor dentition. MM dry
NECK: Supple with no JVD.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Palpating the area just lateral to the LLSB reproduces her dull
chest pain
LUNGS: Upper left chest wall with well-healed scar from PPM. No
fluctuance or erythema. No chest wall deformities, scoliosis or
kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: No c/c. b/l non-pitting pedal edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Radial 2+
Left: Carotid 2+ Radial 2+
Pertinent Results:
___ 12:45PM BLOOD WBC-6.6 RBC-4.09* Hgb-13.1 Hct-39.2
MCV-96 MCH-32.1* MCHC-33.5 RDW-13.0 Plt ___
___ 12:45PM BLOOD Neuts-55.1 ___ Monos-6.8 Eos-1.9
Baso-1.0
___ 12:45PM BLOOD Glucose-94 UreaN-20 Creat-1.2* Na-140
K-3.3 Cl-98 HCO3-28 AnGap-17
___ 09:41AM BLOOD Glucose-197* UreaN-18 Creat-0.9 Na-138
K-3.9 Cl-102 HCO3-26 AnGap-14
___ 12:45PM BLOOD CK-MB-1
___ 12:45PM BLOOD cTropnT-<0.01
___ 11:23PM BLOOD CK-MB-1 cTropnT-<0.01
___ 12:45PM BLOOD CK(CPK)-33
___ 11:23PM BLOOD CK(CPK)-31
___ 12:45PM BLOOD D-Dimer-684*
.
EKG: A-V sequential pacing at 70 beats per minute with
occasional premature
ventricular contractions. Compared to the previous tracing of
___
the paced rhythm is new.
.
CXR: FINDINGS: There is little change in comparison to prior
study from
___. The lungs remain clear with no evidence of
consolidation,
effusion, or pneumothorax. The cardiomediastinal silhouette
remains normal.
Pacemaker leads remain in place. The osseous structures remain
grossly
unremarkable.
IMPRESSION: No acute cardiopulmonary process.
.
IMPRESSION:
1. No pulmonary embolus or aortic dissection detected.
2. 4-mm nodule at the right lower lobe. Per ___
guidelines, no
followup is necessary if there are no high-risk factors such as
smoking or
history of malignancy; otherwise a 12 month follow up chest CT
is advised.
3. Cardiomegaly with biatrial enlargement.
Medications on Admission:
Pradaxa 150 mg BID
Furosemide 40 mg daily
Amiodarone 200 mg daily
Premarin 0.3 mg daily
Levothyroxine 88 mcg daily
Gabapentin 300 mg BID
Discharge Medications:
1. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day:
Please restart this medication on ___.
3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. conjugated estrogens 0.3 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
7. acetaminophen 500 mg Tablet Sig: ___ Tablets PO every ___
hours as needed for pain: Do not take more than 3 grams per day.
8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Please
apply to the affected area of your chest.
Disp:*7 Adhesive Patch, Medicated(s)* Refills:*0*
9. Outpatient Physical Therapy
Evaluate and treat, activity as tolerated
Discharge Disposition:
Home
Discharge Diagnosis:
Atypical chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Evaluation of patient with chest pain and shortness of breath.
COMPARISON: Chest radiograph from ___.
FINDINGS: Frontal and lateral chest radiographs were obtained.
FINDINGS: There is little change in comparison to prior study from
___. The lungs remain clear with no evidence of consolidation,
effusion, or pneumothorax. The cardiomediastinal silhouette remains normal.
Pacemaker leads remain in place. The osseous structures remain grossly
unremarkable.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: Chest pain.
No comparison studies available.
TECHNIQUE: MDCT-acquired 2.5-mm axial images of the chest were obtained
following the uneventful administration of 100 cc of Optiray intravenous
contrast. Coronal and sagittal reformats were performed at 5-mm slice
thickness. Additional right and left oblique reconstructions were performed
for further evaluation of the pulmonary vessels.
FINDINGS:
The great vessels are patent and normal in caliber. There is no aortic
dissection. No pulmonary embolus is detected to the subsegmental levels.
Left and right atrial enlargement is present (4:45). Pacemaker wires
terminate in the right atrium and ventricle. There is no axillary or
mediastinal lymphadenopathy. A 4-mm nodule is located within the right lung
base (3:49). Lungs are otherwise clear. Airways are patent to the level of
segmental bronchi. No pleural or pericardial effusion is present.
Included views of the liver, pancreas, kidneys, adrenal glands, spleen, and
stomach are normal.
OSSEOUS STRUCTURES: There is no acute fracture. No concerning blastic or
lytic lesions are identified.
IMPRESSION:
1. No pulmonary embolus or aortic dissection detected.
2. 4-mm nodule at the right lower lobe. Per ___ guidelines, no
followup is necessary if there are no high-risk factors such as smoking or
history of malignancy; otherwise a 12 month follow up chest CT is advised.
3. Cardiomegaly with biatrial enlargement.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: SOB
Diagnosed with CHEST PAIN NOS, RESPIRATORY ABNORM NEC
temperature: 97.3
heartrate: 71.0
resprate: 18.0
o2sat: 100.0
sbp: 106.0
dbp: 81.0
level of pain: 5
level of acuity: 2.0 | Summary: Ms. ___ is a ___ lady with ___ and
subsequent tachycardia induced cardiomyopathy (EF 49%) s/p PPM
admitted for shortness of breath and new atypical, reproducible
chest discomfort.
# Atypical chest pain: Musculoskeletal. Pain is 100%
reproducible. It was not directly at the pacemaker pocket, and
she had nothing to suggest the pacer site is infected. No CAD
history, and there were no warning signs for cardiac disease.
She ruled out for MI with normal cardiac enzymes, and was
prescribed tylenol and a lidocaine patch for relief.
.
#. Shortness of breath: unclear etiology but chronic and
long-standing. She reports being at her baseline. Has
previously been attributed to her tachycardia and subsequent
cardiomyopathy. TTE is to be repeated next month by her
cardiologist, she has excellent outpatient cardiology ___.
CTA did not show any evidence for PE, and she is very dry on
exam - unlikely to be CHF exacerbation. COPD is unlikley as she
has no history, and she reports having spirometry done by her
PCP. Dabigatran and amiodarone and lasix were continued.
.
# ___: Improved back to baseline without intervention.
Suspected to be pre-renal in setting of lasix use and dry mucous
membranes.
.
# Pulmonary nodules: Noted on CTA obtained by emergency room.
Pt a previous smoker, and will likely need a 12 month follow up
CT scan.
.
.# Hypothyroidism: stable
-continued synthroid
.
#. h/o fasciitis: stable
-continued outpatient gabapentin
.
# s/p hysterectomy: stable
-continued premarin (conjugated estrogen)
.
====== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Codeine / ertapenem
Attending: ___
Chief Complaint:
Rlq ABD Pain, UTI
Major Surgical or Invasive Procedure:
LEFT PICC PLACEMENT ___ by ___ guidance
History of Present Illness:
___ with history of COPD, CAD, HTN, DM2, ESRD s/p renal
transplant in ___, disseminated aspergillosis with CNS, lung
and mediastinal involvement on life long suppression therapy and
recurrent UTIs presenting with persistent UTI on oral
antibiotics.
She was recently admitted from ___ to ___ for E. coli UTI
treatment with IV cefepime. She was then diagnosed with UTI and
started on PO cipro on ___. However, she has continued to have
cloudy urine. She has also developed RLQ pain and right back
pain. She states she has no pain now, but that she develops pain
when moving around. She was experiencing burning with urination,
but this resolved over last 2 days. Continues to experience
increased frequency and urgency. No N/V/fevers/chills. Has had
normal appetite.
Of note, she has grown Enterobacter in the past with an
extensive resistance pattern (see UCx ___ she has grown E.
coli in the past resistant to Bactrim and Ampicillin.
In the ED, initial vitals were: 97.8 92 121/45 18 97% RA
- Labs were significant for: WBC 10.1, Hgb 10.5, Na 131, Cl 95,
lactate 0.9. UA was grossly positive.
- Renal transplant U/S showed:
1. Increased resistive indices rela tive to prior examination
dated ___ which in the lower pole measure up to 0.97.
Additionally new is lack of convincing diastolic flow within the
intrarenal arteries of the mid and lower pole.
2. Patent main renal artery and vein. Main renal artery
demonstrates normal waveform.
3. Multiple renal cysts and moderate hydronephrosis not
significantly changed. No perinephric fluid collection.
- The patient was given: IV CefePIME 2g
Vitals prior to transfer were: 97.9 68 140/68 18 97% RA
Upon arrival to the floor, patient is comfortable, denies
current abdominal pain. She reports that the urine has been an
issue for two months, and recently she's had worsening of the
cloudy urine, pain with urination and increased urinary
frequency. She denies urinary incontinence but is wearing a
diaper here; she denies doing so at home (she has a LLQ
colostomy bag to collect her stools). She denies f/c, n/v,
cp/sob, abdominal pain, diarrhea, muscle aches, new joint pains
(has chronic knee pains). She is compliant with her medications
at home, as her daughters sort them out for her and she takes
them day by day.
Past Medical History:
- ERSD ___ to DM vs HTN.
- S/p renal transplant in ___. Followed by Dr. ___.
- IDDM, followed at the ___. HbA1c 6.5% in ___
- Disseminated aspergillosis, in ___. Followed by Dr. ___, on
voriconazole
- colon cancer s/p colectomy and colostomy placement
- CAD
- dCHF followed by Dr. ___.
- HTN
- HLD
- Osteoporosis, on risendronate (h/o intolerance of
alendronate).
- Pulmonary nodules, have been reported as stable
- Right breast mass, noted as stable since ___ on mammogram in
___. Patient has declined further mammograms
- H/o rectal squamous cell cancer. In ___, s/p ___
(abdominoperineal resection) with colostomy as well as ChT ___
and mitomycin-C) and XRT. Last colonscopy was in ___ and was
wnl (sig for diverticulosis.
- H/o hepatic fibrosis related to chronic biliary obstruction?
- S/p craniostomy with evacuation of aspergilloma
- Recurrent urinary tract infections.
- Requires intermittent straight catheterizations due to
urinary retention.
Social History:
___
Family History:
Sister had ovarian cancer. No other cancers or coronary artery
disease known. No history of renal disease.
Physical Exam:
ADMISSION:
Vitals: 97.6 157/56 76 16 98%RA
General: Thin, elderly lady, alert, oriented, no acute distress
HEENT: NCAT, EOMI, PERRLA, anicteric sclera, edentulous, clear
OP
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: +RLQ tenderness, LLQ colostomy bag, otherwise benign
exam
GU: Wearing diaper
Ext: WWP, no edema
Neuro: Face symmetric, moving all four extremities on command
DISCHARGE:
Vitals: Tmax 98.2 BP 123/38 HR 79 RR 18 98 % RA
BS: 100s-200s
General: Thin woman sitting up in bed, alert, oriented, no acute
distress
HEENT: NCAT, EOMI, PERRLA, anicteric sclera, clear posterior OP
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, anterior and posterior
chest, no wheezes, rales, rhonchi
Abdomen: soft, non distended, non tender to palpation, LLQ
colostomy bag with pink ostomy, otherwise benign exam
GU: Wearing diaper, no CVA tenderness
Ext: WWP, no edema; RUE AV fistula with thrill, no bruit
Neuro: CNII-XII intact, face symmetric,
Lines: L PICC line in place without surrounding erythema, no
tenderness to palpation
Pertinent Results:
ADMISSION:
___ 06:13PM BLOOD WBC-10.1* RBC-2.99* Hgb-10.5* Hct-31.1*
MCV-104* MCH-35.1* MCHC-33.8 RDW-14.1 RDWSD-53.3* Plt ___
___ 06:13PM BLOOD Neuts-78.1* Lymphs-10.3* Monos-10.5
Eos-0.1* Baso-0.1 Im ___ AbsNeut-7.88* AbsLymp-1.04*
AbsMono-1.06* AbsEos-0.01* AbsBaso-0.01
___ 06:13PM BLOOD Plt ___
___ 06:13PM BLOOD Glucose-254* UreaN-14 Creat-1.0 Na-131*
K-4.2 Cl-95* HCO3-25 AnGap-15
___ 06:25PM BLOOD Lactate-0.9
DISCHARGE:
___ 05:40AM BLOOD WBC-7.6 RBC-2.86* Hgb-9.9* Hct-29.9*
MCV-105* MCH-34.6* MCHC-33.1 RDW-14.2 RDWSD-53.6* Plt ___
___ 05:40AM BLOOD Plt ___
___ 05:40AM BLOOD Glucose-203* UreaN-14 Creat-1.0 Na-132*
K-4.5 Cl-97 HCO3-26 AnGap-14
MICRO:
___ 4:23 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- 16 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 16 R
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
___ BLOOD CULTURE Blood Culture,
Routine-PENDING EMERGENCY WARD
IMAGING:
CXR ___
FINDINGS:
1. The accessed vein was patent and compressible.
2. Brachialvein approach single lumen left PICC with tip in the
distal SVC.
IMPRESSION:
Successful placement of a left 45 cm brachial approach single
lumen PowerPICC
with tip in the distal SVC. The line is ready to use.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ with UTI diagnosed on ___, on cipro, persistent symptoms
// eval for pyelonephritis
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Renal ultrasound dated ___.
FINDINGS:
The right iliac fossa transplant renal morphology is normal. Relative to
prior examination dated ___, numerous cysts are again identified,
the largest cyst measures 4.9 x 3.8 x 4.8 cm within the inferior pole. There
is moderate hydronephrosis, not significantly changed. There is no
perinephric fluid collection.
Within the upper pole, intrarenal resistive indices measure 0.79 previously
0.76. Within the mid pole, resistive indices within the intrarenal arteries
measure 0.86, previously 0.81. Within the lower pole, resistive index
approaches 1 as no significant diastolic flow is seen, potentially technical.
It had previously been 0.76.
The main renal artery is patent with brisk upstroke. The main renal vein is
patent.
IMPRESSION:
1. Slightly increased resistive indices within the lower and mid pole renal
transplant relative to prior examination, potentially technical. Short term
follow up is advised.
2. Patent main renal artery and vein. Main renal artery demonstrates normal
waveform.
3. Multiple renal cysts and moderate hydronephrosis not significantly
changed. No perinephric fluid collection.
RECOMMENDATION(S): Short-term follow-up renal ultrasound.
Radiology Report
INDICATION: ___ year old woman with ESRD s/p transplant with multiple UTIs
presenting with resistant UTI found to have ESBL E coli. Requires 14 days of
IV abx, ___ nursing team unable to thread catheter. // please place PICC for
14 day IV antibiotics. Thank you
COMPARISON: None available
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: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS: None
CONTRAST: None
FLUOROSCOPY TIME AND DOSE: 0.8 min, 0 mGy
PROCEDURE:
1. Single lumen PICC placement through the brachial vein on the left.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the brachial
vein on the left was punctured under direct ultrasound guidance using a
micropuncture set. Permanent ultrasound images were obtained before and after
intravenous access, which confirmed vein patency. A peel-away sheath was then
placed over a guidewire. The guidewire was then advanced into the superior
vena cava using fluoroscopic guidance. A single lumen PIC line measuring 45 cm
in length was then placed through the peel-away sheath with its tip positioned
in the distal SVC under fluoroscopic guidance. Position of the catheter was
confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and
guidewire were then removed. The catheter was secured to the skin, flushed,
and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. The accessed vein was patent and compressible.
2. Brachialvein approach single lumen left PICC with tip in the distal SVC.
IMPRESSION:
Successful placement of a left 45 cm brachial approach single lumen PowerPICC
with tip in the distal SVC. The line is ready to use.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: RLQ abdominal pain, UTI
Diagnosed with Right lower quadrant pain
temperature: 97.8
heartrate: 92.0
resprate: 18.0
o2sat: 97.0
sbp: 121.0
dbp: 45.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ year old woman with history of COPD, CAD,
HTN, DM2, ESRD s/p renal transplant in ___, disseminated
aspergillosis with CNS, lung and mediastinal involvement on life
long suppression therapy and recurrent UTIs presenting with
dysuria and UTI found to have ESBL Ecoli UTI. Patient was
started on IV zosyn to be continued with home infusions for
total ___SBL ECOLI UTI:
Patient with abdominal pain, found to have ESBL Ecoli urinary
tract infection resistant to ciprofloxacin. Likely secondary to
straight catheterizations and unsterile technique. Given
patient's allergy history (seizures with ertapenem) and ESBL
Ecoli, infectious disease consulted and recommended IV zosyn,
for total ___, last dose ___. LEFT
PICC placed ___. Additionally ecoli sensitive to ertapenem
and fosfomycin for future reference. Patient will need to resume
prophylactic fosfomycin at renal transplant follow up with Dr.
___. Patient was counseled on importance of sterile
straight catheterization technique.
CHRONIC MEDICAL ISSUES:
# Disseminated Aspergillosis involving mediastinum and brain s/p
evacation of cerebral aspergilloma.
-continued levetiracetam 750 mg BID.
-continued voriconazole.
# s/p Kidney Transplant:
- Continued mycophenolate, prednisone
- Continued bisphosphonate & Ca supplementation
- Continued Bactrim, Valacyclovir ppx
# CAD:
- continued aspirin 81 mg daily
- continued atorvastatin 20 mg daily.
- continued metoprolol succinate 12.5 mg daily.
# IDDM:
- Continued home 70-30 (insulin asp prt-insulin aspart) 12U QAM
- held home repaglinide
- Humalog insulin sliding scale used for meal time coverage
while inpatient.
# Hypertension:
- Continued amlodipine & losartan
- Continued metoprolol succinate as noted above.
# Cough/Sinusitis/Asthma:
- Continued tessalon pearles
- Continued Flonase & Duoneb prn, tiotropium, switch Symbicort
to Advair
# GERD:
- Continued PPI, rantidine
# Anemia: Stable and at baseline.
- Continued home iron supplementation
# Constipation:
- Continued docusate, senna.
# Eye drops:
- Continued prednisone eye drops
# Psych:
- Continued quetiapine QHS |
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
Major Surgical or Invasive Procedure:
___: Laparoscopic appendectomy
History of Present Illness:
___ with 1 day history of abdominal pain. Reports it began as
vague and diffuse abdominal discomfort and then last evening
became localized to RLQ. Denies nausea/vomiting. No anorexia.
Denies fevers/chills/sweats. Does report that about 5 days ago,
he had subjective fevers and diarrhea but that resolved prior to
yesterday's abdominal pain.
Past Medical History:
___:
BEHAVIOR PROBLEMS ___
Referred to ASK in past. History of multiple suspensions in
middle school for being late, fighting, not listening to rules
___: per ___ and ___ no concerns regarding behavior at
school or home. No suspensions since middle school. PHQ2 score
0. Denies feeling sad for long periods of time or getting angry
easily. ___ and ___ both decline ___ referral.
PSH:
None
Social History:
___
Family History:
HTN
Physical Exam:
Admission Physical Exam:
T 98.4, HR 120, BP 133/75
GEN: NAD, AAOx3
HEENT: neck supple
CV: regular rhythm, tachycardic
PULM: CTAB
ABD: soft, ND, tender to palpation focally in RLQ, negative
Rovsing's, negative Psoas, negative Obturator
BACK: no CVA tenderness
EXTR: no calf swelling or tenderness
Discharge Physical Exam:
VS: T: 97.8, BP: 142/92, HR: 62, RR:18, O2: 99% RA
CV: RRR
PULM: CTA b/l
ABD: laparoscopic sites c/d/I, no erythema or s/s infection.
Abd soft, mildly distended and mildly tender at incision sites
Extremities: warm, well-perfused.
Pertinent Results:
___ 09:38PM GLUCOSE-86 UREA N-14 CREAT-0.9 SODIUM-136
POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-27 ANION GAP-14
___ 09:38PM ALT(SGPT)-15 AST(SGOT)-16 ALK PHOS-91 TOT
BILI-0.3
___ 09:38PM LIPASE-24
___ 09:38PM ALBUMIN-4.4
___ 09:38PM WBC-12.3*# RBC-5.07 HGB-15.7 HCT-46.4 MCV-92
MCH-31.0 MCHC-33.8 RDW-12.7 RDWSD-41.6
___ 09:38PM NEUTS-69.9 ___ MONOS-5.1 EOS-0.6*
BASOS-0.2 IM ___ AbsNeut-8.61* AbsLymp-2.93 AbsMono-0.63
AbsEos-0.08 AbsBaso-0.03
___ 09:38PM PLT COUNT-227
___ 09:38PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:38PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:38PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 09:38PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 09:38PM URINE MUCOUS-RARE
Imaging:
___: US Appendix:
The appendix was not seen, but there are no fluid collections or
signs of
inflammation in the right lower quadrant.
___: CT Abd&Pel:
1. Dilated, hyperemic retrocecal appendix with mild surrounding
fat stranding suggests acute appendicitis. No fluid collection
or extraluminal air.
2. Diverticulosis of the descending colon is seen.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
please hold for loose stool
3. Ibuprofen 800 mg PO Q8H:PRN pain
please take with food
4. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
do NOT drink alcohol or drive while taking this medication
RX *oxycodone 5 mg ___ tablet(s) by mouth every three (3) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: US APPENDIX
INDICATION: ___ year old man with RLQ pain // Appendicitis?
TECHNIQUE: Grey scale ultrasound images of the right lower quadrant were
obtained.
COMPARISON: None available.
FINDINGS:
In the right lower quadrant, in the area of the patient's pain, normal
structures are seen. The appendix is not seen, but there are no echogenic
areas to suggest inflammation, nor are there fluid collections identified.
IMPRESSION:
The appendix was not seen, but there are no fluid collections or signs of
inflammation in the right lower quadrant.
Radiology Report
INDICATION: NO_PO contrast; History: ___ with RLQ painNO_PO contrast // Eval
for 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: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 31.3 mGy (Body) DLP =
15.6 mGy-cm.
4) Spiral Acquisition 4.9 s, 53.0 cm; CTDIvol = 14.2 mGy (Body) DLP = 752.4
mGy-cm.
Total DLP (Body) = 768 mGy-cm.
COMPARISON: None available.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Diverticulosis of
the descending colon is noted, without evidence of wall thickening and fat
stranding. The appendix is dilated up to 11 mm, is slightly hyperemic, and
there is mild surrounding fat stranding. No fluid collection or extraluminal
air.
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 mesenteric lymphadenopathy. Scattered
retroperitoneal lymph nodes are not pathologically enlarged. There is no
pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Dilated, hyperemic retrocecal appendix with mild surrounding fat stranding
suggests acute appendicitis. No fluid collection or extraluminal air.
2. Diverticulosis of the descending colon is seen.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by WALK IN
Chief complaint: R Flank pain
Diagnosed with Unspecified abdominal pain
temperature: 99.4
heartrate: 120.0
resprate: 18.0
o2sat: 100.0
sbp: 133.0
dbp: 75.0
level of pain: 7
level of acuity: 3.0 | Mr. ___ is an ___ year-old male who was admitted to the
General Surgical Service on ___ for evaluation and
treatment of abdominal pain. Admission abdominal/pelvic CT
revealed acute appendicitis. The patient was admitted to the
Acute Care Surgery service for further medical management.
The patient underwent laparoscopic appendectomy on ___,
which went well without complication (reader referred to the
Operative Note for details). After a brief, uneventful stay in
the PACU, the patient arrived on the floor tolerating on IV
fluids, and pain medicine for pain control. The patient was
hemodynamically stable.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R ankle trimalleolar fracture dislocation
Major Surgical or Invasive Procedure:
R ankle open reduction internal fixation
History of Present Illness:
___ male with history of DM 2 presents with right ankle
fracture/dislocation after being a bicyclist struck by a vehicle
going 10 to 15 mph. Patient was struck in the right ankle and
was thrown from the bike. Reports pain in the right ankle but
denies any other joint pain. No numbness or paresthesias
distally. No history of surgery on that ankle.
Past Medical History:
Diabetes, HTN, depression, HLD
Social History:
___
Family History:
NC
Physical Exam:
GEN: AOx3, WN, in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR
PULM: unlabored breathing with symmetric chest rise, no
respiratory distress
EXT:
Right lower extremity:
Short leg splint in place, clean dry intact
Fires ___
SILT sural, saphenous, superficial peroneal, deep peroneal and
tibial distributions
Dorsalis pedis pulse 2+ with distal digits warm and well
perfused
Pertinent Results:
See OMR
Medications on Admission:
sertraline 125mg qhs
lisinopril 20mg daily
metformin 500mg BID
Asa 81mg daily
Simvastatin 20mg daily
Trazadone 100mg qhs
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 325 mg PO DAILY
Start after discharge from rehab and take 1 tab daily until 28
days (4 weeks) after surgery
RX *aspirin 325 mg 1 tablet(s) by mouth once a day Disp #*28
Tablet Refills:*0
3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 40 mg SC QHS
Take this in rehab, after discharge home this can be replaced
with aspirin 325mg daily
RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneous once a day Disp
#*14 Syringe Refills:*0
6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate
Reason for PRN duplicate override: oxycodone to be
discontinued
RX *hydromorphone 2 mg 1 tablet(s) by mouth Every 4 hours as
needed Disp #*35 Tablet Refills:*0
7. Senna 8.6 mg PO DAILY
8. Aspirin 81 mg PO DAILY
Resume taking 4 weeks after surgery once your lovenox and
full-dose aspirin are completed.
9. Lisinopril 20 mg PO DAILY
10. MetFORMIN (Glucophage) 500 mg PO BID
11. Sertraline 125 mg PO QHS
12. Simvastatin 20 mg PO DAILY
13. TraZODone 100 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R trimalleolar ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(crutches, walker or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) RIGHT
INDICATION: History: ___ with lateral mal fracture // Fracture
TECHNIQUE: Frontal and lateral view radiographs of
COMPARISON: Right ankle x-ray dated ___ at 9:48 a.m.
FINDINGS:
There is casting material overlying the right lower extremity obscuring the
underlying structure. There is redemonstration of oblique distal fibular
fracture. There is also redemonstration of acute medial malleolar/transverse
fracture and posterior malleolar fracture. There is moderate overlying soft
tissue swelling.
IMPRESSION:
Redemonstration of distal fibular and medial and posterior malleoli fracture.
No fracture seen of the more proximal tibia or fibula.
Radiology Report
EXAMINATION: CT LOW EXT W/O C RIGHT Q61R
INDICATION: ___ year old man with ankle fracture / dislocation // Please
obtain CT of right ankle to further characterize ankle fracture
TECHNIQUE: Axial CT images of the distal tibia fibula and ankle with sagittal
coronal reformats.
DOSE: Acquisition sequence:
1) Spiral Acquisition 8.7 s, 18.5 cm; CTDIvol = 14.2 mGy (Body) DLP = 262.9
mGy-cm.
Total DLP (Body) = 263 mGy-cm.
COMPARISON: Prior radiographs of the right tibia and fibula.
FINDINGS:
There is a minimally displaced vertically oriented fracture of the posterior
malleolus with approximately 3 mm of posterior displacement. There is a
horizontal fracture through the medial malleolus with intra-articular
extension and minimal widening of the medial clear space. There is a well
corticated osseous fragment inferior to the medial malleolus fracture that
likely reflects an old avulsion injury involving the deltoid ligament (series
2, image 53).
There is a comminuted mildly displaced fracture of the distal fibula and
lateral malleolus level the. There is slight posterior displacement of the
major distal fracture fragment by approximately 4 mm.
There is no fracture identified in the talus and the talar dome is intact.
Multiple small calcific densities anterior to the ankle in the expected
location of the deltoid and anterior talofibular ligament, highly suspicious
for ligamentous injury.
No acute fracture or dislocation in the hindfoot or midfoot. Small well
corticated osseous fragment medial to the navicular likely represents an os
navicularis (series 2, image 69). Small plantar calcaneal spur. Small
enthesophyte at the insertion of the Achilles tendon.
The comminuted distal lateral malleolus fracture abuts the peroneus longus and
brevis tendons without evidence of tendon entrapment.
There is soft tissue swelling surrounding the foot and ankle. Multiple foci
of gas within the anterior soft tissues suggestive of an open fracture or
prior intervention. Casting material overlies the right lower extremity.
Mild chronic degenerative changes with subchondral sclerosis of the subtalar
joint. There is spurring of the intercuneiform joint (series 2, image 84).
IMPRESSION:
1. Comminuted trimalleolar fracture of the right ankle as described. There
are multiple osseous fragments at the expected location of the deltoid and
anterior talofibular ligaments, highly suspicious for ligamentous injury.
2. No evidence of tendon entrapment.
3. multiple scattered foci of subcutaneous gas suggestive of an open fracture
or prior intervention.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: ___ male with trimalleolar right ankle fracture
TECHNIQUE: As below.
COMPARISON: Same-day right ankle radiograph and CT
FINDINGS:
14 intraoperative images were acquired without a radiologist present.
Images show placement of a lateral fixation plate with interlocking screws, 2
which are syndesmotic, along the lateral distal fibula as well as placement of
2 additional cannulated screws transfixing a fracture of the medial malleolus.
IMPRESSION:
Intraoperative images were obtained during ORIF of the right ankle. Please
refer to the operative note for details of the procedure.
Radiology Report
EXAMINATION: WRIST(3 + VIEWS) LEFT
INDICATION: ___ year old man with L wrist pain s/p trauma // R/o fx
TECHNIQUE: Frontal, oblique, and lateral view radiographs of the left wrist.
COMPARISON: None
FINDINGS:
No acute fractures or dislocation are seen. There are mild degenerative
changes. Carpal bones are well aligned. Mineralization is normal. There are
no erosions.
IMPRESSION:
No acute fractures or dislocations are seen. Mild degenerative changes
involving the carpal bones.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: History: ___ with R ankle deformity after bike accident //
PORTABLE?dislocaiton/fracture PORTABLE?dislocaiton/fracture
TECHNIQUE: Right ankle x-ray two views.
COMPARISON: Right foot x-ray dated ___.
FINDINGS:
There is a medially displaced oblique fracture of the distal fibula. There is
also acute intra-articular fracture involving the medial malleolus. Posterior
malleolar fracture is also likely present. There is an acute anterior tibia
dislocation at the tibiotalar joint. Disrupted ankle mortise. There is a 8
mm bone fragment superior to the talus. The evaluation of talar dome is
limited due to overlying bone fragments. There is severe overlying soft
tissue swelling.
IMPRESSION:
Right ankle fracture dislocation, with the distal tibia is dislocated
anteriorly in relation to the talus. Trimalleolar fracture. Disrupted ankle
mortise. There is significant overlying soft tissue swelling. Additional
x-ray of the proximal fibula is recommended.
Radiology Report
EXAMINATION: ANKLE (2 VIEWS) RIGHT
INDICATION: History: ___ with R ankle fx s/p reduction // eval for
dislocation eval for dislocation
TECHNIQUE: Right ankle two views.
COMPARISON: Right ankle x-ray dated ___ at 9:05 a.m.
FINDINGS:
There is interval reduction of the tibiotalar dislocation. There is
redemonstration of acute trimalleolar fracture involving the distal fibula and
medial and posterior malleoli, with interval improvement in alignment.
Oblique distal fibular fracture demonstrates mild posterior displacement on
the current study. There is overlying soft tissue swelling.
IMPRESSION:
Interval reduction of the tibiotalar dislocation. Redemonstration of
trimalleolar fracture, in improved alignment.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with pre-op // PNA
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
No focal consolidation is seen. There is no large pleural effusion. No
evidence of pneumothorax is seen. Cardiac silhouette is borderline in size.
Mediastinal contours are unremarkable. No pulmonary edema is seen.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Ped struck, R Ankle injury
Diagnosed with Displaced trimalleolar fracture of right lower leg, init, Pedl cyc driver inj pick-up truck, pk-up/van in traf, init
temperature: 97.8
heartrate: 90.0
resprate: 18.0
o2sat: 99.0
sbp: 152.0
dbp: 110.0
level of pain: 9
level of acuity: 2.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right ankle trimalleolar fracture dislocation. He was
closed reduced in the emergency department and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for right ankle open reduction
internal fixation, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
Patient had left wrist pain and is referred and has a scheduled
appointment with hand surgery on ___. He was given a
prefabricated wrist splint while admitted; XR were negative for
bony injury.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the right lower extremity in a short leg
splint, and will be discharged on Lovenox for DVT prophylaxis
while he is in rehab, which boot will be transition to aspirin
325 mg daily for the remainder of the 4-week postoperative
course when discharged home. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
glyburide / erythromycin base
Attending: ___
___ Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old lady with history of
hypertension, DM2, depression, asthma, SVT, with now diagnosis
of intravascular B cell lymphoma, currently receiving R-CHOP
chemotherapy.
She is presenting to the ED with fevers and hypotension. She was
feeling moderately unwell at home with mild fevers and chills
(did not take her temperature). Denies CP/SOB, N/V/abdominal
pain. She does endorse dysuria which is chronic for her and no
change in her medications.
Per chart review, she was recently hospitalized ___
for pancytopenia when she presented with 2 months of fatigue,
night sweats, fevers, lightheadedness, and weight loss of over
20 pounds. She had an essentially negative work-up including
HIV, Hepatitis B and C, Multiple Myeloma, Parasitic and viral
infections, as well as nutritional deficiencies. CT imaging did
not show any adenopathy and EDG and colonoscopy did not show
reason for anemia. She underwent bone marrow biopsy with
pending results at her discharge on ___. Unfortunately,
she had recurrent symptoms of fatigue, lightheadedness, fevers,
cough, and chills and was readmitted on ___.
For further disease assessment, it was arranged for Ms.
___ to undergo bilateral bone marrow biopsies under ___ and
with sedation on ___ but, when she presented for the
procedure, she was noted for SVT and was admitted. She has a
known history of SVT, felt due to AVRT/AVNRT. She has been on
Atenolol but had noted increasing episodes of palpitations. SVT
initially broken with IV adenosine. While in the hospital, she
continued to have episodes of hemodynamically stable AVNRT,
broken with both carotid massage and IV metoprolol boluses. TTE
showed normal cardiac function and negative pharmacologic
nuclear myocardial perfusion test. She was started on Sotalol
for better management of her SVT. She was given Cycle 5 of
RCHOP on ___.
___ cycle of treatment was complicated by readmission with
dysphagia after eating a piece of meat. An EGD was performed on
___ which revealed food impaction with some evidence of
esophagitis and hypertonic LES suggesting dysmotility disorder.
The obstructive piece of food was retrieved without
complications. She spent a few days in the hospital as her diet
was advanced. She was also noted for UTI with yeast and was
treated with 3 days of Fluconazole. She underwent bilateral
bone marrow biopsy with sedation in radiology on ___,
___ which showed no evidence of her lymphoma. She
received her 6 cycle of R-CHOP on ___.
Following her ___ cycle, Ms. ___ has been followed with
noted lower counts requiring transfusion support. She has had
increasing bone pain which has been an issue with her while on
Neupogen. She has continued with urinary
symptoms with pain with urination. She has been evaluated by
Dr. ___ urology. Renal ultrasound was normal. Urine
cultures have repeatedly showed yeast. She has received short
course of Fluconazole. She was evaluated by Dr. ___
Infectious disease on ___.
When she was seen on ___, Ms. ___ required
transfusion of red cells with noted complaints of chills without
fevers. Her ANC was recovering over 500. She had urine culture
sent which again grew out yeast. Blood cultures x 2 are
negative to date. She returned today with noted fever to 101.9.
ANC now
___ with counts slowly recovering. Urine culture sent again;
blood cultures sent x 2. She was given Cefepime 2 gms IV and
another dose of Neupogen. Blood pressure was 122/71 when
resented to clinic but SBP is now 89 to 91.
With concern for infection, Ms. ___ was admitted for
further evaluation.
On the floor, she was no longer hypotensive and was in no acute
distress
Past Medical History:
ONCOLOGY HISTORY:
The ___ bone marrow biopsy on ___ showed a hypercellular
bone marrow with trilineage hematopoiesis and rare clusters of
very large basophilic cells with cytoplasmic blebs and
fragmentation, of undetermined origin. Repeat bone marrow
biopsy
was done on ___ showed a hypercellular bone marrow with
extensive sinusoidal infiltration by CD5 positive intravascular
large B cell lymphoma. The large lymphoma cells were also
positive for CD20, PAX5, CD5, and CD45. MIB-1 revealed a high
proliferation fraction. Head MRI excluded cerebral involvement
of her disease. She was started on CHOP therapy on ___
and
completed her first cycle with no major
complications.
Her B-symptoms resolved a few days after starting her
chemotherapy. She did note some abdominal pain which was felt
related to known peptic ulcer disease; improved with increasing
PPI dosing. CT scan showed mild splenomegaly but, otherwise,
nothing concerning. She received Neupogen for support during
her
nadir and required transfusion support. She received Rituxan
and
then cycle 2 of RCHOP on ___, again supported with
Neupogen and transfusion. She has needed more Magnesium
replacement in the setting of her diabetes and PPI. She
received
Cycle 3 of treatment as an outpatient on ___. She was
supported with Neupogen and her insulin requirements were
increased during her steroids. She required less transfusion
support but still needed magnesium replacement. She received
Cycle 4 RCHOP on ___.
PMH:
- Intravascular lymphoma
- Asthma
- Type 2DM (A1C 5.8% in ___
- Esophageal Reflux
- Lower back pain
- Hematuria
- Osteopenia
- Hyperlipidemia
Social History:
___
Family History:
Brother has prostate cancer, otherwise no history of cancer in
her family.
Physical Exam:
ADMISSION PHYSICAL EXAM
GENERAL: Tired appearing female, no acute distress.
VITAL SIGNS: 97.1 HR: 79 BP: 103/82 Resp: 18 O(2)Sat: 98 room
air
HEENT: Oropharynx moist, no lesions or thrush noted.
NECK: Supple without adenopathy
HEART: RRR, normal S1, S2. No murmurs
CHEST: CTAB, no wheezing or rales noted
ABDOMEN: Soft without tenderness. ND, BS+. No HSM noted.
EXTREMITIES: No edema of LEs.
SKIN: No rashes.
NEURO: Alert and oriented x3, full affect, appropriately
conversational
DISCHARGE PHYSICAL EXAM
VITAL SIGNS: 98.0 110/68 78 18 95% on RA
GENERAL: sleeping prior to interview, AOx3, no acute distress,
speaking quickly.
HEENT: diffuse alopecia covered by headwrap, oropharynx moist,
no lesions or thrush noted, EOMI, PERRLA
NECK: Supple without adenopathy, no JVD
HEART: RRR, normal S1, S2. No murmurs
CHEST: CTAB, no wheezing or rales noted
ABDOMEN: Soft without tenderness. ND, BS+. No HSM noted. No
suprapubic tenderness.
EXTREMITIES: No c/c/e, pulses 2+ symmetric
SKIN: No rashes.
NEURO: Alert and oriented x3, full affect, appropriately
conversational
Pertinent Results:
ADMISSION LABS
___ 01:45PM BLOOD WBC-1.8*# RBC-2.45* Hgb-7.7* Hct-22.6*
MCV-92 MCH-31.4 MCHC-34.1 RDW-13.8 RDWSD-46.6* Plt Ct-49*
___ 01:45PM BLOOD Neuts-89* Bands-0 Lymphs-4* Monos-6 Eos-0
Baso-1 ___ Myelos-0 AbsNeut-1.60 AbsLymp-0.07*
AbsMono-0.11* AbsEos-0.00* AbsBaso-0.02
___ 01:45PM BLOOD Glucose-390* UreaN-16 Creat-1.0 Na-132*
K-3.7 Cl-97 HCO3-26 AnGap-13
___ 06:30AM BLOOD ALT-10 AST-16 LD(LDH)-141 AlkPhos-248*
TotBili-0.4
___ 01:45PM BLOOD Albumin-3.2* Calcium-9.2 Mg-1.3*
___ 06:30AM BLOOD Hapto-233*
DISCHARGE LABS
___ 05:04AM BLOOD WBC-2.1* RBC-3.52* Hgb-10.6* Hct-31.9*
MCV-91 MCH-30.1 MCHC-33.2 RDW-14.0 RDWSD-46.8* Plt Ct-91*
___ 05:04AM BLOOD Glucose-184* UreaN-14 Creat-0.9 Na-140
K-4.0 Cl-101 HCO3-30 AnGap-13
___ 05:04AM BLOOD Calcium-9.6 Phos-4.5 Mg-1.4*
___ 02:45PM URINE Color-Yellow Appear-Hazy Sp ___
___ 02:45PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 02:45PM URINE RBC-15* WBC->182* Bacteri-NONE Yeast-FEW
Epi-2
___ 09:18AM URINE HISTOPLASMA ANTIGEN-PND
___ 05:05PM URINE BK VIRUS BY PCR, URINE-PND
IMAGING
___ CT Torso
IMPRESSION:
1. 2-mm left lower lobe opacity is less conspicuous from the
prior exam.
2. Persistent mild diffuse peribronchiolar thickening suggests
chronic small airway disease.
IMPRESSION:
1. Mild bladder wall thickening and fat stranding suggests
cystitis.
2. Sequelae of papillary necrosis including clubbed calyx as
well as cortical scarring in the left upper and mid kidney.
3. Nonspecific small amount of free fluid in the pelvis and
inferior tip of the liver could be reactive.
4. Persistent mild splenomegaly up to 13 cm, unchanged.
5. Prominent endometrium and possible left adnexal cyst, more
than expected for the patient's postmenopausal status in age. A
nonemergent ultrasound is recommended to further evaluate.
RECOMMENDATION(S): Nonemergent pelvic ultrasound to further
evaluate the
endometrium and adnexa.
___ CXR
FINDINGS: Right-sided Port-A-Cath terminates in the cavoatrial
junction without evidence of pneumothorax. No focal
consolidation is seen. No pleural effusion or pneumothorax is
seen. The cardiac and mediastinal silhouettes are stable.
IMPRESSION: No acute cardiopulmonary process. No focal
consolidation to suggest pneumonia.
MICROBIOLOGY
___ 2:50 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:50 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:45 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 ORGANISMS/ML..
___ 9:15 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ 5:05 pm URINE Source: ___.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Sotalol 80 mg PO BID
3. Acetaminophen 650 mg PO Q6H:PRN pain/fever
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
5. Magnesium Oxide 140 mg PO TID
6. MetFORMIN (Glucophage) 500 mg PO TID
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Promethazine 25 mg PO Q8H:PRN nausea
10. QUEtiapine Fumarate 200 mg PO QHS
11. Senna 8.6 mg PO BID
12. LOPERamide 2 mg PO QID:PRN diarrhea
13. Glargine 15 Units Bedtime
14. Fexofenadine 60 mg PO Q24H
15. Phenazopyridine 100 mg PO QHS
16. Miconazole Nitrate Vag Cream 2% 1 Appl VG BID
17. Multivitamins 1 TAB PO DAILY
18. Omeprazole 40 mg PO BID
19. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing, shortness of
breath
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
2. Acyclovir 400 mg PO Q12H
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/wheeze
4. Fexofenadine 60 mg PO Q24H
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Glargine 15 Units Bedtime
7. LOPERamide 2 mg PO QID:PRN diarrhea
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. QUEtiapine Fumarate 200 mg PO QHS
11. Sotalol 80 mg PO BID
12. Senna 8.6 mg PO BID
13. Omeprazole 40 mg PO BID
14. MetFORMIN (Glucophage) 500 mg PO TID
15. Miconazole Nitrate Vag Cream 2% 1 Appl VG BID
16. Multivitamins 1 TAB PO DAILY
17. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing, shortness of
breath
18. Fluconazole 200 mg PO Q24H
RX *fluconazole 200 mg 1 tablet(s) by mouth daily Disp #*26
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Cystitis
Intravascular B-cell lymphoma
Secondary diagnosis:
Anemia
Type II, diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: ___ year old woman with neutropenic fever // eval for pneumonia
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Right-sided Port-A-Cath terminates in the cavoatrial junction without evidence
of pneumothorax.No focal consolidation is seen. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are stable.
IMPRESSION:
No acute cardiopulmonary process. No focal consolidation to suggest
pneumonia.
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: ___ woman with primary effusion lymphoma, s/p RCHOP, p/w
fevers and chronic dysuria. Evaluate for extramedullary sites of lymphoma,
infection.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 17.6 s, 0.2 cm; CTDIvol = 300.2 mGy (Body) DLP =
60.0 mGy-cm.
3) Spiral Acquisition 6.2 s, 68.6 cm; CTDIvol = 4.1 mGy (Body) DLP = 275.5
mGy-cm.
Total DLP (Body) = 337 mGy-cm.
COMPARISON: CT abdomen and pelvis dated ___.
FINDINGS:
LOWER CHEST: Please refer to the dedicated CT chest report from the same day
for description of thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. No evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is surgically absent with
clips in the gallbladder fossa. There is a small amount of ascites at the
inferior tip of the right lobe (series 5, image 63).
PANCREAS: There is uniform lipomatosis of the pancreas, a normal variant.
The pancreas has normal attenuation throughout, without evidence of focal
lesions or pancreatic ductal dilatation. No peripancreatic stranding.
SPLEEN: The spleen is top-normal in size, measuring up to 13.5 mm, similar to
the prior exam. The attenuation of the spleen is normal 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 nephrograms.
A tiny hypodensity in the left mid pole renal cortex is unchanged and too
small to characterize on CT (series 5, image 64). Mild cortical thinning in
the left upper renal pole is unchanged and likely reflects scarring, sequelae
of prior insult (series 5, image 59). Rounded appearance of the renal calyces
in the upper and mid poles suggest sequelae of papillary necrosis (series 8,
image 32). Mild prominence of the right renal pelvis without overt
hydronephrosis is unchanged. No perinephric abnormality.
GASTROINTESTINAL: Ingested oral contrast reaches the splenic flexure. The
stomach is unremarkable. Small bowel loops demonstrate normal caliber, wall
thickness, and enhancement throughout. The colon and rectum are within normal
limits. The appendix is normal. No bowel obstruction, free air, or
intra-abdominal fluid collection. The terminal ileum is within normal limits.
PELVIS: The the urinary bladder is relatively decompressed but there appears
to be mild wall thickening and perhaps minimal fat stranding, suggesting
cystitis. Fat stranding around the distal ureters bilaterally is mild.
Dependent excreted intravenous contrast is seen in the urinary bladder.
Bilateral ureteral jets of contrast are visualized. A small amount of simple
free fluid is seen in the pelvis and nonspecific (series 8, image 24).
REPRODUCTIVE ORGANS: The endometrium is thickened, measuring up to 8 mm, more
than is normal for the patient's age. There is a possible left adnexal cyst
verses free fluid.
LYMPH NODES: No retroperitoneal or mesenteric lymphadenopathy. No pelvic or
inguinal lymphadenopathy.
VASCULAR: No abdominal aortic aneurysm. Mild atherosclerotic disease is
noted.
BONES: No evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits other than
probable injection granuloma in the right lower abdominal wall (series 5,
image 87).
IMPRESSION:
1. Mild bladder wall thickening and fat stranding suggests cystitis.
2. Sequelae of papillary necrosis including clubbed calyx as well as cortical
scarring in the left upper and mid kidney.
3. Nonspecific small amount of free fluid in the pelvis and inferior tip of
the liver could be reactive.
4. Persistent mild splenomegaly up to 13 cm, unchanged.
5. Prominent endometrium and possible left adnexal cyst, more than expected
for the patient's postmenopausal status in age. A nonemergent ultrasound is
recommended to further evaluate.
6. Please refer to the dedicated CT chest report from the same day for
description of thoracic findings.
RECOMMENDATION(S): Nonemergent pelvic ultrasound to further evaluate the
endometrium and adnexa.
NOTIFICATION: The impression and recommendation above was entered by Dr.
___ on ___ at 21:43 into the Department of Radiology critical
communications system for direct communication to the referring provider.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ woman with a history of primary effusion lymphoma,
status post RCHOP,, now presenting with fevers and chronic dysuria. Evaluate
for extra medullary sites of lymphoma or infection.
TECHNIQUE: Multidetector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agent reconstructed as
contiguous 5- and 1.25-mm thick axial, 2.5-mm thick coronal and parasagittal,
and 8 x 8 mm MIPs axial images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 17.6 s, 0.2 cm; CTDIvol = 300.2 mGy (Body) DLP =
60.0 mGy-cm.
3) Spiral Acquisition 6.2 s, 68.6 cm; CTDIvol = 4.1 mGy (Body) DLP = 275.5
mGy-cm.
Total DLP (Body) = 337 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: CT Chest dated ___.
FINDINGS:
There is conventional 3 vessel aortic arch anatomy. The thoracic aorta is
normal in caliber with minimal atherosclerotic calcifications. The main,
left, and right pulmonary arteries are normal in caliber without evidence of a
filling defect to suggest an incidental central pulmonary embolus on this
non-dedicated exam. The heart is top-normal in size, unchanged. Coronary
artery calcifications are mild, unchanged. No pericardial effusion. The
right Port-A-Cath tip ends in the right atrium.
No pathologically enlarged axillary, supraclavicular, mediastinal, or hilar
lymph nodes. The top-normal size retrocrural lymph node on the prior exam is
not clearly appreciated today. Asymmetric mild hypertrophy of the right
thyroid lobe is unchanged without evidence of a discrete nodule.
The airways are patent to at least the subsegmental level. Mild
peribronchiolar thickening persists, suggesting chronic small airways disease.
No focal consolidation, edema, effusion, or pneumothorax. Segmental
atelectasis on the prior exam has resolved. A small subpleural cyst in the
left lower lobe is unchanged (series 5, image 28). A small 2-mm left lower
lobe pulmonary micronodule is less conspicuous from the prior exam (series 5,
image 39). No suspicious pulmonary nodules are identified.
No osseous lesion suspicious for infection or malignancy in the thoracic cage.
Please refer to the dedicated CT abdomen and pelvis report from the same day
for description of sub- diaphragm findings.
IMPRESSION:
1. 2-mm left lower lobe opacity is less conspicuous from the prior exam.
2. Persistent mild diffuse peribronchiolar thickening suggests chronic small
airway disease.
3. Please refer to the dedicated CT abdomen and pelvis report from the same
day for description of sub- diaphragm findings.
Radiology Report
EXAMINATION: US, OTHER SOFT TISSUE AREA
INDICATION: ___ year old woman with history of HTN, depression, DM2, asthma,
SVT with now diagnosis of intravascular lymphoma s/p 6 cycles of R-CHOP who is
admitted with fever and hypotension. Now having persistent pain around Port
site // Please ultrasound Port site and area around it to look for possible
sources of pain such as swelling, collection, retained object
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the right upper chest.
COMPARISON: CT chest from ___
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
right upper chest.
No retained foreign body. Small amount of soft tissue swelling is noted. No
abscess or fluid collection
IMPRESSION:
Small amount of soft tissue swelling seen surrounding the port. No abscess or
fluid collection. No foreign body.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Fever, Hypotension
Diagnosed with Fever, unspecified
temperature: 97.1
heartrate: 79.0
resprate: 18.0
o2sat: 98.0
sbp: 103.0
dbp: 82.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ year old woman with history of
intravascular lymphoma who is being admitted with fever and
hypotension.
# Fungal cystitis: increased risk for infection given
immunocompromised status and diabetes mellitus with glycosuria.
CT torso showed evidence of cystitis which would fit with her
clinical symptoms and prior culture. Fever workup otherwise with
no localizing sources (port considered by evaluated multiple
times without significant findings), negative culture data and
negative CT Torso (other than previously described). No further
hypotension after admission with persistent SBP >110s. Initially
started on cefepime which was discontinued after ID consulted.
Started on fluconazole 400mg daily, then dose adjusted to 200mg
daily to complete at 4 week course Urology consulted and agreed
with ID recommendations with additional recommendations to send
viral studies which were pending at time of discharge. Given
lack of gross hematuria (15 RBCs on U/A), there was no need for
acute management of this did indeed represent hemorrhagic
cystitis- they recommended outpatient follow-up with Dr. ___
cystoscopy and urodynamic testing.
# Intravascular B-cell lymphoma: confirmed by bone marrow
biopsy, s/p recent R-CHOP, has required transfusion support
after most recent cycle. Continued on VZV prophylaxis with
acyclovir. Patient evaluated by Port team for a sensation of a
"needle" sensation at port site. No change of sensation with
accessing vs. deaccessing. Physical exam and CT failed to show
any specific abnormality. Ultrasound showed some nonspecific
surrounding soft tissue swelling but no contained fluid
collection or foreign body. Discussed possible removal of port
but after discussion with primary oncologist this was deferred
given her high risk for disease relapse and possible need for
additional treatment. Patient will follow-up with Dr. ___ as
an outpatient for further care.
# Anemia: chronic normocytic anemia slightly patient's baseline
on presentation (baseline ___ in the setting of recent
chemotherapy. Hemolysis labs negative. No evidence of active
bleed with the exception of microscopic hematuria. Received 1U
pRBCs with good response and stable counts thereafter.
# Diabetes mellitus, type II: home metformin held, titrated ISS
and glargine for target blood glucose <180. Early in admission,
she had labile blood sugars with occasional symptomatic episodes
of hypoglycemia (50s) prompting a more conservative sliding
scale with no further events.
# History SVT (AVNRT): continued on sotalol and monitored QTc
while on fluoconazole (and home quetiapine) with daily EKGs
(460s).
Transitional Issues
===================
[ ] continue fluconazole 200mg daily until ___ per ID, f/u yeast
speciation
[ ] f/u urine infectious studies (BK, culture, histoplasma)
[ ] check magnesium at next visit (discharge Mg 1.4 and received
4g IV), discontinued home magnesium oxide due to patient
complaint of loose stools since starting
[ ] monitor QTc with EKG while on fluconazole and sotalol,
recommend avoiding additional QT-prolonging agents (discharge
QTc 460s)
[ ] patient discontinued on Pyridium given absence of relief and
risks associated with medication after discussion with Pharmacy
[ ] obtain nonemergent pelvic ultrasound to characterize
findings on CT Torso |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro / Quinolones / Reglan / Compazine / Percocet
Attending: ___.
Chief Complaint:
Nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
NGT placement and d/c
History of Present Illness:
Ms. ___ is a ___ year old woman with a PMH of cystic
fibrosis c/b chronic pancreatitis s/p pancreatectomy, islet cell
transplant, J tube (removed), splenectomy, multiple episodesof
E.
coli bacteremia and recurrent C diff, presenting with fevers,
nausea/vomiting, abdominal pain since this morning.
Patient has history of multiple episodes of E coli bacteremia
and
was recently admitted from ___ for fevers, epigastric pain,
hypotension, leukocytosis (WBC ___, and was treated with 3 days
C/F resulting in resolution of her leukocytosis, and she was
transitioned to PO augmentin for ___long with PO
vanco, although she had negative blood cultures and unclear
infectious source per ID. Two days after her discharge,
beginning
last evening into this morning, patient began having sharp upper
abdominal pain occasionally radiating to the back, fevers at
home
(measuring 101), and nausea/vomiting (2 episodes of bilious
emesis). She states that her abdominal pain is similar in
quality
to that during her prior admission, though her pain today is
slightly worse. She does note a history of a small bowel
obstruction several years ago which was treated non-surgically.
She had a bowel movement yesterday evening (diarrhea), and notes
that she has been passing flatus, though when asked if she has
passed flatus since this AM she is unsure. She has been taking
her medications as prescribed. Denies hematochezia, melena.
Her current ED course was notable for a tachycardia responsive
to
fluid boluses from HR 133 to 100s, WBC of 25.1 (from 9.5 on
___,
Tmax 99.3, ALT 81 (from 92), AST 166 (from 49), AP 128 (from
___, T bili <0.2, CT scan showing multiple dilated fluid and
air-filled loops of small bowel with transition point in LLQ
suggestive of partial SBO.
ACS surgery was consulted to evaluate for SBO.
ROS: Negative except as noted in HPI
Past Medical History:
- Gastroparesis - Hospitalized almost every month with
vomiting.
Has had a J tube in past. No change in frequency of admissions
for this since pancreatectomy which was done in ___.
- Chronic pancreatitis s/p pancreatectomy with auto-islet cell
transplant ___
- Jejunostomy
- Splenectomy
- Thrombocytosis
- Eating disorder
- J-tube placement (removed ___
- Thymoma
- Chronic pain
- Anxiety
- Depression
- Urinary retention
- Hypoglycemia
- Hypothyroidism
- Insomnia
- GERD
- Chronic abdominal pain
- Iron deficiency anemia
- DVT of RUE
- Fungemia
- Restless leg syndrome
- Microangiopathic hemolytic anemia
- Cystic Fibrosis Carrier
Social History:
___
Family History:
Brother - DM
Mother - colon cancer, gallstone pancreatitis and hypothyroid
Father - HTN
Physical ___:
ADMISSION PHYSICAL EXAM
PE:
Vitals - Tmax 99.3; Tcurrent 98.7;
GEN - Tired appearing
HEENT - NCAT, EOMI, sclera anicteric
CV - Mildly tachycardic
PULM - No signs of respiratory distress.
ABD - soft, mild to moderate focal tenderness at epigastrium,
mildly distended, no rebound or guarding.
EXT - Warm, well-perfused
NEURO - A&Ox3, no focal neurologic deficits
DISCHARGE PHYSICAL EXAM
Vitals: 24 HR Data (last updated ___ @ 751)
Temp: 98.1 (Tm 98.7), BP: 113/75 (107-125/67-78), HR: 79
(75-91), RR: 18 (___), O2 sat: ra% (91-96)
General: Thin, fatigued appearing, pale, female in no acute
distress
HEENT: Moist mucous membranes, PERRL, EOMI, tolerating clears.
CV: Regular rate and rhythm, no murmurs.
RESP: Clear to auscultation bilaterally, normal work of
breathing
GI: Soft, non-tender, normal bowel sounds, no hepatosplenomegaly
GU: Voiding independently
MSK: no joint swelling, no edema
Skin: no rash; pale; warm and dry
Neuro: Moving all extremities, alert, and oriented. Speech is
clear. No sensory deficits. No weakness noted.
Access: PIV
Pertinent Results:
___ 04:07AM BLOOD WBC-25.1* RBC-3.10* Hgb-7.6* Hct-25.1*
MCV-81* MCH-24.5* MCHC-30.3* RDW-18.6* RDWSD-54.4* Plt ___
___ 11:05PM BLOOD WBC-39.1* RBC-2.86* Hgb-7.0* Hct-23.2*
MCV-81* MCH-24.5* MCHC-30.2* RDW-18.7* RDWSD-55.5* Plt ___
___ 04:25AM BLOOD WBC-35.4* RBC-2.77* Hgb-6.9* Hct-22.2*
MCV-80* MCH-24.9* MCHC-31.1* RDW-18.6* RDWSD-53.6* Plt ___
___ 06:00AM BLOOD WBC-16.8* RBC-2.81* Hgb-6.9* Hct-22.4*
MCV-80* MCH-24.6* MCHC-30.8* RDW-18.9* RDWSD-54.4* Plt ___
___ 06:15AM BLOOD WBC-12.4* RBC-3.00* Hgb-7.4* Hct-24.0*
MCV-80* MCH-24.7* MCHC-30.8* RDW-18.8* RDWSD-54.5* Plt ___
___ 05:07AM BLOOD WBC-10.0 RBC-3.07* Hgb-7.4* Hct-24.5*
MCV-80* MCH-24.1* MCHC-30.2* RDW-19.1* RDWSD-55.0* Plt ___
___ 04:07AM BLOOD Neuts-94.9* Lymphs-1.6* Monos-1.1*
Eos-1.3 Baso-0.3 NRBC-0.9* Im ___ AbsNeut-23.76*
AbsLymp-0.41* AbsMono-0.28 AbsEos-0.33 AbsBaso-0.08
___ 04:07AM BLOOD ___ PTT-33.1 ___
___ 04:07AM BLOOD Glucose-92 UreaN-6 Creat-1.0 Na-139 K-4.1
Cl-106 HCO3-17* AnGap-16
___ 05:07AM BLOOD Glucose-107* UreaN-6 Creat-0.8 Na-138
K-3.9 Cl-106 HCO3-22 AnGap-10
___ 04:07AM BLOOD ALT-81* AST-166* AlkPhos-128*
TotBili-<0.2
___ 05:07AM BLOOD ALT-28 AST-21
___ 11:05PM BLOOD Calcium-8.4 Phos-2.9 Mg-1.6
___ 11:30PM BLOOD Type-MIX pO2-56* pCO2-43 pH-7.35
calTCO2-25 Base XS--1 Comment-GREEN TOP
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
3. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL QID
4. Vancomycin Oral Liquid ___ mg PO BID
5. Topiramate (Topamax) 100 mg PO BID
6. Prochlorperazine 10 mg IV Q6H:PRN Nausea/Vomiting - First
Line
7. Prazosin 5 mg PO QHS night terrors
8. PARoxetine 40 mg PO QHS
9. Pantoprazole 40 mg PO Q24H
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Mirtazapine 15 mg PO QHS
12. Levothyroxine Sodium 100 mcg PO 1X/WEEK (___)
13. Levothyroxine Sodium 50 mcg PO 6X/WEEK (___)
14. DiphenhydrAMINE 50 mg IV Q6H:PRN allergy to compazine
15. DICYCLOMine 10 mg PO QID
16. BuPROPion (Sustained Release) 150 mg PO QAM
17. Zenpep (lipase-protease-amylase) 25,000-79,000- 105,000 unit
oral TID W/MEALS pancreatic insufficiency
18. Vitamin D ___ UNIT PO 3X/WEEK (___)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL QID
Consider prescribing naloxone at discharge
3. BuPROPion (Sustained Release) 150 mg PO QAM
4. DICYCLOMine 10 mg PO QID
5. DiphenhydrAMINE 50 mg IV Q6H:PRN allergy to compazine
6. Levothyroxine Sodium 100 mcg PO 1X/WEEK (___)
7. Levothyroxine Sodium 50 mcg PO 6X/WEEK (___)
8. Mirtazapine 15 mg PO QHS
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Pantoprazole 40 mg PO Q24H
11. PARoxetine 40 mg PO QHS
12. Prazosin 5 mg PO QHS night terrors
13. Prochlorperazine 10 mg IV Q6H:PRN Nausea/Vomiting - First
Line
14. Topiramate (Topamax) 100 mg PO BID
15. Vitamin D ___ UNIT PO 3X/WEEK (___)
16. Zenpep (lipase-protease-amylase) 25,000-79,000- 105,000
unit oral TID W/MEALS pancreatic insufficiency
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
Small bowel obstruction
Secondary Diagnosis
c. diff colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with significant abdominal surgery,
sepsis, re-presents with abdominal pain.NO_PO contrast// Intra-abdominal
abscess?
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.3 s, 56.7 cm; CTDIvol = 15.0 mGy (Body) DLP = 849.3
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 14.4 s, 0.5 cm; CTDIvol = 80.5 mGy (Body) DLP =
40.3 mGy-cm.
Total DLP (Body) = 891 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
LOWER CHEST: There is mild right basilar atelectasis. Otherwise, visualized
lung fields are within normal limits. There is no evidence of pleural or
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is surgically absent.
Punctate foci of pneumobilia are due to hepaticojejunostomy.
PANCREAS: The pancreas is surgically absent.
SPLEEN: The spleen is surgically absent. Subcentimeter accessory spleens are
again noted.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The patient is status post gastrojejunostomy. There are
multiple dilated fluid and air-filled loops of small bowel measuring up to 3.5
cm (601:24, 601:17) with approach tapering in the left lower quadrant (02:59),
and collapse of small-bowel distally. The biliary limb is decompressed.
The large bowel contains large amount of stool and appears normal in caliber.
There is redemonstration of a left upper quadrant omental infarct (02:33).
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. Small-bowel obstruction with dilatation of the gastrojejunal limb and
transition point in the left lower quadrant, new since exam from 5 days ago.
Biliary limb is decompressed.
2. Status post pancreatectomy
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with NGTube// eval NGT placement
TECHNIQUE: Upright AP view of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Enteric tube is looped in the stomach with tip off of the inferior borders of
the film. Left-sided Port-A-Cath tip terminates at the SVC/right atrial
junction. Mild cardiac silhouette size enlargement is unchanged. Mediastinal
and hilar contours are similar. There is mild pulmonary vascular congestion
without pulmonary edema. Patchy atelectasis is seen in the lung bases, but no
focal consolidation. No pleural effusion or pneumothorax. Dextroscoliosis of
the thoracic spine is re-demonstrated along with multiple clips in the right
upper quadrant of the abdomen.
IMPRESSION:
Enteric tube is looped in the stomach with tip off of the inferior borders of
the film. Mild atelectasis in the lung bases and minimal pulmonary vascular
congestion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with NGT- pulled back 15cm from prior.// assess
NGT placement
TECHNIQUE: Semi-upright AP view of the chest
COMPARISON: None.
FINDINGS:
Enteric tube tip is now within the stomach. Left subclavian central venous
catheter tip terminates at the cavoatrial junction. Heart size is borderline
normal, unchanged. The mediastinal and hilar contours are normal. The
pulmonary vasculature is now within normal limits. Mild patchy atelectasis in
the lung bases. No pleural effusion or pneumothorax is seen. There are no
acute osseous abnormalities. Multiple clips are seen in the right upper
quadrant of the abdomen. Mild dextroscoliosis of the thoracic spine.
IMPRESSION:
Enteric tube tip within the stomach. Mild atelectasis in the lung bases.
Radiology Report
INDICATION: ___ year old woman total pancreatectomy, splenectomy, islet cell
tsp, CCY, multiple episodes bacteremia/recurrent C diff, p/w n/v, abdominal
pain, WBC 25, CT c/f partial SBO, given PO contrast.// ?progression of PO
contrast. Please obtain ___ at 00:30
TECHNIQUE: Abdomen portable one view
COMPARISON: CT abdomen ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel. Oral contrast
is seen diffusely within large bowel and rectum.
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 small-bowel obstruction.
There is contrast throughout a nondilated colon.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, Nausea, Transfer
Diagnosed with Fever, unspecified
temperature: 99.3
heartrate: 122.0
resprate: 18.0
o2sat: 99.0
sbp: 113.0
dbp: 80.0
level of pain: 6
level of acuity: 2.0 | Ms. ___ is an ___ F with PMH of cystic fibrosis c/b by
chronic pancreatitis s/p pancreatectomy in ___, and islet cell
transplant, jejunostomy, splenectomy, eating disorder and
multiple episodes of E coli bacteremia and recurrent C diff
infection, recent discharge for fever with presumed transient
bacteremia from gut translocation (discharged on Augmentin), now
presenting with fever, leukocytosis, and partial SBO obstruction
(relieved with NPO and NGT decompression).Infectious disease was
consulted to help manage her presumed chronic c.diff infection.
Her WBC count continued to rise to 39.0. Her abdominal exam
remained benign. ___ Transferred to
medicine for continued management of possible sepsis on IV
Flagyl
and for advancement of diet. Clinically stabilized, Flagyl d/c'd
per ID, diet advanced. Discharged on extended vancomycin taper.
ACUTE ISSUES:
===============
# Partial SBO: Unclear trigger although patient does have risk
factors of prior abdominal surgery including pancreatectomy and
jejunostomy. She was admitted to ___ for serial monitoring,
resolved with NPO and NGT. KUB on ___ showed no
evidence of small bowel obstruction. NGT removed, diet advanced
and tolerated. Home nausea medications continued.
# Leukocytosis: suspected to be secondary to SBO
# Sepsis, unclear source: History of transient sepsis (during
most recent admission) from gut translocation, prior E. coli
bacteremia on the admission before that. Improved with
antibiotics now HD stable, initially on Flagyl which was
discontinued per ID recs after clinical improvement, afebrile
with improving WBC. Continued on vancomycin with extended taper
per below. Blood cultures pending.
# Chronic diarrhea
# C. diff colitis
C diff toxin pending but notably patient has been on po
vancomycin for over a month and continued her po vancomycin
prophylactic dosing at most recent discharge, multiple stool
studies sent and pending upon discharge. ID consulted and
recommended d/c Flagyl given clinical improvement and extended
PO vancomycin taper given incomplete resolution of her symptoms.
c.diff toxin pending on d/c.
Vanc taper recs per ID as follows and outpatient ID f/u in ___
weeks.
125mg po q6h x 14 days
125mg po BID x 7 days
125mg po daily x 7 days
125mg po every other day x 8 days (4 doses)
125mg po every third day x 15 days (5 doses)
# Elevated LFTs: initially elevated, normalized on d/c.
CHRONIC ISSUES:
===============
#Chronic microcytic anemia
Hb b/l ___. Hb at baseline on admission. Receives IV iron q2
weeks. Will defer transfusions unless absolutely necessary given
frequent history of transfusions. No evidence of bleed while
admitted.
#Chronic pain: Continue suboxone 1 film QID and Continue Tylenol
PRN. Patient has history of gastritis on EGD in ___, avoided
NSAIDs
#Chronic nausea/vomiting. Continued home IV prochlorperazine
10mg q6h prn, continued home dicyclomine 10mg PO QID
#Hypothyroidism. Continued home levothyroxine 50mcg PO 6x/week,
100mcg PO 1x/wk
#Nutrition
#H/o eating disorder
#H/o J tube
Previously had J-tube placed at ___, couldn't tolerate and
removed in ___, followed by TPN c/b fungemia and discontinued
in ___. Difficulty maintaining adequate PO intake and had port
placed in ___ for IV fluids to maintain hydration. Tolerating
PO intake and diet here.
#H/o splenectomy. Ensure patient has augmentin on discharge,
plan to f/u with PCP to ensure up to date on appropriate
vaccines
#H/o pancreatectomy on creon as inpatient, restarted zenpep on
discharge
#Anxiety and depression
-Continued home mirtazapine
-Continued home paroxetine
-Briefly held prazosin in setting of hypotension, restarted
prior to discharge.
#migraine headache
- Continued home topiramate
- Did not require sumatriptan PRN for migraine
#GERD
- Continued home pantoprazole
# Health maintenance
- Continued home vit D, multivitamins
TRANSITIONAL ISSUES
===================
[] f/u with PCP: need to f/u to ensure vaccines are up-to-date
[] f/u pending blood cultures, c.diff toxin.
[] f/u with ID ___ weeks
NEW MEDICATIONS
None
CHANGED MEDICATIONS |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Gadolinium-Containing Agents
Attending: ___.
Chief Complaint:
cough and confusion
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with hx of HL, AS, DMII, mild "short term memory problems"
per son who presents with cough and confusion. Per the patient
he has had a nonproductive cough for about the last week, but
has worsened over the last 2 days, without chest pain or
difficulty breathing. Today he was noted to be confused by his
son and did not know what month he was in (he typically would
know this). He has had no fevers or chills. He has had no sick
contacts, not recently hospitalized, and no recent travel. He
has not had his flu shot yet this season.
In the ED intial vitals were: 100.2 90 144/69 16 96% though T
reached a max of 103. Exam showed an erythematous throat,
diminished breath sounds on right, with no meningimus and no
focal neurologic findings. Labs were significant for HCT 35.5,
lactate 2.4, and troponin 0.01. CXR showed no acute findings.
EKG demonstrated 1-2mm STD in I, II, v2-v6 and TWI in III, which
is similar to prior but just more pronounced. Patient was given:
1g acetaminophen, 325mg aspirin, and 750mg levofloxacin. Vitals
on transfer: 99.0 83 113/48 16 96% RA.
Upon arrival to the floor, he has no complaints and is
alert-oriented x3.
Review of Systems:
(+) per HPI
(-) fever, chills, sore throat, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
Anemia - documented by PCP, though pt denies
Abnormal EKG - Nonspecific ST-T wave abnormalities increasing
over years likely secondary to LVH ___.. RBBB ___
Dermatitis
DM II
HL
GERD
Hx syncope
B/l knee arthroscopies 1980s by history
Hx Bilateral achilles tendonitis
Hx L rotator cuff tear s/p surgery by Dr ___ at ___
___
Social History:
___
Family History:
Per OMR: Father died in his ___ of CVA. Paternal grandmother
with DM. Mother died at ___. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
ADMISSION EXAM:
Vitals-97.7 112/47 70 20 97 RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear and not
particularly erythematous. tonsils not enlarged.
Neck- supple
Lungs- Clear to auscultation bilaterally with minimal rhonchi at
the RLL, no wheezes, rales
CV- Regular rate and rhythm, with SEM at the LUSB, normal S1 +
S2
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:
VS: 97.9, 56, 123/56, 18, 100 on RA
GENERAL: asleep, comfortable, pleasant when aroused
HEENT: NC/AT, no head/neck lymphadenopathy, sclerae anicteric,
no conjunctival injection or pallor; oropharynx clear without
erythema or exudate; MMM
LUNGS: Clear to auscultation except minor crackles at b/l bases,
otherwise no w/r/r
HEART: RRR; III/VI SEM
ABDOMEN: NABS, soft/NT/ND.
EXTREMITIES: WWP
NEURO: awake, A&Ox3
Pertinent Results:
=============
ADMISSION LABS:
=============
___ 06:00PM BLOOD WBC-8.1 RBC-3.97* Hgb-12.4* Hct-35.5*
MCV-90 MCH-31.3 MCHC-35.0 RDW-12.8 Plt ___
___ 06:00PM BLOOD Neuts-82.4* Lymphs-8.8* Monos-6.4 Eos-1.9
Baso-0.7
___ 06:00PM BLOOD Glucose-120* UreaN-13 Creat-1.1 Na-139
K-3.7 Cl-102 HCO3-26 AnGap-15
___ 06:00PM BLOOD CK(CPK)-123
___ 06:00PM BLOOD CK-MB-2
___ 06:00PM BLOOD cTropnT-0.01
___ 06:00PM BLOOD Calcium-9.0 Phos-2.3* Mg-1.8
___ 06:22PM BLOOD Lactate-2.4*
=============
DISCHARGE LABS:
=============
___ 07:05AM BLOOD WBC-6.4 RBC-3.69* Hgb-11.4* Hct-33.7*
MCV-92 MCH-31.0 MCHC-33.9 RDW-13.5 Plt ___
___ 07:05AM BLOOD WBC-6.4 RBC-3.69* Hgb-11.4* Hct-33.7*
MCV-92 MCH-31.0 MCHC-33.9 RDW-13.5 Plt ___
___ 07:05AM BLOOD Glucose-88 UreaN-14 Creat-1.1 Na-139
K-4.4 Cl-103 HCO3-28 AnGap-12
___ 07:05AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.9
=============
OTHER RESULTS:
=============
___ 07:20AM BLOOD CK(CPK)-352*
___ 07:20AM BLOOD CK-MB-3 cTropnT-<0.01
___ 08:43AM BLOOD Lactate-1.6
___ 08:15PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 08:15PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 1:15 am Influenza A/B by ___
Source: Nasopharyngeal swab.
**FINAL REPORT ___
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Negative for Influenza B.
`
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO DAILY
2. GlyBURIDE 7.5 mg PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO DAILY
2. Levofloxacin 750 mg PO Q48H
End date ___.
RX *levofloxacin 750 mg 1 tablet(s) by mouth every other day
Disp #*2 Tablet Refills:*0
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
RX *albuterol sulfate 90 mcg ___ puffs every 4 hours Disp #*1
Inhaler Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Presumed community acquired pneumonia
Secondary diagnosis:
Diabetes mellitus, type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
___.
CLINICAL HISTORY: Cough, confusion, question pneumonia.
FINDINGS: PA and lateral views of the chest were provided. Lung volumes are
low, though given this, there is no definite evidence of pneumonia or CHF.
There is likely bibasilar atelectasis and bronchovascular crowding. No large
effusion or pneumothorax is seen. The cardiomediastinal silhouette appears
normal. Imaged osseous structures are intact. Anchors are noted in the left
humeral head. No free air below the right hemidiaphragm.
IMPRESSION: No acute findings in the chest.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: COUGH/WEAKNESS
Diagnosed with FEVER, UNSPECIFIED, COUGH
temperature: 100.2
heartrate: 90.0
resprate: 16.0
o2sat: 96.0
sbp: 144.0
dbp: 69.0
level of pain: 0
level of acuity: 3.0 | ___ year old gentleman with type 2 diabetes not on insulin who
presents with worsening nonproductive cough and confusion found
to be febrile to 103 in the emergency department.
# Presumed community-acquired pneumonia:
Fever and increased neutrophils on differential suggest
bacterial source of symptoms. Non-productive cough and clear
chest xray are more suggestive of viral URI. Influenza swab
negative. Blood cultures negative. UA benign. Patient was
started on levofloxacin for presumed community-acquired
pneumonia. His confusion resolved and he remained afebrile. His
cough remained unchanged. He was discharged the following day
to complete a five-day course of antibiotics. He declined home
___ services. He will follow-up with his PCP in two days.
# EKG changes:
On admission, EKG demonstarted more pronounced ST segment
depression in leads I, II, v2-v6 when compared with prior EKG in
___. There was unchanged right bundle branch block and t
wave inversion in lead III. Patient denied any chest pain or
dyspnea. He had two negative troponins, ad EKG changes resolved
in the morning without intervention.
# Diabetes mellitus, type 2:
Patient's glyburide was held on admission. Overnight he had an
episode of hypoglycemia that resolved with administration of
juice. In discussion with the PCP, it was decided to
discontinue the glyburide permanently.
# HL:
Patient continued on home statin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
left hemiarthroplasty
History of Present Illness:
___ F w dementia who presents from ALF/HD after a witnessed
mechanical fall. The patient was walking in the dining room and
tripped her a dustpan, landing on her R side. This was a
witnessed fall with no apparent loss of consciousness, however
the patient has dementia and does not recall the event and is
unable to give further history.
Pt initially presented to ___ where she had a CT that showed
a ___ R femoral neck fracture. She was originally to
be transferred to ___, but were concered about her medical
comorbidities and therefore transferred to ___.
Vitals in ___ ED: 97.2 85 121/61 16 95% ra. Initial labs in
the ED, chemistries, CBC were unremarkable. UA appars
contaminated.
Pt was given morphine for pain control in the ED and admitted to
the floor for further treatment. Ortho evaluated in the ED,
unable to view the CT scan from OSH so obtained plain films,
fracture now appears . Ortho also recommended ceftriaxone for
UTI which she received in ED. Admitted to medicine for pain
control. added on for hemiarthroplasty partial hip replacement,
would be able to walk after, now displaced. At baseline patient
is walking on flat ground with a walker, but not noted to be
limited by dyspnea or discomfort, can walk long hallways with no
problem. She has not climbed stairs in awhile.
On the floor, pt is repeating "oh my god" and is unable to
answer questions. She thinks she is in a forest and is not aware
of her name or the year.
REVIEW OF SYSTEMS:
(+):
(-): Chest pain, shortness of breath, cough, sputum production,
nausea, vomiting, diarrhea, abdominal pain, dysuria, urinary
urgency, urinary frequency, hematochezia, melena, visual
changes, numbness, weakness.
Past Medical History:
- Dementia, independent in getting dressed. AOx1 at baseline to
self. usually can recognize family, but usually not able to
engage in conversation
- Recurrent falls
- GERD
- Depression
- Chronic vertebral compression fractures (L2, T11)
- Recurrent UTIs
- rheumatic heart disease as a child
- breast cancer s/p mastectomy
Social History:
___
Family History:
___
Physical Exam:
Admission Physical:
GEN: sleeping comfortably in bed, AxOxself only. "brick
building" "not sure of year"
HEENT: NCAT, PERRL
NECK: supple, no lymphadenopathy
COR: RRR, nl s1, s2 no m/r/g
PULM: ctab auscultated anteriorly
___: soft, nt, nd +bs
EXT: no c/c/e, RLE shortened compared to left and ext rotated
NEURO: unable to cooperate with exam, cranial nerves grossly
intact. AOx1
Discharge Physical:
Afebrile, normotensive
GEN: calm, oriented to person
HEENT: MMM, OP clear
COR: RRR, nl s1, s2 no m/r/g
PULM: CTAB
___: soft, nt, nd +bs
EXT: bandage to R hip, staples intact, warm, dry, 2+ DP pulses
NEURO: unable to cooperate with exam, cranial nerves grossly
intact. AOx1
(pt's baseline oriented to self only)
Pertinent Results:
Admission Labs:
___ 10:20PM BLOOD ___
___ Plt ___
___ 10:20PM BLOOD ___
___
___ 10:20PM BLOOD ___
___
___ 07:47AM BLOOD ___
___ 10:20PM BLOOD ___
___ Plt ___
Hgb/Hct trend:
___ 07:47AM BLOOD ___
___ Plt ___
___ 06:00AM BLOOD ___
___ Plt ___
___ 06:05AM BLOOD ___
___ Plt ___
___ 06:05AM BLOOD ___
___ Plt ___
___ 03:35PM BLOOD ___
___ 06:10AM BLOOD ___
___ Plt ___
___ 06:10AM BLOOD ___
Pertinent labs:
___ 06:05AM BLOOD ___
___
___ 06:05AM BLOOD ___
Discharge Labs:
___ 06:10AM BLOOD ___
___ Plt ___
___ 06:10AM BLOOD ___
___
___ 06:10AM BLOOD ___
Imaging:
CXR ___:
FINDINGS: There are no old films available for comparison.
Right upper
quadrant clips are present. The right humerus is superiorly
subluxed. There is some increased opacity in the right inferior
hilum that could represent a calcified node. The right
paratracheal stripe is also prominent that could be due to
vascular changes or adenopathy. There are increased lung
markings at the right base, but no definite infiltrate. A
lateral film would be helpful when the patient is able.
Hip films ___: IMPRESSION: Persistent right subcapital
femoral neck fracture. If further evaluation is needed,
recommend comparison to the outside hospital CT.
Hip film ___ done in OR: HISTORY: Hemiarthroplasty.
SINGLE AP PORTABLE VIEW OF THE RIGHT HIP. The patient is status
post right hip hemiarthroplasty with femoral cerclage wire, in
overall anatomic alignment on this single view. Relative
lucency of the greater tuberosity is noted, but is likely
accentuated due to overlying postoperative air. On current
film, the possibility of a nondisplaced greater tuberosity
fracture cannot be excluded, but the greater tuberosity is
secured at its base by the cerclage wire. Attention to this
area on followup films is requested.
Microdata:
___ 3:48 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
PROBABLE ENTEROCOCCUS. ~1000/ML STRAIN 2.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=0.5 S
Repeat UCx ___:
___ 4:11 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. ___ ORGANISMS/ML..
SENSITIVITIES PERFORMED ON CULTURE # ___
___.
Pathology femur ___:
DIAGNOSIS:
Femoral head, arthroplasty:
Consistent with fracture
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Calcium Carbonate 500 mg PO TID
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth three times a day Disp #*90 Tablet Refills:*0
2. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
daily Disp #*60 Tablet Refills:*0
4. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*84 Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
HOLD if loose stools
RX *polyethylene glycol 3350 17 gram 17 gm by mouth daily Disp
#*30 Packet Refills:*0
7. Senna 2 TAB PO HS constipation
HOLD if loose stools
RX *sennosides [senna] 8.6 mg 2 tablets by mouth at bedtime Disp
#*60 Tablet Refills:*0
8. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
HOLD for sedation, RR<10
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*56 Tablet Refills:*0
9. Enoxaparin Sodium 40 mg SC DAILY
continue for at least 2 weeks until you see orthopedics in
___
RX *enoxaparin 40 mg/0.4 mL 40mg subcutaneously daily Disp #*20
Syringe Refills:*0
10. Quetiapine Fumarate 6.25 mg PO HS
HOLD for sedation
please give at 1800
RX *quetiapine 25 mg 0.25 tablet(s) by mouth at bedtime Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Hip fracture s/p hemiarthroplasty
Urinary tract infection, uncomplicated
Delirium
Anemia
Secondary:
Dementia
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
STUDY: AP pelvis and two views of the right hip ___.
Note, images were provided for review on ___.
COMPARISON: None available for review.
INDICATION: Right hip pain status post mechanical fall. Outside hospital CT
demonstrated non-displaced femoral neck fracture.
FINDINGS: Non-obstructed bowel gas pattern which obscures the bony detail of
the sacrum. Mild degenerative changes of the SI joints. Unremarkable pubic
symphysis. Incompletely evaluated severe degenerative changes of the lower
lumbar spine. The single AP view of the left hip is unremarkable. The right
hip is unremarkable. Again seen is a subtle linear lucency through the
subcapital region of the femoral neck, consistent with the known fracture. No
new fracture. No dislocation.
IMPRESSION: Persistent right subcapital femoral neck fracture. If further
evaluation is needed, recommend comparison to the outside hospital CT.
Radiology Report
CHEST ON ___
HISTORY: Hip fracture pre-op.
FINDINGS: There are no old films available for comparison. Right upper
quadrant clips are present. The right humerus is superiorly subluxed. There
is some increased opacity in the right inferior hilum that could represent a
calcified node. The right paratracheal stripe is also prominent that could be
due to vascular changes or adenopathy. There are increased lung markings at
the right base, but no definite infiltrate. A lateral film would be helpful
when the patient is able.
Radiology Report
HISTORY: Hemiarthroplasty.
SINGLE AP PORTABLE VIEW OF THE RIGHT HIP. The patient is status post right
hip hemiarthroplasty with femoral cerclage wire, in overall anatomic alignment
on this single view. Relative lucency of the greater tuberosity is noted, but
is likely accentuated due to overlying postoperative air. On current film,
the possibility of a nondisplaced greater tuberosity fracture cannot be
excluded, but the greater tuberosity is secured at its base by the cerclage
wire. Attention to this area on followup films is requested.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HIP FX
Diagnosed with FX NECK OF FEMUR NOS-CL, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE
temperature: 97.2
heartrate: 85.0
resprate: 16.0
o2sat: 95.0
sbp: 121.0
dbp: 61.0
level of pain: 13
level of acuity: 3.0 | Brief Course:
Ms. ___ is a ___ F with dementia presents from NH after a
witnessed fall that resulted in a ___ R femoral head
fracture, s/p left hemiarthroplasty. Her course was complicated
by enterococcal UTI and delirium. She was discharged back to her
assisted living with ___ and ___ services. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / skale fish
Attending: ___.
Chief Complaint:
Incarcerated incisional hernia w/ small bowel obstruction
Major Surgical or Invasive Procedure:
___: Exploratory laparotomy, extensive lysis of
adhesions taking over 90 minutes
Incisional hernia repair with component separation
and mesh placement.
Anterior Gastric nodule resection
History of Present Illness:
___ M w/ hx of bilateral TKA, complicated diverticulitis
(s/p sigmoid colectomy w/ diverting colostomy, s/p reversal
___,
___), c/b large ventral incisional hernia, who presents to ___
with nausea, vomiting, watery diarrhea, and poor PO intake. The
patient states that he ate a large meal last ___ and later
that evening experienced his first episode of emesis. The
patient
continued to experience symptoms throughout the week and noted
multiple episodes of watery diarrhea and found himself
incontinent at night. The patient denies any episodes of
obstipation of distention during this time. The patient denies
any prior similar episodes or any significant abdominal pain
associated with his current presentation. He denies any fevers,
chills, or recent sick contacts. On ___, the patient
underwent
CT scan at the recommendation of a close friend ___
gastroenterologist)and was found to have imaging concerning for
partial SBO.
Past Medical History:
PMH: TIA (___) no residual neurologic deficits, diverticulitis,
BPH
PSH: diveriticulitis s/p ___ and reversal (___),
osteoarthritis s/p bilateral total knee replacements
Social History:
___
Family History:
Family hx: noncontributory
Physical Exam:
P/E:
Vital Signs
GEN: WD, WN in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR,
PULM: no respiratory distress
BACK: no vertebral tenderness, no CVAT
ABD: soft, appropriate incisional tenderness, nondistended
EXT: WWP, no CCE, no tenderness, 2+ B/L ___
NEURO: A&Ox3, no focal neurologic deficits
Pertinent Results:
___ 03:30PM ___ PTT-26.0 ___
___ 03:06PM LACTATE-1.4
___ 02:55PM GLUCOSE-88 UREA N-15 CREAT-0.9 SODIUM-134
POTASSIUM-4.5 CHLORIDE-95* TOTAL CO2-24 ANION GAP-20
___ 02:55PM estGFR-Using this
___ 02:55PM ALT(SGPT)-20 AST(SGOT)-39 ALK PHOS-69 TOT
BILI-0.6
___ 02:55PM LIPASE-19
___ 02:55PM ALBUMIN-3.8
___ 02:55PM WBC-7.5 RBC-4.65 HGB-13.6* HCT-42.0 MCV-90
MCH-29.2 MCHC-32.4 RDW-13.0 RDWSD-43.1
___ 02:55PM NEUTS-63.2 LYMPHS-18.8* MONOS-15.6* EOS-1.6
BASOS-0.4 IM ___ AbsNeut-4.74 AbsLymp-1.41 AbsMono-1.17*
AbsEos-0.12 AbsBaso-0.03
___ 02:55PM PLT COUNT-251
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Terazosin 4 mg PO QHS
3. Pravastatin 40 mg PO QPM
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth Daily Disp #*30
Capsule Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) to six
(6) hours Disp #*50 Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. Pravastatin 40 mg PO QPM
7. Terazosin 4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Incarcerated incisional hernia with obstruction.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old man intubated // ETT and NGT positioning ETT
and NGT positioning
IMPRESSION:
COMPARED TO CHEST RADIOGRAPHS ___.
ET tube in standard placement. Nasogastric drainage tube passes below the
diaphragm and out of view. Borderline cardiomegaly unchanged. Borderline
vascular engorgement is chronic, exaggerated by even low lung volumes, but I
see no pulmonary edema. Pleural effusion is mild if any. Opacification in
the left lower lobe is most likely atelectasis. An apparent left upper lobe
lung nodule on one view clears on the second view, when an overlying device
most laterally indicating that it is instead an external artifact.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: N/V
Diagnosed with Unspecified intestinal obstruction
temperature: 97.4
heartrate: 89.0
resprate: 18.0
o2sat: 98.0
sbp: 177.0
dbp: 84.0
level of pain: 0
level of acuity: 2.0 | The patient presented on ___ for a symptoms of a small bowel
obstruction secondary to an incisional hernia. Thereafter, he
was admitted to the ___ surgery service for bowel rest,
resuscitation, and optimization. The patient underwent
exploratory laparotomy, lysis of adhesions, ventral hernia
repair with mesh, component separation, and gastric mass biopsy
on ___. Please see the full operative report for further
details. Thereafter, the patient was mildly hypotensive
postoperative and was left intubated and would be admitted to
the SICU for close clinical monitoring of his hemodynamics and
extubation. The patient was extubated uneventfully on ___.
The patient would transfer to the floor on ___.
#NEURO: The patient was alert and oriented throughout
hospitalization; pain was initially managed with PCA at low-dose
setting. Once the patient had return of bowel function he was
transitioned to an oral pain regimen.
#CV: The patient was initially hypotensive after his operation
and was taken to the SICU for close clinical monitoring. His
pressures improved with IVF resuscitation postoperatively. The
patient was noted to have ST depression on telemetry during his
SICU admission, but remained asymptomatic and hemodynamically
stable. The remainder of the ___ hospital
course was uneventful.
#PULMONARY: The patient remained stable from a pulmonary
standpoint after his extubation on ___ vital signs were
routinely monitored. Good pulmonary toilet, early ambulation and
incentive spirometry were encouraged throughout hospitalization.
#GI/GU/FEN: The patient had a foley placed intra-operatively for
close urine output monitoring. During his SICU course he
received IVF boluses for marginal UOP and responded
appropriately. The patient's foley catheter was removed on
___ and he would void without issue. The patient had an NGT
placed intraoperatively given his significant abdominal
operation. The NGT was clamped on ___ once the patient had
flatus. The patient would tolerate a clear liquid diet on
___. The patient was tolerating a regular diet prior to
discharge.
#ID: The patient's fever curves were closely watched for signs
of infection, of which there were none.
#HEME: Patient received BID SQH for DVT prophylaxis, in addition
to encouraging early ambulation and Venodyne compression
devices.
At the time of discharge, the patient's pain was well controlled
on oral pain medications, his mental status was at his baseline,
he was tolerating a regular diet and having bowel function. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
malaise, hematuria
Major Surgical or Invasive Procedure:
cystoscopy and transurethral resection of bladder tumor
History of Present Illness:
Mr. ___ was admitted to the urology service with malaise one
day prior to his scheduled cystoscopy/TURBT. He was started on
fluids and antibiotics and prepped for his scheduled procedure
in the OR.
Past Medical History:
Problem list:
1. gross hematuria
2. ___, CT a/p and cystoscopy --> right ureteral lesion
3. ___, TURBT Dr ___: HG, TCC Ta, attempted retrograde, right
sided-obstruction.
4. CT a/p from ___ showed a 4 cm right distal ureteral
lesion
suspicious for malignancy.
5. ___, TURBT showed papillary urothelial, Ta (muscle present)
6. In ED 3x post surgery, last on ___, for obstructed
catheter.
7. ___, TURBT large-sized bladder tumors. Right robotic
nephroureterectomy, instillation of Gemcytobine intravesical
chemotherapy.
8. Pathology: Bladder - high grade Papillary TCC, Ta (muscle
present). Right ureter - High grade, invasive papillary
urothelial carcinoma, T3, node and margin negative.
ABDOMINAL AORTIC ANEURYSM
CORONARY ARTERY DISEASE
DIABETES TYPE II
DIABETIC NEPHROPATHY
GASTRITIS
HYPERLIPIDEMIA
HYPERTENSION
OBESITY
OSTEOARTHRITIS
SKIN CANCERS
COLONIC POLYPS
DIABETIC RETINOPATHY
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
No history of MI, stroke, cardiac stents, DVT, or PE. He is not
on any long term anticoagulation. He had a negative stress test
in ___.
APPENDECTOMY
___ CYSTOSCOPY TRANSURETHRAL RESECTION BLADDER TUMOR WITH
BIPOLAR, LEFT URETERAL STENT PLACEMENT. ___
___ CYSTOSCOPY TURBT; LAPAROSCOPIC ROBOTIC RIGHT
NEPHROURETERECTOMY ___
___ CYSTOSCOPY TRANSURETHRAL RESECTION OF A BLADDER TUMOR
WITH BIPOLAR ___
___ CYSTOSCOPY, CLOT EVACUATION, resection bladder tumor ~
3cm and 2.5 cm. Bilateral retrogrades ___
___ ENDOVASCULAR ABDOMINAL AORTIC ANEURYSM REPAIR
Social History:
Country of Origin: ___
Marital status: Married
Children: Yes: 4
Lives with: ___
Lives in: House
Work: ___
Tobacco use: Former smoker
Year Quit: ___
Years Since ___
Quit:
Pack Years: 60
Alcohol use: Present
drinks per week: 12
Alcohol use beer
comments:
Depression: Based on a PHQ-2 evaluation, the patient
does not report symptoms of depression
Exercise: None
Seat belt/vehicle Always
restraint use:
Family History:
Mother ___ CANCER unsure what
___ cancer
Father ___ MYOCARDIAL
INFARCTION
Other Deceased DIABETES MELLITUS diabetis
paternanal
grandfather
Physical Exam:
Gen: resting in bed
Resp: conversing easily
Abd: soft nontender
GU: foley in place draining pyridium orange colored urine, no
clots
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Bacitracin Ointment 1 Appl TP QID
3. Docusate Sodium 100 mg PO BID
4. Senna 17.2 mg PO QHS
5. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
6. CARVedilol 25 mg PO BID
7. Furosemide 40 mg PO DAILY
8. Losartan Potassium 100 mg PO DAILY
9. MetFORMIN (Glucophage) 850 mg PO TID
10. Omeprazole 20 mg PO BID
11. Tiotropium Bromide 1 CAP IH DAILY
12. Atorvastatin 40 mg PO QPM
13. walker 1 ROLLING WALKER miscellaneous DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
3. Atorvastatin 40 mg PO QPM
4. Bacitracin Ointment 1 Appl TP QID
5. CARVedilol 25 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Furosemide 40 mg PO DAILY
8. Losartan Potassium 100 mg PO DAILY
9. MetFORMIN (Glucophage) 850 mg PO TID
10. Omeprazole 20 mg PO BID
11. Senna 17.2 mg PO QHS
12. Tiotropium Bromide 1 CAP IH DAILY
13. walker 1 ROLLING WALKER miscellaneous DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
bladder tumor
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 DoE. Eval acute process
TECHNIQUE: Chest PA and lateral
COMPARISON: Radiograph dated ___
FINDINGS:
Lungs are fully expanded. Previously seen hazy opacity at the left lung base
has resolved. No evidence for pneumothorax. No pleural effusion. No
consolidation to suggest pneumonia.
IMPRESSION:
No acute intrathoracic abnormality.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Hematuria
Diagnosed with Hematuria, unspecified, Anemia, unspecified
temperature: 98.0
heartrate: 74.0
resprate: 14.0
o2sat: 99.0
sbp: 111.0
dbp: 42.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ was admitted to the urology service the day prior to
his scheduled cystoscopy/TURBT. He was started on fluids and
antibiotics. He was then taken to the OR for his TURBT; please
see the operative note for further details. He recovered well
from the procedure and had no further hematuria. He did have
some bladder spasms overnight but otherwise recovered well. He
was discharged home with foley in place and will return to
clinic for a void trial in a week. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lactose
Attending: ___.
Chief Complaint:
Fevers, Myalgias and Malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with no significant past medical history is
coming in with ___ days of fevers and myalgias. Patient said
she had recently returned from a trip to ___ where she
travelled to ___, ___ and ___. She returned ___ days
prior to admission. 5 days prior to admission she developed
fatigue, but thought it was jet lag. ___ days prior to
admission, she developed fevers to 102, chills, sweats, and
agonizing back and hip pain that she described as feeling like
she was in a "vice grip". She also reported headache at the
time. ___ days prior to admission she also had elbow and hand
pain as well. She went to the ED 2 days prior to admission and
infectious work up was negative including smear for malaria and
there was plan for follow up in ___ clinic. She went home and
the day prior woke up feeling a little improved, but then later
that day, her symptoms came on with full force and so she called
her stepfather who brought her back to the ED.
Of note, prior to her travel she received a typhoid vaccine in
___. She was immune to measles, mumps, rubella. While in
___, she did not take malaria prophylaxis. She used tap water
to brush her teeth, but did not drink large amounts of it. She
also swam in the ocean and she felt it was very dirty (she said
she saw someone cleaning his behind near where she was swimming)
and she swallowed a lot of the water. She was also on a pig
farm and walked around barefoot. She had a few mosquito bites
while she was in ___. She has 2 cats at home. She has not
travelled anywhere else except maybe ___. She denies any
tick bites. She has not had any rashes during this acute
illness or in the recent past. No IV drug use. No recent
incarcerations, not sexually active for over a year and last HIV
test prior to that was negative. No recent sick contacts that
she is aware of. Works in an office.
On review of systems was positive as per HPI. In addition had
one episode of loose stools 2 days prior to admission as well as
some mild nausea.
She denies vomiting, urinary sx, edema, hematochezia,
photophobia, visual changes, rash or bruising.
In the ED, initial vitals: 103 89 117/62 18 100%. No physical
exam findings for meningitis. CXR negative. Initial labs
concerning for WBC 1.5 (N:73.5 L:20.8 M:4.8 E:0.2 Bas:0.7), ANC
1100. plt 104-->77, ALT 29-->60, AST 75-->114, LDH 366-->314.
Rpt U/A negative, Rpt smear negative, Blood cultures pending.
According to the ED note, they spoke with ___ (no
note from ID and could not find ___ in pager system)
from Infectious disease. Patient's symptoms are suspicious for
Salmonella infection and recommended 3g ceftriaxone one time
dose. Given patient's neutropenia from repeat CBC and high
fevers she will be admitted to the medicine service. Other
medications given were: zofran for nausea, toradol for fever and
myalgia. Vitals prior to transfer were: 98.3 73 ___ 100%.
10 point ros is otherwise negative, except per above
Past Medical History:
Anxiety
Social History:
___
Family History:
Mother past away from Multiple Myeloma in her ___. denies
family history of HTN, DM, HLD, CAD
Physical Exam:
Admission Exam:
VS - Temp 98.7F, BP: 115/85 , HR: 53, RR: 18, O2-sat 99% RA
GENERAL - NAD, comfortable, appropriate
HEENT - EOMI, sclerae anicteric, MMM, OP clear, no lesions
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
LYMPH Node: No axillary, cervical, supra/infraclavicular
adenopathy, shotty inguinal adenopathy on the right.
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
.
Discharge Exam:
Afebrile
GENERAL - NAD, comfortable, appropriate
HEENT - EOMI, sclerae anicteric, MMM, OP clear, no lesions
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
LYMPH Node: No axillary, cervical, supra/infraclavicular
adenopathy, shotty inguinal adenopathy on the right.
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
Pertinent Results:
CBC:
___ 02:40PM BLOOD WBC-1.5*# RBC-4.48 Hgb-14.3 Hct-40.5
MCV-90 MCH-31.9 MCHC-35.3* RDW-13.1 Plt ___
___ 04:20AM BLOOD WBC-3.6* RBC-4.15* Hgb-13.1 Hct-37.6
MCV-91 MCH-31.6 MCHC-34.9 RDW-12.8 Plt ___
___ 04:35AM BLOOD WBC-4.9 RBC-3.93* Hgb-12.3 Hct-35.8*
MCV-91 MCH-31.2 MCHC-34.3 RDW-12.9 Plt ___
DIFF:
___ 02:40PM BLOOD Neuts-73.5* ___ Monos-4.8 Eos-0.2
Baso-0.7
___ 04:35AM BLOOD Neuts-32* Bands-0 Lymphs-50* Monos-15*
Eos-0 Baso-0 ___ Myelos-0 Plasma-3*
BMP:
___ 02:40PM BLOOD Glucose-93 UreaN-5* Creat-0.8 Na-136
K-3.5 Cl-99 HCO3-24 AnGap-17
___ 04:35AM BLOOD Glucose-83 UreaN-7 Creat-0.7 Na-142 K-4.2
Cl-107 HCO3-29 AnGap-10
LFT:
___ 02:40PM BLOOD ALT-29 AST-75* LD(LDH)-366* AlkPhos-55
TotBili-0.3
___ 04:15AM BLOOD ALT-87* AST-84* AlkPhos-47 TotBili-0.4
ELECTROLYTES:
___ 04:20AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.0
___ 04:35AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.2
MISC:
___ 04:15AM BLOOD HAV Ab-POSITIVE
___ 09:40AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
___ 04:20AM BLOOD HIV Ab-NEGATIVE
___ 09:40AM BLOOD HCV Ab-NEGATIVE
MICRO:
CHIKUNGUNYA IGG SCREEN NEGATIVE
CHIKUNGUNYA IGM SCREEN NEGATIVE
LEPTOSPIRA AB SCREEN NEGATIVE
W/REFLEX TO TITER
Test Result Reference
Range/Units
A. PHAGOCYTOPHILUM IGG <1:64 <1:64
A. PHAGOCYTOPHILUM IGM <1:20 <1:20
___ VIRUS VCA-IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS VCA-IgM AB (Final ___:
NEGATIVE <1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
In most populations, 90% of adults have been infected at
sometime
with EBV and will have measurable VCA IgG and EBNA
antibodies.
Antibodies to EBNA develop ___ weeks after primary
infection and
remain present for life. Presence of VCA IgM antibodies
indicates
recent primary infection.
___ 8:15 pm SEROLOGY/BLOOD
**FINAL REPORT ___
LYME SEROLOGY (Final ___:
NO ANTIBODY TO B. BURG___ DETECTED BY EIA.
Reference Range: No antibody detected.
Negative results do not rule out B. burg___ infection.
Patients
in early stages of infection or on antibiotic therapy may
not produce
detectable levels of antibody. Patients with clinical
history and/or
symptoms suggestive of lyme disease should be retested in
___ weeks.
___ 5:36 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
___ 5:32 am STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
FEW POLYMORPHONUCLEAR LEUKOCYTES.
___ 4:20 am IMMUNOLOGY
**FINAL REPORT ___
HIV-1 Viral Load/Ultrasensitive (Final ___:
HIV-1 RNA is not detected.
___ 4:15 am Immunology (CMV)
**FINAL REPORT ___
CMV Viral Load (Final ___:
CMV DNA not detected.
Time Taken Not Noted Log-In Date/Time: ___ 9:38 am
Blood (CMV AB) CHEM # ___ ___.
**FINAL REPORT ___
CMV IgG ANTIBODY (Final ___:
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
37 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
IMAGING:
___ CXR:
FINDINGS: PA and lateral views of the chest. No prior. The
lungs are clear. Cardiomediastinal silhouette is within normal
limits. Osseous and soft tissue structures are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
___ RUQ U/S:
FINDINGS:
The liver does not show any focal lesions or structural
abnormality. There is no intrahepatic or extrahepatic biliary
dilatation. The gallbladder appears normal with no wall
thickening and no stones. The pancreas appears unremarkable
with no focal lesions or ductal dilatation. Common bile duct
measures 0.54 cm and the main portal vein is patent with
hepatopetal flow. The right kidney measures 10.7 cm and the left
kidney measures 10.3 cm. There is no hydronephrosis. The
spleen is 10.9 cm and has homogeneous echotexture. The
visualized portions of the aorta and inferior vena cava are
unremarkable.
.
___ 04:20
DENGUE FEVER ANTIBODIES (IGG, IGM)
Test Name In Range Out of Range
Reference Range
--------- -------- ------------
---------------
Dengue Fever Antibodies (IgG, IgM)
Dengue Fever IgG 3.13 H
<0.90
Dengue Fever IgM 4.90 H
<0.90
Interpretation:
These assays detect both IgG and IgM class antibodies against
all four
Dengue fever virus types. Except for very early IgM responses,
the immune
response to Dengue fever is not type specific. Therefore, type
specific
reactions are not reported. As with most serological assays,
paired testing
of acute and convalescent samples is preferred. This is
especially important
when the acute phase sample is taken within the first six days
following onset.
In most patients, Dengue antibodies are detectable after the
sixth day
following the onset of symptoms. Crossreactivity with other
flaviviruses is
known to occur. The extent and degree of crossreaction varies.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Propranolol LA 60 mg PO DAILY
2. Lorazepam 0.5 mg PO Q4H:PRN anxiety
3. EpiPen *NF* (EPINEPHrine) 0.3 mg/0.3 mL Injection PRN
Anaphylaxis
Discharge Medications:
1. Lorazepam 0.5 mg PO Q4H:PRN anxiety
2. EpiPen *NF* (EPINEPHrine) 0.3 mg/0.3 mL Injection PRN
Anaphylaxis
3. Propranolol LA 60 mg PO DAILY
4. Meclizine 12.5 mg PO TID
RX *meclizine [Antivert] 12.5 mg 1 tablet(s) by mouth three
times a day Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Viral Illness, likely dengue fever
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS: ___
HISTORY: ___ female with fever to 103.
FINDINGS: PA and lateral views of the chest. No prior. The lungs are clear.
Cardiomediastinal silhouette is within normal limits. Osseous and soft tissue
structures are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ woman with fevers, myalgias, abdominal pain and
abnormal LFTs with neutropenia and thrombocytopenia and recent travel to
___. Rule out pyogenic liver abscess.
COMPARISON: None available.
TECHNIQUE: Gray-scale and color Doppler ultrasound images of the abdomen were
obtained.
FINDINGS:
The liver does not show any focal lesions or structural abnormality. There is
no intrahepatic or extrahepatic biliary dilatation. The gallbladder appears
normal with no wall thickening and no stones. The pancreas appears
unremarkable with no focal lesions or ductal dilatation. Common bile duct
measures 0.54 cm and the main portal vein is patent with hepatopetal flow.
The right kidney measures 10.7 cm and the left kidney measures 10.3 cm. There
is no hydronephrosis. The spleen is 10.9 cm and has homogeneous echotexture.
The visualized portions of the aorta and inferior vena cava are unremarkable.
IMPRESSION:
No focal liver lesions identified.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: PAIN
Diagnosed with FEVER, UNSPECIFIED
temperature: 103.0
heartrate: 89.0
resprate: 18.0
o2sat: 100.0
sbp: 117.0
dbp: 62.0
level of pain: 4
level of acuity: 3.0 | ___ year old female with no significant past medical history and
recent trip to ___ presenting from home with 4 days of fever
and myalgias with and new neutropenia and thrombocytopenia
concerning for an acute viral process, with positive dengue
serology.
# Fevers, myalgias, hematologic abnormalities likely due to
dengue fever:
Concerning for acute viral process. Differential diagnosis
includes Influenza, EBV, HIV, Chikungunya (although tends to
involve joints and with rash), Dengue fever, rickettsial
diseases, leptospirosis and Typhoid and paratyphoid infection.
We considered a malignant process although much less likely
given her recent history. Given acute febrile illness, recent
travel, headache, myalgias, leukopenia, thrombocytopenia,
elevated AST concerning most for dengue fever(in addition to
positive serology). We sent off an array of labs and consulted
ID for any further work up that may be necessary. She was
placed on cefepime on day 1 and then her ANC was increasing and
so it was discontinued. She then had a blood culture bottle
positive with GPC and vancomycin was added and then stopped when
the culture speciated coag negative staph. RUQ U/S was also
unremarkable. Her ANC increased to 1590, her thrombocytopenia
resolved and her LFT abnormalities also trended towards normal.
In terms of diagnostic work up, at the time of discharge,
nothing was positive but several days after, dengue serology
came back positive. At the time of writing this summary her HIV
ab and VL were negative. EBV IgG was positive, but IgM was
negative. CMV IgG was positive, but VL and IgM was negative,
Chikungunya IgM/IgG was negative, anaplasma - negative, lyme -
negative, hepatitis serologies negative. Babesia smear was
negative and malaria smear was negative. The patient showed no
active signs of bleeding during her course at ___.
.
# LFT abnormalities: AST>ALT with close to 2:1 ration. Patient
denies alcohol intake. No new medications. Could also see this
in muscle injury and cirrhosis. RUQ U/S was normal and GGT and
CK were unrevealing. Her LFT were trending down at the time of
discharge.
# Neutropenia and thrombocytopenia: Likely ___ viral infection
(dengue fever). Bandemia 6%, and other thing to consider is
hematologic malignancy, but given her HPI, infectious process in
more likely etiology. She does have a family history of
hematologic malignancy so must keep it in the differential at
this time. No anemia so HUS or DIC much less likely. See above
for management.
# Dizziness: On HD 4, the patient was complaining of
intermittent light headedness and difficulty reading. Neuro
exam with without focal abnormalities. ___ negative.
Orthostatics was negative as well. Her symptoms were not severe
and she was given a script of meclizine to take on a PRN basis.
She was not that interested in taking this medication, but I
told her she did not have to take it, but if she wanted to try
it she could. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin / celecoxib / ketorolac / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
fatigue / weakness
Major Surgical or Invasive Procedure:
esophagogastroduodenoscopy (EGD) ___
History of Present Illness:
I have read and agree with the MICU admission note as
documented,
and agree with transfer of patient to the medicine service. In
brief, this is a ___ woman with PMHx notable for COPD,
atrial fibrillation (not on home anti-coagulation),
hypertension,
and hyperlipidemia who initially presented to ___
___
for weakness and transferred to ___ for acute liver and renal
failure.
Initially presented to OSH for fatigue and weakness and was
diagnosed with a UTI for which she received an antibiotic. Given
persistence of symptoms she returned to the OSH where she was
discovered to have severe lab abnormalities prompting transfer
to
___.
Upon arrival to ED patient had single episode of coffee ground
emesis prompting urgent endoscopy which revealed gastric and
esophageal erosions. Evaluated by hepatology and liver
transplant
who recommended monitoring in the MICU.
Past Medical History:
epilepsy
hypertension
hyperlipidemia
arthritis
depression
stroke
asthma
atrial fibrillation
COPD
"enlargement of neck"
Past Surgical History:
laparoscopic cholecystectomy
C-section
shoulder replacement
orthopedic procedures on back, knee, hip (unspecified)
colonoscopy
Social History:
___
Family History:
No history of liver or GI disease per family
Physical Exam:
ADMISSION EXAM
=============================
GEN: A&O, appears tired, +asterixis
HEENT: No scleral icterus, mucus membranes moist, +repetitive
lip
smacking
CV: irregularly irregular per ED monitor, rate controlled
PULM: nonlabored respirations
ABD: Soft, nondistended, nontender, no rebound or guarding, no
palpable masses, no liver edge palpated
Ext: No ___ edema, ___ warm and well perfused
DISCHARGE EXAM
=============================
Vital signs stable
General: Thin, elderly appearing woman in no acute distress.
Comfortable.
Neuro: AAOx3. Dysarthric speech (baseline)
HEENT: Normocephalic, atraumatic. MMM.
Cardiac: Regular rate & rhythm. Normal S1/S2. II/VI holosystolic
murmur present.
Pulmonary: Fine crackles at the inferior and mid-lung fields
bilaterally.
Abdomen: Soft, non-tender, non-distended. no rebound/guarding
Extremities: Warm, well perfused, non-edematous.
Pertinent Results:
ADMISSION LABS
============================
___ 09:03PM BLOOD WBC-10.4* RBC-3.28* Hgb-11.0* Hct-32.6*
MCV-99* MCH-33.5* MCHC-33.7 RDW-16.2* RDWSD-59.2* Plt ___
___ 09:03PM BLOOD Neuts-95.1* Lymphs-1.7* Monos-2.6*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-9.90* AbsLymp-0.18*
AbsMono-0.27 AbsEos-0.00* AbsBaso-0.01
___ 09:03PM BLOOD ___ PTT-35.3 ___
___ 09:03PM BLOOD Plt ___
___ 09:03PM BLOOD Glucose-70 UreaN-48* Creat-2.5* Na-141
K-4.6 Cl-100 HCO3-19* AnGap-22*
___ 09:03PM BLOOD ALT-4191* AST-8226* LD(LDH)-4825*
CK(CPK)-154 AlkPhos-201* TotBili-1.6*
___ 09:03PM BLOOD Albumin-4.0 Iron-97
___ 09:03PM BLOOD calTIBC-202* ___ TRF-155*
___ 09:03PM BLOOD TSH-0.25*
___ 09:03PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:36AM URINE Color-Yellow Appear-Hazy* Sp ___
___ 07:36AM URINE Blood-SM* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR*
___ 07:36AM URINE RBC-2 WBC-9* Bacteri-FEW* Yeast-NONE
Epi-1 TransE-1
___ 07:36AM URINE CastHy-38*
___ 07:36AM URINE AmorphX-OCC*
___ 07:36AM URINE WBC Clm-FEW* Mucous-RARE*
___ 01:38AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
PERTINENT LABS
============================
___ 06:20AM BLOOD WBC-4.7 RBC-2.67* Hgb-8.9* Hct-27.1*
MCV-102* MCH-33.3* MCHC-32.8 RDW-16.5* RDWSD-59.4* Plt ___
___ 04:50PM BLOOD ___
___ 06:30AM BLOOD ___ PTT-32.6 ___
___ 06:20AM BLOOD ___ PTT-32.6 ___
___ 06:20AM BLOOD ___ PTT-33.5 ___
___ 09:03PM BLOOD Glucose-70 UreaN-48* Creat-2.5* Na-141
K-4.6 Cl-100 HCO3-19* AnGap-22*
___ 06:20AM BLOOD Glucose-76 UreaN-9 Creat-0.4 Na-144 K-4.0
Cl-107 HCO3-27 AnGap-10
___ 09:03PM BLOOD ALT-4191* AST-8226* LD(___)-4825*
CK(CPK)-154 AlkPhos-201* TotBili-1.6*
___ 07:40AM BLOOD ALT-2956* AST-4465* LD(LDH)-1519*
AlkPhos-169* TotBili-1.3
___ 03:19PM BLOOD ALT-2398* AST-2870* LD(___)-513*
AlkPhos-166* TotBili-1.7*
___ 06:45AM BLOOD ALT-1652* AST-1112* LD(LDH)-258*
AlkPhos-147* TotBili-2.1*
___ 06:30AM BLOOD ALT-1202* AST-364* LD(LDH)-215
AlkPhos-145* TotBili-2.6*
___ 06:20AM BLOOD ALT-882* AST-156* LD(___)-210
AlkPhos-149* TotBili-2.1*
___ 06:20AM BLOOD ALT-637* AST-78* LD(LDH)-216 AlkPhos-142*
TotBili-1.7*
___ 06:20AM BLOOD Albumin-3.2* Calcium-8.8 Phos-3.0 Mg-1.6
___ 04:50PM BLOOD VitB12-1885* Folate-20
___ 09:03PM BLOOD calTIBC-202* ___ TRF-155*
___ 07:40AM BLOOD Hapto-55
___ 09:03PM BLOOD TSH-0.25*
___ 06:45AM BLOOD T3-39* Free T4-1.2
___ 04:50PM BLOOD HBsAg-NEG HBcAb-NEG
___ 07:40AM BLOOD IgM HAV-NEG
___ 09:03PM BLOOD HBsAb-NEG HAV Ab-POS*
___ 09:03PM BLOOD AMA-NEGATIVE Smooth-POSITIVE*
___ 09:03PM BLOOD ___
___ 09:03PM BLOOD IgG-441* IgA-90 IgM-37*
___ 09:03PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:03PM BLOOD HCV Ab-NEG
___ 09:03PM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 (IGG)-Test
___ 01:38AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
DISCHARGE LABS
============================
___ 06:20AM BLOOD WBC-4.7 RBC-2.67* Hgb-8.9* Hct-27.1*
MCV-102* MCH-33.3* MCHC-32.8 RDW-16.5* RDWSD-59.4* Plt ___
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD ___ PTT-33.5 ___
___ 06:20AM BLOOD Glucose-76 UreaN-9 Creat-0.4 Na-144 K-4.0
Cl-107 HCO3-27 AnGap-10
___ 06:20AM BLOOD ALT-637* AST-78* LD(LDH)-216 AlkPhos-142*
TotBili-1.7*
___ 06:20AM BLOOD Albumin-3.2* Calcium-8.8 Phos-3.0 Mg-1.6
PERTINENT STUDIES
============================
RUQUS (___)
1. Patient is status post cholecystectomy with mild intrahepatic
biliary
ductal dilation. The common hepatic duct measures 10 mm and
there is a 4 mm
echogenic shadowing structure in the distal common bile duct
likely
representing choledocholithiasis. Recommend further evaluation
with MRCP.
2. 2.2 cm echogenic lesion in the right hepatic lobe likely
represents
hemangioma. Further evaluation can be obtained during follow-up
MRCP.
3. The main portal and right portal vein branches are patent
with hepatopetal
flow. The left portal vein is patent with hepatofugal flow.
MRCP (___)
Mild intrahepatic ductal dilatation and dilatation of the common
bile duct
measuring up to 10 mm. There is a 3-4 mm stone in the distal
common bile duct, confirmatory of the recent ultrasound. 2 cm
lesion right lobe liver with imaging characteristics most
compatible with a hemangioma.
MICRO
============================
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ VIRUS VCA-IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS VCA-IgM AB (Final ___:
NEGATIVE <1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
In most populations, 90% of adults have been infected at
sometime
with EBV and will have measurable VCA IgG and EBNA
antibodies.
Antibodies to EBNA develop ___ weeks after primary
infection and
remain present for life. Presence of VCA IgM antibodies
indicates
recent primary infection.
CMV IgG ANTIBODY (Final ___:
NEGATIVE FOR CMV IgG ANTIBODY BY EIA.
<4 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
If acute infection is suspected request IgM antibody
testing and/or
submit convalescent serum in ___ weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Pravastatin 80 mg PO QPM
3. LamoTRIgine 50 mg PO BID
4. LevETIRAcetam 750 mg PO BID
5. Ondansetron 4 mg PO Q8H:PRN nausea
6. FoLIC Acid 1 mg PO DAILY
7. Losartan Potassium 50 mg PO DAILY
8. Metoprolol Succinate XL 12.5 mg PO DAILY
9. Oxazepam 10 mg PO DAILY
10. Gabapentin 300 mg PO QID
11. carisoprodol 350 mg oral TID:PRN
12. Ferrous Sulfate 325 mg PO DAILY
13. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
14. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
15. Sertraline 50 mg PO DAILY
16. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
17. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID:PRN
15MLS TO THE MOUTH OR THROAT TWICE A DAY FOR 14 DAYS
Discharge Medications:
1. Pantoprazole 40 mg PO Q12H
2. Sucralfate 1 gm PO QID
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. carisoprodol 350 mg oral TID:PRN muscle spasm
RX *carisoprodol 350 mg 1 tablet(s) by mouth three times daily
Disp #*10 Tablet Refills:*0
5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID:PRN
15MLS TO THE MOUTH OR THROAT TWICE A DAY FOR 14 DAYS
6. Clopidogrel 75 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Gabapentin 300 mg PO QID
10. LamoTRIgine 50 mg PO BID
11. LevETIRAcetam 750 mg PO BID
12. Metoprolol Succinate XL 12.5 mg PO DAILY
13. Ondansetron 4 mg PO Q8H:PRN nausea
14. Oxazepam 10 mg PO DAILY
RX *oxazepam 10 mg 1 capsule(s) by mouth daily Disp #*3 Capsule
Refills:*0
15. Pravastatin 80 mg PO QPM
16. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
17. Sertraline 50 mg PO DAILY
18. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth q8 hours Disp #*10
Tablet Refills:*0
19. HELD- Losartan Potassium 50 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until you discuss with
your regular doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
acute liver failure
SECONDARY DIAGNOSES
acute renal failure
esophagitis
acute upper GI bleed
choledocholithiasis
anemia
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
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with acute liver failure// Liver pathology?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. There is a 2.2 cm
echogenic lesion in the right hepatic lobe, with no mass clarity within it.
The main portal and right portal vein branches are patent with hepatopetal
flow. The left portal vein is patent with hepatofugal flow. There is no
ascites.
BILE DUCTS: There is mild intrahepatic biliary dilation. The CHD measures 10
mm and there is a 4 mm echogenic foci with posterior shadowing in the distal
common bile duct.
GALLBLADDER: The patient is status post cholecystectomy.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 9.2 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. Patient is status post cholecystectomy with mild intrahepatic biliary
ductal dilation. The common hepatic duct measures 10 mm and there is a 4 mm
echogenic shadowing structure in the distal common bile duct likely
representing choledocholithiasis. Recommend further evaluation with MRCP.
2. 2.2 cm echogenic lesion in the right hepatic lobe likely represents
hemangioma. Further evaluation can be obtained during follow-up MRCP.
3. The main portal and right portal vein branches are patent with hepatopetal
flow. The left portal vein is patent with hepatofugal flow.
RECOMMENDATION(S): MRCP. The right lobe 2.2 cm echogenic lesion will also be
better characterized on the MRI.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 10:09 am, 15 minutes
after discovery of the findings.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with weakness// Pneumonia, effusions?
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are
unremarkable. Right shoulder arthroplasty noted. Mid thoracic level
vertebroplasty changes noted.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ PMHx COPD, atrial fibrillation (not on home
anti-coagulation), hypertension, and hyperlipidemia who initially presented to
OSH for weakness and transferred to ___ for acute liver and renal failure.
Course complicated by single episode hematemesis but otherwise hemodynamically
stable with improving liver and renal function. RUQ U/S showing "patient is
status post cholecystectomy with mild intrahepatic biliary ductal dilation.
The common hepatic duct measures 10 mm and there is a 4 mm echogenic shadowing
structure in the distal common bile duct likely representing
choledocholithiasis.
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 5 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: Ultrasound of the abdomen ___
FINDINGS:
Lower Thorax: The heart is normal in size. The lung bases are not adequately
visualized secondary to motion degradation.
Liver: There is a 2 cm subcapsular lesion in the right lobe of the liver which
is hyperechoic on ultrasound and demonstrates peripheral nodular enhancement
on today's study. Findings are most compatible with a hemangioma. There is a
2 x 2.6 cm subcapsular area enhancement in the dome of the liver, likely a
vascular shunt.
Biliary: There is mild intrahepatic ductal dilatation. The common bile duct
is dilated measuring 10 mm. There is a 3-4 mm stone in the distal common bile
duct, confirmatory of the recent ultrasound. This is seen best on series 4,
image 24 and on coronal 3D series 5, image 43.
Pancreas: The pancreas is not adequately evaluated secondary to
misregistration artifact due to respiratory motion. The common bile duct is
not dilated.
Spleen: The spleen is normal in size.
Adrenal Glands: No adrenal masses are evident
Kidneys: The kidneys are symmetric in size; there is no hydronephrosis.
Gastrointestinal Tract: There is no gross small bowel dilatation however
evaluation is compromised by motion degradation.
Lymph Nodes: There is no bulky para-aortic adenopathy.
Vasculature: The aorta maintains normal caliber.
Osseous and Soft Tissue Structures: Degenerative changes are noted in the
spine.
IMPRESSION:
Mild intrahepatic ductal dilatation and dilatation of the common bile duct
measuring up to 10 mm.
There is a 3-4 mm stone in the distal common bile duct, confirmatory of the
recent ultrasound.
2 cm lesion right lobe liver with imaging characteristics most compatible with
a hemangioma.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal labs, Weakness, Transfer
Diagnosed with Weakness
temperature: 96.8
heartrate: 90.0
resprate: 15.0
o2sat: 98.0
sbp: 110.0
dbp: 69.0
level of pain: 0
level of acuity: 2.0 | ___ woman with PMHx notable for COPD, atrial
fibrillation (not on home anti-coagulation), hypertension, and
hyperlipidemia who initially presented to ___
for weakness and transferred to ___ for acute liver and renal
failure. Course complicated by single episode hematemesis s/p
EGD but otherwise remained hemodynamically stable. Liver and
kidney function rapidly improved with fluids and supportive
care. Evaluated by physical therapy who recommended discharge to
rehab.
# ACUTE LIVER FAILURE / SHOCK LIVER
Initially presented to outside hospital for fatigue in setting
of outpatient treatment for UTI where was discovered to have
markedly abnormal LFTs (AST/ALT in thousands). Transferred to
___ where imaging and laboratory workup was negative for
thrombosis, acute viral hepatitis, auto-immune hepatitis, or
other acute cause other than likely shock liver from hypotension
from urosepsis. Admitted to the ICU where tox-screen notable for
low-level Tylenol and so received N-acetylcysteine gtt, however
this was not felt to be significant contributor to acute liver
failure. LFTs rapidly improved with treatment of UTI and fluids.
RUQUS and MRCP without evidence of cirrhosis, though did note
4mm stone in distal bile duct. Per ERCP service this was also
unlikely to be a major cause of acute liver failure and so was
discharged with plan for outpatient follow up for ERCP at a
later date. LFTs rapidly improved and were approach normal range
by time of discharge.
# HEMATEMESIS
Upon arrival to ___ had single episode of coffee ground
emesis. Underwent EGD notable for esophagitis though no evidence
of varices or active bleeding. Started octreotide (later
discontinued) and PPI (to be continued at discharge). Did not
have any recurrent episodes of hemoptysis. CBC stable.
# ACUTE RENAL FAILURE
Presented with acutely elevated Cr to 2.5. Improved to 0.4 by
time of discharge with fluids and PO intake. Likely pre-renal in
setting of shock liver.
# UTI
UA notable for bacteria and pyuria. Also with increased urinary
frequency, no dysuria. Urine culture with mixed flora. Completed
course of ceftriaxone ___ - ___.
# FATIGUE / WEAKNESS
In setting of acute hepatitis, UTI, uremia due to ___. CK
normal. ___ recommended discharge to rehab.
# COAGULOPATHY
Elevated INR in setting of acute liver failure. Received IV
vitamin K and FFP. INR approaching normal with resolution of
acute liver failure.
CHRONIC / STABLE ISSUES
============================
# ATRIAL FIBRILLATION
Reported history though currently in sinus rhythm. Not on home
anti-coagulation. Continued home metoprolol.
# ASTHMA
- albuterol prn
# SEIZURE DISORDER
- continued home levatiracetam
- continued home lamotrigine
# HYPERTENSION
Held losartan in setting of GI bleed. Blood pressure remained
normotensive for remainder of hospitalization and so held at
discharge.
# HYPERLIPIDEMIA
- continued home pravastatin
# DEPRESSION
- continued home sertraline
# Hx STROKE
Dysarthric at baseline. No other focal deficits.
- Holding ASA and Plavix in setting of GI bleed. Continue
statin.
TRANSITIONAL ISSUES
================================= |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left leg pain
Major Surgical or Invasive Procedure:
1. Irrigation debridement of traumatic lacerations, left lower
extremity skin to muscle with excision of dead tissue and
foreign bodies.
2. Open primary repair of tibialis anterior tendon, left lower
extremity.
3. Open repair of peroneus brevis tendon, left lower extremity.
4. Open repair of left peroneus longus tendon, left lower
extremity.
5. Closure of complex wound, left lower extremity.
History of Present Illness:
___ with ___ notable for motorcycle injury s/p pelvic, ulna,
clavicle, radius fracture, & bilateral lung collapse, with new
motorcycle injury to LLE c/w 3 deep lacerations on lower left
fibula.
Patient reports he was pulling out on his motorcycle of a gas
station when a car driving ___ mph hit him. His leg was pushed
between his motorcycle and the bumper of the car. He deeply
lacerated his left leg in 3 locations and superficially
scratched his left arm. He rates his leg pain as ___. He
denies falling on any additional body parts. He was wearing a
helmet at the time. He denies alcohol or drug use. He denies
back pain, hip pain, tingling, numbness, dizziness, fatigue.
He was taken to ___ where he had CXR,
Pelvis, and FAST done reported as negative; no fracture reported
of left lower extremity. He was transferred to ___ for further
management of deep lacerations with possible foreign body.
Past Medical History:
Motorcycle Crash - ___ years ago, multiple surgeries
Past Surgical History:
-Pelvic Fracture s/p metal plate: ___ years ago motorcycle injury
-Ulna and Radius Fracture: ___ years ago motorcycle injury
-Clavicle Fracture: ___ years ago motorcycle injury
-Bilateral Lung Collapse: ___ years ago motorcycle injury
-Reported Open heart surgery without intervention: ___ years ago
motorcycle injury
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
Temp: 97.0 HR: 115 BP: 121/92 Resp: 18 O(2)Sat: 99 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft
Extr/Back: LLE with splint, large lacerations x 3 into
muscle
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood
Discharge Phsycial Exam:
VS: 98.3, 89, 124/82, 16, 99 RA
Gen: Awake, alert, sitting up in bed.
HEENT: No deformity. PERRL, EOMI. neck supple, trachea midline.
Mucus membranes pink moist.
CV: RRR
Pulm: Clear bilaterally
Abd: Soft, non-tender, non-distended. Active Bowel sounds x 4
quadrants.
Ext: Warm and dry. LLE with ace wrap. sensation intact. 2+ ___
pulses. Hard boot to LLE.
Neuro: A&Ox3. Follows commands and moves all extremities equal
and strong. Speech is clear and fluent.
Pertinent Results:
___ 01:22PM BLOOD WBC-10.0 RBC-3.01* Hgb-9.4* Hct-27.7*
MCV-92 MCH-31.2 MCHC-33.9 RDW-12.6 RDWSD-41.4 Plt ___
___ 04:10AM BLOOD WBC-11.4* RBC-3.10*# Hgb-9.4*# Hct-28.8*
MCV-93 MCH-30.3 MCHC-32.6 RDW-12.8 RDWSD-43.3 Plt ___
___ 10:05PM BLOOD WBC-19.9* RBC-4.16* Hgb-12.8* Hct-38.3*
MCV-92 MCH-30.8 MCHC-33.4 RDW-12.6 RDWSD-42.4 Plt ___
___ 10:05PM BLOOD ___ PTT-25.2 ___
___ 10:05PM BLOOD Glucose-186* UreaN-16 Creat-0.9 Na-141
K-3.8 Cl-105 HCO3-24 AnGap-16
___ Left Foot:
1. No acute fracture or malalignment.
2. Mild degenerative changes of first MTP joint.
___ Pelvis:
1. Severe lateral left lower leg laceration with locules of gas
and punctate radiopacities consistent with foreign bodies.
2. No acute fracture or acute malalignment.
3. Status post pubic symphysis plate and surgical screws with
right surgical screw projecting over the right obturator
foramen.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
hold for diarrhea
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
Take lowest effective dose.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*80 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*30 Tablet Refills:*0
5. 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
6.Crutches
Dx: Left lower extremity laceration and tendon injury
Px: Good
___: 13 months
Discharge Disposition:
Home
Discharge Diagnosis:
1. Traumatic laceration, left lower extremity x3.
2. Traumatic laceration, left tibialis anterior tendon.
3. Traumatic laceration, left peroneus brevis tendon.
4. Traumatic laceration, peroneus longus tendon.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: DX PELVIS, FEMUR AND TIB/FIB
INDICATION: ___ with left leg pain and lacerations. Assess for fracture.
TECHNIQUE: Single AP view of pelvis, two views of left femur, two views of
left knee, two views of left ankle.
COMPARISON: None.
FINDINGS:
Pelvis: No acute fracture or malalignment. Mild multilevel degenerative
changes are noted throughout the lower lumbar spine with osteophyte formation
and endplate sclerosis. The femoral heads are well seated within the
acetabulum. Visualized bowel gas pattern is nonobstructive. Plate and
surgical screws are seen along the pubic symphysis. A right surgical screw
projects into the right obturator foramen.
Left femur: No acute fracture.
Left knee: No acute fracture or acute malalignment. No joint effusion.
Multiple punctate radiopacities and locules of gas along the left lateral leg
is consistent with known laceration and foreign bodies.
Left ankle: No acute fracture or acute malalignment. An os trigonum is
present. No joint effusion.
IMPRESSION:
1. Severe lateral left lower leg laceration with locules of gas and punctate
radiopacities consistent with foreign bodies.
2. No acute fracture or acute malalignment.
3. Status post pubic symphysis plate and surgical screws with right surgical
screw projecting over the right obturator foramen.
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL LEFT
INDICATION: ___ with left leg pain and lacerations. Assess for fracture
TECHNIQUE: Non-weightbearing frontal, oblique, and lateral view radiographs
of left foot
COMPARISON: None.
FINDINGS:
A bipartite sesamoid bone is present. Mild degenerative changes of the first
MTP joint with subchondral sclerosis and small osteophyte formation. No
fracture, or dislocation. No erosion or lytic or sclerotic lesion is
identified. No soft tissue calcification or radio-opaque foreign body is
detected. Os trigonum is noted.
IMPRESSION:
1. No acute fracture or malalignment.
2. Mild degenerative changes of first MTP joint.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Transfer, Motorcycle accident
Diagnosed with Laceration without foreign body, left lower leg, init encntr, Mtrcy driver injured pick-up truck, pk-up/van in traf, init
temperature: 97.0
heartrate: 115.0
resprate: 18.0
o2sat: 99.0
sbp: 121.0
dbp: 92.0
level of pain: 7
level of acuity: 2.0 | Mr. ___ is a ___ yo M ___ who was struck on the
left leg by a car admitted to the Acute Care Surgery Service on
___. He was noted to have 3 deep lacerations to the left
lower leg and X-ray showed no fracture. Informed consent was
obtained and he was taken to the operating room for a lower
extremity wash out. Intraoperatively he was found to have
multiple deep wounds involving lacerations of the anterior and
lateral compartment tendons and orthopedic surgery was was
contacted to provide assistance. He underwent operative repair
of the tibias anterior tendon, preens braves tendon, left preens
longs tendon, and closure of complex wounds. Please see
operative report for details. He was admitted to the surgical
floor for post operative management.
On HD1 he remained afebrile and pain was well controlled on oral
pain medications. He remained stable from a hemodynamic
standpoint. His diet was advanced to regular which he tolerated
well. He voided adequate urine without difficulty. His left
lower extremity remained warm and well perfused with good
capillary refill. He received wound care teaching and a CAM
boot. He was seen and evaluated by physical therapy who
determined safe discharge to home.
The patient was discharged to home on HD1 in stable condition.
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:
Vicodin / Risperidone / Meropenem / Codeine / Demerol / Dilaudid
/ Percocet / aspirin / Primaxin IV
Attending: ___.
Chief Complaint:
Abdominal Pain, Chest Pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms. ___ is a ___ yof with history of necrotizing pancreatitis,
schizoaffective disorder, fibromyalgia, chronic back pain,
chronic abdominal pain, DMII, and HTN who presents with
abdominal pain and chest pain for past week. She reports pain
started yesterday in lower abdomen and migrated up to include
chest and flanks bilaterally. Patient has radiation of pain to
neck and scapula. The pain is a sharp, pressure is diffusely
throughout abdomen with some radiation to chest. Pain improved
from ___ to ___ with morphine. She also reports "torturing"
pain today in her abdomen and chest that felt like she did when
she was raped by a family member. ___ pain does not occur with
exertion and is not associated with shortness of breath. She was
seen at ___ late last night and found to have neg
CXR, WBC 12, and cardiac enzymes neg x1. She reports
temperatures up to 99.9 at home for past month and says she has
long standing history of heat intolerance. She denies any
vomiting, diarrhea, or dysuria but does report some intermittent
nausa and baseline dyspnea. Last BM yesterday and was normal.
ED Course
- Initial Vitals/Trigger: ___ 74 143/74 18 98%
- EKG: nonischemic
- ASA 325 -> pt reufsed
- Morphine, Zofran
- Admit for pain control, trop x2
- Guaic negative
- Additional CP at 1200hr, repeat ECG non-ischemic
- Hx VRE
- BMP wnl, WBC 11.5, Hgb 12.9, Alk Phos 140, Lipase 15, Lact 1.5
- U/A negative
ROS: Negative except for above.
Past Medical History:
schizoaffective disorder
OSA
asthma
transverse myelitis
HTN
venous insufficiency
DMT2
chronic pain
chronic constipation
ovarian cyst
LUE DVT
s/p pancreatic pseudocyst gastrostomy ___
___ drainage pseudocyst and splenic abscess ___
cholecystectomy
Social History:
___
Family History:
No family history of pancreatitis. Father died in his ___ of
COPD and "heart condition." Mother with HTN and asthma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - AF 98.2 172/84 HR69 sat 92% on RA
Gen: NAD, lying in bed, cushinoid appearing, obese, patient is
tender almost everywhere she is touched
HEENT: moist mucosa
Neck: thick neck with cervical lordosis
CV: NR, RR, no murmur
Pulm: CTAB, no wheeze
Abd: diffuse tenderness to very light palpation, obese but
nondistended, soft, no rebound
Ext: no peripheral edema
Skin: some acne on upper back, no other skin lesions noted
Neuro: moves all 4 extremities, ambulates, no focal deficit,
EOMI
DISCHARGE PHYSICAL EXAM:
AF 98.3 137/68 HR 70 sat 99% on RA
Gen: NAD, sitting in chair, obese, patient is tender almost
everywhere she is touched.
HEENT: moist mucosa
Neck: thick neck with cervical lordosis
CV: NR, RR, no murmur
Pulm: CTAB, no wheeze
Abd: diffuse tenderness to very light palpation, obese but
nondistended, soft, no rebound
Ext: no peripheral edema
Skin: some acne on upper back, no other skin lesions noted
Neuro: moves all 4 extremities, ambulates, no focal deficit,
EOMI
Pertinent Results:
___ 07:54AM BLOOD WBC-11.5* RBC-4.53 Hgb-12.9 Hct-39.5
MCV-87 MCH-28.5# MCHC-32.7 RDW-15.0 Plt ___
___ 07:54AM BLOOD Glucose-78 UreaN-19 Creat-0.7 Na-143
K-4.2 Cl-103 HCO3-31 AnGap-13
___ 06:55PM BLOOD CK(CPK)-57
___ 07:54AM BLOOD ALT-16 AST-18 AlkPhos-140* TotBili-0.2
___ 03:10AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:55PM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:54AM BLOOD TSH-6.4*
___ 08:23AM BLOOD Lactate-1.5
___ CT Abd/Pelv with Contrast:
ABDOMEN:
The liver is hypodense diffusely suggestive of fatty
infiltration. No focal
mass is present. The gallbladder has been removed and metallic
clips remain
in the gallbladder fossa. The intra- and extra-hepatic bile
ducts are
unremarkable. The pancreas demonstrates mild fatty infiltration
within the
head. No peripancreatic stranding or fluid collection is present
and the
pancreatic duct is not enlarged. A 2.9 x 2.0 cm (2:21)
hypodense lesion along
the lateral aspect of the spleen is stable since the prior exam
of ___, and compatible with a subcapsular collection likely
related to prior
trauma or infarct. Adrenal glands are normal. Kidneys enhance
symmetrically
and excrete contrast promptly. The ureters are normal in course
and caliber.
Suture material along the lesser curvature of the stomach is
compatible with
prior pseudocyst gastrostomy. The stomach is otherwise
unremarkable. The
small and large bowel enhance homogeneously and have a normal
course and
caliber. The appendix is normal (601B:35).
No retroperitoneal or mesenteric lymphadenopathy. The portal
and systemic
intra-abdominal vasculature is unremarkable. No free abdominal
fluid or
pneumoperitoneum. The stoma of a fat-containing ventral wall
hernia (2:41)
measures 17 mm. Small fat-containing periumbilical hernia is
also present.
PELVIS: The bladder is unremarkable. The uterus and ovaries
are
unremarkable. No free pelvic fluid or inguinal hernia. No
pelvic or inguinal
lymphadenopathy.
OSSEOUS STRUCTURES: Multilevel thoracolumbar spine degenerative
changes. No
focal lytic or sclerotic lesion concerning for malignancy.
IMPRESSION:
1. No acute intra-abdominal process. No evidence of
pancreatitis or
pseudocyst.
2. Stable size of 2.9-cm splenic subcapsular fluid collection.
3. Hepatic steatosis.
CXR Portable ___:
FINDINGS:
Single frontal portable view of the chest was obtained. The
patient is
rotated with respect to the film. The heart is of normal size
with normal
cardiomediastinal contours. Lungs are clear without focal or
diffuse
abnormality. No large pleural effusion or pneumothorax. No
radiopaque
foreign body. Osseous structures are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
HISTORY: Chest pain. Evaluate for pneumonia, pneumothorax, or
pneumoperitoneum.
COMPARISON: Multiple prior chest radiographs, most recently ___.
FINDINGS:
Single frontal portable view of the chest was obtained. The patient is
rotated with respect to the film. The heart is of normal size with normal
cardiomediastinal contours. Lungs are clear without focal or diffuse
abnormality. No large pleural effusion or pneumothorax. No radiopaque
foreign body. Osseous structures are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ female with diffuse abdominal pain. Evaluate for
pancreatic pseudocyst.
COMPARISONS: Multiple prior abdominal CTs, most recently CTU of ___.
TECHNIQUE: MDCT sections were obtained from the lung bases to the pubic
symphysis after administration of 130 cc of IV Omnipaque contrast. Axial
images were interpreted in conjunction with coronal and sagittal reformats.
FINDINGS:
The visualized portion of the heart is unremarkable. The lung bases are
clear. No pericardial or pleural effusion is visualized.
ABDOMEN:
The liver is hypodense diffusely suggestive of fatty infiltration. No focal
mass is present. The gallbladder has been removed and metallic clips remain
in the gallbladder fossa. The intra- and extra-hepatic bile ducts are
unremarkable. The pancreas demonstrates mild fatty infiltration within the
head. No peripancreatic stranding or fluid collection is present and the
pancreatic duct is not enlarged. A 2.9 x 2.0 cm (2:21) hypodense lesion along
the lateral aspect of the spleen is stable since the prior exam of ___, and compatible with a subcapsular collection likely related to prior
trauma or infarct. Adrenal glands are normal. Kidneys enhance symmetrically
and excrete contrast promptly. The ureters are normal in course and caliber.
Suture material along the lesser curvature of the stomach is compatible with
prior pseudocyst gastrostomy. The stomach is otherwise unremarkable. The
small and large bowel enhance homogeneously and have a normal course and
caliber. The appendix is normal (601B:35).
No retroperitoneal or mesenteric lymphadenopathy. The portal and systemic
intra-abdominal vasculature is unremarkable. No free abdominal fluid or
pneumoperitoneum. The stoma of a fat-containing ventral wall hernia (2:41)
measures 17 mm. Small fat-containing periumbilical hernia is also present.
PELVIS: The bladder is unremarkable. The uterus and ovaries are
unremarkable. No free pelvic fluid or inguinal hernia. No pelvic or inguinal
lymphadenopathy.
OSSEOUS STRUCTURES: Multilevel thoracolumbar spine degenerative changes. No
focal lytic or sclerotic lesion concerning for malignancy.
IMPRESSION:
1. No acute intra-abdominal process. No evidence of pancreatitis or
pseudocyst.
2. Stable size of 2.9-cm splenic subcapsular fluid collection.
3. Hepatic steatosis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABDO PAIN
Diagnosed with ABDOMINAL PAIN OTHER SPECIED, CHEST PAIN NOS
temperature: 98.3
heartrate: 74.0
resprate: 18.0
o2sat: 98.0
sbp: 143.0
dbp: 74.0
level of pain: 5
level of acuity: 3.0 | Ms. ___ is a ___ yo f with history of necrotizing
pancreatitis, schizoaffective disorder, fibromyalgia, chronic
back pain, chronic abdominal pain, DMII, and HTN who presented
with abdominal pain and chest pain for past week.
# Abdominal Pain, generalized: Patient's abdominal pain is
relatively inconsistent on exam and appears to be superficial.
Her CT abd/pelv with contrast did not show any sources of pain.
DDx somatoform disorder, GI process, GU process, or GYN process.
Patient's only lab abnormalities was mild WBC elevation of 11.5.
Afebrile, normal lactate, negative CT abd/pelv with contrast,
lipase wnl, Hgb and vital signs stable.
- continued home omeprazole and ranitidine
- given po morphine PRN plus home pain medication
# Chest Pain, Intermittent: She was diffusely tender to
palpation and not currently suffering from pain. Very unlikely
ACS, could be due to her fibromyalgia. Pneumonia or PE was
unlikely based on history, vitals, EKG and neg OSH CXR. Her trop
on admission was negative. EKG negative x2 in ED. CP overnight
with normal EKG and cardiac enzymes. Patient monitored on
telemetry.
# DM
- insulin SS while inpatient
# HTN: Stable
- continued home antihypertensives
# CODE STATUS: DNR/DNI- confirmed with patient on admission
# CONTACT: ___ (sister)- ___
# PCP: ___ MD
# DISPO: Medicine to home.
# Transitional Issues:
- Will follow up with Primary Care Provider |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Taxol
Attending: ___.
Chief Complaint:
anemia
Major Surgical or Invasive Procedure:
___: Repositioned a new 8 ___ pigtail drainage catheter in
the left upper quadrant adjacent to the G-tube. Exchanged the
G-tube with a new 20 ___ Ponsky PEG tube.
___: EGD
___: PICC line placement
___: G-tube exchange/replacement
History of Present Illness:
___ yo F with stage IV serous adenocarcinoma of the fallopian
tube with widespread abd mets and peritoneal tumors p/w anemia.
Pt recently admitted ___ for a clogged G tube, nausea, and
vomiting. She had a para during that admission which showed
gross purulence. JP drain placed. G tube found to be leaking
into peritoneum and was replaced ___. Regarding antibiosis,
initially pt placed on vanc/cefepime/flagyl, later narrowed to
unasyn. GNRs/GPCs on gram. Cxs grew mixed bacterial flora: coag
+staph only organism speciated out. She was discharged on a
course of ertapenem. Pt seen in clinic for routine chemo and was
found to have hct 20.2, down from last hct 27.9 on discharge.
She was sent in to the ED for eval.
.
In the ED: 96.8 109 135/69 18 98% RA. On hx, pt denied blood in
the stool, melena or abdominal pain. She denied vaginal bleeding
or hematuria. Her only complaints were chronic fatigue and
chronic nighttime nausea with non-bloody vomiting. Exam was
benign. Admitted to OMED.
.
ROS: as above; otherwise complete ROS negative
Past Medical History:
Onc history:
- early ___: abdominal cramping, bloating and early satiety
- ___ CT abd/pelvis with omental caking, peritoneal implants,
ascites
- ___ CT chest with pleural nodularity, trace effusions
- ___ CA125 59
- ___ ex lap, TAH/BSO, transverse colectomy with primary
side-to-side functional end-to-end anastomosis, total
omentectomy, appendectomy, optimal tumor debulking, IP port
placement
- ___: 6 cycles of IV/IP cis/taxol, required taxol
desensitization after second cycle for taxol reaction
- ___ CA125 19
- ___ CT chest/abd/pelvis: residual nodularity on sigmoid
colon, soft tissue mass associated with distal ileum, soft
tissue on anterior abdominal wall, 2-3mm pleural-based nodular
densities
- ___ PET-CT: FDG-avid lesions in the sigmoid, above the
bladder, RUQ peritoneal surface, abdominal small bowel, and T9
sclerotic lesion
- ___: started ___ for recurrent disease
- ___ - ___: admitted for vomiting due to partial SBO
- ___: started gemcitabine
___ CT Torso: No significant change from ___.
Mild distension of a loop of proximal jejunum, transition left
mid-abdomen. Unchanged peritoneal thickening and ascites with
loculated appearance. Bilat pleural effusions, R > L.
___ 1,Day 15 Gemzar
Past Medical History:
- fallopian tube cancer
- HTN
- Hypothyroidism
Obstetric History: G2P2, LTCS x 2
Gynecologic History:
- fallopian tube cancer as above
- no abnormal Paps or STIs
Past Surgical History:
- Removal of IP port ___
- Exploratory lapaparotomy, TAH/BSO, transverse colectomy with
primary side-to-side functional end-to-end anastomosis, total
omentectomy, appendectomy, optimal tumor debulking, IP port
placement (___)
- LTCS x 2 (___)
- knee arthroscopy
- cervical polypectomy
Social History:
___
Family History:
She denies gyn, colon or breast cancer. Her grandfather was a
smoker and died of lung cancer. Her grandmother had
hypertension. She otherwise denies family history of
cardiovascular disease, diabetes or venous thromboembolic
events.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T97.9 HR102 (99-108) BP118/72 RR20 95%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: G-tube in place with overlying wet dressing; JP bulb on
left side of abdomen with minimal draining yellow output, soft,
non-tender, non-distended, bowel sounds present, no rebound
tenderness or guarding; mild ttp over G tube and JP drain sites
BACK: no hematoma of posterior back
GU: no foley
Ext: warm, well perfused, 2+ pulses, 3+ pitting edema of
bilateral ___. Left sided PICC line in place.
DISCHARGE PHYSICAL EXAM
Tm/c 98.2 140/84 102 20 96% RA
I/O: 1824/ 3200 O + 805 (G) + 800 (J) + 0 (JP)
GEN: Alert, oriented x3, NAD
HEENT: Sclera anicteric
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally with diminished breath
sounds at bases L sl worse than right. Dull to percussion at
bases, no wheezes or rales
CV: Tachycardic, normal S1 + S2, systolic flow murmur
appreciated
Abdomen: G-tube in place; JP bulb with very minimal drainage.
___ tube draining light green fluid with no overt blood, abdomen
non-tender, non-distended, bowel sounds present, some firmness
to palpation periumbilica, no rebound tenderness or guarding;
not ttp over G tube and JP drain sites
GU: no foley
Ext: warm, well perfused, 2+ pulses, 1+ pitting edema of
bilateral ___. no evidence of line infection
Pertinent Results:
ADMISSION LABS
___ 09:15PM BLOOD WBC-8.4 RBC-2.16*# Hgb-6.6*# Hct-20.2*#
MCV-93 MCH-30.3 MCHC-32.5 RDW-20.1* Plt ___
___ 09:15PM BLOOD Neuts-88.0* Lymphs-7.7* Monos-4.1 Eos-0
Baso-0.1
___ 09:15PM BLOOD ___ PTT-25.2 ___
___ 09:15PM BLOOD Glucose-114* UreaN-22* Creat-0.8 Na-137
K-3.8 Cl-95* HCO3-35* AnGap-11
___ 06:34AM BLOOD ALT-28 AST-22 LD(LDH)-182 AlkPhos-133*
TotBili-1.3
___ 09:15PM BLOOD Calcium-7.4* Phos-4.6* Mg-2.0
___ 06:34AM BLOOD Albumin-2.1* Calcium-7.8* Phos-4.6*
Mg-2.1 Iron-167*
___ 06:34AM BLOOD calTIBC-191* VitB12-488 Folate-11.0
Hapto-356* Ferritn-702* TRF-147*
___ 10:55PM URINE Color-Yellow Appear-Hazy Sp ___
___ 10:55PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
___ 10:55PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-15
PERTINENT LABS (hgb/hct trend)
___ 12:42AM Hgb-7.1* Hct-22.5*
___ 06:34AM Hgb-6.7* Hct-20.2*
___ 06:01PM Hgb-8.5*# Hct-25.1*
___ 05:49AM Hgb-7.8* Hct-23.8*
___ 04:00PM Hgb-9.1* Hct-26.8*
___ 05:54AM Hgb-8.7* Hct-26.9*
___ 06:00AM Hgb-8.2* Hct-25.0*
___ 04:11PM Hgb-9.0* Hct-26.7*
___ 11:11PM Hct-26.1*
___ 06:00AM Hgb-8.3* Hct-24.8*
___ 04:29PM Hgb-8.8* Hct-26.5*
___ 05:10AM Hgb-8.2* Hct-23.9*
___ 12:00PM Hgb-8.5* Hct-25.9*
___ 06:23AM Hgb-9.2* Hct-27.9*
___ 06:16AM Hgb-7.3* Hct-22.3*
___ 11:05AM Hgb-7.4* Hct-22.2*
___ 02:33PM Hgb-7.9* Hct-23.9*
ASCITES FLUID
___ 12:22PM ASCITES WBC-3875* RBC-975* Polys-97* Lymphs-2*
___ Macroph-1*
MICROBIOLOGY
___ 12:22 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___:
Reported to and read back by ___ ___
3:30PM.
ENTEROCOCCUS SP.. RARE GROWTH.
Daptomycin SENSITIVITY REQUESTED BY ___. ___ ___
___.
Daptomycin 3.0 MCG/ML Sensitivity testing performed by
Etest.
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. RARE
GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 1 COLONY ON 1
PLATE.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| STENOTROPHOMONAS
(XANTHOMONAS) MALTOPH
| |
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ Blood cx pending
PERTINENT IMAGING
___ CXR
In comparison with the study of ___, the tip of the PICC line
extends to the mid portion of the SVC. The left pleural
effusion appears less
prominent, though this may merely reflect a more upright
position of the
patient. Cardiac silhouette is within normal limits and there
is no
appreciable pulmonary vascular congestion.
___ CT a/p
1. Reaccumulation of fluid within the peritoneal cavity,
particularly on the right side of the abdomen. There is little
fluid in the left flank along the existing catheter as well as
in the pelvis. There is diffuse thickening of the peritoneum
and superinfection cannot be excluded.
2. Bilateral pleural effusions, left greater than right are
stable.
3. Gastrostomy tube in adequate position.
4. Peritoneal nodules are again noted and are stable.
___ CXR
Lungs are clear. Bilateral pleural effusions, left greater than
right. Right PICC terminates in the low SVC.
___ KUB
No evidence of pneumoperitoneum. Non-obstructive bowel gas
pattern.
___ CT Abd/Pelvis with contrast
IMPRESSION:
1. Ascites, unchanged with resolution of prior air inclusions.
2. Lack of oral contrast limits evaluation of known peritoneal
implants.
3. Duodenal and small bowel dilatation with transition point in
left mid
abdomen. A partial small bowel obstruction cannot be excluded.
4. Gastric tube with tip terminating in lumen but coiled tubing
and disc seen
outside the lumen wall.
___ portable CXR
The PICC line is unchanged. The NG tube is been removed. There
are moderate
bilateral pleural effusions which have increased slightly
compared to the
study from 6 days prior. There is minimal pulmonary vascular
redistribution.
Cardiac size is upper limits of normal.
PROCEDURES
___ G-TUBE CHECK/REPLACE
1. 8 ___ biliary drainage catheter successfully repositioned
into the left upper quadrant.
2. Successful exchange of a 14 ___ mic gastrostomy tube for a
new 20 ___ Ponsky gastrostomy tube. Intraluminal location
was confirmed with a contrast injection that showed gastric
rugae.
IMPRESSION:
Successful exchange of a 14 ___ mic gastrostomy tube for a
new 20 ___ Ponsky gastrostomy tube.
RECOMMENDATION: Please place the 8 ___ biliary drainage
catheter to a
large JP bulb for suction for at least 48 hr to ensure adequate
drainage from the left upper quadrant. Please use the
gastrostomy as needed for venting.
EGD ___:
Large hiatal hernia
Reflux esophagitis
PEG was not visualized
Ulcers in the hernia sac
Esophagus and the stomach were completely full of fluid
No evidence of tumor within the stomach
___ G-tube replacement
FINDINGS:
1. Malpositioned percutaneous gastrostomy tube.
2. Successful repositioning of a catheter into the stomach from
a
percutaneous approach.
3. Successful placement of a shortened 18 ___ MIC
gastrojejunostomy tube.
IMPRESSION:
Successful repositioning of a 18 ___ MIC gastrojejunostomy
tube.
Radiology Report
HISTORY: PICC placement.
FINDINGS: In comparison with the study of ___, the tip of the PICC line
extends to the mid portion of the SVC. The left pleural effusion appears less
prominent, though this may merely reflect a more upright position of the
patient. Cardiac silhouette is within normal limits and there is no
appreciable pulmonary vascular congestion.
Radiology Report
CT OF THE ABDOMEN AND PELVIS WITH IV CONTRAST
INDICATION: ___ woman with new anemia and recent paracentesis. Rule
out retroperitoneal bleed.
CT OF THE ABDOMEN AND PELVIS WITH IV CONTRAST TECHNIQUE: Multidetector
scanning is performed from the diaphragm through the symphysis during dynamic
injection of Omnipaque.
Comparison is made to ___.
CT OF THE ABDOMEN WITH IV CONTRAST: There are bilateral pleural effusions,
left greater than right. These are not significantly changed. There is mild
atelectasis at the lung bases bilaterally. The liver enhances homogeneously.
A moderate hiatal hernia is noted. The spleen is normal in size. The
pancreas enhances normally. The adrenal glands are unremarkable. The kidneys
enhance homogeneously. There is no retroperitoneal lymphadenopathy. The
aorta is normal in caliber. There is no free fluid throughout the abdomen and
enhancement of the peritoneum is seen. The fluid contains some air inclusions
on the right (series 4, ___ 35).
CT OF THE PELVIS WITH IV CONTRAST: A catheter is identified in the fluid
collection that was introduced from the left. There is little fluid around
the catheter in the pelvis and in the left flank; however, more fluid is seen
anteriorly to the small bowel. This fluid has newly accumulated compared to
___. The bladder is unremarkable. There is no pelvic lymphadenopathy.
There is no inguinal lymphadenopathy. Peritoneal nodules as noted on PET-CT
from ___ are again noted and are stable.
On bone windows, there is a small sclerotic focus in the vertebral body of L5.
IMPRESSION:
1. Reaccumulation of fluid within the peritoneal cavity, particularly on the
right side of the abdomen. There is little fluid in the left flank along the
existing catheter as well as in the pelvis. There is diffuse thickening of
the peritoneum and superinfection cannot be excluded.
2. Bilateral pleural effusions, left greater than right are stable.
3. Gastrostomy tube in adequate position.
4. Peritoneal nodules are again noted and are stable.
Radiology Report
INDICATION: ___ year old woman with g tube malpositioned // Attention : ___ G
TUBE REPOSITION REQUEST
COMPARISON: CT of the abdomen and pelvis from ___.
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and Dr.
___ radiology attending) performed the procedure. The
attending, Dr. ___ was present and supervising throughout the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
250 mcg of fentanyl and 3 mg of midazolam throughout the total intra-service
time of 2 hr. During which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site
MEDICATIONS: None
CONTRAST: 20 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 15 min, 250 mGy
PROCEDURE: 1. Replacement and repositioning of an 8 ___ peritoneal drain
into the left upper quadrant.
2. Exchange of an existing 14 ___ MIC G tube for a new 20 ___ Ponsky
G-tube.
PROCEDURE DETAILS:
Following the discussion of the risks, benefits and alternatives to the
procedure, written informed consent was obtained from the patient. The patient
was then brought to the angiography suite and placed supine on the exam table.
A pre-procedure time-out was performed per ___ protocol. The right
gastrostomy tube and peritoneal drainage catheter were prepped and draped in
the usual sterile fashion.
Following injection of 1% lidocaine, the paracentesis catheter was cut and a
___ wire was advanced through the catheter into the peritoneal cavity.
Over the wire an 8 ___ sheath was advanced and a second wire, a ___
wire, was advanced into the peritoneum. The sheath was then withdrawn over
both wires and advanced over the ___ wire. Using a Kumpe catheter the ___
wire was directed towards the left upper quadrant into the vicinity of the
stomach. The sheath was then removed and an 8 ___ biliary catheter was
advanced over the wire into the left upper quadrant. The wire and inner
stiffener were removed, the catheter was locked, secured with stay sutures and
a Flexitrack device and sterile dressings were applied. The catheter was
attached to a large ___ bulb for suction.
Next attention was turned towards exchanging the existing G-tube. Dr.
___ joined the procedure. The glidewire was advanced through
the gastrostomy tube into the stomach. Before an endoscope could be advanced
into the oral cavity, the wire was noted to enter the esophagus under
fluoroscopy. The wire was pushed through the mouth and secured. At this point
further involvement from the gastroenterologists was not required.
A 5 ___ angled glide catheter was advanced over the wire and through and
through access was obtained. The wire was then removed and the introducer wire
from a Ponsky G-tube kit was advanced through the wire and secured through the
oral cavity. The G-tube was then pulled through the oral cavity into the
stomach. The existing G-tube was removed after its balloon was deflated. The
gastrostomy catheter was cut and a clamp and hub was placed. Contrast
injection confirmed appropriate location of the new catheter. The catheter was
secured with 0 silk sutures and sterile dressings were applied. The patient
tolerated the procedure well.
FINDINGS:
1. 8 ___ biliary drainage catheter successfully repositioned into the left
upper quadrant.
2. Successful exchange of a 14 ___ mic gastrostomy tube for a new 20 ___
Ponsky gastrostomy tube. Intraluminal location was confirmed with a contrast
injection that showed gastric rugae.
IMPRESSION:
Successful exchange of a 14 ___ mic gastrostomy tube for a new 20 ___
Ponsky gastrostomy tube.
RECOMMENDATION: Please place the 8 ___ biliary drainage catheter to a
large JP bulb for suction for at least 48 hr to ensure adequate drainage from
the left upper quadrant. Please use the gastrostomy as needed for venting.
Radiology Report
INDICATION: ___ year old woman with venting G tube, peritonitis, vomiting, and
75cc bloody emesis, evaluate for perforation.
TECHNIQUE: Upright and supine radiographs of the abdomen and pelvis were
obtained.
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS:
There is air and contrast material seen within the ascending colon, descending
colon and the rectum. Overall bowel gas pattern is nonobstructive. There is no
intraperitoneal free air. There are likely small bilateral pleural effusions,
left greater than right. A pigtail catheter projects over the left
hemi-abdomen. Surgical clips are seen over the right mid abdomen.
IMPRESSION:
No evidence of pneumoperitoneum. Non-obstructive bowel gas pattern.
Radiology Report
INDICATION: ___ year old woman with venting G tube, peritonitis, vomiting, and
75cc bloody emesis. // to eval pna?
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
A right PICC ens in the low SVC. The moderate left pleural effusion is likely
unchanged allowing for differences in technique with associated atelectasis.
Pulmonary vascular congestion has improved. A small right pleural effusion is
unchanged. Heart size and mediastinal contours are normal. No pneumothorax.
IMPRESSION:
Stable moderate left and small right pleural effusions with associated
atelectasis. Interval improvement in pulmonary vascular congestion. No focal
consolidation.
Radiology Report
INDICATION: Patient with fallopian cancer status post brief intubation for
EGD this morning now with tachypnea, hypoxia and abnormal breath sounds left
base. Question aspiration pneumothorax.
COMPARISON: ___.
FINDINGS:
A right PICC ends in the mid SVC. Compared to the prior study there are new
patchy bibasilar opacities with increase in left pleural effusion. The heart
size and mediastinal contours are stable. No right pleural effusion or
pneumothorax.
IMPRESSION:
New bibasilar patchy opacities could reflect aspiration, infection or edema.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 3:22 ___, 15 minutes after discovery of the
findings.
Radiology Report
INDICATION: New intubation. Assess ETT placement.
COMPARISON: ___ at 14:12.
FINDINGS:
Portable frontal radiograph of the chest demonstrates the ET tube ending 2.5
cm above the carina. A esophageal probe is noted in the upper esophagus. The
right PICC is in unchanged position. An NG tube within the stomach. There is
overall worsening of lower lobe opacities which are now becoming more
confluent and involving the left upper lobe. Small bilateral pleural
effusions are possible. Stable heart size and mediastinal contours. No
pneumothorax.
IMPRESSION:
Tubes and lines in satisfactory position. Overall worsening of lower lobe
opacities with new upper lobe opacities could reflect aspiration or
superimposed edema.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 3:22 ___, 5 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman, intubated with new NG tube // NG tube
placement?
COMPARISON: ___
IMPRESSION:
As compared to the previous image, a new nasogastric tube has been inserted.
The course of the tube is unremarkable, the tip projects within 2 cm of the
old tube. No evidence of complications, notably no pneumothorax. The other
monitoring and support devices are constant. Constant is severe bilateral
parenchymal opacities, notably at the lung bases. Retrocardiac atelectasis
and mild left pleural effusion are unchanged.
Radiology Report
INDICATION: ___ year old woman with metastatic fallopian tube CA s/p NG tube
placement // NG tube placement.
TECHNIQUE: Portable AP radiograph of the chest.
COMPARISON: Chest radiograph from ___.
FINDINGS:
The nasogastric tube terminates within the body of the stomach however the
side port is immediately distal to the gastroesophageal junction. Right-sided
PICC line terminates in the mid SVC. Severe bilateral parenchymal opacities,
notably at the lung bases, right greater than left are persistent. Small
bilateral pleural effusions and retrocardiac atelectasis is unchanged. There
is no evidence of a pneumothorax. The visualized osseous structures are
unremarkable.
IMPRESSION:
1. Nasogastric tube extends below the diaphragm however the side port is
immediately distal to the gastroesophageal junction. This tube must be
advanced if the patient is to be fed.
2. Persistent severe bilateral parenchymal opacities at the lung bases.
Persistent mild left pleural effusion.
NOTIFICATION: These findings were discussed with Dr. ___ by Dr. ___
by phone at 11:00 on the day of the exam.
Radiology Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: ___ year old woman with obstruction secondary metastatic fallopian
tube cancer. Please evaluate position of NGT, Gtube and JP drain.
TECHNIQUE: Portable abdominal radiograph.
COMPARISON: ___
FINDINGS:
The tip of the nasogastric tube is in the stomach with the proximal side hole
past the gastroesophageal junction. The previous pigtail catheter in the left
upper quadrant is in an unchanged position, likely the JP drain. The
additional catheter in the left upper quadrant, the tip of which terminates
near the nasogastric tube, is likely the G-tube. There is a relative paucity
of bowel gas with air noted in the rectum.
IMPRESSION:
1. Left upper quadrant pigtail catheter in unchanged position since ___.
2. Nasogastric tube terminates in the stomach.
3. New left upper quadrant catheter, presumably the G-tube, terminates in the
area of the NG tube tip.
Radiology Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: ___ year old woman with G-tube recently revised, please evaluate
placement.
TECHNIQUE: Portable abdominal radiograph
COMPARISON: 1 day prior
FINDINGS:
The left upper quadrant JP drain is in an unchanged position. The G-tube
appears to terminate in the area of the stomach. There has been interval
removal of the nasogastric tube. Continued relative paucity of bowel gas with
visualization of loops of small bowel in the left upper quadrant.
IMPRESSION:
Unchanged position of the JP drain. Tip of the G tube appears to terminate in
the area of the stomach.
Radiology Report
INDICATION: ___ year old woman with stage IV adenocarcinoma of the fallopian
tube with peritoneal deposits. Evaluate ascites and known peritoneal
metastasis.
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous administration of 130cc of Omnipaque. Coronal and
sagittal reformations were performed.
DOSE: DLP: 1859 mGy-cm.
COMPARISON: CT dated ___.
FINDINGS:
Chest: When compared to examination dated ___, there has been
minimal change in bilateral pleural effusions, the left greater than right.
There is mild associated atelectasis. The heart and pericardium are
unremarkable. The liver enhances homogeneously without focal lesions
identified. The gallbladder pancreas spleen and adrenal glands are
unremarkable. The kidneys enhance contrast symmetric freely without focal
lesion identified. There is no hydronephrosis.
There is a dilated esophagus. A G-tube is seen with just the tip identified
within the lumen of the stomach. The disc and more proximal tubing is coiled
outside the lumen. The duodenum appears mildly dilated and the proximal small
bowel distended to approx 3 cms. A transition level is seen within the left
mid abdomen with collapsed loops of bowel distally. A partial obstruction
cannot be excluded.
When compared to prior examination. There has been no change in the amount of
free fluid within the abdominal cavity. Since prior examination, there has
been resolution of prior identified air inclusions.
The abdominal aorta is patent and normal in caliber without aneurysmal
dilatation.
Pelvic CT: Since prior examination, the previously identified catheter within
the left flank has been replaced with a drain terminating more superiorly in
the left upper quadrant. Lack of oral contrast and collapsed loops of disyal
small bowel makes separation from and identification of peritoneal implants
difficult. The bladder is unremarkable. There is no pelvic free fluid.
Osseous structures: Redemonstration of stable appearing sclerotic lesion
within T9 vertebral body. No new suspicious lytic or blastic lesion is
identified.
IMPRESSION:
1. Ascites, unchanged with resolution of prior air inclusions.
2. Lack of oral contrast limits evaluation of known peritoneal implants.
3. Duodenal and small bowel dilatation with transition point in left mid
abdomen. A partial small bowel obstruction cannot be excluded.
4. Gastric tube with tip terminating in lumen but coiled tubing and disc seen
outside the lumen wall.
NOTIFICATION: These findings regarding the G tube were discussed with the
___ Radiologist ___ at 11:00 on ___ by Dr. ___
at the time of the findings.
Radiology Report
INDICATION: ___ year old woman with peritoneal mets complicated by bowel
obstruction // please exchange/reposition displaced g tube
COMPARISON: CT of the abdomen from ___.
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow), Dr.
___ Dr. ___ radiology ___ performed the
procedure. The attending, Dr. ___ was present and supervising throughout the
procedure.
ANESTHESIA: General anesthesia was administered by the anesthesiology
department. Please refer to anesthesiology notes for details.
MEDICATIONS: None.
CONTRAST: 60 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 40 min, 370 mGy
PROCEDURE: Following the discussion of the risks, benefits and alternatives
to the procedure, written informed consent was obtained from the patient. The
patient was then brought to the angiography suite and placed supine on the
exam table. A pre-procedure time-out was performed per ___ protocol. The
tube site was prepped and draped in the usual sterile fashion.
Under fluoroscopic guidance, a Glidewire was introduced into the gastrostomy
tube. A second wire was introduced through the nasogastric tube and the
nasogastric tube was removed. A 6 ___ renal double curve guiding catheter
was advanced over the wire into the stomach through the nares. The wire was
then removed and a ensnare was advanced into the stomach. The glidewire
through the gastrostomy tube was advanced in the stomach and snared. The wire
that was pulled out through the nose. A ___ catheter was advanced over the
Glidewire and was used to exchanged the Glidewire for an Amplatz wire. The
existing gastrostomy tube and biliary catheter were removed over the wire.
A peel-away sheath was advanced over the Amplatz wires through the
percutaneous gastrostomy site. Through the peel-away sheath, a Kumpe catheter
and Glidewire were advanced and attempts were made to position the Kumpe
catheter in a post-pyloric location. After multiple unsuccsesful attempts, the
Kumpe catheter was removed. A 18 ___ MIC GJ tube was advanced. After
initial difficulty, the jejunal portion of the tube was cut and the shortened
tube was advanced into the stomach. Contrast injection confirmed appropriate
position. The tube was then secured to the skin using sutures. Sterile
dressings were applied. The nasogastric tube was removed. The patient
tolerated the procedure well.
FINDINGS:
1. Malpositioned percutaneous gastrostomy tube.
2. Successful repositioning of a catheter into the stomach from a
percutaneous approach.
3. Successful placement of a shortened 18 ___ MIC gastrojejunostomy tube.
IMPRESSION:
Successful repositioning of a 18 ___ MIC gastrojejunostomy tube.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with metastatic ovarian carcinoma p/w with
anemia and G-tube dysfunction // please evaluate for worsening L effusion v
consolidation
TECHNIQUE: Portable chest
COMPARISON: ___.
FINDINGS:
The PICC line is unchanged. The NG tube is been removed. There are moderate
bilateral pleural effusions which have increased slightly compared to the
study from 6 days prior. There is minimal pulmonary vascular redistribution.
Cardiac size is upper limits of normal.
IMPRESSION:
Increased bilateral pleural effusions. No focal infiltrate
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Anemia
Diagnosed with ANEMIA NOS, HYPERTENSION NOS
temperature: 96.8
heartrate: 109.0
resprate: 18.0
o2sat: 98.0
sbp: 135.0
dbp: 69.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ yo F with stage IV serous adenocarcinoma of
the fallopian tube with widespread abd mets peritoneal
carcinomatosis s/p venting G tube placement and JP drain
placement for recurrent SBO/malignant ascites, who was admitted
for asymptomatic anemia (HCT ___ with hospital course
complicated by recurrent peritonitis and hematemesis.
# Hematemesis: On initial presentation, patient was asymptomatic
with no evidence of active bleeding. Labs had no evidence of
hemolysis with normal Tbili and LDH. Etiology of anemia was
thought to be multifactorial including secondary to
chemotherapy, anemia of chronic disease, and malignancy. Patient
was transfused with improvement in hct. She was maintained on
max dose PPI. Hospital course was complicated by hematemesis of
50cc (dark red blood) initially thought to be secondary to a
___ tear or ulceration from the tubing. Patient
remained hemodynamically stable and did not require further pRBC
tranfusion, so EGD was not performed at that time. However, on
the afternoon of ___, the patient had nearly continuous drainage
of dark blood out of her G-tube followed by 300cc of
hematemesis. She remained hemodynamically stable but hematocrit
had dropped from 27.9 to 22.3 so she was transfused 2 units
pRBCs. She was transferred to the MICU for closer monitoring as
well as EGD. The EGD was performed on ___ and revealed ulcers
in the stomach and esophagitis. No active bleeding was seen. She
was continued on BID PPI. Her hematocrit did continue to trend
downwards and she required multiple blood transfusions thought
to be related to small ___ tears in the setting of
emesis.
# Nausea and vomiting: Initially felt to be secondary to
malpositioned peritoneal drain, G-tube, and recurrent ascites.
There was no evidence of obstruction on imaging and patient was
having bowel movements and passing gas. 8 ___ biliary
drainage catheter was successfully repositioned into the left
upper quadrant by ___ on ___. In addition, the patient's 14
___ mic gastrostomy tube was exchanged for a new 20 ___
Ponsky gastrostomy tube also on ___. She was treated with
standing ondansetron, PRN lorazepam, and she was started on
olanzapine 2.5mg BID which was uptitrated to 5mg BID due to
persistent emesis. An NGT was placed while the patient was in
the ICU and drained ~600ml/24-hours. The G tube was exchanged
for a G-J tube on ___ with successful drainage and control of
nausea vomiting. She was discharged on standing zyprexa, IV
octreotide and prn zofran/ativan.
# PNA: Aspiration event during EGD on ___ requiring
reintubation. She was successfully extubated on ___ and weaned
to room air on the floor. Daptomycin was changed to linezolid
and zosyn was started. The patient defervesced. Bactrim,
linezolid and zosyn were continued through ___.
# Recurrent malignant ascites: Patient has hx of secondary
peritonitis. Patient had been recently discharged on a 10 day
course of ertapenem at last admission and completed course (on
unasyn on ___. CT a/p had incidental findings of
reaccumulation of fluid on the right side of the abdomen. On
___, patient underwent repositioning of a new 8 ___ pigtail
drainage catheter in the left upper quadrant adjacent to the
G-tube and exchange of the G-tube with a new 20 ___ Ponsky
PEG tube. Peritoneal fluid from JP drain with leukocytosis, 97%
polys, and fluid culture grew stenotrophomonas (sensitive to
Bactrim) and VRE (sensitive to daptomycin). Bactrim and
daptomycin were ultimately changed to bactrim, linezolid, zosyn
secondary to aspiration pneumonia as above, and then spillage of
large amounts of gastric contents in the peritoneum secndary to
displaced G-tube. She completed antibiotics on ___. She has a
JP drain in place to continue to drain ascites which was straw
colored on day of discharge.
# Tachycardia: The patient had persistent sinus tachycardia
since last hospital stay, likely in the setting of decreased
intake, anemia and stress of advanced malignancy. Patient denied
any associated shortness of breath and remained hemodynamically
stable.
#. Serous Adenocarcinoma of the Fallopian Tube: Recurrent cancer
s/p ex lap, TAH/BSO, transverse colectomy, total omentectomy,
tumor debulking, 6 cycles of IV/IP cis/taxol, and ___,
now on gemcitabine (last dose ___. Chemotherapy on ___ was
held in the setting of acute illness. With improvement of the
above issues, she received gemcitabine on ___ which she
tolerated well. Further outpatient chemotherapy per Dr. ___.
# Pain control: Initially on home fentanyl patch, which was
discontinued when acutely ill in the ICU. She had no ongoing
pain and was discharged off of pain medications.
# Nutrition: She was continued on TPN. She tolerated clear
liquid diet at the time of discharge which may be advanced as an
outpatient |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / Feraheme / atenolol
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Foley catheter (___)
History of Present Illness:
___ with history of HTN, HLD, polyvalvular disease, and anemia
who presents with one week of shortness of breath. She was in
her usual state of health until one week ago when she started
developing nausea and shortness of breath with acute worsening
on the morning of admission. She has noticed difficulty walking
up stairs and around the block, activities she was able to do
without getting short of breath prior to last week. She endorses
PND and orthopnea (using 2 pillows in past week compared to 1
pillow prior to that). Furthermore, she has noticed increased
swelling in her legs and has felt fatigued. She did have a cough
this prior ___ but it resolved the same day. She denies any
fever, chills, vomiting, diarrhea, chest pain, lightheadedness,
or diaphoresis.
Of note, she has been reported to have exertional shortness of
breath in the past, which has been attributed to her worsened
anemia from chronic GI blood loss. She receives iron sucrose
infusions every 4 weeks. She has had an extensive evaluation for
her low-grade chronic Gi bleeding and only vessel ectasia has
been found.
In the ED, initial vitals: 98.0 102 177/66 20 98% 4L. Labs were
notable for Cr 1.6 (baseline past ___ years), BNP 1887, and Hgb
6.1 Hct 19.8. Exam was notable for diminished lung sounds in R
base without wheezes or crackles and trace foot edema. Rectal
exam was negative. She received IV Zofran 4 mg for nausea and IV
Ceftriaxone 1 gm and IV Azithromycin 500 mg for possible
pneumonia. Vitals prior to transfer: 98.8 82 151/53 26 94% 1L
NC.
Currently, she is on 1L NC without any respiratory distress,
resting comfortably in bed. Although her O2 sat remains stable
on RA, she subjectively becomes short of breath.
Past Medical History:
-Anemia secondary to iron deficiency with question of
myelodysplastic syndrome. Patient had endoscopoies and capsule
studies ___ years ago that showed no source of bleeding. On
monthly iron infusions
-s/p total abdominal hysterectomy with oophorectomy.
-lung cancer in ___ with surgery and removal of part of her
left lung. She had no chemo. She smoked one pack per day for
___ years, but not now.
-sickle cell trait
-benign breast lesions
-polyvalvular disease (2+ MR/2+ TR)
Social History:
___
Family History:
Both parents are deceased, one sister, one brother alive and
well. She had a total of six brothers and four sisters, a
nephew died of sickle cell disease, it is her sister's son. She
has three children. Her daughter had cancer of the breast. She
has five grandchildren alive and well.
Physical Exam:
At admission:
VS: 98.8 150/64 94 18 94% 1L NC 93% RA
GENERAL: Alert, oriented, no acute distress, pleasant and
well-appearing
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: supple, JVP elevated, no LAD
RESP: diminshed breath sounds with absent sounds in R base,
crackles heard at bases, no wheezes or rhonchi
CV: RRR, Nl S1, S2, +S4, ___ systolic murmur heard at apex
ABD: 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, motor function grossly normal
SKIN: No excoriations or rash.
At discharge:
VS: 100.3 98.6 70-100s 130-160s/40-70s 18 94%RA
Wt: 64.7 kg (65.2 kg yesterday, admission 69 kg)
I/O's: incomplete but at least p24H ___ pMN NR/350
GENERAL: Alert, oriented, no acute distress, pleasant and
well-appearing
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: stiff to flexion and rotation, JVP not elevated, no LAD
RESP: Diminshed breath sounds at bilateral bases, no crackles,
wheezes, or rhonchi
CV: RRR, Nl S1, S2, ___ holosystolic murmur heard at apex
ABD: Soft, NT/ND bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: foley in place
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; mild L knee pain now improving, able to passively flex
and extend, no erythema/swelling/effusion noted
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: No excoriations or rash
Pertinent Results:
Labs at admission:
___ 11:25AM ___ PTT-27.3 ___
___ 11:25AM PLT COUNT-266
___ 11:25AM NEUTS-72.0* ___ MONOS-5.7 EOS-2.1
BASOS-0.4
___ 11:25AM WBC-4.0 RBC-2.49* HGB-6.1* HCT-19.8* MCV-80*
MCH-24.3* MCHC-30.5* RDW-17.8*
___ 11:25AM ALBUMIN-3.6 CALCIUM-9.2 PHOSPHATE-3.2
MAGNESIUM-2.2
___ 11:25AM proBNP-1887*
___ 11:25AM LIPASE-34
___ 11:25AM ALT(SGPT)-10 AST(SGOT)-32 ALK PHOS-64 TOT
BILI-0.3
___ 11:25AM estGFR-Using this
___ 11:25AM GLUCOSE-90 UREA N-19 CREAT-1.6* SODIUM-141
POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-23 ANION GAP-15
___ 11:42AM LACTATE-1.9
Labs at discharge:
___ 05:37AM BLOOD WBC-7.8 RBC-2.83* Hgb-7.0* Hct-23.5*
MCV-83 MCH-24.7* MCHC-29.8* RDW-16.8* RDWSD-51.4* Plt ___
___ 05:37AM BLOOD Plt ___
___ 05:37AM BLOOD Glucose-100 UreaN-46* Creat-1.7* Na-136
K-4.3 Cl-102 HCO3-25 AnGap-13
___ 05:37AM BLOOD Calcium-9.4 Phos-4.1 Mg-2.9*
Micro:
BLOOD CULTURE (___): NO GROWTH.
BLOOD CULTURE (___): pending
BLOOD CULTURE (___): pending
BLOOD CULTURE (___): pending
BLOOD CULTURE (___): pending
BLOOD CULTURE (___): pending
URINE CULTURE (Final ___: NO GROWTH.
C. difficile DNA amplification assay (Final ___: Negative
for toxigenic C. difficile by the Illumigene DNA amplification
assay.
Imaging:
CXR (___):
1. Findings consistent with moderate congestive heart failure
including
pleural effusions with suspected left basilar atelectasis.
Pneumonia is not
excluded, however.
2. Possible developing opacity at the right lung base versus
regional edema.
In addition to that, right hilum appears enlarged. Although
these findings
may be congestive in nature, re-evaluation in follow-up
radiographs is
recommended after treatment.
TTE (___):
Moderate to severe mitral regurgitation. Moderate pulmonary
artery hypertension. Normal left ventricular cavity size with
preserved regional and global systolic function. Mild right
ventricular cavity dilation with preserved free wall motion.
Moderate tricuspid regurgitation.
Compared with the report of the prior study (images unavailable
for review) of ___, the severity of mitral regurgitation
and the estimated PA systolic pressure have both increased. The
right ventricle is now mildly dilated.
CXR (___):
No relevant change as compared to the previous image. Known
left postoperative changes with missing left rib. Elevation of
the left hemidiaphragm with small left pleural effusion. Mild
pulmonary edema. Mild cardiomegaly. Atelectasis at both the
left and the right lung bases.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 10 mg PO QHS
2. Omeprazole 20 mg PO DAILY
3. Pravastatin 40 mg PO QPM
4. NIFEdipine CR 30 mg PO DAILY
5. Venofer (iron sucrose) 200 mg/10 mL iron injection q4week
Discharge Medications:
1. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6
hours as needed Disp #*10 Tablet Refills:*0
2. Acetaminophen 500 mg PO Q6H:PRN pain
3. Amitriptyline 10 mg PO QHS
4. Omeprazole 20 mg PO DAILY
5. Pravastatin 40 mg PO QPM
6. Venofer (iron sucrose) 200 mg/10 mL iron INJECTION Q4WEEK
7. Lidocaine 5% Patch 1 PTCH TD QPM knee pain
8. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
stomach discomfort
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Congestive Heart Failure
Polyvalvular Heart Disease
Acute on Chronic Kidney Disease
Chronic Anemia
Mechanical Left Knee Pain
Neck Muscle Stiffness
SECONDARY DIAGNOSES:
Hypertension
Hyperlipidemia
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 RADIOGRAPHS
INDICATION: Shortness of breath.
TECHNIQUE: Chest, AP upright and lateral.
COMPARISON: ___ and ___.
FINDINGS:
There again surgical clips in the mediastinum. The heart appears mildly
enlarged. There is increased prominence in the aortopulmonary window which is
suggestive of enlarged left atrial appendage. On the right there is probably
a trace pleural effusion. On the left, there is a small to moderate pleural
effusion with associated opacity probably due to atelectasis in the posterior
left lower lobe. More generally, a moderate interstitial abnormality is most
suggestive of congestive heart failure. Fissures are thickened. The right
hilum appears more prominent than before and in addition there is the
possibility of developing focal opacity at the right lung base. Streaky
opacities in the lingula appear unchanged suggesting background scarring and
mild volume loss, as depicted on prior studies.
IMPRESSION:
1. Findings consistent with moderate congestive heart failure including
pleural effusions with suspected left basilar atelectasis. Pneumonia is not
excluded, however.
2. Possible developing opacity at the right lung base versus regional edema.
In addition to that, right hilum appears enlarged. Although these findings
may be congestive in nature, re-evaluation in follow-up radiographs is
recommended after treatment.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with clinically volume overloaded undergoing
diuresis, now with acute hypoxia to 79%on room air // eval pleural effusions,
pulm edema
COMPARISON: ___
IMPRESSION:
No relevant change as compared to the previous image. Known left
postoperative changes with missing left rib. Elevation of the left
hemidiaphragm with small left pleural effusion. Mild pulmonary edema. Mild
cardiomegaly. Atelectasis at both the left and the right lung bases.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ former smoker with history of HTN, HLD, and anemia presenting
with dyspnea. Now with fever // please eval for pneumonia
COMPARISON: ___.
IMPRESSION:
As compared to the previous image, there is evidence of increasing
radiodensity in the right lung apex. Part of this observation might be caused
by rotation of the patient. However, coexisting developing pneumonia might
also be present. Short term radiographic followup is recommended. Otherwise,
the radiograph is unchanged. Mild cardiomegaly and postoperative appearance
of the left lung base is constant.
Radiology Report
INDICATION: Evaluate for fracture or other abnormality in a patient with
acute knee pain.
COMPARISON: None available.
FINDINGS:
AP and lateral left knee radiographs demonstrate no acute fracture,
dislocation, or joint effusion. There are mild degenerative changes in the
lateral and patellofemoral compartments, without significant loss of joint
space. Chondrocalcinosis in the lateral compartment is noted, as are vascular
calcifications. There is no focal lytic or sclerotic lesion.
IMPRESSION:
1. No acute fracture or dislocation.
2. Mild degenerative changes of the lateral and patellofemoral compartments,
with chondrocalcinosis in the lateral compartment as well as vascular
calcifications.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with acute on chronic renal failure in setting
of diuresis. Please evaluate for hydronephrosis or other abnormalities.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT from ___.
FINDINGS:
The right kidney measures 9.2 cm. The left kidney measures 10.0 cm. There is
no hydronephrosis, stones, or masses bilaterally. The kidneys are echogenic
bilaterally, consistent with medical renal disease. There are multiple small
bilateral cysts similar to the prior study. The cyst in the upper pole of the
right kidney appears minimally complex with internal echoes and/or septations.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Echogenic kidneys consistent with medical renal disease. No evidence of
urinary obstruction.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with new fevers to 101.9 and previous x-rays
suggesting pneumonia // Please eval for interval change
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, a pre-existing right basal parenchymal
opacity has completely cleared. The left hemi thorax is unchanged, the
postoperative lesions at the level of the hilus and the costophrenic sinus are
constant. No new focal parenchymal opacities suggesting pneumonia.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with ANEMIA NOS, SHORTNESS OF BREATH
temperature: 98.0
heartrate: 102.0
resprate: 20.0
o2sat: 98.0
sbp: 177.0
dbp: 66.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a previously highly functional ___ year old female
with history of HTN, HLD, polyvalvular heart disease, and
chronic anemia who presented with worsening dyspnea over the
past week. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Keflex / Bactrim
Attending: ___.
Chief Complaint:
Fevers, Rash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI:
___ male, previously healthy, presenting with high
fever,
and pruritic erythematous rash. Patient reported that several
weeks ago, he developed a boil on his right chest, which he
subsequently popped. Approximately 1 week ago, the boil
continued to drain pus, increased in size, "appear infected."
Patient initially presented to his PCP ___ ___, and was
prescribed Bactrim. During that time, the patient reported a
temperature to 104, which improved within a few days. 3 days
prior to presentation, the patient reported that he "felt sick,"
and presented to an outside hospital, where he was prescribed
Keflex for left middle ear infection. Patient began to have a
pruritic generalized erythematous rash initially over his chest
and torso. On the morning of admission, patient noted that
after
he took a shower, the rash spread across his whole body and he
"looked like a tomato".
In the ED, initial vital signs were 99.1 102 167/97 16 100% on
RA.
Labs were notable for a CBC with a WBC of 3.7 (70% neutrophils,
19% lymphocytes, 3% monocytes, 6.8% eosinophils), BMP WNL, LFTs
with ALT 207, AST 191 146, T bili 0.3, lactate elevated at 2.5.
ProBNP 44. UA notable for protein and ketones.
Physical exam was notable for mild erythematous eruption over
bilateral upper extremities, chest, back, and a healing skin
lesion on his right upper chest, with inferior auricular
lymphadenopathy.
Patient was evaluated by dermatology who felt that his syndrome
was overall consistent with DRESS. She received IV Zofran, IV
Benadryl, 100 mg doxy, 1000 mg of acetaminophen, normal saline,
prednisone 80 mg ×1.
Upon arrival to the floor, the patient tells the story as above.
He reports that he first became ill approximately ___ weeks ago.
During that time, he was noted to have high fevers, up to 104,
and he went to a clinic. Reportedly, the doctor told him "his
spleen was enlarged" which was assessed via physical exam,
without radiographic evidence. He took antibiotics at that
time,
but he does not know which one. He also reports that he was told
he had a viral infection. Reportedly, he was tested for mono
during that time, and he believes this came back negative. At
that visit, he was also told that his liver enzymes were
abnormal, but reports no further testing. Review of pharmacy
records show that in early ___, he took a course of penicillin
and most likely dexamethasone, so it is unclear if this is the
episode he is mentioning. He did not have a rash at that time.
He reports that in the last month, he has had increasing fatigue
and lack of energy. He tells a story as above, beginning with a
boil, with antibiotic history as above. However he notes, that
whenever he has high fevers, he feels extremely unwell,
associated with headaches, chills, rigors. She reports that the
lymph nodes in his neck swell to the point that is extremely
painful, and seems to be associated both with this incident as
well as his incident of fevers approximately ___ months ago. He
reports some nausea without vomiting that occurs with these
episodes. On the day of admission, the patient was taking both
Bactrim and Keflex as prescribed.
He otherwise denies chest pain, abdominal pain, dysuria,
diarrhea, bloody bowel movements. She otherwise denies sick
contacts, recent travel, recent hiking or outdoor activity, or
recent tick bites. He reports that his family recently traveled
to ___, but he "stayed in hotel" and did not
participate in outdoor activities.
Past Medical History:
Denies ___
Social History:
___
Family History:
+ DM, Parkinsons, +CAD requiring heart surgery in
his father. He denies FH of cancers.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: 98.6 PO ___ 20 97 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
Mucous membranes dry, with no obvious mucous membranes lesions
Significant postauricular lymphadenopathy, standing down the
anterior cervical chain, lymphadenopathy tender to palpation
Lymph: Cervical lymphadenopathy as well, no axillary or inguinal
lymphadenopathy
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally
GI: Abdomen soft, non-distended, non-tender to palpation, no
appreciable hepatosplenomegaly
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: Faint erythematous confluent rash on the upper extremities
and anterior torso, < 1 cm ulceration on right upper chest
without fluctuance
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
DISCHARGE PHYSICAL EXAM
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Improving but still painful post-auricular lymphadenopathy,
also with anterior cervical chain, lymphadenopathy tender to
palpation, particularly on L
Lymph: Cervical lymphadenopathy as well, no axillary or inguinal
lymphadenopathy
CV: RRR, no mrg
RESP: CTAB
GI: Abdomen soft, non-distended, non-tender to palpation, no
appreciable hepatosplenomegaly
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: Faint erythematous confluent rash on the upper extremities
and anterior torso, < 1 cm ulceration on right upper chest
without fluctuance, UE non pitting edema b/l
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
LABS
___ 03:04PM BLOOD WBC:3.7* RBC:5.28 Hgb:14.5 Hct:44.4
MCV:84
MCH:27.5 MCHC:32.7 RDW:14.6 RDWSD:45.0 Plt Ct:155
___ 08:10AM BLOOD WBC:3.8*# RBC:5.28 Hgb:14.5 Hct:44.7
MCV:85 MCH:27.5 MCHC:32.4 RDW:14.8 RDWSD:45.5 Plt Ct:184
___ 03:04PM BLOOD Neuts:70.4 ___ Monos:3.0* Eos:6.8
Baso:0.0 Im ___ AbsNeut:2.58 AbsLymp:0.71* AbsMono:0.11*
AbsEos:0.25 AbsBaso:0.00*
___ 08:10AM BLOOD Neuts:34.3 ___ Monos:8.0 Eos:5.3
Baso:0.3 Im ___ AbsNeut:1.29*# AbsLymp:1.94 AbsMono:0.30
AbsEos:0.20 AbsBaso:0.01
___ 07:35AM BLOOD ___ PTT:36.4 ___
___ 08:10AM BLOOD Glucose:93 UreaN:10 Creat:0.8 Na:146*
K:4.5 Cl:103 HCO3:26 AnGap:17*
___ 08:10AM BLOOD ALT:184* AST:74* LD(LDH):303*
AlkPhos:155*
TotBili:0.3 DirBili:<0.2 IndBili:0.3
___ 03:04PM BLOOD ALT:207* AST:191* LD(LDH):502*
AlkPhos:146* TotBili:0.3
___ 07:35AM BLOOD Albumin:4.1 Calcium:8.0* Phos:4.0 Mg:1.9
___ 08:10AM BLOOD Ferritn:2324*
___ 07:35AM BLOOD HBsAg:NEG HBsAb:NEG HBcAb:NEG
___ 08:10AM BLOOD ANCA:PND
___ 08:10AM BLOOD RheuFac:<10 ___ CRP:36.8*
___ 07:35AM BLOOD HIV Ab:NEG
___ 07:35AM BLOOD HCV Ab:NEG
___ 07:35AM BLOOD CMV VL:NOT DETECT
___ 04:53PM BLOOD Lactate:2.5*
___ 07:59AM BLOOD Lactate:1.4
___ 02:50PM URINE Blood:NEG Nitrite:NEG Protein:30*
Glucose:NEG Ketone:40* Bilirub:SM* Urobiln:2* pH:6.5 Leuks:NEG
___ 02:50PM URINE RBC:<1 WBC:5 Bacteri:NONE Yeast:NONE
Epi:0
DISHCARGE LABS
WBC 3.8 HB 14.5 Plt 184
Na 146/K 4.5/CL 103/BUN 10/Cr 0.8
AST 74/ALT 184/LDH 303 Alk P ___ Tbili 0.5
Ca 8.7/Phos ___ 2.1
Hep B: negative, HIV negative
CMV pending
EBV: negative
CRP 36.8
Ferritin 2324
UA: small bili, small protein, neg leuk esterase, neg bacteria
Imaging:
CT Chest:
1. Mildly enlarged, bilateral axillary lymph nodes up to 1.1 cm
on the right
and 1.0 cm in the left. No supraclavicular, mediastinal or
hilar
lymphadenopathy.
2. 2 mm solid nodule at the left lung apex.
3. Please refer to separate report for same day CT abdomen
pelvis study for
discussion of findings below the diaphragm.
CT NECK
1. Increased number and prominence of cervical lymph nodes
bilaterally which
are nonspecific. Involvement of level V lymph nodes can still
be reactive
although there are no other signs of ongoing infection.
Clinically correlate.
CT ABD/PELVIS
No lymphadenopathy by strict size criteria. Nonspecific
subcentimeter
mesenteric lymph nodes may be reactive.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
2. Cephalexin 500 mg PO Q6H
3. Sulfameth/Trimethoprim DS 1 TAB PO BID
4. Ondansetron 4 mg PO Q8H:PRN nausea
5. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
6. Ibuprofen 200-600 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every 12
hours Disp #*16 Capsule Refills:*0
2. Mupirocin Ointment 2% 1 Appl TP BID to drained absecess on
right chest
RX *mupirocin [Centany] 2 % 1 application every day Refills:*0
3. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
4. Ibuprofen 200-600 mg PO Q6H:PRN Pain - Mild
5. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Fevers
Skin Infection
Inflammatory/Infectious or Autoimmune condition
Elevated liver function tests
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old man with significant anterior cervical
lymphadenopathy, fevers, transaminitis, which of note, the
transaminitis/fevers occurred at least one month ago, now presenting with rash
(?DRESS), would like to further r/o lymphoma due to need to treat with empiric
steroids// evidence of lymphoma, mediastinal mass, other lymphadenopathy
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) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 1.9 s, 0.2 cm; CTDIvol = 31.6 mGy (Body) DLP =
6.3 mGy-cm.
3) Spiral Acquisition 10.2 s, 66.4 cm; CTDIvol = 9.9 mGy (Body) DLP = 648.2
mGy-cm.
Total DLP (Body) = 656 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. Normal appendix. No ascites.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Prostate gland is not enlarged.
LYMPH NODES: There is no retroperitoneal lymphadenopathy. Several scattered
mesenteric lymph nodes are noted predominantly on the left, the largest
measuring up to 0.6 cm (07:20, 4:63). Small bilateral pelvic sidewall nodes,
the largest measuring up to 0.6 cm on the right (4:99). No inguinal
adenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted. Likely a replaced right hepatic artery (04:54).
BONES: There is a 0.5 cm sclerotic lesion in the posterior inferior pubic
ramus/ischial tuberosity on the left (4:111), which may represent a bone
island.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
No lymphadenopathy by strict size criteria. Nonspecific subcentimeter
mesenteric lymph nodes may be reactive.
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK
INDICATION: ___ year old man with significant anterior cervical
lymphadenopathy, fevers, transaminitis, which of note, the
transaminitis/fevers occurred at least one month ago, now presenting with rash
(?DRESS), would like to further r/o lymphoma due to need to treat with empiric
steroids// eval lymphadenopathy for reactive lymphadenopathy and/or evidence
of mass/lymphoma
TECHNIQUE: Imaging was performed after administration of 170 ml of Omnipaque
intravenous contrast material.
MDCT acquired helical axial images were obtained from the thoracic inlet
through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.8 s, 31.4 cm; CTDIvol = 7.1 mGy (Body) DLP = 217.0
mGy-cm.
Total DLP (Body) = 217 mGy-cm.
COMPARISON: None.
FINDINGS:
Evaluation of the aerodigestive tract demonstrates no mass and no areas of
focal mass effect.
There are increased number and prominence of cervical lymph nodes bilaterally
in level Ia, Ib, IIa, IIb, III, IV, and V. A lymph node in the left level V
appears hypodense and measures 1.4 cm
(3; 36). The salivary glands enhance normally and are without mass or
adjacent fat stranding. The thyroid gland appears normal. The neck vessels are
patent.
The imaged portion of the lung apices are clear and there are no concerning
pulmonary nodules. There are no osseous lesions.
IMPRESSION:
1. Increased number and prominence of cervical lymph nodes bilaterally which
are nonspecific. Involvement of level V lymph nodes can still be reactive
although there are no other signs of ongoing infection. Clinically correlate.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ man with significant anterior cervical
lymphadenopathy, fevers, transaminitis, now presenting with rash. Evaluate
for lymphoma.
TECHNIQUE: Multi-detector helical scanning of the chest was performed with
intravenous iodinated contrast agent and reconstructed as 5 and 1.25 mm thick
axial, 2.5 mm thick coronal and sagittal, and 8 mm MIP axial images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 1.9 s, 0.2 cm; CTDIvol = 31.6 mGy (Body) DLP =
6.3 mGy-cm.
3) Spiral Acquisition 10.2 s, 66.4 cm; CTDIvol = 9.9 mGy (Body) DLP = 648.2
mGy-cm.
Total DLP (Body) = 656 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: Same day CT abdomen pelvis and CT neck.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: The imaged thyroid is unremarkable.
Prominent axillary lymph nodes measure up to 1.1 cm on the right (04:12) and
1.0 cm on the left (04:11). There is no supraclavicular lymphadenopathy. The
esophagus is unremarkable.
UPPER ABDOMEN: Please refer to separate report for same day CT abdomen pelvis
study for discussion of findings below the diaphragm.
MEDIASTINUM: Several mediastinal lymph nodes measure up to 9 mm in the lower
right anterior paratracheal station (4:20). No mediastinal mass is seen.
HILA: There is no hilar mass or lymphadenopathy.
HEART and PERICARDIUM: Heart size is normal. The thoracic aorta is normal in
caliber. There is no pericardial effusion.
PLEURA: No pleural effusion or pneumothorax.
LUNG:
1. PARENCHYMA: Minimal dependent atelectasis is noted. A 2 mm solid nodule
is noted in the left lung apex (5:71). No suspicious masses, nodules or focal
consolidations are seen.
2. AIRWAYS: The airways are patent to the level of the segmental bronchi
bilaterally.
3. VESSELS: Main pulmonary artery diameter is within normal limits.
Suboptimal evaluation of the pulmonary vasculature demonstrates no evidence of
central pulmonary embolism.
CHEST CAGE: No worrisome osseous lesions are identified. There is no acute
fracture.
IMPRESSION:
1. Mildly enlarged, bilateral axillary lymph nodes up to 1.1 cm on the right
and 1.0 cm in the left. No supraclavicular, mediastinal or hilar
lymphadenopathy.
2. 2 mm solid nodule at the left lung apex.
3. Please refer to separate report for same day CT abdomen pelvis study for
discussion of findings below the diaphragm.
Gender: M
Race: ASIAN
Arrive by WALK IN
Chief complaint: Fever, Malaise, Rash
Diagnosed with Rash and other nonspecific skin eruption, Adverse effect of cephalospor/oth beta-lactm antibiot, init, Oth places as the place of occurrence of the external cause
temperature: 99.1
heartrate: 102.0
resprate: 16.0
o2sat: 100.0
sbp: 167.0
dbp: 97.0
level of pain: 10
level of acuity: 2.0 | Summary: ___ otherwise healthy presenting with erythroderma,
fevers, and lymphadenopathy with recent outpatient treatment
with Bactrim and Keflex, found to have transaminitis, with
clinical presentation concerning for possible DRESS, however,
with over 1 month of fevers and lymphadenopathy at home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
cisplatin
Attending: ___.
Chief Complaint:
Bilateral Nephrostomy Tube Leakage
Major Surgical or Invasive Procedure:
Replacement of Bilateral nephrostomy tubes with ___ ___
Repeat Right nephrostomy tube exchange ___ with ___
History of Present Illness:
Mr. ___ is s a ___ female with history of
recurrent metastatic cervical cancer complicated by bilateral
ureteral narrowing and rectovaginal fistulas, requiring
diverting
colostomy and bilateral nephrostomy tubes who presents for
nephrostomy tube evaluation.
She reports that there has been drainage around all of the tubes
for the past few days and the bandages have fallen off. She has
decreased output in left nephrostomy tube. The color of the
drainage has been more brown but without blood. She has pain at
her tube sites that is worse with movement. After the last
nephrostomy change things had been working well. She notes her
mother help with tube management and dressing changes. She does
not currently have a ___. She also reports mild abdominal pain
for the past few days associated with skin breakdown. She ran
out
of ostomy supplies so has not changed her ostomy bag in some
time
so believes the surrounding skin has become irritate. Also with
right leg swelling for the past 2 days without pain. She notes
chills without fever. She is currently wheelchair bound due to
leg weakness.
Of note, she has duplicated collecting system on left with a PCN
in low pole and PCNU in upper moeity, last exchanged ___.
On arrival to the ED, initial vitals were 98.5 118 111/68 20
100%
RA. Exam was notable for ill-appearing with poor hygiene, ostomy
bag in place with skin breakdown and erythema around the navel,
2+ right lower extremity unilateral edema, and 3 nephrostomy
tubes in place draining clear urine without clots and bandages
in
disrepair and dirty with mild erythema at access sites. Per RN
"upon exam dressings over nephrostomies noted to be saturated in
brown foul smelling drainage with redness noted around umbilicus
and multiple areas of stage 2 ulcers around groin". Labs were
notable for WBC 3.9, H/H 8.6/27.6, Plt 151, Na 143, K 3.9,
BUN/Cr
___, and lactate 1.3. Blood cultures were sent. Urine
cultures
from the nephrostomy tubes were ordered but not sent. ___ was
consulted and recommended placing new clean dressings on tubes,
obtaining abdominal x-ray to assess tube positioning, and NPO at
midnight for possible drain exchange. Right leg ultrasound was
negative for DVT. Abdominal x-ray showed tubes in place. Patient
was given oxycodone 5mg PO x 2 and Zosyn 4.5g IV. Prior to
transfer vitals were 98.8 114 114/73 14 99% RA.
On arrival to the floor, patient reports ___ pain around her
nephrostomy tubes. She denies fevers, headache, vision changes,
dizziness/lightheadedness, weakness/numbness, shortness of
breath, cough, hemoptysis, chest pain, palpitations,
nausea/vomiting, diarrhea, hematemesis, hematochezia/melena,
dysuria, hematuria, and new rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
Stage ___ cancer (Diagnosed in ___:
s/p chemoradiation (cisplatin course limited ___ ototoxicity)
c/b radiation proctitis and rectovaginal fistulas s/p diverting
ostomy, and ureteral obstruction s/p bilateral nephrostomy tubes
PAST ONCOLOGIC HISTORY:
- ___: Initial evaluation of postpartum menorrhagia, diagnosed
with cervical cancer. Had prior history of abnormal Pap tests
that normalized on follow-up.
- ___: Received RT + cisplatin (truncated due to tinnitus)
at ___, ? switch to carboplatin.
- ___: Developed rectal bleeding, ultimately had colonoscopy
___ showing RT proctitis and rectovaginal fistula.
- ___: Underwent lap diverting colostomy due to persistent
rectal bleeding. Later developed urine leakage and blood from
vagina, diagnosed with vesicovaginal fistula. Underwent
bilateral
PCNs due to worsening hydronephrosis. Hospitalized at ___ for 2
months, providers recommended palliative exenteration.
- ___: First admission at ___, presenting with
abdominal pain and decreased ostomy output, found to have left
hydronephrosis and pyelonephritis, as well as pelvic fluid
collections that appeared chronic, uninfected. Second left PCN
was placed and pt was treated for pan-sensitive enterococcus
bacteremia/urosepsis. Planned for outpatient evaluation for
pelvic exenteration.
- ___: Admitted to ___ for back pain, chills,
vomiting,
blood from ostomy site. Repositioned PCNs, no evidence of UTI.
- ___: Admitted to ___ with N/V/abd pain, now found to
have UTI and possible pyelonephritis on CT, treated for fungal
UTI.
- ___: Initial evaluation by Dr. ___ with
Drs. ___ for consideration of pelvic exenteration.
Felt to be a poor candidate due to nutritional status.
- ___: Admitted to ___ for fevers, found to have
severe left hydronephrosis and pyelonephritis, as well as left
upper lung cavitary lesion. Underwent PCN replacement followed
by
EBUS and transbronchial biopsy on ___, path showing
well-differentiated squamous cell carcinoma.
- ___: C1 ___ AUC 4 & Taxol 140 mg/m2
- ___: C2 Cabo/Taxol
Social History:
___
Family History:
- ___ disease in father and uncles
- melanoma in grandmother
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 97.9, BP 116/76, HR 117, RR 16, O2 sat 99% RA.
GENERAL: Pleasant woman, in no distress, lying in bed
comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: Tachycardic, regular rhythm, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, diffuse tenderness to palpation, non-distended,
positive bowel sounds. LLQ ostomy (patient declined ostomy
change
overnight so unable to visualize stoma or underlying skin).
Periumbilical erythema and dryness.
GU: 2 left nephrostomy tubes and 1 right nephrostomy tubes with
surrounding erythema at insertion site. Dressings soaked through
and soiled. Minimal urine in bags. Partial thickness skin loss
in
bilateral groin folds. Foul-smelling brown vaginal discharge.
EXT: Warm, well perfused, 2+ right lower extremity edema.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
Discharge physical exam
========================
T 97.8 HR ___ BP 96 / 62 RR 14
GENERAL: Appears comfortable, sitting in chair. NAD
HEENT: Anicteric, PERLL, OP clear. no LAD
CARDIAC: Tachycardic, regular rhythm, normal s1/s2, no m/r/g.
LUNG: clear to auscultation bilaterally, no crackles, wheezes,
or
rhonchi.
ABD: Soft, tender to palpation in LLQ around ostomy site,
non-distended, positive bowel sounds. LLQ ostomy with red
healthy-appearing stoma. Periumbilical erythema and dryness,
with
skin under abdominal folds dry and less erythematous than
yesterday.
GU: Left nephrostomy upper and lower tube sites clean and dry,
with no induration, redness or swelling, Right nephrostomy tube
with dressing c/d/I and no urine leakage visualized
EXT: Warm, well perfused, 2+ right lower extremity edema.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
Pertinent Results:
Admission Labs
==================
___ 05:37PM BLOOD WBC-3.9* RBC-2.75* Hgb-8.6* Hct-27.6*
MCV-100* MCH-31.3 MCHC-31.2* RDW-16.0* RDWSD-58.4* Plt ___
___ 05:37PM BLOOD Neuts-74.2* Lymphs-13.8* Monos-9.7
Eos-1.5 Baso-0.3 Im ___ AbsNeut-2.89 AbsLymp-0.54*
AbsMono-0.38 AbsEos-0.06 AbsBaso-0.01
___ 05:37PM BLOOD Plt ___
___ 06:33AM BLOOD ___ PTT-25.8 ___
___ 05:37PM BLOOD Glucose-103* UreaN-19 Creat-1.0 Na-143
K-3.9 Cl-102 HCO3-24 AnGap-17
___ 05:37PM BLOOD Calcium-9.2 Phos-4.2 Mg-1.7
___ 05:50PM BLOOD Lactate-1.3
Micro
=====
___ URINE URINE CULTURE-FINAL INPATIENT
___ URINE URINE CULTURE-FINAL {PROBABLE
ENTEROCOCCUS} INPATIENT
___ MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS} INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, NGTD
___ BLOOD CULTURE Blood Culture, NGTD
Imaging
========
___ ___
IMPRESSION:
No evidence of deep venous thrombosis in the right lower
extremity veins.
___ Abd xray
IMPRESSION:
Bilateral percutaneous nephrostomy tubes, left percutaneous
nephroureterostomy, and right ureteral stent in place.
Discharge Labs
===============
___ 07:30AM BLOOD WBC-4.0 RBC-2.74* Hgb-8.4* Hct-26.3*
MCV-96 MCH-30.7 MCHC-31.9* RDW-17.9* RDWSD-62.3* Plt ___
___ 07:30AM BLOOD Glucose-106* UreaN-15 Creat-0.9 Na-139
K-4.6 Cl-104 HCO3-22 AnGap-13
___ 06:33AM BLOOD ALT-10 AST-13 LD(LDH)-244 AlkPhos-55
TotBili-0.4
___ 07:30AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0
___ 07:44AM BLOOD calTIBC-213* Hapto-677* Ferritn-640*
TRF-164*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Megestrol Acetate 800 mg PO DAILY
2. Mirtazapine 7.5 mg PO QHS
3. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
4. Oxybutynin 5 mg PO TID
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
6. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortnes of
breath/wheezing
7. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Miconazole Powder 2% 1 Appl TP TID to rash in skin folds
under ostomy
apply to areas of moist, irritated skin under ostomy and lower
stomach
RX *miconazole nitrate [Anti-Fungal] 2 % apply to irritated
moist skin twice per day Disp #*1 Bottle Refills:*0
2. Naloxone Nasal Spray 4 mg IH ONCE MR1 opiate overdose
Duration: 1 Dose
RX *naloxone [Narcan] 4 mg/actuation 1 spray nasal PRN Disp #*1
Spray Refills:*3
3. OxyCODONE SR (OxyconTIN) 10 mg PO QHS:PRN moderate-severe
pain Duration: 14 Days
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth every
evening as needed Disp #*14 Tablet Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H:PRN Disp #*36
Tablet Refills:*0
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
6. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortnes of
breath/wheezing
7. Megestrol Acetate 800 mg PO DAILY
8. Mirtazapine 7.5 mg PO QHS
9. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
10. Oxybutynin 5 mg PO TID
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
===================
Nephrostomy tube
Hydronephrosis
Pyelonephritis
Metastatic Cervical Squamous Cell Carcinoma
Secondary Diagnosis
====================
Fatigue
Sinus Tachycardia
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ yo F with stage 4 cervical cancer, unilateral swelling of
right leg// ?DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: No relevant comparison identified.
FINDINGS:
There is normal compressibility, flow, and augmentation of the right 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:
No evidence of deep venous thrombosis in the right lower extremity veins.
Radiology Report
INDICATION: ___ year old woman with nephrostomy tubes concern for
malplacement// ?malplacement of nephrostomy tubes
COMPARISON: Prior CT of the abdomen pelvis from ___
FINDINGS:
AP supine views of the abdomen pelvis provided. Bilateral percutaneous
nephrostomy tubes are in place. There is a right ureteral stent which appears
well positioned. There is also a left percutaneous nephroureterostomy the
catheters appear well positioned. Bowel gas pattern is unremarkable. Bony
structures are intact.
IMPRESSION:
Bilateral percutaneous nephrostomy tubes, left percutaneous
nephroureterostomy, and right ureteral stent in place.
Radiology Report
INDICATION: ___ year old woman with ___ PCNU and L PCN (duplicated system) with
leakage and probable kink on xray// ___ PCNU and L PCN exchange
COMPARISON: Multiple prior exchanges
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___
performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
200 mcg of fentanyl and 4.5 Mg of midazolam throughout the total intra-service
time of 40 mins during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS:
CONTRAST: 10 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE:
PROCEDURE:
1. Bilateral diagnostic antegrade nephrostogram.
2. Bilateral 8 ___ nephrostomy to 12 ___ upsize.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient.The patient was then brought to the angiography suite and placed prone
on the exam table. A pre-procedure time-out was performed per ___ protocol.
The right and left flank were prepped and draped in the usual sterile fashion.
Diluted contrast was injected into the left nephrostomy to confirm catheter
position. The image was stored on PACS. Local anesthesia was administered with
instillation of lidocaine jelly and 1% subcutaneous lidocaine injection. The
catheter was cut. A ___ wire was advanced into the left nephrostomy tube
and advanced into the distal ureter. The stay sutures were cut and the
catheter was removed over the wire. A new 12 ___ nephrostomy catheter was
flushed and advanced with its plastic stiffener over the wire into appropriate
position. The wire and stiffener were removed and the pigtail was formed.
Contrast injection confirmed appropriate positioning. The final image was
saved. The catheter was then flushed and the catheter was secured with a
Stayfix and sterile dressings. The catheter was attached to a bag for
drainage.
On the left side, the upper pole PCNU was also interrogated, however this was
patent without evidence of obstruction so this was not changed.
Diluted contrast was injected into the right nephrostomy to confirm catheter
position. The image was stored on PACS. Local anesthesia was administered
with instillation of lidocaine jelly and 1% subcutaneous lidocaine injection.
The catheter was cut. A ___ wire was advanced into the right nephrostomy
tube and advanced into the distal ureter. The stay sutures were cut and the
catheter was removed over the wire. A new 12 ___ nephrostomy catheter was
flushed and advanced with its plastic stiffener over the wire into appropriate
position. The wire and stiffener were removed and the pigtail was formed.
Contrast injection confirmed appropriate positioning. The final image was
saved. The catheter was then flushed and the catheter was secured with a
Stayfix and sterile dressings. The catheter was attached to a bag for
drainage.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Both nephrostomy tubes were clogged
2. PCNU on the left was patent
3. Appropriate final position of bilateral ___ F nephrostomy tubes.
IMPRESSION:
Technically successful upsizing of bilateral nephrostomy tubes to ___ given
frequent clogging. PCNU to upper pole of left kidney was not exchanged.
Radiology Report
INDICATION: ___ year old woman with post radiation obstruction. // Right PCN
leaking; Right PCN check/reposition/ exchange
COMPARISON: ___ Upsizing of bilateral nephrostomy tubes
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and
Dr. ___. ___, interventional Radiology resident performed the
procedure. Dr. ___ supervised the trainee during any key
components of the procedure where applicable and reviewed and agrees with the
findings as reported below.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
150mcg of fentanyl and 3 mg of midazolam throughout the total intra-service
time of 20 during which the patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse. 1% lidocaine was injected
in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: 1 g Cefazolin IV
CONTRAST: 10 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 2.0 minutes, 12 mGy
PROCEDURE:
1. Right side diagnostic antegrade nephrostogram.
2. Right 12 ___ modified nephrostomy exchange.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient.The patient was then brought to the angiography suite and placed prone
on the exam table. A pre-procedure time-out was performed per ___ protocol.
The right flank was prepped and draped in the usual sterile fashion.
Diluted contrast was injected into the right nephrostomy to confirm catheter
position. The image was stored on PACS. Local anesthesia was administered
with instillation of lidocaine jelly and 1% subcutaneous lidocaine injection.
The catheter was cut. A ___ wire was advanced into the right nephrostomy
tube and advanced into the renal pelvis. The stay sutures were cut and the
catheter was removed over the wire. A new 12 ___ nephrostomy catheter was
then modified with two additional side holes cut proximal to the pigtail. The
catheter was flushed and advanced with its plastic stiffener over the wire
into appropriate position. The wire and stiffener were removed and the pigtail
was formed. Contrast injection confirmed appropriate positioning. The final
image was saved. The catheter was then flushed, stay sutures applied and the
catheter was secured with a Stat Lock device and sterile dressings. The
catheter was attached to a bag for drainage.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Right side antegrade nephrostogram shows appropriate positioning of the
percutaneous nephrostomy tube..
2. Appropriate final position of 12 ___ modified nephrostomy tube.
IMPRESSION:
Technically successful Right 12 ___ modified nephrostomy exchange.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: NEPHROSTOMY TUBE EVAL
Diagnosed with Cellulitis of right lower limb
temperature: 98.5
heartrate: 118.0
resprate: 20.0
o2sat: 100.0
sbp: 111.0
dbp: 68.0
level of pain: 9
level of acuity: 3.0 | Summary
=========
Ms. ___ is s a ___ female with history of
recurrent metastatic cervical cancer complicated by bilateral
ureteral narrowing and rectovaginal fistulas, requiring
diverting
colostomy and bilateral nephrostomy tubes who presents for
nephrostomy tube evaluation. There was initial concern for UTI
given WBCs in UA on admission, and she was treated with ___bx, until infection was r/o. She underwent bilateral
nephrostomy tube replacement ___, with leakage of the R PCN
requiring repeat exchange on ___.
Active Issues
==============
# Nephrostomy Tube Malfunction:
# Hydronephrosis ___ Malignancy:
# Concern for Cellulitis:
# Pyelonephritis:
Patient with a history of bilateral nephrostomy tubes secondary
to ureteral narrowing due to malignancy presented with leaking
around nephrostomy tubes. The patient is poor nephrostomy tube
care at home he does not currently have ___ home services.
Leaking around the tube was initially concerning for malposition
but abdominal x-ray obtained on admission demonstrated good
position of all tubes. Given this it is likely that the
nephrostomy tubes had occluded. On ___ the patient's
nephrostomy tubes were replaced by interventional radiology.
The patient's urine was also examined and demonstrated signs of
infection. Given that the source of the patient's urine was at
the nephrostomy tube this was considered pyelonephritis. After
receiving a dose of Zosyn in the ED, The patient was switched to
Unasyn and vancomycin, which was discontinued ___ d/t negative
urine and blood cx, lack of symptoms, and remaining afebrile.
The patient was seen by social work and case management. SW will
continue to follow up with patient through outpatient oncology
office.
#Skin breakdown with possible cellulitis
#Rectovaginal fistula
Patient has a history of a recto-vaginal fistula who presented
with a white and brown foul-smelling vaginal discharge.
Additionally the patient had erythema surrounding her ostomy
site as well as skin breakdown surrounding the nephrostomy sites
likely from continuous urine leakage. Given the above there was
initial concern for skin and soft tissue infections as well as
some concern for intra-abdominal process. Given that the
patient was afebrile with mild leukopenia and pyelonephritis on
admission did not initially undergo CT scan of the abdomen. She
was treated with 3 day course of vancomycin and Unasyn, which
was discontinued after urine and blood cx were negative and
clinical status improved. Wound ostomy nurse was consulted for
breakdown under pannus and around ostomy. Skin breakdown and
irritation was treated with miconazole powder.
# Metastatic Cervical Squamous Cell Carcinoma:
She is s/p chemoradiation with curative intent at ___ in ___
though recent biopsy of LUL lesion unfortunately showed evidence
of squamous cell carcinoma consistent with recurrent metastatic
disease. She is currently being treated with palliative
Carboplatin/Paclitaxel (s/p 2 cycles) with plan for 6 cycles, if
tolerated. The patient is to her third cycle on ___ but
skipped his not feeling well. The primary team reached out to
the patient's oncologist Dr. ___ direction on chemotherapy
regimen.
# Cancer-Related Debility/Fatigue:
Patient reports she is now wheelchair dependent due to lower
extremity weakness. She states this is a chronic issue as she
has not been utilizing her lower extremities for some time.
Exam demonstrated ___ strength in bilateral lower extremities.
The patient was seen by ___ who recommended that she be
discharged to a rehabilitation facility due to the fact that she
will need 24-hour assistance for mobility and ADLs. Patient
refused ___ rehabilitation and was able to vocalize the
risks of not going. Her mother is available to assist her on a
24-hour basis at home. She is also being discharged with ___
services and at-home ___.
# Cancer-Related Pain:
The patient's pain was attributed to her bilateral nephrostomy
tubes and was treated with p.o. oxycodone and IV Dilaudid for
breakthrough pain. Palliative care was consulted, who
recommended oxycontin every night for longer-lasting pain
control in addition to her oxycodone PRN.
# Sinus Tachycardia: Patient notes that her baseline is
tachycardia in the 120s. An ECG done here shows sinus
tachycardia at a rate in the 110s.
Chronic Issues
=================
# Malnutrition: Continued home Megestrol and Mirtazipine
# GU Symptoms: Continued home Oxybutynin 5mg TID
# Nausea: Continued home Zofran PRN
# Anemia
Hgb trended downward to 6.6 today from baseline Hgb ___. Likely
due to mixed anemia (chronic disease, iron deficiency d/t poor
nutritional intake). Hgb responded appropriately and was stable
at 8.4 on discharge.
Transitional Issues
====================
[] will need monitoring of anemia as outpatient in the event
that Hgb drops again and patient requires additional future
transfusion
[] nephrostomy drains are high risk of becoming clogged or
dislodged; placed by ___ here and will need an evaluation if they
become dislodged or fail to function
[] patient needs more ostomy bags than her insurance currently
covers
[] initiated oxycontin QHS 10mg but did not assess how well she
tolerates this in the hospital, titrate as needed outpatient
Code: full
Contact: ___ (sister) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Increasing size of liver lesions
Major Surgical or Invasive Procedure:
Liver biopsy ___
History of Present Illness:
___ PMH of PE (lovenox), Anxiety, AML (in complete remission,
undergoing consolidation with high dose ara-C), who was recently
admitted for neutropenic fever found to have hepatic
microabscesses, now admitttd with increased size of hepatic
lesions despite ___s per review of discharge summary from 1 week ago, patient was
admitted for febrile neutropenia, for which ID was consulted and
felt that patient likely had transient bacteremia from
mucositis,
as she was found to have hepatic microabscesses. She was
discharged on 14 day course of ertapenem (planned to end
___ and was supposed to have a CT scan following
completion
of therapy. CT was completed on ___ and was found to have
increased size of hypodense lesions with hyperemia so was
referred to ED for admission.
In the ED, initial vitals: 97.2 103 142/87 18 100% RA. WBC 2.5,
Hgb 9.0, plt 218, CHEM wnl, Lactate wnl, UA with few bact, sm
Bld, Tr prot, lactate 0.6.
CT A/P revealed:
1. The previously noted hypodense hepatic lesions are increased
in size compared to prior imaging now measuring up to 14 mm
(previously 4-5 mm). There is still geographic
enhancement/hyperemia surrounding some of these lesions. These
lesions are nonspecific and may be infective/inflammatory in
nature or may be neoplastic/metastatic. Correlation with blood
cultures with or without histology is recommended.
2. No other findings of note.
Patient was given vancomycin, zosyn, voriconazole, lovenox,
acyclovir and admitted to oncology for further care. VS prior to
transfer were pain 0, T 98, HR 76, BP 114/65, RR 18, O2 100%RA.
On arrival to the floor, patient has no acute complaints. She
denies any recent fevers, chills, or rigors. She has no nausea
or
RUQ pain. No headaches or visual change. No URTI symptoms. No
CP,
SOB or cough. No N/V/D. No dysuria. Her only focal symptom is
increased fatigue over the last few days. She also notes some
intermittent vaginal spotting since last ___ she does
receive Lupron for ovarian suppression and received her last
injection on ___ (about a week late); she also had an IUD in
place.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
As per last discharge summary:
___ with one month hx bruising and progressive fatigue. At
the time of presentation she was found with WBC count of 61.9K,
hemoglobin of 9.9, platelets of 28K with 22% blasts on the
differential. Previous WBC on ___ was 6.9, with baseline
hemoglobin of 13.2 and platelets of 248. Other labs notable for
ESR of 45, INR of 1.1, PTT of 28, ALT of 27 from 10 previously,
AST elevated to 50 from 16 previously, BUN/Cr of ___, uric
acid 4.7, LDH 1470, negative U/A. She was transferred here
where she was initially started on Hydroxyurea from ___
given concerns for APML however further information from bone
marrow reveled AML vs APML. She then moved forward with .
induction chemotherapy cytarabine and daunorubicin ___.
Her course was complicated by febrile neutropenia, Right IJ
thrombus and acute kidney injury.
The patient developed fever on ___. She had minor mucositis and
some diarrhea with possible colitis noted on CT A/P, other
workup unrevealing. Initially on vanc/cefepime, vanc d/c in
setting of ___, cefepime changed to zosyn for increased
anaerobic coverage in light of evidence of colitis on CT. This
was later changed to meropenem after rash developed. TTE (___)
showed no evidence of endocarditis. All cultures negative.
Patient remained afebrile until ___ when spiked fever, at that
time no localizing symptoms, again started on vancomyin. Both
vancomycin and mereopenem were d/c ___ and ___, respectively)
as patient remained afebrile and ANC > 500. G6PD normal.
Repeat BM Bx on ___ showed hypocellular marrow with no
morphologic evidence of disease however ___ metaphase cells
showing t(8,21). FISH was RUNX1/RUNX1T1 positive in 15% of the
uncultured interphase cells examined.
___: BMBX consistent with morphologic and cytogenetic
remission.
___: New PE started on therapeutic Lovenox
___: C1D1 HiDAC
___: C2D1 HiDAC
___: C2D1 HIDAC
PAST MEDICAL HISTORY:
- AML as above
- Pulmonary embolism on lovenox (___)
- lyme disease
- mononucleosis
- IUD
- PICC associated RIJ and brachial vein thrombi (resolved)
- anxiety
- Headache/migraines
- Febrile Neutropenia, thought to be ___ bacteremia in light of
liver microabscesses, discharged on 2 week course of ertapenem
(planned to end ___
Social History:
___
Family History:
No known family history of leukemia or hematologic malignancy
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.9 HR 71 BP 110/76 RR 16 SAT 100% O2 on RA
GENERAL: Pleasant well appearing young woman with recovering
alopecia, sitting up in bed in no distress
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops; 2+ radial pulses
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; no hepatomegaly, no
splenomegaly
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk
NEURO: Alert, oriented, CN III-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. Bruising over lower abdomen
PHYSICAL EXAM:
___ 0507 Temp: 98.1 PO BP: 101/69 HR: 73 RR: 16 O2 sat: 97%
O2 delivery: RA
GENERAL: Pleasant and well appearing young woman sitting up in
bed in no distress
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
mildly tender to deep palpation in RUQ. No rebound or guarding.
No ___ sign. No hepatomegaly, no
splenomegaly. Right sided biopsy site dressed with occlusive
dressing is c/d/I. Small bruising just inferior to site. No
pain
around biopsy site.
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk
NEURO: Alert, oriented, motor and sensory function grossly
intact
SKIN: No significant rashes
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. Bruising over lower abdomen
Pertinent Results:
ADMISSION LABS:
===============
___ 08:30PM BLOOD WBC-2.5* RBC-2.80* Hgb-9.0* Hct-27.1*
MCV-97 MCH-32.1* MCHC-33.2 RDW-17.7* RDWSD-49.9* Plt ___
___ 08:30PM BLOOD Neuts-54.0 ___ Monos-23.0*
Eos-0.0* Baso-0.8 Im ___ AbsNeut-1.34* AbsLymp-0.54*
AbsMono-0.57 AbsEos-0.00* AbsBaso-0.02
___ 08:30PM BLOOD ___ PTT-43.0* ___
___ 08:30PM BLOOD Glucose-98 UreaN-7 Creat-0.6 Na-143 K-4.1
Cl-102 HCO3-25 AnGap-16
___ 08:30PM BLOOD ALT-18 AST-18 AlkPhos-87 TotBili-0.3
___ 10:33AM BLOOD Calcium-9.4 Phos-4.4 Mg-2.0
DISCHARGE LABS:
===============
___ 12:00AM BLOOD WBC-3.5* RBC-2.88* Hgb-9.6* Hct-28.0*
MCV-97 MCH-33.3* MCHC-34.3 RDW-19.6* RDWSD-67.7* Plt ___
___ 12:00AM BLOOD Neuts-56 Bands-0 ___ Monos-21*
Eos-0 Baso-1 ___ Myelos-0 AbsNeut-1.96 AbsLymp-0.77*
AbsMono-0.74 AbsEos-0.00* AbsBaso-0.04
___ 12:00AM BLOOD Glucose-84 UreaN-10 Creat-1.0 Na-142
K-3.6 Cl-102 HCO3-26 AnGap-14
___ 12:00AM BLOOD ALT-10 AST-13 LD(LDH)-202 AlkPhos-83
TotBili-0.4
___ 12:00AM BLOOD Calcium-9.6 Phos-4.1 Mg-1.9
MICROBIOLOGY:
=============
___: Liver bx:
Gram stain 1+ PMN; no micro-organism
Culture - No growth
___ prep - No fungal elements
Fungal culture - PND
Nocardia - PND
Viral Cx - Negative
CMV Antigen - PND
AFB smear - Negative
AFB Cx - PND
___: EBV Serology - IgG positive; IgM Negative
___: CMV Serology - Negative
___: Cryptococcal antigen - Negative
___: Mycolytic blood cultures - PND
___: Urine Culture x1 - <10K CFU
___: Blood Culture x2 - Negative
___: CMV VL - Negative
___: EBV VL - PND
___: Aspergillus Galactomannan - Negative
___: B-Glucan - 161 (Positive)
___: Urine histoplasmosis antigen - Negative
___: Aspergillus Galactomannan - Negative
___: B-Glucan - Negative
___: Urine Culture - Vanc sensitive enterococcus ___
CFU
PATHOLOGY
=========
___: Liver Bx - C/w resolving abscess
___: Liver Bx Flow Cytometry - PND
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Escitalopram Oxalate 5 mg PO DAILY
3. LORazepam 0.5-1 mg PO Q4H:PRN
nausea/vomiting/anxiety/insomnia
4. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN mouth
pain
5. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain -
Moderate
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
7. Enoxaparin Sodium 60 mg SC Q12H
Discharge Medications:
1. Fluconazole 400 mg PO Q24H
RX *fluconazole 100 mg 4 tablet(s) by mouth daily Disp #*56
Tablet Refills:*0
2. Piperacillin-Tazobactam 4.5 g IV Q8H
RX *piperacillin-tazobactam 4.5 gram 4.5 g IV q8 hours Disp #*42
Vial Refills:*0
3. Acyclovir 400 mg PO Q12H
4. Enoxaparin Sodium 60 mg SC Q12H
5. Escitalopram Oxalate 5 mg PO DAILY
6. LORazepam 0.5-1 mg PO Q4H:PRN
nausea/vomiting/anxiety/insomnia
7. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN mouth
pain
8. OxyCODONE (Immediate Release) 2.5-5 mg PO Q6H:PRN Pain -
Moderate
9. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Hepatosplenic candidiasis
# Liver abscess
# AML, in remission
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with AML in remission on consolidation HiDAC.
Recent admission for febrile neutropenia with ? microabscess. Now growing
liver lesion despite ertapenem.// ? aspiration/sampling of presumed liver
abscess.
COMPARISON: CT abdomen dated ___
PROCEDURE: Ultrasound-guided targeted liver biopsy.
OPERATORS: Dr. ___ radiologist personally
supervised the trainee during the key components of the procedure and reviewed
and agrees with the trainee's findings.
FINDINGS:
Limited preprocedure grayscale and Doppler ultrasound imaging of the liver was
performed. The lesion for biopsy was identified in the right hepatic lobe
measuring 9 x 8 x 7 mm in size. A suitable approach for targeted liver biopsy
was determined.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
Based on the preprocedure imaging, an appropriate skin entry site for the
biopsy was chosen. The site was marked. The skin was then prepped and draped
in the usual sterile fashion. The superficial soft tissues to the liver
capsule were anesthetized with 10 mL 1% lidocaine.
Under real-time ultrasound guidance, 4- 18-gauge core biopsy sample was
obtained. 1 sample was sent for microbiology and cultures in saline, while
the other samples were sent in formalin for
The skin was then cleaned and a dry sterile dressing was applied. There were
no immediate complications.
SEDATION: Moderate sedation was provided by administering divided doses of
2.5 mg Versed and 125 mcg fentanyl throughout the total intra-service time of
55 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
IMPRESSION:
Uncomplicated 18-gauge targeted liver biopsy x 4, with specimen sent for
microbiology and cultures as well as histopathology.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal CT
Diagnosed with Hepatomegaly, not elsewhere classified
temperature: 97.2
heartrate: 103.0
resprate: 18.0
o2sat: 100.0
sbp: 142.0
dbp: 87.0
level of pain: 0
level of acuity: 3.0 | PRINCIPLE REASON FOR ADMISSION:
___ PMH of PE (lovenox), Anxiety, AML (in complete remission,
undergoing consolidation with high dose ara-C), who was recently
admitted for neutropenic fever found to have hepatic
microabscesses, admitttd with increasing size of hepatic lesions
despite ___ntibiosis initially changed
to vancomycin, pip/tazo, micafungin; later changed micafungin to
fluconazole. She underwent liver biopsy on ___. Surgical
pathology is consistent with resolving abscess, although
microbiologic studies to date have been negative aside from
positive B-Glucan. Plan to continue empiric IV zosyn with po
fluconazole was made and she will follow up with ID to determine
final abx course.
Etiology of her abscess is unclear, which will make
determination
of abx course difficult. Given imaging findings and positive
glucan (and since it worsened despite ertapenem) favor possible
hepato-splenic candidiasis. afebrile with normal LFTs, and
appears to be healing. Favor continue broad GNR/anaerobic
coverage with pip/tazo and fluconazole for candidiasis. Will
need
likely prolonged treatment of at least two weeks. Will arrange
home services and ID follow up next week. Otherwise she had
developed moderate neutropenia which improved
after initiating treatment as above. Likely related to resolving
abscess.
# Hepatic microabscesses:
Etiology of abscesses remains unclear. Grew in size despite 2
weeks of ertapenem as outpatient. No significant fevers and no
liver test abnormalities. Antibiosis initially changed to
vancomycin, pip/tazo, micafungin; later changed micafungin to
fluconazole. She underwent liver biopsy on ___. Surgical
pathology is consistent with resolving abscess, although
microbiologic studies to date have been negative aside from
positive B-Glucan. Plan to continue empiric IV zosyn with po
fluconazole was made and she will follow up with ID to determine
final abx course.
- ___ remaining infectious studies
- ___ flow cytometry on liver sample
- Con't pip-tazo/fluconazole; D1 effectively ___.
- ___ in ___ clinic next week for final abx course
# Neutropenia: Admitted with mild neutropenia. ___ eventually
dropped to 750 on ___ before recovering prior to discharge.
Potentially medication induced vs effect of infectious abscess.
#Hx of PE: Lovenox was held prior to liver biopsy. Of note, she
was not maintained on heparin gtt due to patients firm desire to
avoid PIV, lack of additional IV access, and asympomtatic nature
after >3 months of anticoagulation. She was restarted on
therapeutic following biopsy without incident.
#Hx of AML in remission
Continued acyclovir ppx. Flow cytometry was sent on liver biopsy
specimen. Will need to follow up with Dr. ___ week
(either ___ or ___ for further treatment planning.
# Vaginal spotting:
Noted on admission. Likely due to delayed Lupron dosing.
Resolved.
#Anxiety
Continued escitalopram
# Anemia in malignancy
Stable to improving sp consolidation chemotherapy
# Billing: >30 minutes spent coordinating and executing this
discharge plan |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Anorexia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ woman with history of
anorexia nervosa, depression with recent serious suicide
attempt, and anxiety who presents from ___
Facility on ___ for anorexia, severe malnutrition, and
weight loss.
She was recently admitted to a hospital in ___ for two
weeks for a purposeful overdose of percocet requiring intubation
and complicated by aspiration pneumonia. She was discharged from
___ and admitted to the ___
yesterday with weight of 67 pounds. Her weight this AM was 64.8
pounds and she was referred to the ED at ___. Vitals there
were 90/59 and HR 116. By report from the ED, she had been
refusing to follow the plan for treatment of her anorexia,
declining NGT and supplements. She was placed on ___ for
transportation to the ED. She is independent in her ADLs. She
denies SI and HI at this time.
She was admitted to the hospital in ___ approximately 2
weeks ago after an overdose attempt on percocet. She states she
was suicidal in the context of learning she had exhaused her
medical leave and would not be able to return to college
___) as previously planned.
She has had anorexia nervosa for ___ years. She has previously
been admitted to medical facilities (including ___ prior to her
last ___ stay) for medically monitored weight gain/anorexia.
She has had at least three previous stays in inpatient eating
disorder hospitals, including ___, a place in ___, and a
place in ___. She states her lowest weight was 57 lbs in
___ and her highest was in the high 80's at her last
discharge from ___, although her mother contends she has been
in the 100's previously. She has had an NG tube previously for
one day, denies percutaneous G tubes or J tubes. She received
TPN during her last hospitalization after the suicide
attempt/intubation. She states her LMP was approximately ___
years ago, at which time she reports being in the low 80lb
range.
She and her mother deny binding, purging, laxitive use, diet
pill use, diuretics, emetics, or excessive exercise. She was
doing "light walking" prior to this last hospitalization,
although she is unable to quantify for how many minutes or for
what distance. She dislikes nuts, penutbutter. She reports not
tolerating milk well. Otherwise no dietary restrictions.
She does not currently have an outpatient psychiatrist. She
previously had a good relationship from a therapist at ___,
although recently has not been followed by them.
- In the ED, initial vitals were: 97.7 58 80/48 16 95% RA.
- Labs were notable for: WBC 3.1, H/H 10.9/30.4, Plt 441, Na
136, K 4.2, Cr 0.5. UA bland. Serum tox negative and urine tox
negative.
- Patient was given: D5NS + 20K @ 125cc/hr.
- Patient ate full lunch tray in ED.
On the floor, she has no further complaints, and endorses
understanding of the eating disorder protocol.
Review of systems:
(+) Per HPI
She denies shortness of breath, chest pain, lower extremity
edema, rashes (aside from irritation at the site of her recent
PICC on right arm), abdominal pain, or other complaints. She
endorses amenorrhea.
Past Medical History:
- Anorexia Nervosa x ___ years
- Depression
- Anxiety
- H/O wisdom teeth removal, uncomplicated.
Social History:
___
Family History:
Maternal grandfather had a stroke. Denies family history of
depression, anxiety, eating disorders, cancers, diabetes, high
blood pressure, or heart attack.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 30.4kg on admission (in ___ and ___, 98.2, 92/66
(orthostatics pending), 65, 16, 100% on RA
General: Extremely emaciated. Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Scaphoid. Soft, non-tender, non-distended, bowel sounds
present, no organomegaly, no rebound or guarding
GU: No foley
Ext: mildly cool to touch, no clubbing, cyanosis or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
DISCHARGE PHYSICAL EXAM:
Vitals: T 97.8 RR 16 O2 100%RA
Orthostatics:
Supine: BP: 98/54 P: 70
Standing: BP: 102/72 P: 110
Weights:
___ 36.0kg
___ 35.6kg
___ 35.5kg
___ 34.9kg
___ 34.7kg
___ 34.7kg
___ 33.9kg
-- admit (___): 29.2 (AM after admit weight)
GEN: Cachectic, emaciated. Diffuse wasting throughout. Frail
___: RRR, no murmurs, rubs, or gallops. pulse 2+ and regular
Lungs: CTAB
Abd: Scaphoid.
Pertinent Results:
ADMISSION LABS:
========================
___ 02:50PM BLOOD WBC-3.1* RBC-3.35* Hgb-10.9* Hct-30.4*
MCV-91 MCH-32.4* MCHC-35.7* RDW-14.3 Plt ___
___ 02:50PM BLOOD Neuts-61.1 ___ Monos-9.2 Eos-2.1
Baso-0.5
___ 07:28AM BLOOD ___ PTT-32.8 ___
___ 02:50PM BLOOD Glucose-89 UreaN-13 Creat-0.5 Na-136
K-4.2 Cl-98 HCO3-25 AnGap-17
___ 02:50PM BLOOD ALT-36 AST-33 AlkPhos-74 TotBili-0.4
___ 02:50PM BLOOD Lipase-79*
___ 02:50PM BLOOD Albumin-4.6 Calcium-10.1 Phos-4.9* Mg-2.2
___ 02:50PM BLOOD TSH-3.1
___ 02:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
=======================
___ 07:18AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.1
___ 07:18AM BLOOD Glucose-75 UreaN-19 Creat-0.5 Na-143
K-4.2 Cl-106 HCO3-26 AnGap-15
STUIDES:
=======================
ECG (___):
Sinus bradycardia. Otherwise, normal tracaing. No previous
tracing available for comparison.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
52 148 76 412 398 43 0 46
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Temazepam 30 mg PO QHS
2. ClonazePAM 0.5 mg PO TID:PRN anxiety
3. Gabapentin 100 mg PO BID
Discharge Medications:
1. ClonazePAM 0.5 mg PO TID:PRN anxiety
2. Gabapentin 100 mg PO BID
3. Temazepam 30 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Anorexia Nervosa
Extreme Malnourishment
Bradycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with a medically unstable eating disorder. //
Please evaluate for signs of heart failure. Please evaluate for signs of
heart failure.
COMPARISON: Prior chest radiographs are not available.
IMPRESSION:
Normal heart, lungs, hila, mediastinum, and pleural surfaces. No evidence of
intrathoracic malignancy or infection, including tuberculosis, or cardiac
decompensation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Anorexia
Diagnosed with ANOREXIA NERVOSA, CARDIAC DYSRHYTHMIAS NEC, OTHER MALAISE AND FATIGUE
temperature: 97.7
heartrate: 58.0
resprate: 16.0
o2sat: 95.0
sbp: 80.0
dbp: 48.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ woman with history of
anorexia nervosa (admit BMI 10.7, 51.2% IBW), depression with
recent suicide attempt, and anxiety who presents from ___
___ for anorexia, severe malnutrition, and
weight loss.
# Severe Malnutrition
# Anorexia Nervosa:
Patient was maintained on an eating disorder refeading protocol
as below. Most recently, patient failed breakfast on ___, was
informed after lunch, mother and patient upset that she was
informed "late". Exam with stable hypotension and bradycardia.
Orthostasis stable.
-By discharge, we were checking Chem-10 QOD and they remained
stable. Would recommend approximately weekly Chem-10 checks once
at ___ EDU, to be determined by medical director there. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bile leak s/p lap cholecystectomy
Major Surgical or Invasive Procedure:
___: ERCP
___: Exploratory laparotomy and Roux-en-Y
hepaticojejunostomy.
History of Present Illness:
Per surgery consult note:
___ with symptomatic cholelithiasis ___ s/p lap
cholecystectomy (___), transferred from ___ on ___ with abdominal pain and CT scan demonstrating
multi-loculated fluid collection in RUQ near liver, s/p ERCP
with
placement of 7cm ___ biliary stent into the common bile duct
(although no leak identified from cystic duct remnant or hepatic
bile ducts), followed by percutaneous, transhepatic gallbladder
fossa drainage for ?intra-abdominal abscess with ___ ___ all
purpose drain by interventional radiology, now returns with
abdominal pain and persistent drainage (~300mL/day). When placed
by ___, the drain immediately put out 450mL dark bilious fluid,
with bilirubin = 27, which prompted subsequent diagnosis of
"resolved cystic stump leak." Following these procedures (ERCP,
___ drain), she was discharged from the ___ service ___ -
___,
then subsequently readmitted to ___ on ___ with persistent
abdominal pain. Subsequent to readmission, an abdominal U/S
demonstrated the percutaneous transhepatic drainage catheter to
be in the correct location, and the fluid collection within the
gallbladder fossa to be largely resolved with only trace fluid
remaining. ERCP was then repeated on ___, during which the
right lobe of the liver appeared to have an area of limited
opacification, suggesting an excluded part, not connected to the
right hepatic duct. The patient has continued drainage of bile
from the percutaneous drain (430mL yesterday, approximately
300mL
at home). Currently, c/o persistent RUQ abdominal pain, on
dilaudid ___ po q3h prn, yet is tolerating a regular diet.
Transplant surgery was consulted for evaluation and
recommendations for management of persistent bile leak. Of note,
no reported or known operative complications with the
cholecystectomy.
Past Medical History:
Depression, Carpal tunnel syndrome s/p Right carpal tunnel
release
Social History:
___
Family History:
--Mother perforated diverticulitis
Physical Exam:
Admission/consult PE:
T 98.4 HR 98 BP 119/69 RR 19 O2sat 94%RA
Drain: 170mL today, 430mL yesterday
Gen: NAD, A+Ox3
CV: RRR
Pulm: clear to auscultation, bilaterally
Abd: well-healed incisions, abdomen soft, obese, tender RUQ,
drain exit site c/d/i, bilious drainage in bag, no guarding, no
rebound tenderness
Ext: wwp, no c/c/e
Pertinent Results:
On Admission: ___
WBC-7.4 RBC-4.33# Hgb-12.9# Hct-39.2# MCV-91 MCH-29.9 MCHC-33.0
RDW-13.3 Plt ___ PTT-30.7 ___
Glucose-85 UreaN-14 Creat-0.8 Na-139 K-4.1 Cl-102 HCO3-24
AnGap-17
ALT-56* AST-43* AlkPhos-241* TotBili-0.5
Albumin-3.7 Calcium-9.1 Phos-3.9 ___: Amylase 182
At Discharge:
WBC-8.8 RBC-3.51* Hgb-10.1* Hct-31.4* MCV-90 MCH-28.9 MCHC-32.3
RDW-14.1 Plt ___ PTT-36.2 ___
Glucose-96 UreaN-10 Creat-0.5 Na-136 K-4.0 Cl-99 HCO3-25
AnGap-16
ALT-8 AST-15 AlkPhos-141* TotBili-0.3
Calcium-8.1* Phos-3.8 Mg-1.8
...
Culture Data:
___ 7:44 pm BILE **FINAL REPORT ___
GRAM STAIN (Final ___:
THIS IS A CORRECTED REPORT ___.
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
PREVIOUSLY REPORTED AS ( ___.
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___ ___ ___ 1245PM.
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..
Work-up of organism(s) listed below discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
GRAM NEGATIVE ROD(S). MODERATE GROWTH.
STAPH AUREUS COAG +. QUANTITATION NOT AVAILABLE.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
..........
Imaging:
CT abdomen (OSH, ___: Fluid collection noted in the
gallbladder fosa tracking over the liver superiorly, density
consistent with bile, fluid layering in the abdominal cavity and
pelvis likely bile based on the density characteristics.
ERCP ___, ___: Normal major papilla, cannulation of
the
biliary duct was successful and deep with a sphincterotome using
a free-hand technique, limited pancreatography demonstrated a
normal caliber pancreatic duct. Normal common bile duct and
intrahepatic biliary tree. No leak identified from cystic duct
remnant or hepatic bile ducts. Given the pretest probability of
a
bile leak, a 7cm ___ biliary stent was placed in the CBD.
___ drain (___): Successful percutaneous, transhepatic
gallbladder fossa drainage with 450 cc, ___ drain in place.
Abdominal U/S (___): A percutaneous transhepatic catheter
is
seen traversing the liver to the gallbladder fossa. There is a
trace residual fluid. The fluid collection within the
gallbladder
fossa is largely resolved. No hepatic collection is seen. There
is no intrahepatic biliary ductal dilatation. The portal vein
is
patent demonstrating a hepatopetal flow. The common bile duct
is
prominent measuring 7 mm.
ERCP ___, ___: Plastic stent in the major papilla
removed. The CBD, CHD, right and left hepatic ducts, biliary
radicles and cystic duct stump were filled with contrast and
visualized. The course and caliber of the structures are normal
with no evidence of extrinsic compression, no ductal
abnormalities, and no filling defects. The right lobe of the
liver seemed to have an area of limited opacification,
suggesting
an excluded part, not connected to the right hepatic duct.
Forcefull contrast injection did not elucidate contrast
extravasation. Suspected bile leak from excluded liver segment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 0.5 mg PO QID:PRN anxiety
2. Duloxetine 60 mg PO DAILY
3. ZYRtec *NF* 10 mg Oral Daily
Discharge Medications:
1. Duloxetine 60 mg PO DAILY
2. Lorazepam 0.5 mg PO QID:PRN anxiety
3. Acetaminophen 1000 mg PO Q8H
4. Docusate Sodium 100 mg PO BID
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
6. Senna 1 TAB PO BID
7. ZYRtec *NF* 10 mg Oral Daily
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
bile duct injury s/p lap ccy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Patient is status post cholecystectomy with fluid collection in
the gallbladder fossa, status post drain placement. Assess for interval
change.
COMPARISONS: Reference CT abdomen of ___ and ultrasound exam of
___.
FINDINGS:
A percutaneous transhepatic catheter is seen traversing the liver to the
gallbladder fossa. There is a trace residual fluid. The fluid collection
within the gallbladder fossa is largely resolved. The liver is normal in
echotexture. No hepatic collection is seen. No suspicious hepatic lesion is
noted. There is no intrahepatic biliary ductal dilatation. The portal vein
is patent demonstrating a hepatopetal flow. The common bile duct is prominent
measuring 7 mm, which likely relates to patient's history of cholecystectomy.
The pancreatic head is unremarkable. The distal body and tail obscured by
overlying bowel gas. There is no ascites.
IMPRESSION:
Percutaneous transhepatic drainage catheter is in place. Fluid collection
within the gallbladder fossa is largely resolved, only trace fluid remaining.
Radiology Report
INDICATION: ___ woman with persistent drainage of bile status post
lap chole, complicated by bile leak status post ___ drain placement.
COMPARISON: Liver ultrasound ___, CT torso ___.
FINDINGS: Pre-contrast spot fluoroscopic image of the right upper quadrant
shows a percutaneous drainage catheter in the expected location of the
gallbladder fossa along with adjacent cholecystectomy clips. 40 cc of
ioversol waster-soluble contrast was gently hand injected through the
percutaneous drainage tube while serial fluoroscopic spot images were taken in
multiple projections. Contrast is seen filling and distending a contained
space which lays inferior to the hepatic shadow and slightly right of the
midline without evidence of contrast material entering the intra- or
extra-hepatic biliary duct system. Surgical staples are seen along the
periphery of the contrast-filled collection. A small amount of contrast is
seen extravasating around the tube track. Additional imaging after 10 minutes
post injection showed no migration of contrast. This fluid collection roughly
corresponds to the collection seen on prior CT torso examination. At the end
of examination, injected contrast material could not be withdrawn.
IMPRESSION: Contained fluid collection in the peritoneum to the right of
midline, which roughly corresponds to the previously seen fluid collection on
CT. There is no contrast material seen leading into the intra- or
extra-hepatic biliary system.
Radiology Report
This is an outside second opinion CT scan.
INDICATION FOR STUDY: Evaluate for injury to main, right and/or left hepatic
artery. Patient is status post laparoscopic cholecystectomy and bile leak.
Note that no outside report by the radiologist is provided.
TECHNIQUE: According to information provided on the images, the patient was
administered 80 mL of Isovue at 2 cc/sec and a helical scan was obtained from
the mid-chest through the abdomen and pelvis down to the level of the hip
joints. Images were reformatted in the axial, coronal and sagittal planes.
The timing of the study was in the mid phase and not acquired to optimize
opacification of the hepatic arteries for that reason; full evaluation of the
intrahepatic arterial patency cannot be performed.
DOSE RESPONSE: No information about dose is provided in the images.
ABDOMEN WITH CONTRAST: Subsegmental atelectasis is noted in both lung bases
with collapse of both the posterior aspect of the left and right lower lobes.
Ascitic fluid is noted around the liver with the largest quantities inferior
to segment III and lateral and superior to segment II. This is causing
perfusion abnormalities in the liver with enhanced perfusion in the left lobe
and somewhat diminished perfusion in the high right lobe of the liver. No
intra- or extra-hepatic bile duct dilatation is noted. Several clips are
noted in the gallbladder fossa. A large fluid collection with layering high
attenuation material is present in the porta hepatis presumably representing
bile with some hemorrhage. The portal vein is widely patent. Careful
evaluation of the hepatic arteries reveals that these are patent on the left
side. The gastroduodenal artery is patent. The images do not convincingly
show patency of the right hepatic artery.
Spleen is unremarkable but is surrounded by ascitic fluid. Stomach is
unremarkable. Head, body and tail of the pancreas are all unremarkable. Left
and right adrenal glands and kidneys are all unremarkable.
PELVIS WITH CONTRAST: Loops of large and small bowel in the abdomen and
pelvis are all unremarkable. A large amount of free fluid is present within
the pelvis. The Hounsfield attenuation of this fluid is approximately 20
suggesting that this is simple fluid. The bladder is well distended. The
uterus and adnexa are unremarkable. No inguinal or deep pelvic adenopathy is
identified. The ureters are unremarkable and not dilated.
SOFT TISSUE WINDOWS: No abnormalities are noted in the subcutaneous tissues.
BONE WINDOWS: No concerning lytic or blastic lesions identified within the
skeleton.
REFORMATTED SEQUENCES: The sagittal and coronal reformatted sequences confirm
the presence of a large amount of fluid around the left lobe of the liver.
IMPRESSION:
1. Please note that the study was not timed to optimize hepatic artery
opacification; however, while the left hepatic artery appears widely patent,
the depiction of satisfactory flow within the right is diminished and if
concern persists Doppler ultrasound of the hepatic artery could be performed.
Alternatively, a CT angiogram might be far more sensitive.
2. Large biloma around the left lobe of the liver with a large amount of
fluid around the spleen throughout the peritoneal cavity and extending down
into the pelvis. This is almost likely related to the recent laparoscopic
cholecystectomy.
Radiology Report
PA AND LATERAL VIEWS OF THE CHEST
REASON FOR EXAM: Fever.
There are low lung volumes. Cardiac size is minimally enlarged. Bibasilar
opacities, larger on the right side are consistent with atelectasis. There is
no pneumothorax or large effusions.
Radiology Report
INDICATION: Persistent drainage of bile status post laparoscopic
cholecystectomy complicated by bile leak with ERCP with stent and ___ drain
placement. Daily drain output is greater than 300 cc , query hepatic bile
leak.
TECHNIQUE: Multiplanar T1- and T2-weighted imaging was performed on a 1.5 T
magnet, including dynamic 3D imaging, prior to, during and subsequent to the
intravenous administration of 9 mL of Eovist. Delayed imaging at two hours
was also performed.
FINDINGS: The liver parenchyma is of normal signal on T2-weighted imaging.
There is an 8.9 x 8.3 cm fluid collection posterior to the left lobe of the
liver, decreased in size when compared to the prior CT dated ___. This
corresponds to the fluid collection on the recent tubogram dated ___.
The drainage catheter traversing the liver does not appear to lie within the
collection, however it does communicate with this collection (as indicated by
the recent tubogram) and may lie within a decompressed portion of the
collection.
There is prominence of the intrahepatic bile ducts within segments V and VIII,
with delayed excretion of gadolinium contrast compared to the remainder of the
liver, indicating a degree of outflow obstruction from these segments. There
is also leakage of contrast from the biliary system into the collection and
the indwelling drain, consistent with a bile leak. There are 2 right anterior
hepatic ducts with the posterior right hepatic duct draining into the more
posterior of the anterior ducts. The point of biliary leak is from the right
main hepatic duct just distal to the confluence of the anterior hepatic ducts.
The segment of the right main hepatic duct adjacent to the collection is not
visualized likely due to adjacent edema. The left hepatic duct and an
abberrent right posterior hepatic duct join with the right main hepatic duct
distal to the leak. There is normal biliary excretion of contrast from the
remainder of the liver.
No suspicious liver lesion. The portal and hepatic veins are patent.
Unfortunately, assessment of the hepatic arterial anatomy is limited by motion
artifact on the arterial phase imaging.
The pancreas is of normal signal and morphology. No focal pancreatic lesion
or pancreatic duct dilatation. The spleen is unremarkable. No adrenal
lesion. The kidneys enhance symmetrically, no suspicious renal lesion or
hydronephrosis.
There is bibasal atelectasis with a small effusion on the right.
No upper abdominal or retroperitoneal lymphadenopathy. The visualized small
and large bowel are unremarkable.
IMPRESSION:
1. Collection posterior to the left lobe of the liver, with evidence of a
bile leak from the right main hepatic duct into this collection and into the
indwelling drainage catheter.
2. Bibasal atelectasis, small right-sided effusion.
Radiology Report
INDICATION: ___ female status post lap cholecystectomy complicated by
bile leak status post ERCP not showing a ductal leak, transhepatic gallbladder
fossa drainage with bile aspirated. MRCP demonstrates bile leaking from
anterior duct. Requesting PTC drainage of the right anterior duct.
PHYSICIANS: Dr. ___ (radiology fellow), Dr. ___
___ (radiology resident) and Dr. ___ (radiology attending) who was
present throughout and supervised the procedure.
RADIATION: 20.54 minutes of fluoroscopy time, 497 mGy.
MEDICATION: The procedure was performed under general anesthesia. Please see
the dedicated anesthesia note for further details. In addition, the patient
received 1 g of ceftriaxone prior to procedure.
PROCEDURE:
1. Exchange of an indwelling transhepatic 8 ___ drainage catheter with
repositioning more centrally within the cavity.
2. PTC with placement of an 8 ___ modified nephrostomy tube through the
right anterior duct into the perihepatic collection.
PROCEDURE DETAILS:
Following discussion of the risks, benefits and alternatives to the procedure,
informed written patient consent was obtained. The patient was brought to the
angiographic suite and placed supine on the table. A preprocedure timeout was
performed using three patient identifiers. The skin of the right and anterior
abdomen was prepped and draped in the usual sterile fashion including the
indwelling 8 ___ drainage catheter in the right upper quadrant. An initial
quadrant image demonstrated multiple surgical clips in the right upper
quadrant and a pigtail drain also in the right upper quadrant. Initially, we
injected a small amount of contrast via this drain which opacified the
subhepatic collection; however, the pigtail was not well positioned within the
cavity. The catheter was cut and ___ wire was advanced over the
catheter which was gradually removed. The ___ wire coiled in the same
place as the pigtail catheter so a Kumpe catheter was used to manipulate the
wire into the bulk of the cavity. Once this had been achieved catheter was
removed and a new 8 ___ drainage catheter was advanced over the wire and
positioned centrally within the cavity without difficulty. This catheter was
left on free drainage.
We then proceeded to attempt access of the right anterior duct. Using a
combination of ultrasound and fluoroscopic guidance with approximately four
passes, we opacified the nondilated right anterior duct system. There was a
single branch of the right anterior system which passed vertically and
inferiorly and we selected this for access as a good site. Using a second
Cook needle, we advanced this inferior branch of the right anterior biliary
tree with subsequent placement of a Headliner wire within the duct. The
AccuStick system did not pass readily over the Headliner wire so a Cook stiff
micropuncture sheath was used initially to dilate the tract followed by the
AccuStick system. This deflected superiorly into the intrahepatic right
anterior duct. The wire and introducer were removed and injection of contrast
demonstrated filling of the right anterior system as well as frank leakage of
contrast into the subhepatic space. The AccuStick sheath was withdrawn so
that it was positioned at the confluence of this right inferior duct with the
right anterior biliary duct and using a combination of Omniflush catheter and
a Glidewire, we gained access to the area of leaking and eventually to the
subhepatic collection. The Omniflush catheter and wire were advanced into the
collection. The wire was removed and exchanged for ___ wire. Both the
AccuStick sheath and the Omniflush catheter were removed at this point and
exchanged for a modified 8 ___ Uresil drain with additional side holes cut
to allow intrahepatic drainage. The pigtail was pulled and the catheter was
retracted so that it was positioned appropriately through the bile duct injury
leak. The catheter was secured to the skin with an 0 silk suture and a
StatLock device. The catheter was attached to a drainage bag. There were no
immediate post-procedure complications.
IMPRESSION:
1. Technically successful PTC access in the right anterior duct with
placement of a modified Uresil drain through the opening in the bile duct into
the intra-abdominal collection (white catheter).
2. Successful exchange of an 8 ___ drainage catheter with repositioning of
the catheter in the subhepatic collection (blue catheter).
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient after right anterior duct
injury and after transhepatic pigtail drainage placement.
PA and lateral upright chest radiographs were reviewed in comparison to
___.
Heart size and mediastinum are stable. There is still present but improved
left basal atelectasis. There is right pleural effusion and potentially
increased area of consolidation on the right that might suggest infectious
process. Pigtail catheters have been placed in the interim. There is no
evidence of appreciable pneumothorax.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient after hepaticojejunostomy,
now with desaturations.
AP radiograph of the chest was compared to ___.
The right pleural effusion is moderate with increased right lower lobe
atelectasis or potentially consolidation. Aspiration is another possibility.
Left lower lobe atelectasis is unchanged, moderate. There is interval
development of mild interstitial pulmonary edema. No pneumothorax is seen.
The epidural catheter is in place. The NG tube tip is in the stomach.
Radiology Report
REASON FOR EXAMINATION: Desaturations, assessment of atelectasis.
COMPARISON: Prior study obtained on ___ at 7:43 p.m.
The NG tube tip is in the stomach. The pig-tail catheter is in place. Heart
size and mediastinum are stable. Slight interval improvement in the aeration
of the right lower lung is demonstrated but still pleural effusion and
atelectasis are seen as well as left lower lobe atelectasis, minimally
improved in the interim.
Radiology Report
HISTORY: Increasing oxygen requirement postop. Please evaluate for interval
change.
TECHNIQUE: Portable AP chest.
COMPARISON: Multiple prior radiographs of the chest most recent ___.
FINDINGS:
The NG tube terminates in the stomach and is coiled in the fundus. The
cardiomediastinal silhouette is not appreciably changed. There is mild
cardiomegaly. Worsening of low lung volumes results in vascular crowding and
somewhat limits the evaluation, however small bilateral pleural effusions are
likely present with adjacent bibasilar atelectasis. The hemidiaphragms are
less well seen. There is no apical pneumothorax. Surgical sutures projected
over the right mid to upper abdomen.
IMPRESSION:
1. Low lung volumes are worse, and small bilateral pleural effusions are
likely present with adjacent bibasilar atelectasis made more prominent by the
low lung volumes.
2. Mild cardiomegaly is unchanged.
Radiology Report
GRAVITY CHOLANGIOGRAM
INDICATION: ___ female status post laparoscopic cholecystectomy
complicated by biliary leak, which was treated with a PTC drainage and
subsequent hepaticojejunostomy. Today, patient comes in for evaluation of the
anastomosis.
PHYSICIANS: Dr. ___, ___ fellow, and Dr. ___, ___
attending who was present throughout and supervising.
RADIATION: 2.2 minutes of fluoroscopy time, 57 mGy.
MEDICATION:
No medication was used to perform this procedure.
PROCEDURE:
1. Gravity cholangiogram.
PROCEDURE DETAILS:
The patient was explained about the procedure. The patient was brought to the
angiography suite and placed supine on the imaging table. Preprocedure
timeout was performed as per ___ protocol.
Initial scout of the upper abdomen was obtained, which demonstrated multiple
surgical clips in the right upper quadrant and a pigtail drain in the right
upper quadrant, across the hepaticojejunostomy. A contrast bottle was
connected into the drain, and was left to drip on gravity force. Initial
opacification of a nondilated intrahepatic biliary tree was obtained. The
hepaticojejunostomy was documented to be patent, and no evidence of bile leak
was identified. Oblique images were also obtained, which also did not
demonstrate any evidence of a residual biliary leak. Based on these findings
the contrast bottle was disconnected and the study was ended.
IMPRESSION:
1. Nondilated intrahepatic biliary tree.
2. Patent hepaticojejunostomy, with no evidence of a biliary leak.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABDOMINAL PAIN
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 98.2
heartrate: 94.0
resprate: 16.0
o2sat: 100.0
sbp: 128.0
dbp: 79.0
level of pain: 6
level of acuity: 3.0 | ___ yo F with symptomatic cholelithiasis ___ s/p lap CCY,
multi-loculated fluid collections in RUQ near liver, s/p ERCP
with no cystic or hepatic duct leak & placement of 7cm ___
biliary stent into the common bile duct, followed by
percutaneous transhepatic gallbladder fossa drainage with ___
___ all
purpose drain by ___, returned with abdominal pain and persistent
drainage. Repeat ERCP was performed with limited opacification
of right lobe of the liver concerning for bile leak from an
excluded liver segment.
Cipro/Flagyl were started after pan-culture for temp to 102.9.
CT scan of abdomen revealed a large biloma around the left lobe
of the liver with a large amount of
fluid around the spleen throughout the peritoneal cavity and
extending down
into the pelvis. The left hepatic artery was widely patent. The
right hepatic artery flow appeared diminished. An abdominal MRI
was performed on ___ that demonstrated
a collection posterior to the left lobe of the liver, with
evidence of a
bile leak from the right main hepatic duct into this collection
and into the
indwelling drainage catheter. Bibasal atelectasis with small
right-sided effusion was noted. On ___, bile culture was sent
with note of 2+ GNRs.
On ___, she underwent ___ cholangiogram with placement of PTC
access in the right anterior duct with placement of a modified
Uresil drain through the opening in the bile duct into the
intra-abdominal collection (white catheter). The transhepatic
catheter in fluid collection was exchanged for an 8 ___
drainage catheter with repositioning of the catheter in the
subhepatic collection (blue catheter). Post procedure she had a
fever to 101 with tachycardia to 140's. EKG showed sinus
tachycardia. Repeat cultures were sent.
On ___, she desat'd to 89%. Nasal cannula was applied. A CXR
was done which showed improved a right pleural effusion and
increased opacity. The left lower lobe atelectasis was improved.
Bile culture from ___ isolated Staph aureus coag + and GNRs.
Blood cultures from ___ and ___ were negative. Cipro and
Flagyl were stopped on ___. She remained afebrile after this
time.
She was taken to the OR on ___ for repair of right anterior
bile duct disruption and underwent exploratory laparotomy and
Roux-en-Y hepaticojejunostomy. Surgeon was Dr. ___.
Intraop the PTC was left in place and was not exchanged. Two JP
drains were placed. Please refer to operative note for details.
Postop, O2 sat decreased to 77% on 5L face mask. She was
asympotmatic. CXR showed significant atelectasis and small R.
pleural effusion. She was transferred to the SICU for close
respiratory monitoring. An Epidural was placed intraop for pain
control. The epidural was split. Toradol and tylenol were added
for better pain control.
On ___, she was well enough to transfer out of the SICU. NG
tube was removed on ___ and then she started on sips. Diet was
slowly progressed. IV Lasix given for fluid retention. O2 was
weaned. CXR demonstrated persistent low lung volumes, bilateral
pleural effusions and atelectasis.
On ___, epidural was removed and a Dilaudid PCA was used for
pain control. She was assisted out of bed to ambulate. ___
evaluated and cleared her for home. LFTs improved. JP drain
outputs decreased. PTC was left open to gravity drainage until
___ when cholangiogram demonstrated biliary patency without
leak. PTC was capped. LFTs were the same the next day except for
slight elevation of alk phos. 145 from 137.
By postop day ___, she was tolerating solids fair. She was
switched to po dilaudid, but experienced nausea with each dose.
Dilaudid was switched to Oxycodone with prn Zofran with relief
of nausea. Incision was intact with staples without redness or
drainage. On ___, the medial JP was removed.
She was ambulating and felt well enough to go home on ___. JP
and PTC drain care education was provided. ___ was
scheduled to follow her at home. She was discharged to home in
stable condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Ancef / adhesive tape / Cymbalta / codeine / Iodinated Contrast
Media - IV Dye / tramadol / lisinopril / Sulfa (Sulfonamide
Antibiotics) / metformin / Dilaudid
Attending: ___.
Chief Complaint:
LLQ abdominal pain, stool from vagina
Major Surgical or Invasive Procedure:
___:
1. Takedown of colovesical vaginal fistula with ___
colectomy, descending left colostomy and closure of rectum.
2. Rigid sigmoidoscopy.
3. Placement of VAC sponge 300 cm2.
4. Rigid sigmoidoscopy and exam under anesthesia.
5. Release of splenic flexure for formation of colostomy.
History of Present Illness:
Ms. ___ is a ___ F who presents as a transfer from ___
___ after presenting there with complaint of 1.5 weeks of
worsening LLQ pain, subjective chills, and stool coming out of
her vagina. CT AP done at ___ demonstrates active
diverticulitis with pelvic abscess suggestive of perforation, in
addition to air and heterogenous material suggestive of stool
within the bladder and vagina.
Of note the patient had an episode of diverticulitis 5 weeks ago
at which time she was managed conservatively with IV antibiotics
and was discharged home.
Today she reports that her LLQ continues to worsen. She endorses
nausea, increasing distention and one episode of vomiting
yesterday. She denies diarrhea, fevers, or other systemic
symptoms. She reports that she continues to pass stool from the
vagina.
Past Medical History:
Diverticulosis
DM not on insulin
HTN
Peripheral edema
AFIB not on anticoagulation
Hip replacement (Left)
BTL
Metatarsal surgery x 3
Right eye x 3
Left knee replacement
Left rotator cup
Neurostimulator (lumbar)
Ortho
Social History:
___
Family History:
Non-contributory
Physical Exam:
At admission:
Vitals:
98.1 106 129/69 18 100RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, obese, protuberant. Moderate distension with
exquisite ttp in the LLQ. No rebound or involuntary guarding. No
masses or hernias
Ext: No ___ edema, ___ warm and well perfused
At discharge:
VS: 98.0, 113, 116/46, 18, 94%ra
Gen: A&O x3, calm, cooperative, in no distress
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: soft, obese. Midline incision with pink granulating tissue.
VAC taken down for tx to rehab. No induration or erythema. JP
site CDI, scant tan output. Colostomy with formed stool.
GU: Foley draining CYU. Known vesico-vaginal fistula, some
leaking of urine.
Ext: no edema
Pertinent Results:
Admission labs:
___ 08:04PM BLOOD WBC-23.9* RBC-3.63* Hgb-10.0* Hct-32.7*
MCV-90 MCH-27.5 MCHC-30.6* RDW-15.7* RDWSD-51.8* Plt ___
Discharge labs:
___ 04:57PM BLOOD WBC-9.2 RBC-2.53* Hgb-7.2* Hct-24.4*
MCV-96 MCH-28.5 MCHC-29.5* RDW-19.2* RDWSD-67.4* Plt ___
Imaging:
CT Abdomen/Pelvis (___):
1. Patient is status post ___ procedure with colostomy in
the left
lower quadrant.
2. The stomach and proximal portion of the duodenum is all
mildly dilated.
There is also a loop of jejunum in the left upper quadrant that
demonstrates fecalization of small bowel material. Findings
could relate to focal ileus. However distal loops of small
bowel are collapsed and small bowel obstruction remains a
consideration.
3. Fecal material with pockets of air is noted in the vaginal
vault, smaller compared to the prior exam.
4. Indeterminate left adrenal nodule, unchanged.
5. Stable 3 mm pulmonary nodule in the right lung base.
6. This preliminary report was reviewed with Dr. ___,
___
radiologist.
KUB (___):
Interval removal of the gastric tube. Increased gaseous
distention of the
stomach and small bowel loops in the left upper quadrant
concerning for
obstruction. The colon is largely decompressed.
CT A/P (___), PO contrast:
1. Improvement in the previously described ileus within the
small bowel with mild residual dilatation. No findings to
suggest mechanical obstruction at this time.
2. Indeterminate left adrenal nodule, unchanged.
3. Stable 3 mm pulmonary nodule in the right lung base.
KUB (___):
Interval placement of enteric tube with decompressed stomach.
Persistent
dilated loops of small bowel in the left upper quadrant not
significantly
changed since prior exam.
CT A/P (___):
1. Findings of a partial small bowel obstruction involving the
proximal
jejunum. It is difficult to identify the transition point
although the bowel does change caliber in the pelvis. This may
be related to extensive pelvic inflammatory changes.
2. Extensive soft tissue infiltration and inflammatory changes
in the pelvis. There are foci of intraperitoneal free air
adjacent to the tip of the ___ pouch. A dehiscence in
this region cannot be completely excluded. Although no oral
contrast is seen within the vagina, there is no clear fat plane
between the vagina and the ___ pouch; a fistula in this
region cannot be completely excluded.
3. Stable changes of the left hip joint from left femoral head
resection and pseudoarthrosis.
4. Stable left adrenal nodule.
CT Cystogram (___):
1. Persistent vesicovaginal fistula. Colonic fistulization is
not visualized. 2. Tiny locules of intraperitoneal free air
again visualized adjacent to the suture line of the ___
pouch, similar to slightly decreased in size.
PATHOLOGIC DIAGNOSIS:
Sigmoid colon, sigmoid colectomy:
- Diverticular disease with perforation and fistula formation,
associated acute inflammation, fat
necrosis, and focal mucosal ulceration.
- Resection margins with no significant pathologic change.
- No malignancy is identified.
Microbiology:
___ 7:17 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
Sensitivity testing per ___. ___ ON ___.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance . FINAL
SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 1 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 1 R
RIFAMPIN-------------- <=0.5 S
VANCOMYCIN------------ 1 S
___ 9:40 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 10:08 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
YEAST. >100,000 CFU/mL.
ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL.
CIPROFLOXACIN SENSITIVITY REQUESTED BY ___ ___
(___)
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ 4 S
CIPROFLOXACIN--------- =>8 R
NITROFURANTOIN-------- 32 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 25 mg PO BID
2. Amitriptyline 25 mg PO QHS
3. Citalopram 60 mg PO DAILY
4. Pravastatin 20 mg PO QPM
5. rOPINIRole 1 mg oral QHS
6. Hydroxychloroquine Sulfate 200 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. LORazepam 1 mg PO BID
10. DiphenhydrAMINE 25 mg PO Q6H:PRN Anxiety
11. melatonin ___ mg oral QHS
12. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
13. Furosemide 20 mg PO BID
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Heparin 5000 UNIT SC BID
3. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
4. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing, SOB
5. Miconazole Powder 2% 1 Appl TP TID:PRN Rash
6. OLANZapine (Disintegrating Tablet) 5 mg PO QPM
7. Oxybutynin 5 mg PO BID
8. Pantoprazole 40 mg PO Q12H
9. Senna 8.6 mg PO BID:PRN constipation
10. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*10 Tablet Refills:*0
11. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
12. Amitriptyline 25 mg PO QHS
13. Citalopram 60 mg PO DAILY
14. DiphenhydrAMINE 25 mg PO Q6H:PRN Anxiety
15. FoLIC Acid 1 mg PO DAILY
16. Furosemide 20 mg PO BID
17. Hydroxychloroquine Sulfate 200 mg PO BID
18. melatonin ___ mg oral QHS
19. Metoprolol Tartrate 25 mg PO BID
20. Multivitamins 1 TAB PO DAILY
21. Pravastatin 20 mg PO QPM
22. rOPINIRole 1 mg oral QHS
23. HELD- LORazepam 1 mg PO BID This medication was held. Do
not restart LORazepam until it is needed. may start PRN
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. ___ fistula due to diverticular perforation.
2. Morbid obesity. BMI greater than 35.
3. Post-operative ileus.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ xfer ___ for perf diverticulitis, cologenital
fistula, s/p hartmans' procedure // ?ileus ?obstruction
TECHNIQUE: Portable supine abdominal radiographs
COMPARISON: Outside facility CT abdomen/ pelvis ___
FINDINGS:
The stomach is markedly distended with air. There are prominent loops of
small bowel in the left abdomen measuring up to 3.7 cm in diameter, which can
be seen in the setting of small bowel obstruction. However, in light of
extensive inflammatory changes noted on the recent CT abdomen/pelvis dated ___, this likely represents secondary ileus. Residual oral
contrast is seen throughout the ascending and transverse colon, with note of
several diverticuli.
Assessment for free intraperitoneal air is limited on supine radiographs. If
there is clinical concern for pneumoperitoneum, advise upright or left lateral
decubitus radiograph, or cross-sectional imaging.
There are chronic changes related to prior resection of the left femoral head.
Left femoral shaft is laterally displaced relative to the acetabulum.
There are 2 catheters projecting over the pelvis.
IMPRESSION:
Prominent loops of small bowel in the left lower quadrant measuring up to 3.7
cm in diameter, most likely representing focal ileus.
Radiology Report
INDICATION: ___ year old woman with perforated diverticulitis, cologenital
fistula, s/p ___ now with emesis, NGT placed // ? Obstruction ?Etiology
for delayed return bowel function
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.0 s, 54.9 cm; CTDIvol = 17.0 mGy (Body) DLP = 931.6
mGy-cm.
Total DLP (Body) = 932 mGy-cm.
COMPARISON: CT from ___.
FINDINGS:
LOWER CHEST: Visualized lung bases demonstrate small bilateral pleural
effusions. Linear opacities within the lung bases is consistent with
atelectasis. 3 mm pulmonary nodule in the right lung base is stable (2:3).
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits. Previously demonstrated
stones within the gallbladder are not visualized. Small amount of perihepatic
fluid.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: 1.4 cm adrenal nodule is unchanged. Right adrenal gland is normal
size and shape.
URINARY: The kidneys are mildly atrophic bilaterally. 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: NG tube is noted in situ. The stomach is unremarkable. The
patient is status post ___ procedure with a colostomy noted in the left
lower quadrant which appears uncomplicated. Two JP drains are noted through a
right frontal approach with tip in the right lower quadrant and through a left
frontal approach with tip in the midline of the pelvis.
The stomach is distended with air and contrast. The proximal portion of the
third part of the duodenum is dilated measuring up to 4.7 cm. There is focal
narrowing of the distal third portion of the duodenum at the level of the SMA.
A loop of jejunum in the left upper quadrant demonstrates fecalization of
material. Findings may relate to ileus.
PELVIS: Bladder is collapsed with Foley catheter in situ. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: Uterus is absent. Pockets of air are again noted in the
vaginal vault but is smaller compared to the prior exam (2:80).
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: Resection of the left femoral head with pseudoarthrosis is unchanged in
appearance. Multilevel degenerative changes of the lumbar spine.
SOFT TISSUES: Laparotomy wound. Spinal stimulator within the subcutaneous
soft tissues of the left back.
IMPRESSION:
1. Patient is status post ___ procedure with colostomy in the left
lower quadrant.
2. The stomach and proximal portion of the duodenum is all mildly dilated.
There is also a loop of jejunum in the left upper quadrant that demonstrates
fecalization of small bowel material. Findings could relate to focal ileus.
However distal loops of small bowel are collapsed and small bowel obstruction
remains a consideration.
3. Fecal material with pockets of air is noted in the vaginal vault, smaller
compared to the prior exam.
4. Indeterminate left adrenal nodule, unchanged.
5. Stable 3 mm pulmonary nodule in the right lung base.
6. This preliminary report was reviewed with Dr. ___
radiologist.
NOTIFICATION: The concern for small bowel obstruction was discussed with ___
___, M.D. by ___, M.D. on the telephone on ___ at 2:53 ___,
5 minutes after discovery of the findings.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ y/o F s/p NGT re-placement // eval to ensure NGT in gastrum
eval to ensure NGT in gastrum
IMPRESSION:
The second of 2 images shows the nasogastric tube correctly positioned in the
stomach, with the side hole approximately 5 cm be low the gastroesophageal
junction. No complications, no pneumothorax.
Radiology Report
INDICATION: ___ y/o F ___ s/p hartmans with N/V // eval for dilated loops,
ileus, sbo
TECHNIQUE: Upright and supine views of the abdomen.
COMPARISON: CT scan dated ___ and radiograph of ___
FINDINGS:
The gastric tube has been removed. There is gaseous distension of the stomach
as well as increased dilatation of small bowel loops projecting over the left
upper quadrant. The colon is largely collapsed. Suboptimal upright
radiograph does not include the entire abdomen and evaluation of air-fluid
levels cannot be assessed. No free air under the diaphragms.
A spinal stimulator with leads is present. Two surgical drains project over
the pelvis. Unchanged degenerative changes of the hips, greater on the left.
IMPRESSION:
Interval removal of the gastric tube. Increased gaseous distention of the
stomach and small bowel loops in the left upper quadrant concerning for
obstruction. The colon is largely decompressed.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with new line // new left PICC 48 cm ___
___ Contact name: ___: ___ new left PICC 48 cm ___
___
IMPRESSION:
Compared to chest radiographs ___.
New left PIC line ends in the low SVC. Esophageal drainage tube passes into
the stomach and out of view. Midline stimulator objects over the lower
thoracic spine.
Peribronchial opacification, both lower lungs improved on the left, worsened
slightly on the right. This could be changes of aspiration. Upper lungs are
clear. Heart is top-normal size. Pleural effusion minimal on the left if
any. No pneumothorax.
Radiology Report
INDICATION: ___ year old woman w/ perf diverticulitis, colovaginal/vesical
fistula, s/p ___, delayed return bowel function w/ NGT placement,
continued WBC rise // ? Collection, ? Obstruction
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 14.6 s, 50.1 cm; CTDIvol = 18.0 mGy (Body) DLP =
877.7 mGy-cm.
Total DLP (Body) = 891 mGy-cm.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
LOWER CHEST: Visualized lung bases demonstrate small bilateral pleural with
compressive atelectasis. Again visualized, a 3 mm nodule in the right lung
base (2:3).
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits. Cholelithiasis without
cholecystitis. Small amount of perihepatic fluid is stable.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: 1.5 cm adrenal nodule is grossly stable. Right adrenal gland is
normal size and shape.
URINARY: The kidneys are mildly atrophic bilaterally. There is no evidence of
focal renal lesions within the limitations of an unenhanced scan. There is
contrast within the renal collecting system, evidence of prior contrast
administration. There is no hydronephrosis. There is no nephrolithiasis.
There is no perinephric abnormality.
GASTROINTESTINAL: NG tube tip is at the distal gastric body. The stomach is
unremarkable. The patient is status post ___ procedure with a
colostomy noted in the left lower quadrant which appears uncomplicated. Two
JP drains are noted through a right frontal approach with tip in the right
lower quadrant and through a left frontal approach with tip in the midline of
the pelvis.
The stomach is distended with air and contrast. The small bowel is dilated up
to 4.2 cm in greatest dimension, which has decompressed compared to the prior
exam. There is normal appearance of contrast within the jejunum which
previously demonstrated fecalization of material. This represents interval
improvement and resolution of ileus compared to the prior exam.
PELVIS: Bladder is collapsed with Foley catheter in situ. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: Uterus is absent. The vaginal vault is without
emphysematous foci.
RETROPERITONEUM: Small volume ascites.
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: Resection of the left femoral head with pseudoarthrosis is unchanged in
appearance. Multilevel moderate to severe degenerative changes of the
thoracolumbar spine.
SOFT TISSUES: Laparotomy wound. Spinal stimulator within the subcutaneous
soft tissues of the left back.
IMPRESSION:
1. Improvement in the previously described ileus within the small bowel with
mild residual dilatation. No findings to suggest mechanical obstruction at
this time.
2. Indeterminate left adrenal nodule, unchanged.
3. Stable 3 mm pulmonary nodule in the right lung base.
Radiology Report
INDICATION: ___ y/o F POD13 hartmans w/ ileus // eval for interval change
TECHNIQUE: AP portable radiograph
COMPARISON: Radiograph dated ___
FINDINGS:
AP portable radiograph of the abdomen demonstrates interval placement of an
enteric tube, its tip in the anticipated location of the stomach. Again seen
is a spinal stimulator. Partially imaged surgical drains project over the
pelvis. The stomach is decreased in gasseous distention relative to
radiograph dated ___. There is persistent increased dilation of
small bowel loops projecting over the left upper quadrant. The colon is
persistently collapsed. No appreciable free air is present.
IMPRESSION:
Interval placement of enteric tube with decompressed stomach. Persistent
dilated loops of small bowel in the left upper quadrant not significantly
changed since prior exam.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ y/o F POD 13 in need of enteral nutrition // 1 of 2 CXRs to
confirm placement DOBHOFF PLACEMENT; 1 OF 2 CXRS TO CONFIRM PLACEMENT
IMPRESSION:
Only one radiographic image is submitted.
Compared to chest radiographs ___. Esophageal feeding tube, wire
stylet in place ends in the mid esophagus, no less than 17 cm above
appropriate position.
Left lower lobe atelectasis is mild. Pleural effusions small on the left if
any. No pneumothorax.
NOTIFICATION: The findings were discussed with Dr ___ by ___, M.D.
on the telephone on ___ at 4:14 ___, 2 minutes after discovery of the
findings.
Radiology Report
INDICATION: ___ y/o F in need of enteral nutrition // pls advance dobhoff
post pyloric
DOSE: Acc air kerma: 24 mGy; Accum DAP: 378.9 UGym2; Fluoro time: 2:19
COMPARISON: Portable abdominal radiograph dated ___
FINDINGS:
Patient arrived to the department with an enteric tube in the left nares.
Under intermittent fluoroscopic guidance, the feeding tube was advanced into
the stomach and then post-pylorically using a guidewire.
10 cc of thin barium contrast were used to confirm post pyloric placement.
Final fluoroscopic spot images demonstrated the type of the feeding tube in
the third portion of the duodenum.
The feeding tube was affixed to the patient's nose using tape.
IMPRESSION:
Successful post-pyloric feeding tube placement. The tube is ready to use.
Radiology Report
INDICATION: ___ y/o F POD15 hartmans w/ ? fecal drainage from vagina // ?
enterovaginal fistula originating in small bowel
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.9 s, 53.9 cm; CTDIvol = 16.8 mGy (Body) DLP = 907.3
mGy-cm.
Total DLP (Body) = 907 mGy-cm.
COMPARISON: CT ___.
FINDINGS:
LOWER CHEST: There are small bilateral pleural effusions with bibasilar
atelectasis.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right adrenal gland appears within normal limits. There is a
stable 1.6 cm left adrenal nodule.
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.
GASTROINTESTINAL:
There is an enteric tube with the distal tip in the third portion of the
duodenum. Loops of the proximal jejunum in the left side of the abdomen
appear dilated up to 5 cm in diameter. However, contrast is seen in the colon
at the level of the right lower quadrant colostomy suggestive of a partial
small bowel obstruction. The patient has a ___ pouch. Adjacent to the
___ pouch there are small foci of extraluminal air. There is extensive
soft tissue stranding and infiltration throughout the pelvis. There is no fat
plane seen between this region and the vagina.
PELVIS: There are 2 surgical drains extending into the pelvis. The urinary
bladder is decompressed by Foley catheter. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized. There is a small amount of
air in the vagina. No definite oral contrast is seen in the vagina.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: Stable changes at the left hip joint with resection of the left femoral
head and pseudoarthrosis.
SOFT TISSUES: A neurostimulator device is noted in the left lower back.
IMPRESSION:
1. Findings of a partial small bowel obstruction involving the proximal
jejunum. It is difficult to identify the transition point although the bowel
does change caliber in the pelvis. This may be related to extensive pelvic
inflammatory changes.
2. Extensive soft tissue infiltration and inflammatory changes in the pelvis.
There are foci of intraperitoneal free air adjacent to the tip of the
___ pouch. A dehiscence in this region cannot be completely excluded.
Although no oral contrast is seen within the vagina, there is no clear fat
plane between the vagina and the ___ pouch; a fistula in this region
cannot be completely excluded.
3. Stable changes of the left hip joint from left femoral head resection and
pseudoarthrosis.
4. Stable left adrenal nodule.
NOTIFICATION: The findings were discussed with ___, N.P. by ___
___, M.D. on the telephone on ___ at 4:35 ___, 10 minutes after
discovery of the findings.
Radiology Report
INDICATION: ?Enterovaginal fistula
TECHNIQUE: One view pelvis.
COMPARISON: CT ___.
FINDINGS:
Again seen is chronic changes of the left femoral acetabular joint with
resection of the femoral head and neck and chronic remodeling. There is
superior lateral subluxation of the femur with regard to the acetabulum.
Drainage tubes overlie the pelvis. There is no contrast within the rectum.
No definite contrast within the region of the vagina. A lateral radiograph
would be helpful for further evaluation.
Radiology Report
INDICATION: ___ y/o F w/ post-pyloric dobhoff, now w/ dobhoff dislodgement //
eval for post-pyloric/gastric placement
TECHNIQUE: Supine portable abdominal radiographs
COMPARISON: ___ intestinal tube placement with fluoro dated ___
and CT abdomen and pelvis dated ___
FINDINGS:
An enteric tube is partially imaged, its terminal tip projecting over the
midline in the anticipated location of the mid to distal esophagus. The
stomach is distended with gas. Air-filled loops of small bowel are distended
up to 4.5 cm. This is not changed relative to prior study. There is a
colostomy in the low left hemiabdomen. High density material within loops of
decompressed colon project over the right lower quadrant. 2 surgical drains
are seen projecting over the pelvis. A spinal stimulator is noted projecting
over the left hemiabdomen. Lung bases appear clear.
IMPRESSION:
Malpositioned enteric tube, its tip in the mid to distal esophagus.
Persistently dilated loops of small bowel and air distended gastric lumen
concerning for obstruction.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 8:16 AM, 1 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ y/o F s/p dobhoff advancement // eval for placement in
gastrum
TECHNIQUE: Portable supine abdominal radiographs
COMPARISON: Radiograph performed ___ approximately 4 hours prior
FINDINGS:
AP supine portable radiograph demonstrates an enteric tube within the gastric
lumen which is gas-filled and distended. Loops of small bowel are gas-filled
and dilated up to 4.6 cm, similar to prior examination. Patient has a
colostomy. High density material within loops of decompressed colon overlies
the right hemi abdomen. A spinal stimulator is noted projecting over the left
hemi abdomen. Two surgical drains project over the pelvis. There is no
evidence to suggest intra-abdominal free air although technique is suboptimal
in its detection.
IMPRESSION:
Interval advancement of enteric tube now terminating in the gas distended
gastric lumen. Multiple dilated loops of small bowel is concerning for
obstruction.
Radiology Report
INDICATION: ___ xfer ___ for perf diverticulitis, cologenital
fistula, s/p hartmans' procedure post-op course c/b delirium and ileus //
evaluate interval change, ?persistent colovesical fistula
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.
Approximately 150 cc of Cysto-Conray were administered through the Foley
catheter into the bladder.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.9 s, 31.4 cm; CTDIvol = 16.6 mGy (Body) DLP = 520.1
mGy-cm.
2) Spiral Acquisition 2.9 s, 31.4 cm; CTDIvol = 16.6 mGy (Body) DLP = 520.2
mGy-cm.
Total DLP (Body) = 1,040 mGy-cm.
COMPARISON: Noncontrast CT abdomen/pelvis from ___.
FINDINGS:
The patient is status post hysterectomy and ___ colectomy. A right
lower quadrant colostomy and suture lines in the right pelvis are unchanged,
as are bilateral approach drains terminating in the midline to right upper
pelvis. A Foley catheter is in place. After administration of contrast into
the bladder, a persistent vesicovaginal fistula is identified (05:29).
Superior extension of the contrast is similar in morphology as previously seen
stool within the vagina on CT from ___, compatible with superior
extension of the vaginal cuff. Fistulization into the colon is not
visualized. Tiny locules of intraperitoneal free air are again visualized
adjacent to the suture line of the ___ pouch, similar to slightly
decreased in size.
LYMPH NODES: Prominent lymph nodes are noted, without pathologic enlargement
by CT size criteria.
VASCULAR: Heavy atherosclerotic disease is noted.
BONES: Resection of the left femoral head with pseudoarthrosis is unchanged in
appearance. No focal lytic or sclerotic osseous lesion is identified.
SOFT TISSUES: A neurostimulator device is noted in the left lower back.
IMPRESSION:
1. Persistent vesicovaginal fistula. Colonic fistulization is not visualized.
2. Tiny locules of intraperitoneal free air again visualized adjacent to the
suture line of the ___ pouch, similar to slightly decreased in size.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Left lower quadrant pain
temperature: 97.6
heartrate: 109.0
resprate: 13.0
o2sat: 94.0
sbp: 124.0
dbp: 75.0
level of pain: 7
level of acuity: 3.0 | Ms. ___ presented to ___ as a transfer from ___
with diagnosis with active diverticulitis with pelvic abscess
concerning for perforation and likely stool within the bladder
and vagina. She was started on vancomycin, ciprofloxacin, and
Flagyl. A Foley was placed and was subsequently upsized after
feculent material was noted in bag. She was taken to the
operating room on ___ where she underwent takedown of
___ fistula and ___ procedure. The fascia
of the midline incision was sutured closed and a VAC was placed
over the incision. Two JP drains were left sewn in, one anterior
in the pelvis and the other posterior. She was extubated and
returned to the PACU in stable condition. Upon satisfactory
recovery from anesthesia, she was transferred to the surgical
floor.
She remained tachycardic despite adequate fluid resuscitation
and metoprolol was titrated to achieve normal heart rate. She
had several episodes of agitation and delirium for which
Geriatrics was consulted and recommended nightly Zyprexa and
avoidance of opiates, benzodiazepines, and antihistamines.
On POD4, she began having large bilious emesis. She initially
refused NGT, but agreed to placement on POD5 after continued
emesis. WBC increased on POD6 and CT abdomen/pelvis showed no
collections and suggested ileus. She was maintained on bowel
rest with NG tube. She had ostomy output on POD7 and NGT was
removed after successful clamp trial. Diet was advanced to clear
liquids which she tolerated until POD8 when she once again had
emesis. KUB was concerning for ileus. Patient was made NPO once
again. She initially refused NGT, but after persistent bilious
emesis, NGT was replaced on POD9. Ostomy output slowed and then
stopped on POD 9. Repeat CT abdomen/pelvis on POD11 showed
improving ileus, no small bowel obstruction or collections. On
POD 13, NGT was removed and replaced with Dobhoff and tube feeds
were started. She initially tolerated this well, but feeds were
held after small bilious emesis. On POD14 ostomy output was once
again noted and tube feeds were resumed. However the patient did
not tolerate tube feeds so TPN was briefly given (___)
until she was able to take food orally.
The wound VAC was changed every 3 days post-operatively.
On POD8, patient was noted to have urinary tract infection with
culture growing enterococcus for which she was started on a 5
day course of Macrobid. On POD9, NGT was replaced and made NPO,
thus she was switched to IV Vancomycin. A PICC was placed on
___ and she completed antibiotic course on ___.
On ___, a CT cystogram was obtained which showed a
vesicovaginal fistula. Therefore the Foley catheter was left in
place and will remain in place for another 3 weeks until the
patient has a repeat cystogram. Prior to discharge, the right
drain which was scant serosanguinous drainage, was removed. The
left drain remained.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. During this
hospitalization, the patient was out of bed to the chair daily
but does not ambulate at baseline. She was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet and having colostomy output, out of bed with assist,
voiding via the Foley, and pain was well controlled. The
patient was discharged to rehab. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
iodine / shellfish derived / oxycodone / Vicodin / Percocet
Attending: ___
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ male with pancreatic cancer
metastatic to liver s/p partial pancratectomy and neoadjuvant
FOLFIRINOX x2, currently on gem/abraxane last dose ___ presents
for fever and generalized malaise that began approximately 1
week
ago. Over past week has noted low grade fevers which had been
controlled with Tylenol until today he spiked temp to 102.7 and
came to ED. also has slight cough. Reported that he felt winded
at home but primary complaint generalized malaise. Patient feels
similar to his last experience with pneumonia. No chest pain,
hemoptysis. Also endorsing left lower extremity pitting edema
just been progressively worsening over the last 2 weeks.
Extremities are nonpainful
Vitals:102.7 102 145/88 18 96% RA
CXR showed new infiltrate
___ negative for DVT
in ED received 1L NS, cefepime 2g, Tylenol 1g and levofloxacin
750mg
on arrival to floor reports feeling better. no recurrence fever
thus far. currently denies any SOB. did have sick contact 2 days
ago with a cold.
Past Medical History:
-___: Presented to ED with above symptoms as well as ___ lb
weight loss. He was anemia and had guaiac-positive stools.
EGD/Colonoscopy showed a stricture in the second portion of the
duodenum.
-___: MRI Abdomen showed 3.7 cm pancreatic head mass causing
duodenal obstruction and gastric distention.
-___: C1D1 neoadjuvant FOLFIRINOX.
-___: Initiated tube feeds to improve nutritional status in
anticipation for resection.
-___: Pylorus-preserving pancreaticoduodenectomy (Whipple)
and open cholecystectomy, uncomplicated. Pathology showed pT3N0,
moderately differentiated, ___ lymph nodes involved, margins
negative to 6 mm, positive large vessel/angiolymphatic invasion,
positive perineural invasion.
-___: C1D1 gemcitabine 1000 mg/m2/abraxane
--hepatic mets discovered
- ___ - C2D1 Gem/Abraxane
- ___ - C3D1 Gem/Abraxane
PAST MEDICAL HISTORY:
1. GERD
2. PUD c/b UGIB
3. Pancreatic cancer (s/p chemo, has bile duct stent)
4. R cerebral aneurysm (at junction of R ACA and common carotid)
Social History:
___
Family History:
HTN, mother with lung CA, grandmother with COPD
Physical Exam:
General: NAD
VITAL SIGNS: 98.2 129/86 85 18 98%RA
HEENT: OMM
Neck: supple, no JVD
CV: RR, NL S1S2 no S3S4 or MRG
PULM: CTAB nonlabored
ABD: BS+, soft, NTND, no masses, prior tube feed site well
healed
EXT: warm well perfused, no edema
SKIN: No rashes or skin breakdown
NEURO: alert and oriented x 4, face symmetric, moves all ext
against resistance bilateral, sensation intact to light touch
Pertinent Results:
___ 05:18AM BLOOD WBC-4.7 RBC-3.06* Hgb-8.1* Hct-27.2*
MCV-89 MCH-26.5 MCHC-29.8* RDW-18.2* RDWSD-59.3* Plt ___
___ 05:18AM BLOOD Glucose-103* UreaN-11 Creat-0.8 Na-135
K-4.4 Cl-101 HCO3-26 AnGap-12
___ 09:20PM BLOOD ALT-16 AST-23 AlkPhos-177* TotBili-0.4
___ 05:18AM BLOOD Calcium-7.9* Phos-3.4 Mg-2.0
___ 09:42PM BLOOD Lactate-1.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Creon 12 2 CAP PO TID W/MEALS
2. LORazepam 0.5-1 mg PO Q12H:PRN anxiety
3. Neomycin-Polymyxin-Bacitracin 1 Appl TP BID
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Pantoprazole 40 mg PO Q24H
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
Discharge Medications:
1. Creon 12 2 CAP PO TID W/MEALS
2. LORazepam 0.5-1 mg PO Q12H:PRN anxiety
3. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Pantoprazole 40 mg PO Q24H
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. Neomycin-Polymyxin-Bacitracin 1 Appl TP BID
8. Vancomycin Oral Liquid ___ mg PO BID c.diff prevention
RX *vancomycin 125 mg 1 capsule(s) by mouth twice a day Disp
#*31 Capsule Refills:*0
9. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp
#*16 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Health Care Associated Pneumonia
Pancreatic Cancer
History of Severe Clostridium Dificile Colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with fever, cough
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___, CT chest ___
FINDINGS:
Left-sided Port-A-Cath tip terminates at the junction of the SVC and right
atrium. Cardiac silhouette size is normal. Mediastinal and hilar contours
are normal. Pulmonary vasculature is not engorged. Ill-defined hazy and
patchy opacity is noted within the left lung base, as well as faint patchy
opacity within the periphery of the right mid lung field, new in the interval.
Small bilateral pleural effusions are demonstrated. No pneumothorax is
present. There are no acute osseous abnormalities. Mild degenerative changes
are noted within the imaged thoracic spine with slight loss of height
anteriorly of the T11 vertebral body, unchanged. Clips are seen within the
right upper quadrant of the abdomen as well as overlying the epigastric
region.
IMPRESSION:
Patchy and ill-defined hazy opacities within the left lung base and right
peripheral mid lung field concerning for infection. Small bilateral pleural
effusions.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: History: ___ with ___ pitting edema // 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.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, Cough
Diagnosed with Pneumonia, unspecified organism
temperature: 102.7
heartrate: 102.0
resprate: 18.0
o2sat: 96.0
sbp: 145.0
dbp: 88.0
level of pain: 2
level of acuity: 2.0 | Mr ___ is a ___ w/ pancreatic cancer mets to liver s/p
pancreatectomy and adjuvant FOLFIRINOX currently C3D22
Gemcitabine/Abraxane who is admitted with fevers and cough. CXR
confirmed PNA. Due to exposure to sick contacts, and his rapid
improvement on admission, his PNA is most likely viral process.
Since he defervesced quickly, he was treated with 2gm
Ceftriaxone. His cultures were NGTD and since he improved so
quickly, was discharged home on oral cefpodoxime. He was
discharged to complete a 10 day course with vancomycin BID
dosing to extend 7 days afterwards for c.diff prophylaxis. He
was encouraged to continue protein supplementation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Codeine / morphine / Amoxicillin / Augmentin
Attending: ___.
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ year old RH woman with a history of low
back pain and migraine headaches who was sent in by Dr. ___
___
status ___ x6 weeks to control headache and rule out
secondary causes of headache.
The patient reports she had her first migraine ___ years ago
after
the birth of her second son. Her typical migraine is always L
sided (never R sided) and associated with a visual aura of
"squiggly lines" and "difficulty with depth perception" which
improves when she covers one eye (?diplopia). HAs are throbbing,
with nausea, vomiting, and photophobia. She was started on
verapamil as a prophylactic medication which was effective: her
migraine frequency decreased to once every ___ months. When she
got a headache she took hydrocodone which was effective in
aborting the headache. She previously tried triptans which gave
her nausea. She still intermittently required ED visits to
"break" a bad migraine. She states she had an MRI of her brain a
long time ago which was reportedly normal.
On ___ the patient was at her ___ house in ___ and was woken up from sleep at 6 AM by what she describes
as her typical migraine headache. No preceding illnesses or head
injuries. She started vomiting later that morning and went to a
local ED, which give her Compazine and another medication IV.
This temporarily resolved her HA, and she went home, but later
that day had recurrence of her headache and went back to a
different ED where she got tramadol and a nausea medication.
Again the next 2 days she continues to have migraine headches.
Her PCP then prescribed her a 20 day prednisone taper, which
improved her headache so that she could function better, but she
continued to have now a daily headache. She is now off the
prednisone and continues to have daily headache. She feels her
daily functioning is impaired. She reports difficulty with
concentration and recently ordered 11 garlic breads by mistake
from Peapod, and paid her bills to the wrong amount (last months
amount instead of this months). She was also started on Depakote
for her headaches, and since then feels that her balance is a
little off and she is stumbling more, and also notes a postural
tremor which impairs her handwriting. She is also taking Fiorcet
TID, indomethacin TID, tramadol TID, but has not noted a big
improvement with any of them. Out of everything, the very first
dose of steroids seemed to help the most, but she continued to
have headaches daily during the long 20 day taper.
She describes her current headache as L sided, throbbing,
associated with L ear tinnitus and photophobia. No nausea or
vomiting.
She did get a NCHCT as part of her work up which was reportedly
normal although neither the imaging nor the records are in our
system.
She was seen by Dr. ___ in Neurology clinic today who sent her
in for admission to Neurology to "break" her headache as well as
exclude underlying brain lesion or temporal arteritis as causes
of secondary headache. She received IV Mg, Compazine, and
dilaudid in the ED.
On neurologic review of systems, the patient endorses headache,
confusion. Denies jaw claudication, PMR symptoms.
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 loss of sensation.
Denies bowel or bladder incontinence or retention.
Endorses difficulty with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss.
Denies chest pain, palpitations, dyspnea, or cough.
Denies nausea, vomiting, diarrhea.
Past Medical History:
- low back pain: MRI with L5/S1 disc degeneration and collapse
with no stenosis or neural compression
- multinodular goiter
- depression/anxiety
- s/p surgery for rotator cuff tear
- s/p hysterectomy
- s/p RT thumb surgery
- s/p tonsillectomy
Social History:
___
Family History:
Daughter has migraines. Son with epilepsy s/p
surgery. Mother with rheumatic fever, valve replacement, and
subsequent strokes.
Physical Exam:
Admission Exam:
Physical Examination:
VS 97.8 96 129/85 18 98% RA
General: NAD, lying in bed comfortably.
Head: NC/AT, + tenderness of the L occiput and L temporal
region.
Unable to palpate temporal artery pulses bilaterally.
Neck: Supple, no nuchal rigidity, no meningismus
Neurologic Examination:
- Mental Status -
Awake, alert, oriented x 3. Attention to examiner easily
attained
and maintained. Concentration maintained when recalling months
backwards. Recalls a coherent history. Structure of speech
demonstrates fluency with full sentences, intact repetition, and
intact verbal comprehension. Content of speech demonstrates
intact naming (high and low frequency) and no paraphasias.
Normal
prosody. No dysarthria. No evidence of hemineglect. No
left-right
agnosia.
- Cranial Nerves -
I. not tested
II. Equal and reactive pupils (3mm to 2 mm). On fundoscopic
exam,
optic disc margins were sharp. Visual fields were full to finger
counting.
III, IV, VI. smooth and full extraocular movements without
diplopia or nystagmus. The patient is mildly uncomfortable with
testing.
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.
Postural
tremor. no asterixis.
Infra Delt Bic Tri ECR Fext Fflex IP Quad Ham TA Gas
EDB
L 4 5 ___ 5 5 5 5 4+ 5 5
4
R 4 5 ___ 5 5 5 5 4+ 5 5
4
- Sensation -
Intact to light touch, pinprick. Mildly decreased proprioception
at the little toes bilaterally.
- DTRs -
Bic Tri ___ Quad Gastroc
L 2 3 3 2 2
R 2 3 3 2 2
Plantar response equivocal on the R, extensor on the L.
- Cerebellar -
No dysmetria with finger to nose or HTS testing bilaterally.
Good
speed and intact cadence with rapid alternating movements.
- Gait -
Normal initiation. Narrow base. Normal stride length and arm
swing. Difficulty with tandem gait, + sway with Rhomberg
testing.
=
=
=
=
=
=
================================================================
Discharge Exam:
Same as above, except Postural tremor improved.
Pertinent Results:
___ 03:15PM BLOOD WBC-5.5 RBC-3.84* Hgb-11.9 Hct-36.4
MCV-95 MCH-31.0 MCHC-32.7 RDW-13.7 RDWSD-47.5* Plt ___
___ 03:15PM BLOOD Plt ___
___ 03:15PM BLOOD Glucose-81 UreaN-21* Creat-0.7 Na-140
K-4.0 Cl-104 HCO3-27 AnGap-13
___ 04:55AM BLOOD ALT-11 AST-21 AlkPhos-68 TotBili-0.2
___ 04:55AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.2
___ 03:15PM BLOOD Mg-2.0
___ 03:15PM BLOOD CRP-6.5*
___ 04:55AM BLOOD Phenoba-<1.2* Valproa-22*
___ 03:15PM BLOOD Phenoba-<1.2* Valproa-12*
___ 03:15PM BLOOD SED RATE-Test
___ 03:15PM URINE Color-Straw Appear-Clear Sp ___
___ 03:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
___ 03:15PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1
IMAGING:
MRI/MRA/MRV ___
1. No acute intracranial abnormality.
2. Unremarkable MRA of the brain.
3. Unremarkable MRV of the brain without evidence of dural
venous sinus
thrombosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Divalproex (EXTended Release) 500 mg PO DAILY
2. Acetaminophen-Caff-Butalbital 1 TAB PO Q8H:PRN headache
3. Famotidine 20 mg PO DAILY
4. Paroxetine 40 mg PO DAILY
5. Pravastatin 20 mg PO QPM
6. TraMADOL (Ultram) 50 mg PO TID
7. Verapamil SR 180 mg PO Q24H
8. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. Famotidine 20 mg PO DAILY
2. Pravastatin 20 mg PO QPM
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Verapamil SR 240 mg PO Q24H
RX *verapamil [Calan SR] 240 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*2
5. Paroxetine 40 mg PO DAILY
6. Topiramate (Topamax) 50 mg PO BID
RX *topiramate [Topamax] 50 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*2
7. Tizanidine 2 mg PO BID
RX *tizanidine 2 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*2
8. Acetaminophen 1000 mg PO TID:PRN pain
9. DiphenhydrAMINE ___ mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI AND MRA BRAIN PT12 MR HEAD
INDICATION: ___ year old woman with headache x 6 weeks, Evaluate for secondary
causes of headache.
TECHNIQUE: 3 dimensional time-of-flight MRA was performed through the brain.
Sagittal and axial T1 weighted imaging were performed along with diffusion
imaging.
After administration of 7 mL of Gadavist intravenous contrast, axial imaging
was performed with gradient echo, FLAIR, T2, and T1 technique. Sagittal MPRAGE
imaging was performed and re-formatted in axial and coronal orientations.
Phase contrast MRV of the brain was also performed.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images.
COMPARISON: None.
FINDINGS:
MRI BRAIN:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are normal in caliber and
configuration. There is no abnormal enhancement after contrast
administration.
There are few scattered foci of T2/FLAIR hyperintensity in the subcortical,
periventricular and deep white matter, nonspecific, likely secondary to small
vessel ischemic disease.
There is a punctate focus of susceptibility in the left frontal centrum
semiovale on image 8:17, either secondary to prior microhemorrhage or
mineralization.
Incidentally seen is a developmental venous anomaly in the left frontal lobe
on image 12:16.
The orbits are unremarkable. Mild mucosal thickening in bilateral ethmoid air
cells. The remaining visualized paranasal sinuses are clear. Bilateral
mastoid air cells are clear. Intracranial flow voids are maintained.
MRA brain: The intracranial vertebral and internal carotid arteries and their
major branches appear normal without evidence of stenosis, occlusion, or
aneurysm formation. Incidentally seen is hypoplastic right A1 segment of
anterior cerebral artery. Also seen is hypoplastic right vertebral artery.
MRV brain: The dural venous sinuses are patent. The vein ___ is patent.
Bilateral internal jugular veins are patent
IMPRESSION:
1. No acute intracranial abnormality.
2. Unremarkable MRA of the brain.
3. Unremarkable MRV of the brain without evidence of dural venous sinus
thrombosis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Headache
Diagnosed with Headache
temperature: 97.8
heartrate: 96.0
resprate: 18.0
o2sat: 98.0
sbp: 129.0
dbp: 85.0
level of pain: 7
level of acuity: 3.0 | Ms. ___ is a ___ yo female admitted to Neurology Service for
status migranosus x7 weeks in setting of multiple medications.
Her fiorecet was tapered off; Her Tramadol, indomethacin,
Percocet, and Depakote were stopped (Depakote not helpful and
causing tremor). Her Verapamil was uptitrated to 240 mg daily.
She was given a standing regimen of IVF, toradol and Zofran q6
hours. Nortryptyline was considered, but it would interact with
her paxil. Topamax was started and titrated up to 50mg BID. She
had significant neck muscle spasm and so was also given
tizanidine which did seem to improve headache somewhat. Pain was
consulted and performed several nerve blocks after which her
headache was much improved. She was then discharged home with
follow up with pain medicine and with neurology.
Transitional Issues:
- Can consider nortryptyline as needed, but would need to taper
off paxil.
- Pain clinic follow up, they will likely do botox as outpatient
since nerve blocks worked well, she needs follow up in one week
in case headache returns and she requires repeat nerve block
(short-term solution).
- Neurology clinic follow up |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
shortness of breath, cough
Major Surgical or Invasive Procedure:
Right anterior mediastinotomy and biopsy
History of Present Illness:
Healthy ___ y.o. female presents from ___ after CXR
performed for evaluation of cough and fevers demonstrated large
anterior mediastinal mass.
Patient reports night sweats x 6 months, SOB at rest while
speaking x 2 months. Night sweats are severe enough that sheets
are soaked. Cough onset was 9 days ago, followed by fevers to
100.4 three days ago. Cough is productive but she denies
hemoptysis. No rhinorrhea, sore throat. No abdominal pain,
changes in bowel or bladder habits. Denies any history of
asthma. Smokes a few cigarettes a month, is a ___ and
occasionally visits prisons to interview inmates. During these
visits she is in the same room as her clients.
She was born in the ___ and has lived here her whole
life. She has never worked in a healthcare setting apart from
briefly working in a nursing home during high school. She denies
any contacts with TB. She has never had a PPD as an adult.
In the ED, initial vitals were: 99.3 94 139/75 18 97% RA
- Labs were significant for leukocytosis to 15.7, Hg 11.1,
platelets 494
- Imaging revealed: CT chest notable for large anterior
mediastinal mass, pericardial effusion vs. thickening without
evidence of tamponade, and RUL and RML consolidation
- The patient was given 2g IV cefepime
Past Medical History:
OB History: G0, P0.
GYN History: Menarche age ___. Regular menses every 28 days,
seven days of heavy flow (cyclic menorrhagia), moderate
dysmenorrhea but no significant pelvic pain. Denies any
dyspareunia, pain with full bladder or bowel movement.
- Denies history of abnormal Pap. Last Pap ___ reportedly
negative. Last mammogram reportedly ___ yr ago also negative.
- currently in a same sex relationship, but is bisexual and was
in heterosexual relationship in the past. reports roughly 15
sexual partners throughout life. Does not currently require any
contraception currently. Denies history of STDs.
PMH:
1. Uterine fibroids (cyclic menorrhagia/dysmenorrhea)
PSH: Negative.
Social History:
___
Family History:
Denies any GYN cancers or any cancers in the family. She
reports the mother with hypertension and hypercholesterolemia
and no other family medical conditions.
Physical Exam:
ADMISSION EXAM:
=================
Vitals: 98.2 128/60 90 20 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, 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-tender, non-distended
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: CNII-XII grossly intact
DISCHARGE EXAM:
=================
Vitals: Temp 98.8 HR 70-80s BP 100-120/60-70s RR 18 SpO2 95% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, 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-tender, non-distended
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: CNII-XII grossly intact
Pertinent Results:
ADMISSION LABS:
=================
___ 04:35PM BLOOD WBC-15.7* RBC-4.54# Hgb-11.1*# Hct-36.5#
MCV-80* MCH-24.4* MCHC-30.4* RDW-16.0* RDWSD-46.3 Plt ___
___ 04:35PM BLOOD Neuts-80.1* Lymphs-10.2* Monos-6.9
Eos-1.8 Baso-0.6 Im ___ AbsNeut-12.58* AbsLymp-1.60
AbsMono-1.09* AbsEos-0.29 AbsBaso-0.10*
___ 08:00AM BLOOD ___ PTT-29.1 ___
___ 04:35PM BLOOD Glucose-82 UreaN-9 Creat-0.7 Na-138 K-4.4
Cl-102 HCO3-24 AnGap-16
___ 04:35PM BLOOD Calcium-9.7 Phos-4.0 Mg-2.1
___ 04:35PM BLOOD HCG-<5
___ 04:38PM BLOOD Lactate-1.5
IMAGING:
===============
___ - TTE
The estimated right atrial pressure is ___ mmHg. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (?#) appear structurally normal with good
leaflet excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is a trivial
circumferential echolucent pericardial effusion. There is a
moderately thick (~2 cm) echodense, fixed mass encasing the
heart seen in multiple views, both anteriorly to the right
ventricle and adjacent to the left ventricle. No right atrial or
right ventricular diastolic collapse is seen.
Trivial pericardial effusion. Mass seen external to the
pericardial space which appears to surround the heart without
apparent hemodynamic compromise. Normal biventricular systolic
function.
___ - CXR
Small right apical pneumothorax. No pneumomediastinum. Large
mediastinal
mass unchanged. No definite change in the lungs. Possible
small right
fissural pleural fluid collection.
___ - CT Chest contrast
1. Very large relatively homogeneous soft tissue density mass
occupying nearly
half of the anterior hemithorax centered in the right
mediastinum encasing the
major vessels and airways. Multiple round relatively hyperdense
lesions in
the right upper mediastinum likely reflecting lymph nodes.
Given the
appearance of the mass would favor lymphoma as the top
differential diagnosis,
less likely of thymic origin.
2. Large amount of intermediate density fluid or soft tissue
thickening of the
pericardium. No radiographic evidence of tamponade.
3. Consolidation in the right upper and middle lobes with air
bronchograms.
While this may reflect atelectasis, a postobstructive pneumonia
is possible.
MICROBIOLOGY:
===============
Urinary legionella ag - negative
___ - Blood cultures x3 - NGTD
___ 4:25 pm TISSUE MEDIASTINAL MASS.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
PATHOLOGY:
=============
Pleural fluid - ___
- Negative for malignant cells.
- Mesothelial cells and macrophages.
Cytogenetics of LN ___
- Pending
Tissue: MEDIASTINUM, MASS, RESECTION ___
- Pending
DISCHARGE LABS:
================
___ 07:45AM BLOOD WBC-14.4* RBC-4.43 Hgb-10.7* Hct-35.3
MCV-80* MCH-24.2* MCHC-30.3* RDW-15.9* RDWSD-45.8 Plt ___
Medications on Admission:
1. ___ FE ___ (28) (norethindrone-e.estradiol-iron) 1.5
mg-30 mcg (21)/75 mg (7) oral DAILY
2. Multivitamins 1 TAB PO DAILY
3. Ibuprofen 400 mg PO Q8H:PRN pain
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 8 Days
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tablet(s) by mouth every 12 hours Disp #*18 Tablet Refills:*0
3. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*21 Capsule Refills:*0
4. Ibuprofen 400 mg PO Q8H:PRN pain
5. ___ FE ___ (28) (norethindrone-e.estradiol-iron) 1.5
mg-30 mcg (21)/75 mg (7) oral DAILY
6. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Anterior mediastinal mass
Post-obstructive pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p mediastinotomy and bx of anterior
mediastinal mass // please assess for PTX or other interval change
please assess for PTX or other interval change
COMPARISON: Chest radiograph ___.
IMPRESSION:
Small right apical pneumothorax. No pneumomediastinum. Large mediastinal
mass unchanged. No definite change in the lungs. Possible small right
fissural pleural fluid collection.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: Cough, Dyspnea, Fever
Diagnosed with Cough
temperature: 99.3
heartrate: 94.0
resprate: 18.0
o2sat: 97.0
sbp: 139.0
dbp: 75.0
level of pain: 0
level of acuity: 2.0 | SUMMARY:
Otherwise healthy ___ y.o. female presents from ___
after CXR performed for evaluation of cough and fevers
demonstrated large anterior mediastinal mass. She reported 6
months of night sweats and shortness of breath/shallow breathing
as reported by her wife (pt denies dyspnea), 9 days of
productive cough.
# Pneumonia: Likely post-obstructive given anterior mediastinal
mass. She did well clinically without fever and had improved
leukocytosis. She will complete a 7 day course of augmentin with
final day = ___. Negative urinary legionella ag. Blood
cultures were NGTD at time of this summary.
# Mediastinal mass: differential includes lymphoma, thymoma,
thyroid, and teratoma. Per radiology report imaging most
suggestive of lymphoma, and she also endorses B symptoms.
Negative micro on biopsy specimen.
- s/p mediasteinotomy ___
- pathology pending at discharge
# Pericardial effusion: intermediate density fluid vs. soft
tissue thickening of pericardium on CT without evidence of
tamponade. TTE without significant pericardial effusion
- no intervention |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Hydrocodone
Attending: ___
Chief Complaint:
Chest pain/ left arm pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is an ___ with dementia, coronary artery disease
s/p CABG ___, atrial fibrillation on coumadin, AVR s/p
bioprosthetic valve who presented to the ED with intermittent
chest pain radiating down the left arm occurring over the past
several days. She described it as a burning sensation extending
down the entirety of the arm occurring principally with exertion
but also occasionally at rest, and lasting typically about 5min.
It would improve slightly with rest but incompletely. She had
accompanying dyspnea at the same time and does complain of a
cough. She denies chest pain or heaviness. She does not recall
similar symptoms in the past though her last cardiology clinic
note suggested similar symptoms.
She sees Dr. ___ management of her multifacetted cardiac
disease, most recently in ___ at which point she was
complaining of left arm pain with exertion that improved with
rest. She had mild heart failure as well, all of which was
attributed to inadequately controlled hypertension. She was felt
to have stable angina.
In the ED, her initial vitals were 96.3 90 175/91 18 96% ra. Her
initial EKG revealed atrial fibrillation with 1mm ST depressions
in the lateral leads which were new, though occurred in the
context of LVH. Her labs were generally unremarkable aside from
an elevated BNP. CXR showed some fluid in the minor fissure and
central venous engorgement without overt pulmonary edema. Her
symptoms were felt to be related to hypertension, and they
responded both clinically and numerically to 0.4mg of SL NTG
with a resultant pressure of 120 systolic. She was admitted with
stable troponins to the cardiology service.
On arrival to the floor, her initial vitals were: T97.3BP129/59
P65 RR18 Sat94RA. She is comfortable. She has some aching in the
right shoulder that she says is always present, but does not
have the full arm pain that ushered her ED visit. She has no
chest pain or shortness of breath currently, and feels well. She
has no current orthopnea or PND and is laying flat in bed.
She does carry a diagnosis of advancing dementia, and appears to
be dependent on her son/daughter in law for all IADLs. Despite
her extensive cardiac history, she could not remember any of her
diagnoses or prior treatments. She is oriented to ___,
name, ___, and ___, but she seems to struggle recollecting
this information.
On review of systems, she denies fevers, chills, naunsea,
vomiting, claudication, dysuria, hematuria, muscle pains,
arthralgias,visiion changes, weakness, fatigue, shortness of
breath, hemoptysis, swelling
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: ___ at ___ LIMA to the LAD; SVG
to OMB; SVG to PDA)
- atrial fibrillation on warfarin
- Aortic Stenosis, s/p bioprosthetic Aortic Valve Replacement
3. OTHER PAST MEDICAL HISTORY:
-Pulmonary HTN
-Sleep apnea, unable to tolerate CPAP
-Stage III renal insufficiency
-Hypothyroid
-Cancer-skin of face
-Difficulty swallowing
-Anxiety
-Depression
-Mild dementia
-Rhinitis
-Tinnitus
-Spinal stenosis
-S/P gallstone
-GERD
PAST SURGICAL HISTORY
-S/P C-section x4
-Right Knee replacement
-CABG
-bioprosthetic AVR
Social History:
___
Family History:
Mother had CAD in her ___ per OMR
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS- T97.3BP129/59 P65 RR18 Sat94RA. Wt74.8
GENERAL- well appearing female, sleeping, in no acute distress.
HEENT- PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis
of the oral mucosa. No xanthalesma.
NECK- Supple with JVP up to the mandibular angle
CARDIAC- irregularly irregular, variable intensity S1, S2. ___
SEM at the ___ right ICS without radiation. No S3 or S4.
LUNGS- crackle in the right base but moving good air and
generally clear
ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES- No c/c/e.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES-
Right: Carotid 2+ DP 2+ ___ 2+
Left: Carotid 2+ DP 2+ ___ 2+
NEURO: A&O x 2, CN2-12 intact grossly, ___ strength throughout,
normal sensation throughout. No focal deficits.
DISCHARGE PHYSICAL EXAMINATION:
VS- T97.6F, BP 130/66 (123-133/59-74), HR 62, RR 18, 97%RA
Weight 72.4kg
GENERAL- well appearing female, sleeping flat on back, in no
acute distress, easily rousable
HEENT- PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of
the oral mucosa, OP clear
NECK- Supple with JVP 7cm
CARDIAC- irregularly irregular, normal S1, S2. ___ systolic
murmur heard best at RUSB.
LUNGS- good air movement, bibasilar crackles R>L
ABDOMEN- Soft, NTND. No HSM or tenderness. +BS
EXTREMITIES- No edema
NEURO: A&Ox2 (not to date or to specific hospital), CN2-12
intact grossly
Pertinent Results:
ADMISSION LABS:
___ 09:20PM BLOOD WBC-5.5 RBC-5.09 Hgb-13.0 Hct-40.8
MCV-80* MCH-25.5* MCHC-31.8 RDW-17.3* Plt ___
___ 09:20PM BLOOD Neuts-75.9* Lymphs-15.2* Monos-7.5
Eos-1.0 Baso-0.4
___ 09:20PM BLOOD ___ PTT-32.8 ___
___ 09:20PM BLOOD Glucose-107* UreaN-20 Creat-1.0 Na-140
K-4.3 Cl-107 HCO3-21* AnGap-16
___ 09:20PM BLOOD proBNP-2637*
___ 09:20PM BLOOD cTropnT-<0.01
___ 07:30AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:30AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.9
PERTINENT LABS:
___ 05:30PM URINE Color-Yellow Appear-Hazy Sp ___
___ 05:30PM URINE Blood-MOD Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
___ 05:30PM URINE RBC-2 WBC-70* Bacteri-MANY Yeast-NONE
Epi-2
___ 09:20PM BLOOD ___ PTT-32.8 ___
___ 07:30AM BLOOD ___ PTT-31.6 ___
___ 07:55AM BLOOD ___
___ 07:30AM BLOOD ___
DISCHARGE LABS:
___ 07:55AM BLOOD WBC-5.8 RBC-4.73 Hgb-11.7* Hct-37.9
MCV-80* MCH-24.7* MCHC-30.9* RDW-17.2* Plt ___
___ 07:30AM BLOOD ___
___ 07:30AM BLOOD Glucose-86 UreaN-19 Creat-0.9 Na-141
K-3.7 Cl-108 HCO3-23 AnGap-14
___ 07:30AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.9
MICRO:
10:45 ___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
___: Urine cultre pending at discharge
CXR ___
FINDINGS: Frontal and lateral views of the chest were obtained.
The patient is status post median sternotomy and CABG. There
is thickening/fluid along the minor fissure. There is elevation
and eventration of the right hemidiaphragm with overlying right
base atelectasis. The cardiac and mediastinal silhouettes are
stable with the aorta calcified and tortuous and the cardiac
silhouette mildly enlarged. Slight prominence of the hila is
stable, which may relate to pulmonary vascular engorgement. No
focal consolidation or evidence of pneumothorax is seen. There
are degenerative changes at the partially imaged left shoulder.
IMPRESSION: Persistent enlargement of the cardiac silhouette
and central pulmonary vascular engorgement without overt
pulmonary edema. Thickening/fluid along the minor fissure. No
focal consolidation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Donepezil 5 mg PO HS
3. Aspirin 81 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Rosuvastatin Calcium 5 mg PO DAILY
6. Digoxin 0.125 mg PO EVERY OTHER DAY
7. Diltiazem Extended-Release 120 mg PO DAILY
8. Fluoxetine 40 mg PO DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY
10. Levothyroxine Sodium 100 mcg PO DAILY
11. Nitroglycerin SL 0.3 mg SL PRN CP
12. Omeprazole 20 mg PO DAILY
13. Metoprolol Succinate XL 150 mg PO HS
14. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
15. Warfarin 2 mg PO DAYS (___)
16. Warfarin 3 mg PO DAYS (___)
17. Potassium Chloride 20 mEq PO DAILY
18. lisinopril-hydrochlorothiazide *NF* ___ mg Oral daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Digoxin 0.125 mg PO EVERY OTHER DAY
3. Diltiazem Extended-Release 120 mg PO DAILY
hold for SBP <100 or HR <55
4. Donepezil 5 mg PO HS
5. Fluoxetine 40 mg PO DAILY
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Metoprolol Succinate XL 150 mg PO HS
Hold for SBP< 100 or HR<55
8. Vitamin D 50,000 UNIT PO 1X/WEEK (WE)
9. Rosuvastatin Calcium 5 mg PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Acetaminophen 650 mg PO Q6H:PRN pain fever
13. Fluticasone Propionate NASAL 1 SPRY NU DAILY
14. Potassium Chloride 20 mEq PO DAILY
15. Furosemide 20 mg PO DAILY
hold for SBP <100
16. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
17. Lisinopril 10 mg PO DAILY
hold for SBP <100
18. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days
Last day ___
19. Nitroglycerin SL 0.3 mg SL PRN CP
take 1 tab for chest pain. If no relief after 5 minutes, repeat
dose. If no relief 5 minutes after 2nd dose, take a third dose
and call ___. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
Last day ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: hypertension, clostridium difficile diarrhea, urinary
tract infection
Secondary: coronary artery disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: Left-sided chest pain, history of coronary disease,
question pneumothorax, question pulmonary edema.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. The patient
is status post median sternotomy and CABG. There is thickening/fluid along
the minor fissure. There is elevation and eventration of the right
hemidiaphragm with overlying right base atelectasis. The cardiac and
mediastinal silhouettes are stable with the aorta calcified and tortuous and
the cardiac silhouette mildly enlarged. Slight prominence of the hila is
stable, which may relate to pulmonary vascular engorgement. No focal
consolidation or evidence of pneumothorax is seen. There are degenerative
changes at the partially imaged left shoulder.
IMPRESSION: Persistent enlargement of the cardiac silhouette and central
pulmonary vascular engorgement without overt pulmonary edema.
Thickening/fluid along the minor fissure. No focal consolidation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CHEST AND ARM PAIN
Diagnosed with CHEST PAIN NOS
temperature: 96.3
heartrate: 90.0
resprate: 18.0
o2sat: 96.0
sbp: 175.0
dbp: 91.0
level of pain: 13
level of acuity: 2.0 | Mrs. ___ is a pleasant ___ F with dementia, coronary artery
disease, atrial fibrillation, and aortic valve replacement who
presented with arm pain and dyspnea concerning for ischemia in
the setting of lateral ST depressions. Symptoms felt to be
anginal equivalent that may have been related to inadequately
controlled blood pressures due to poor medication compliance in
setting of recent social stressors, change in home situation.
Found to have urinary tract infection and Clostridium difficile
diarrhea.
# STABLE ANGINA: Patient presenting with left arm pain. Though
history clouded by dementia, her symptoms and EKGs were
consistent with angina in patient with known coronary artery
disease, improved with SL NTG and blood pressure control. No ST
elevations or cardiac enzyme elevation to suggest an acute
coronary syndrome, and her pain was easily managed. Isosorbide
mononitrate was added to her regimen for long term antiangina
management, and she was continued on medical management of her
coronary artery disease as below.
# CORONARY ARTERY DISEASE: status post CABG in ___. Current
presentation was consistent with prior stable angina per
cardiology clinic notes, and without persistent EKG changes or
enzyme elevations. Symptoms improved with blood pressure control
(presented with pressures in the 180s). Continued aspirin,
statin, beta blockade, ACE inhibitor, sublingual nitroglycerin
prn. Added isosorbid mononitrate as above.
# ACUTE ON CHRONIC DIASTOLIC/SYSTOLIC HEART FAILURE: EF 45-50%.
Presented with dyspnea on exertion and some central engorgement
and fluid in fissure on admission CXR. Appeared volume
overloaded but improved with 40mg PO furosemide x1, then daily
20mg PO thereafter. Exacerbation occurred in setting of
discontinuation of furosemide as outpatient due to urinary
incontinence. Of note, per documentation, patient was also
hospitalized in ___ for overload when furosemide was
stopped for urinary incontinence as well. This patient may need
long term loop diuretic therapy, and urinary incontinence and
its effect on her quality of life will need to be balanced with
desire to avoid recurrent hospitalizations.
# HYPERTENSION: Management as above with metoprolol, diltiazem,
lisinopril
# Urinary tract infection: Patient asymptomatic but poor
historian, with positive UA. Started on 3 day course of Bactrim
DS, urine culture pending at time of discharge. Last day of
bactrim ___.
# Clostridium difficile diarrhea: patient presented with
diarrhea, noted to have ___ loose bowel movements daily, no new
ingestions or sick contacts, no abdominal pain or leukocytosis.
C. diff assay was positive, started metronidazole ___ for
two week course, last day of metronidazole ___.
# GERD: Felt to be contributing to this patient's vague chest
pain complaints as symptoms worse with eating, laying flat.
Increased omeprazole to 40mg daily. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
Upper Endoscopy
Capsule endoscopy
History of Present Illness:
___ male with a past medical history of AVMs of GI
tract,
T1DM, CAD w/ 3vd, COPD, PVD, and aortic stenosis, revision of a
left femoral-popliteal bypass on apixiban, recently hospitalized
at ___ for BRBRPR and NSTEMI, presenting nausea, abdominal
pain as well as increasing lightheadness, and DOE.
Patient himself is a poor historian and denies having any black
or bloody stools nor any other symptoms. Of note, patient
underwent a revision of a left femoral-popliteal bypass about 2
months ago, now on xarelto. He was recently admitted from ___
to
___ with melena and acute on chronic anemia found to have AVMs
in small intestine as source, and new ST depressions in lateral
precordial leads c/w demand (Type II) NSTEMI. His blood counts
stabilized on heparin drip and he was transitioned to apixaban
for its lower rates of GI bleed.
Patient went to his PCP today given these symptoms for 1 week
and
was found to have a drop in Hgb from 8.2 to 6.7. He was
transferred to the ED for further care.
In the ED,
Initial Vitals: 98.0 100 111/55 18 100% RA
Exam:
General: Well appearing, no acute distress
Cardiac: RRR no rgm
Pulmonary: Clear to auscultation bilaterally, no
crackles/wheezes
Abdominal/GI: No tenderness or masses
Renal: No CVA tenderness
MSK: No deformities or signs of trauma
Derm: No rashes or signs of trauma
Psych: Normal judgment, mood appropriate for situation
Guaic positive stools with visualized melena.
Labs: Hgb 6.6, INR 2.1, trop 2.51 -> 1.71, MBI 8.1
Imaging:
Consults: Atrius cardiology - transfuse PRN, continue to
monitor
GI- Keep on PPI 40 mg twice daily
- Monitor H/H serially; maintain 2 large bore peripheral IV's
- Maintain active type & screen
- Will determine need and timing of EGD based on clinical
trajectory
- Call/page for unstable bleeding
Interventions: IV PPI, 1u pRBC
VS Prior to Transfer: 97.9 96 107/61 20 100% RA
On arrival to the ICU, patient feels fine without any
complaints.
His daughters are at bedside who report patient has just had
abdominal discomfort for the past week with ___ episodes of
vomiting. Patient also felt short of breath with minimal
exertion
which is different than his baseline. This is primarily what
prompted them to see their PCP.
Past Medical History:
prostate CA
Type 1 DM
diabetic retinopathy
Acute on chronic combined systolic and diastolic congestive
heart
failure
CAD w/ 3vd
COPD
PVD
aortic valve stenosis
Social History:
___
Family History:
Father - deceased ___ lung cancer, smoker
Mother - ___
Physical ___:
ADMISSION PHYSICAL EXAM
=========================
VS: Reviewed in metavision
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
oropharynx clear.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___
systolic murmur at the LLSB.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: 2+ edema L shin and 1+ edema on the right. Pulses
DP/Radial 2+ bilaterally.
SKIN: Warm. Cap refill less than 2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait is normal, assisted by ___. AOx3.
DISCHARGE PHYSICAL EXAM
==========================
24 HR Data (last updated ___ @ 1708)
Temp: 97.8 (Tm 98.4), BP: 115/75 (104-115/64-75), HR: 93
(58-100), RR: 16 (___), O2 sat: 96% (93-99), O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. Pale
conjunctiva. MMM. Oropharynx clear.
NECK: No cervical lymphadenopathy. No JVD
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___
systolic murmur at the LLSB.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No edema bilaterally. Pulses DP/Radial bilaterally
SKIN: Warm. Cap refill less than 2s. No rash.
NEUROLOGIC: CN grossly intact. Normal spontaneous movement.
sensation grossly intact. Gait not assessed
Pertinent Results:
ADMISSION LABS
====================
___ 01:51PM BLOOD Anisocy-1+* Poiklo-1+* Polychr-1+*
Ovalocy-1+* Schisto-1+* Echino-1+* RBC Mor-SLIDE REVI
___ 01:51PM BLOOD ___ PTT-34.0 ___
___ 01:51PM BLOOD Glucose-289* UreaN-24* Creat-0.9 Na-137
K-4.6 Cl-95* HCO3-24 AnGap-18
___ 01:51PM BLOOD ALT-33 AST-47* CK(CPK)-505* AlkPhos-163*
TotBili-0.3
___ 01:51PM BLOOD CK-MB-41* MB Indx-8.1*
___ 01:51PM BLOOD cTropnT-2.51*
___ 01:51PM BLOOD Albumin-2.9*
___ 01:51PM BLOOD WBC-7.5 RBC-2.44* Hgb-6.6* Hct-21.9*
MCV-90 MCH-27.0 MCHC-30.1* RDW-18.6* RDWSD-58.9* Plt ___
___ 01:51PM BLOOD Neuts-79* Lymphs-9* Monos-11 Eos-1 Baso-0
AbsNeut-5.93 AbsLymp-0.68* AbsMono-0.83* AbsEos-0.08
AbsBaso-0.00*
PERTINENT LABS
====================
___ 05:31PM BLOOD cTropnT-1.71*
___ 02:58AM BLOOD CK-MB-12* MB Indx-5.3 cTropnT-1.49*
___ 01:51PM BLOOD WBC-7.5 RBC-2.44* Hgb-6.6* Hct-21.9*
MCV-90 MCH-27.0 MCHC-30.1* RDW-18.6* RDWSD-58.9* Plt ___
___ 02:58AM BLOOD WBC-5.6 RBC-2.58* Hgb-7.1* Hct-22.7*
MCV-88 MCH-27.5 MCHC-31.3* RDW-17.7* RDWSD-54.0* Plt ___
___ 05:14AM BLOOD WBC-4.2 RBC-3.19* Hgb-8.9* Hct-28.0*
MCV-88 MCH-27.9 MCHC-31.8* RDW-17.3* RDWSD-54.4* Plt ___
___ 01:51PM BLOOD ALT-33 AST-47* CK(CPK)-505* AlkPhos-163*
TotBili-0.3
___ 01:51PM BLOOD cTropnT-2.51*
DISCHARGE LABS
====================
___ 05:14AM BLOOD WBC-4.2 RBC-3.19* Hgb-8.9* Hct-28.0*
MCV-88 MCH-27.9 MCHC-31.8* RDW-17.3* RDWSD-54.4* Plt ___
___ 05:14AM BLOOD Plt ___
___ 05:14AM BLOOD Glucose-52* UreaN-11 Creat-0.7 Na-140
K-4.3 Cl-104 HCO3-24 AnGap-12
___ 05:14AM BLOOD Albumin-2.2* Calcium-8.0* Phos-3.9 Mg-1.9
MICROBIOLOGY
====================
None
IMAGING
====================
EGD ___: IMPRESSION:
- Irregular z-line of the mucosa was noted in the
gastroesophageal junction. Biopsies were not taken in order to
prevent distortion of capsule images
- Normal mucosa in the whole stomach
- A few small non-bleeding angioectasias were seen in the
duodenal bulb and second part of the duodenum. Cautery was not
performed since AVMs were not actively bleeding and to prevent
distortion on images of subsequently placed capsule
- A separate consent was obtained for capsule endoscopy. The
capsule was placed endoscopically and released in the duodenum
without complications.
Study arterial duplex lower extremity ___:
- Reason femoropopliteal bypass.
- Duplex evaluations formed the left lower extremity bypass
graft. Peak
velocities from proximal to distal starting in the common
femoral artery are
190, 90, 44, 30, 42, 66, 92. There is a seroma in the distal
thigh.
- Impression widely patent left femoral to popliteal artery
bypass graft. Small
seroma
Portable abdominal x-ray (___):
IMPRESSION:
Endoscopic capsule in the distal colon.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN wheeze
2. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation
inhalation DAILY
3. Felodipine 5 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY
6. Ramelteon 8 mg PO QHS
7. Senna 8.6 mg PO BID:PRN Constipation - First Line
8. Lidocaine 5% Patch 1 PTCH TD QAM lumbar lower back pain
9. Acetaminophen 650 mg PO Q6H
10. Aspirin EC 81 mg PO DAILY
11. Atorvastatin 80 mg PO QPM
12. Furosemide 40 mg PO DAILY
13. Gabapentin 100 mg PO TID
14. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
15. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
16. Pantoprazole 40 mg PO Q24H
17. Spironolactone 25 mg PO DAILY
18. Apixaban 5 mg PO BID
19. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
20. Glargine 30 Units Bedtime
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily at night Disp
#*30 Tablet Refills:*0
2. needle (disp) 32 gauge 32 gauge x ___ miscellaneous Other
RX *needle (disp) 32 gauge [Easy Touch Hypodermic Needle] 32
gauge X ___ To use with Kwikpen As directed Disp #*1 Package
Refills:*0
3. Glargine 8 Units Breakfast
Glargine 7 Units Bedtime
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. Acetaminophen 650 mg PO Q6H
5. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN wheeze
6. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25
mcg/actuation inhalation DAILY
7. Aspirin EC 81 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
10. Furosemide 40 mg PO DAILY
11. Gabapentin 100 mg PO TID
12. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE QHS
13. Lidocaine 5% Patch 1 PTCH TD QAM lumbar lower back pain
14. Metoprolol Succinate XL 25 mg PO DAILY
15. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
16. Pantoprazole 40 mg PO Q24H
17. Polyethylene Glycol 17 g PO DAILY
18. Ramelteon 8 mg PO QHS
Should be given 30 minutes before bedtime
19. Senna 8.6 mg PO BID:PRN Constipation - First Line
20. HELD- Spironolactone 25 mg PO DAILY This medication was
held. Do not restart Spironolactone until you see your
cardiologist
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary diagnosis:
Acute on chronic anemia
Secondary diagnosis:
Chronic arteriovenous malformations
NSTEMI
CAD
Type 1 diabetes
Peripheral vascular disease
HFrEF
Aortic stenosis
COPD
Hypertension
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
Study arterial duplex lower extremity
Reason femoropopliteal bypass.
Duplex evaluations formed the left lower extremity bypass graft. Peak
velocities from proximal to distal starting in the common femoral artery are
190, 90, 44, 30, 42, 66, 92. There is a seroma in the distal thigh.
Impression widely patent left femoral to popliteal artery bypass graft. Small
seroma
Radiology Report
EXAMINATION: Abdominal radiograph, portable AP supine view.
INDICATION: Status post capsule study.
COMPARISON: ___.
FINDINGS:
Endoscopic capsule projects over the left upper quadrant, very likely in the
lower descending or upper sigmoid portion of the colon. Bowel gas pattern is
unremarkable. No indications of free air. Partly visualized brachytherapy
seeds in the prostate. Moderate vascular calcification. Degenerative changes
of the L4-L5 facet joints.
IMPRESSION:
Endoscopic capsule in the distal colon.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Anemia
Diagnosed with Anemia, unspecified
temperature: 98.0
heartrate: 100.0
resprate: 18.0
o2sat: 100.0
sbp: 111.0
dbp: 55.0
level of pain: 0
level of acuity: 2.0 | Key Information for Outpatient ___ male with
a past medical history of AVMs of GI tract
with recent admission for UGIB needing transfusions, T1DM, CAD
w/
3vd, COPD, PVD, and aortic stenosis, revision of a left
femoral-popliteal bypass on apixiban presenting with abdominal
pain and DOE, found to have acute blood loss anemia ___
recurrent
GIB and NSTEMI, likely type II. His course was complicated by
difficulty controlling her blood glucoses.
#Acute on chronic anemia: Initial HgB on presentation was 6.6.
He received 3u of pRBCs during his exam and his hemoglobin
stabilized between 8.1 and 8.9 (8.9 on discharge). He has had
multiple hospitalizations for anemia d/t presumed GI source.
Upper EGD demonstrated irregular z-line of the mucosa at the GE
junction, normal mucosa of the stomach, and a few small
non-bleeding angioectasias. Interventions were not performed to
preserve the capsule endoscopy, but the capsule endoscopy also
did not reveal obvious sources of bleeding. He presented on
apixaban and had previously been on Xarelto at the last
hospitalization. We held an informed discussion with the
patient's daughter regarding the risks of bleeding vs. clotting.
Having failed two anticoagulation regimens, the decision was
made to transition to Plavix rather than restarting
anticoagulation. The family was informed that there was a higher
risk of clotting on Plavix vs. anticoagulation, but there was
also a lower risk of bleeding. Family expressed significant
concerns about his continued hospitalizations for anemia, and
thus, the decision was made to start him on dual antiplatelet
therapy. He was instructed to get a repeat CBC next week,
___ with his PCP, his gastroenterologist and his vascular
surgeon to continue the discussion of anticoagulation vs. DAPT.
#NSTEMI: Patient with significant troponin leak to 2.51 that
improved to 1.49. ECG did not reveal new ischemic changes. The
troponin leak was felt to be d/t anemia. Patient has known
history of significant CAD with 3vd (LAD 90%, LCx 90% and 100%
RCA lesion on ___, but family and his cardiologist at
___ had elected for conservative management. After
discussions with ___ cardiology, the decision was made to
defer TTE and continue conservative management.
#Type 1 diabetes: Patient seen by ___ for management of his
diabetes. His insulin dosing was changed to 15U of lantus in the
AM, 5U Humalog fixed for each meal and corrective dosing of
200/50/1/1. Patient has a continuous glucose monitor at home,
which his daughter helps manage.
#PVD s/p L femoral-popliteal bypass revision (___): Patient
had previously been on rivaroxaban before transitioning to
apixaban during recent hospitalization for anemia. Based upon
recurrent GI bleeds, the decision was made to start DAPT and
hold anticoagulation. As stated above, the family agreed with
this plan. He was encouraged to ___ with his PCP.
#HFrEF: Patient's last known EF was 40%. His furosemide,
spironolactone and metoprolol were initially held. He was
restarted on furosemide 40mg PO/NG daily and metoprolol
succinate XL 25mg PO daily with instructions to followup with
his cardiologist regarding his spironolactone.
================================= |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o female w/ PMHx HTN, DM, CKD stage IV, anemia thought ___
renal failure on epo as an outpatient who presents with headache
and shortness of breath x10 days. Was in her usual state of
health when headache started, intermittent, squeezing sensation.
SOB started few days ago, mildly worse than her baseline SOB,
worsening with exertion. No chest pain. No fevers, chills,
sweats, cough.
In ___, she was seen in the ___ clinic for fatigue and
shortness of breath and found to acute drop in H/H to 7.6/23.0.
She did not want a transfusion at that time and was treated with
aransep injections. Her repeat H/H 2 weeks later was 8.3/26.0.
In the ED, initial VS were:98.2 75 152/44 20. Labs showed K of
5.7, Cr of 2.1, BNP of 808, H/H 8.4/27.0 (10.0/32.1 in ___.
UA showed mod bacteria and 14 WBC. EKG showed NSR ___hanges or peaked Ts. CXR showed low lung volumes with mild
pulmonary vascular congestion. She was given cipro 500mg PO to
cover for a UTI and furosemide 40mg IV. Patient refused
transfusion. VS on transfer: 99.1 68 ___ 24 96%.
Overnight, her headache has resolved and she had no SOB at rest.
Stated that if she were to walk around, she would become
dyspneic. No chest pain ever. No urinary symptoms. States her
leg swelling is at baseline. Has not noted any blood in stool or
elsewhere.
In the AM, her fatigue and dyspnea have resolved. She is able to
walk to the bathroom without difficulty.
Please see nightfloat admission note for home medications,
allergies, FH, and SH, which I have confirmed with the patient.
Past Medical History:
Hypertension.
Chronic kidney disease.
Hypothyroidism.
Depression
Anemia
Osteoarthritis
Urinary incontinence
Chronic tremor
Cataracts
Glaucoma
Obesity
History of carpal tunnel syndrome
History of rotator cuff tear
Status post of scapulolunate tear
Social History:
___
Family History:
Diabetes in her sister. The patient lost multiple family members
when she came from ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 147/53 68 18 100%RA
GENERAL: well appearing female in NAD
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM, poor
dentition
NECK: supple, no LAD, JVD difficult to appreciate but 2 cm above
clavicle at 30 degrees
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, obese, soft, non-tender,
non-distended, no rebound or guarding, declined rectal exam
EXTREMITIES: 2+ edema, 2+ pulses radial and dp, small bruises
throughout arms
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
DISCHARGE PHYSICAL EXAM:
VS: 98.1 62 147/58 18 95%RA
GENERAL: well appearing female in NAD
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM, poor
dentition
NECK: supple, no LAD, JVD difficult to appreciate but 2 cm above
clavicle at 30 degrees
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, obese, soft, non-tender,
non-distended, no rebound or guarding, declined rectal exam
EXTREMITIES: 2+ edema, 2+ pulses radial and dp, small bruises
throughout arms
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
Pertinent Results:
___ 08:40PM URINE HOURS-RANDOM
___ 08:40PM URINE UHOLD-HOLD
___ 08:40PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
___ 08:40PM URINE RBC-0 WBC-14* BACTERIA-FEW YEAST-NONE
EPI-1
___ 08:40PM URINE MUCOUS-RARE
___ 07:37PM LACTATE-0.7
___ 07:25PM GLUCOSE-182* UREA N-68* CREAT-2.1* SODIUM-141
POTASSIUM-5.7* CHLORIDE-108 TOTAL CO2-25 ANION GAP-14
___ 07:25PM LD(LDH)-193
___ 07:25PM proBNP-808*
___ 07:25PM IRON-38
___ 07:25PM calTIBC-269 FERRITIN-205* TRF-207
___ 07:25PM WBC-4.9 RBC-2.77* HGB-8.4* HCT-27.0* MCV-98
MCH-30.4 MCHC-31.2 RDW-13.2
___ 07:25PM NEUTS-67.5 ___ MONOS-5.0 EOS-2.7
BASOS-0.3
___ 07:25PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
___ 07:25PM PLT COUNT-145*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aliskiren 300 mg PO DAILY
hold for SBP < 90
2. Atorvastatin 40 mg PO DAILY
3. Calcitriol 0.25 mcg PO MWF
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES DAILY
5. Multivitamins 1 TAB PO DAILY
6. Calcium Carbonate 1250 mg PO DAILY
7. Doxazosin 4 mg PO BID
hold for SBP < 90
8. Furosemide 80 mg PO QAM
9. Furosemide 40 mg PO QPM
10. Travatan Z *NF* (travoprost) 0.004 % ___ 1 drop daily
11. Acetaminophen 650 mg PO Q8H
12. Vitamin D ___ UNIT PO DAILY
13. 70/30 23 Units Breakfast
Glargine 26 Units Bedtime
14. Aranesp (in polysorbate) *NF* (darbepoetin alfa in
polysorbat) 100 mcg/mL Injection q4weeks
15. Metoprolol Succinate XL 200 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
2. Aliskiren 300 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Calcitriol 0.25 mcg PO MWF
5. Calcium Carbonate 1250 mg PO DAILY
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES DAILY
7. Doxazosin 4 mg PO BID
8. Furosemide 80 mg PO QAM
9. Furosemide 40 mg PO QPM
10. 70/30 23 Units Breakfast
Glargine 26 Units Bedtime
11. Multivitamins 1 TAB PO DAILY
12. Vitamin D ___ UNIT PO DAILY
13. Aranesp (in polysorbate) *NF* (darbepoetin alfa in
polysorbat) 100 mcg/mL Injection q4weeks
14. Metoprolol Succinate XL 200 mg PO DAILY
15. Travatan Z *NF* (travoprost) 0.004 % ___ 1 drop daily
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
pulmonary edema
chronic anemia
chronic kidney disease - stage IV
hyperkalemia
Secondary diagnoses:
Hypertension
Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Weakness.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
Lung volumes are low. The cardiac, mediastinal and hilar contours are
unchanged, with mild enlargement of cardiac silhouette noted. Crowding of the
bronchovascular structures is present as a result of the low lung volumes,
with possible mild pulmonary vascular congestion, but no overt pulmonary
edema. No focal consolidation, pleural effusion or pneumothorax is present.
There are no acute osseous abnormalities.
IMPRESSION:
Low lung volumes with possible mild pulmonary vascular congestion.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: PALE/SOB/WEAK
Diagnosed with ANEMIA NOS, HYPERKALEMIA
temperature: 98.2
heartrate: 75.0
resprate: 20.0
o2sat: nan
sbp: 152.0
dbp: 44.0
level of pain: nan
level of acuity: 2.0 | ___ y/o female w/ PMHx HTN, DM, CKD stage IV, anemia thought ___
renal failure on epo as an outpatient who presents with
shortness of breath x 10 days, worsening anemia, and headache.
# Shortness of breath - Feels better on discharge. Most likely
mild volume overload based on CXR findings, vs worsening anemia.
After a one-time dose of 40mg IV lasix overnight, her shortness
of breath resolved in the morning. She no longer was dyspneic
with exertion, and her ambulatory sat was 94-96% on RA. We held
off on transfusion at this time as patient was sating well, and
did not have profound anemia. Pt refused guiac exam multiple
times.
# Acute on chronic normocytic anemia - Related to worsening of
her anemia of chronic disease, consistent with repeat iron
studies sent. Patient continued to decline rectal exam in the ED
and on floor. No signs of gross bleeding on exam otherwise and
no history of blood loss. Her blood smear was unremarkable and
her LDH did not show signs of hemolysis.
# Hyperkalemia - Resolved. Initially K of 5.7 with no signs of
instability on EKG. Received lasix in the ED with a repeat K of
5.1. She will need to discuss with her PCP the continuation of
aliskiren given its side effect of hyperkalemia.
# Headache - Resolved. No concerning signs/symptoms at this
time. History sounded like a tension headache, treated with
acetaminophen.
# Asymptomatic bacteriuria - Received ciprofloxacin in the ED.
However, she was asymptomatic and antibiotics were not
continued. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with h/o HTN, CAD s/p MI and stent in RCA here with
acute onset of mid-back and abdominal pain that started a few
hours prior to admission. C/O difficulties breathing ___ pain.
Seen at ___ ED and CT scan showed Type B dissection. BP was
elevated at 180's and pt given labetolol. Also given full dose
___.
Patient currently stable on arrival to ___. Recieved morphine
in ED and currently denies back or abdominal pain. No extremity
pain. No headaches.
Past Medical History:
PMhx: Breast cancer, Ulcerative colitis (last C-scope ___ years
ago
and was per pt WNL), HTN, OA, ^lipid, CAD (2 vessel disease)
with
MI (inferior STEMI ___, SCC of lip
PShx: Left Mx with XRT, lap tubal ligation, RCA stent, excision
of lip SCC
Social History:
___
Family History:
No family history of early MI, otherwise non-contributory. Her
sister has CAD with stents in place. Her mother died at age ___
from ___, and her father at age ___ from ___. There is also a
family history of CVA's.
Physical Exam:
Afebrile, vital signs stable
MMM, no scleral icterus, tongue and trachea midline, no palpable
lymphadenopathy
RRR
CTAB
Soft, NT/ND, no masses felt
R: P/P/P/P
L: P/P/P/P
Left radial pulse palp and equal to right
Pertinent Results:
CT: Type B dissection originating from left subclavian extending
to renals. Celiac supplied by both true and false lumen whereas
both SMA and renals supplied by true lumen.
Medications on Admission:
Atenolol 12.5', crestor 10', ___ 325'
Discharge Medications:
1. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
2. Labetalol 100 mg PO BID
RX *labetalol 100 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*1
3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
4. Rosuvastatin Calcium 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Type B aortic dissection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Aortic dissection.
TECHNIQUE: Contiguous axial MDCT images were taken through the chest,
abdomen, and pelvis after the administration of 130 cc of Omnipaque
intravenous contrast material. Coronal and sagittal reformats as well as 3D
reformats were also examined.
DLP: 1000.62 mGy-cm.
COMPARISON: CT ___.
FINDINGS:
An approximately 5 mm hypodense lesion is noted within the left lobe of the
thyroid. The airways are patent to the subsegmental level. There is no
mediastinal, hilar, or axillary lymphadenopathy. The heart and pericardium are
unremarkable. Note is made of new bilateral pleural effusions, left greater
than right with associated atelectasis.
Again seen is the aortic dissection starting just distal to the left
subclavian extending to just above the renal arteries. The celiac trunk
arises from the false lumen, and the superior mesenteric artery arises from
the true lumen. The appearance of the dissection is stable compared to the
prior study.
Again seen is a hypodense lesion in the right lobe of the liver, measuring 12
x 20 mm, stable since the prior study. There is no intra or extrahepatic
biliary ductal dilatation. There is a small amount of fluid around the
gallbladder, which is new since the prior study. Gallstones are again
visualized within the gallbladder, but there is no adjacent fat stranding.
The spleen is homogeneous and normal in size. The pancreas is unremarkable
without any focal lesions, peripancreatic stranding, or fluid collection. The
bilateral adrenal glands are unremarkable. Multiple bilateral renal
hypodensities are seen, the largest measuring 1.2 cm in the interpolar region
of the right kidney, too small to characterize.
The stomach and small bowel are unremarkable with no evidence of thickening or
obstruction. The colon is unremarkable. There is no ascites, free air, or
abdominal wall hernias. There is no retroperitoneal or mesenteric
lymphadenopathy.
The bladder and terminal ureters are unremarkable. Note is made of a fibroid
uterus. There is no pelvic sidewall or inguinal lymphadenopathy. There is no
pelvic free fluid.
No suspicious lesion is seen is visualized osseous structures.
IMPRESSION:
1. Stable appearance of type B aortic dissection.
2. Pericholecystic fluid, which is new since the prior study but nonspecific.
There are no definite signs of cholecystitis.
3. Hypodense nodule in the left lobe of the thyroid, which may be
investigated further with ultrasound if clinically indicated.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: AORTIC DISSECTION
Diagnosed with DISS THORACOABD AORTIC ANEURYSM
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | The patient was admitted to the vascular surgery service at the
___ on ___. CT scan revealed the patient was experiencing a
type B aortic dissection, and she was admitted to the CVICU. She
was put on an esmolol drip for strict blood pressure control.
The patient's vital signs and clinical status were monitored
closely. After a period of observation in the CVICU, it was
determined that the patient was stable for transfer to the
floor. She was weaned off of antihypertensive drips, and
transitioned to an oral antihypertensive regimen.
While on the floor, she remained hemodynamically stable. Her
blood pressure was optimized on oral pain medications, and while
the oral regimen was being titrated, she received hydralazine
PRN for blood pressure control. A cardiology consult was
obtained regarding management of her blood pressure. They
recommended she be started on labetalol 100mg BID. She will
follow-up with her primary care physician ___ 3 days. She was
able to ambulate independently, void independently, she was able
to tolerate a PO diet.
The patient received aspirin and heparin subcutaneously.
Prior to discharge, the patient received a CTA of the torso to
monitor any interval change of the aortic dissection, which was
stable.
At the time of discharge, the patient was on a stable oral
antihypertensive regimen, tolerating PO, voiding and ambulating
indepdnently, and able to verbalize understanding with the
discharge plan/instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o male with a history of BPH (with chronic
foley) and Mechanical AVR/MVR (on coumadin) who was sent to the
ED from his cardiologist's office for anorexia, generalized
weakness, and BP 80/40.
Mr. ___ reports that he was in his usual state of health
living indepdenetly at his house, and had no acute complaints,
but went in to see his cardiologist today for a "check-up" and
was referred here because "my blood pressure was low." He
denied lightheadedness, syncope, fevers, chills at home.
He has had poor intake "since my wife died ___ years ago." Mr.
___ reports he has had poor PO intake for years, but it is
usually worse during this time of year since his wife died in
the ___, and he is still grieving. He denies SI - "I'm a
churchgoing man." The patient has been followed closely by PCP
for anorexia (BMI stable ~18 for past ___ years).
Mr. ___ lives in his own home and reports that he is able to
cook, clean, and take care of himself at home. He usually eats
frozen dinners, or has his son bring him food, or eats at
restaurants. Yesterday evening, his son brought him ___
food, and he reports eating "a little bit." He denies
N/V/D/constipation, abdominal pain. He usually has one formed
bowel movement daily.
Given his hypotension, he was referred to the ___ ED for
further evaluation.
In the ED, initial vitals were T 98 BP 88/48 HR 58 RR 14 SaO2
99% on RA. EKG revealed AFL @ 77bpm. U/A not performed due to
anuria. He was given 2L NS with improvement in blood pressure.
He was also given vancomycin/pipercillin-tazobactam emprically.
VS prior to transfer where HR 89 BP 127/64 RR 18 SaO2 100%
On the floor, vs were T 97.6 BP 139/87 HR 96 RR 18 SaO2 100% on
RA.
Currently, Mr. ___ denies acute complaints. He reports
minimal discomfort "not pain" at foley insertion site. He
states he was scheduled to have his foley taken out this
___ after having it put in for months "for my prostate."
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, HA, URI sx, cough, SOB, CP,
palpitations, lightheadedness, weakness, tingling, numbness,
vision changes, N/V/D/constipation, abdominal pain, melena,
hematochezia, arthralgias, myalgias, rashes.
Past Medical History:
- Myxomatous valve disease: Mechanical replacement of the aortic
and mitral valves in ___.
- Hemolytic Anemia, thought to be related to mechanical valves
- Atrial fibrillation
- Atrial Flutter
- COPD (PFTs ___: FEV1/FVC 44%, FEV1 67% predicted
- Cachexia
- BPH
- Ulcer surgery in the past - does not recall details
- Small CVA in ___ without residual deficits
- CKD stage III
- Gallstone disease: s/p ERCP ___
- CAD: abnormal stress, managed medically
Social History:
___
Family History:
- No history of malignancy
- No history of heart valve problems
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 97.6 BP 139/87 HR 96 RR 18 SaO2 100% 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,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Nonedematous. Dry scaling, dark skin on RLE ankle patient
states is chronic from venous stasis
Neuro: A&Ox3. Remarkably cognitively intact for ___ year old.
Knows children's phone numbers by memory. Knows medication
names and doses by memory. Intact strength and sensation in
upper and lower extremities. CN II-XII grossly intact. Follows
commands.
DISCHARGE PHYSICAL EXAM:
Vitals: T 98.8 BP 146/82 HR 74 RR 16 SaO2 100% on RA
Telemetry: Atrial flutter, HR in ___
I/O: Voiding well in BR, PVR 160 this AM.
General: Alert, oriented. NAD.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: JVP flat
Lungs: CTAB
CV: RRR, loud click heard on S1 and S2. Visible sternotomy
wires through chest wall.
Abdomen: Soft, nontender, nondistended. Bladder nonpalpable.
Ext: Nonedematous. Dry scaling, dark skin on RLE ankle patient
states is chronic from venous stasis
Neuro: A&Ox3. Moving all four extremities spontaneously.
Follows commands. CN II-XII grossly intact. Follows commands.
Pertinent Results:
___ 12:50PM BLOOD Glucose-112* UreaN-16 Creat-1.8* Na-142
K-4.3 Cl-107 HCO3-23 AnGap-16
___ 05:53AM BLOOD Glucose-107* UreaN-16 Creat-1.4* Na-143
K-4.3 Cl-116* HCO3-21* AnGap-10
___ 05:49AM BLOOD Glucose-79 UreaN-13 Creat-1.3* Na-140
K-4.3 Cl-116* HCO3-21* AnGap-7*
___ 12:50PM BLOOD cTropnT-0.04*
___ 07:45PM BLOOD CK-MB-4 cTropnT-0.02*
___ 12:50PM BLOOD TSH-4.3*
___ 01:13PM BLOOD Lactate-4.0*
___ 07:58PM BLOOD Lactate-2.3*
___ 05:53AM BLOOD Albumin-2.8* Calcium-7.5* Phos-3.1 Mg-1.8
Iron-27*
___ 06:42PM URINE Blood-MOD Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 06:42PM URINE RBC-86* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
___ 06:42PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 05:49AM BLOOD WBC-3.5* RBC-3.38* Hgb-8.3* Hct-28.8*
MCV-85 MCH-24.6* MCHC-28.9* RDW-19.3* Plt ___
___ 05:51AM BLOOD WBC-3.2* RBC-3.08* Hgb-7.7* Hct-25.4*
MCV-83 MCH-25.2* MCHC-30.5* RDW-19.7* Plt ___
___ 05:53AM BLOOD ___ PTT-104.1* ___
___ 05:49AM BLOOD ___ PTT-66.5* ___
___ 05:51AM BLOOD ___ PTT-58.0* ___
___ 05:51AM BLOOD Glucose-74 UreaN-15 Creat-1.2 Na-141
K-4.1 Cl-115* HCO3-20* AnGap-10
EKG (___)
Atrial flutter with slow ventricular response. Voltage criteria
for left
ventricular hypertrophy with secondary repolarization
abnormalities. T wave inversions in the anterior leads are new
suggestive of possible anterior ischemia/infarction. Compared to
the previous tracing of ___ the rhythm is more regular
suggesting flutter as opposed to fibrillation and the anterior T
wave inversions are new. Clinical correlation is suggested.
CHEST X-RAY (___)
FINDINGS: PA and lateral views of the chest were provided.
Midline
sternotomy wires and cardiac valve replacements are again noted.
Clips are also noted at the level of the GE junction. The
lungs are clear and well expanded. No focal consolidation,
effusion, or pneumothorax is seen. The cardiomediastinal
silhouette is normal. A dextroscoliosis is noted with the apex
at the TL junction. Bony structures are intact.
IMPRESSION: No acute intrathoracic process.
___ 6:42 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. Mirtazapine 45 mg PO HS
4. Diltiazem Extended-Release 360 mg PO DAILY
5. Amiodarone 200 mg PO DAILY
6. Warfarin 1.5 mg PO DAYS (___)
7. Warfarin 3 mg PO DAYS (___)
8. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
9. Tamsulosin 0.4 mg PO DAILY
10. Albuterol Inhaler ___ PUFF IH QID
11. Sertraline 100 mg PO DAILY
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
3. Losartan Potassium 25 mg PO DAILY
4. Mirtazapine 45 mg PO HS
5. Sertraline 100 mg PO DAILY
6. Tamsulosin 0.4 mg PO DAILY
7. Warfarin 3 mg PO DAYS (___)
8. Warfarin 1.5 mg PO DAYS (___)
9. Albuterol Inhaler ___ PUFF IH QID
10. Cyanocobalamin 100 mcg PO DAILY
11. Diltiazem 60 mg PO QID Atrial flutter/fibrillation rate
control
12. Docusate Sodium 100 mg PO BID
13. Ferrous Sulfate 325 mg PO DAILY Iron deficiency
14. FoLIC Acid 1 mg PO DAILY
15. Heparin IV per Weight-Based Dosing Guidelines
16. Multivitamins 1 TAB PO DAILY
17. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
18. Sulfameth/Trimethoprim DS 1 TAB PO BID UTI Duration: 4 Days
Last dose ___.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hypovolemia
Urinary tract infection
Failure to thrive
Atrial flutter
Anemia
Mechanical valve replacement
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
___.
CLINICAL HISTORY: Weakness, question pneumonia.
FINDINGS: PA and lateral views of the chest were provided. Midline
sternotomy wires and cardiac valve replacements are again noted. Clips are
also noted at the level of the GE junction. The lungs are clear and well
expanded. No focal consolidation, effusion, or pneumothorax is seen. The
cardiomediastinal silhouette is normal. A dextroscoliosis is noted with the
apex at the TL junction. Bony structures are intact.
IMPRESSION: No acute intrathoracic process.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: ANOREXIA
Diagnosed with HYPOTENSION NOS, DEHYDRATION, LONG TERM USE ANTIGOAGULANT
temperature: 98.0
heartrate: 58.0
resprate: 14.0
o2sat: 99.0
sbp: 88.0
dbp: 48.0
level of pain: 0
level of acuity: 1.0 | NARRATIVE SUMMARY
=================
Regarding his hypotension and bradycardia with Atrial flutter,
Mr. ___ was initially hypotensive in the ED to 88/48 with HR
58 but patient was asymptomatic and appeared hypovolemic. He
responded to 2 L NS with recovery of BPs to 100-120/50-70s with
HRs in the ___. His medications were reconciled, and he was
given his home dose of diltiazem XR (360mg) since he reported he
had not taken it that day.
On the morning of HD#2, he triggered for hypotension to ___
and marked bradycardia to the high ___. He denied
lightheadedness and was mentating well. EKG showed atrial
flutter with 5:1 AV block with rate of 44. Likely due to
calcium channel blocker overdose. Suspect patient was not
taking home diltiazem. IV calcium gluconate was given with
recovery of HR and BP. No atropine given. Cardiology consulted
and recommended decreasing CCB dose and discontinuing
amiodarone. His hemodynamics were subsequently stable.
Regarding his BPH with obstruction, his foley was discontinued
and he had good UOPs subsequently with PVRs consistently <
180ml. He was continued on tamsulosin QHS and finasteride QD.
We coordinated with his outpatient urologist Dr. ___
should follow-up with urology as an outpatient.
Regarding his acute on chronic anemia, hemolytic, he was found
to be anemic on CBC, with positive hemolysis labs. He was
transfused 1 U pRBC with appropriate bump and started on iron,
folate, and B12. On the day of discharge he had a drop in his
hematocrit without apparent bleeding. Theorized to be due to
mechanical valve hemolysis versus hypoproliferative bone marrow
due to malnutrition. Nevertheless, a CBC should be checked at
rehab and he should be transfused there if hct < 21%.
SUMMARY BY PROBLEM
==================
#) HEMODYNAMICS: His blood pressures and heart rates normalized
after volume resuscitation and decreasing his calcium channel
blocker to 60mg QID. He may need further titration of his CCB
tailored to his heart rate.
#) WEAKNESS: Major barrier seems to be food preparation. He has
demonstrated good appetite while in house. Would like to get
meals on wheels at home, but apparently unable to do so since
son lives with him.
- TSH mildly elevated, likely related to amiodarone. Repeat
TFTs in ___ weeks.
#) NSTEMI: Troponin mildly elevated at 0.04 and decreased to
0.02 with hydration. Repeat EKG without ischemic changes.
#) ACUTE KIDNEY INJURY: Resolved. Creatinine 1.8 on presentation
improved back to baseline of 1.4 with fluids. Continued to
down-trend after removal of foley to 1.2.
#) CATHETER-ASSOCIATED UTI: With frankly cloudy urine output,
highly suspect CAUTI. UCx grew pansensitive E.coli > 10^5.
Treated with ciprofloxacin for ___nding ___.
#) BPH/Urinary Retention: Did well after weaning foley with low
PVRs, robust UOP, and persistently baseline creatinine.
Continued on tamsulosin and finasteride.
#) MECHANICAL VALVE, MVR/AVR: Subtherapeutic INR and ___.
Started on a heparin gtt with goal PTT ___ and goal INR
2.5-3.5. Will need cardiology follow-up.
TRANSITIONAL ISSUES
===================
[] Re-check CBC within 3 days. Transfuse 1 U pRBCs if
hematocrit < 21%
[] Titrate diltiazem to HR goal 55-100 and BP >100/60.
Currently on diltiazem 60mg QID. Once equilibrium dose is
achieved with stable hemodynamics for ___ days, can change to
equivalent long acting diltiazem XR.
[] Continue heparin gtt with goal PTT 60-100 with transition to
warfarin until INR is 2.5-3.5 for 48 hours, then heparin can be
discontinued. PTTs can be checked daily since they have been
consistently at goal here on his current rate of 750 U/hr.
[] Continue ___
[] Encourage PO intake
[] Please help arrange for home-care after discharge. Would
benefit hugely from meals preparation at home.
FOLLOW-UP APPOINTMENTS NEEDED BUT NOT SCHEDULED
===============================================
[] Follow-up with urology within two weeks with Dr. ___
___ ___
[] Follow-up with cardiology within two weeks with Dr. ___
___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Flaxseed
Attending: ___.
Chief Complaint:
OUTPATIENT CARDIOLOGIST: ___ MD, MPH
PCP: ___.
CHIEF COMPLAINT: Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ F with AFib, HTN, HLD who presents two
recent falls with weakness, ___, TWI's, and mild trop leak in
the setting of UTI.
Patient fell 4 days prior to admission in what she describes as
a mechanical fall including a head strike. No LOC or post-ictal
features. She then fell again the night prior to admission with
a similar story. Her last fall prior to these was over a year
ago. She does report weakness for the past year without clear
worsening to her. Patient reports subjective fevers and rigors
for past few days. She did have some nocturia, but denies
dysuria. Decreased po intake for past few days. Patient said she
also felt weak prompting her last admission in ___ when
found to have UTI per pt.
In ED:
- initial vitals were 97.3 82 149/55 16 98%
- documented as regular rhythm
- no sx head trauma, neg CT head
- CXR no obvious infiltrate
- Cr 1.4 w/ baseline 1.0
- EKG shows NEW TWI in v2/v3 which are stable on repeat EKG.
- given aspirin 325mg and admitted to ___.
ROS: Detailed 8 pt review of systems negative except for above
in HPI. Of note, denies nausea, vomiting, dyspnea, chest pain,
cough.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: + Dyslipidemia, + Hypertension
2. CARDIAC HISTORY:
-CABG: N/A
-PERCUTANEOUS CORONARY INTERVENTIONS: N/A
-PACING/ICD: N/A
3. OTHER PAST MEDICAL HISTORY:
-Atrial Fibrillation (off anticoagulation due to hx SAH)
-Hypothyroidism
-s/p L4/5 laminectomy
-b/l corneal transplants
Social History:
___
Family History:
Mother - HTN, rheumatoid arthritis
Father - unknown
3 children - all healthy
Physical Exam:
ADMISSION:
VS: afebrile 97.8 172/75 HR 84 sat 98% on RA
General: NAD
HEENT: clear OP
Neck: no JVD
CV: irregular, normal rate, no murmur
Lungs: CTAB, nonlabored
Abdomen: NT, ND, soft
GU: no Foley
Ext: no lower ext edema
Neuro: CNs intact, ___ strength, A&Ox3
Skin: no lesions
Psych: appropriate
DISCHARGE:
VS: afebrile 98.4 146/55 64 sat 100% on RA
General: NAD
HEENT: clear OP
Neck: no JVD
CV: regular, normal rate, no murmur
Lungs: CTAB, nonlabored
Abdomen: NT, ND, soft
GU: no Foley
Ext: no lower ext edema
Neuro: CNs intact, ___ strength, A&Ox3
Skin: no lesions
Psych: appropriate
Pertinent Results:
LABS:
___ 02:10AM BLOOD WBC-13.2*# RBC-3.81* Hgb-11.5* Hct-34.3*
MCV-90 MCH-30.2 MCHC-33.5 RDW-14.2 Plt ___
___ 05:44AM BLOOD WBC-9.3 RBC-3.10* Hgb-9.3* Hct-27.6*
MCV-89 MCH-30.1 MCHC-33.8 RDW-14.3 Plt ___
___ 12:35PM BLOOD Hct-30.9*
___ 06:25AM BLOOD WBC-8.1 RBC-3.01* Hgb-8.9* Hct-27.0*
MCV-90 MCH-29.6 MCHC-33.1 RDW-14.2 Plt ___
___ 06:30AM BLOOD WBC-7.2 RBC-2.85* Hgb-8.6* Hct-25.3*
MCV-89 MCH-30.0 MCHC-33.8 RDW-14.1 Plt ___
___ 03:00PM BLOOD Hct-27.2*
___ 05:34AM BLOOD WBC-8.9 RBC-3.07* Hgb-9.3* Hct-27.5*
MCV-90 MCH-30.4 MCHC-34.0 RDW-14.2 Plt ___
___ 02:10AM BLOOD ___ PTT-33.3 ___
___ 06:30AM BLOOD Ret Aut-1.9
___ 02:10AM BLOOD Glucose-139* UreaN-27* Creat-1.4* Na-139
K-3.6 Cl-101 HCO3-25 AnGap-17
___ 05:44AM BLOOD Glucose-95 UreaN-30* Creat-1.5* Na-139
K-4.0 Cl-108 HCO3-26 AnGap-9
___ 06:30AM BLOOD Glucose-92 UreaN-26* Creat-1.3* Na-144
K-3.7 Cl-111* HCO3-25 AnGap-12
___ 05:34AM BLOOD Glucose-92 UreaN-22* Creat-1.2* Na-141
K-4.1 Cl-108 HCO3-27 AnGap-10
___ 02:10AM BLOOD ALT-13 AST-30 AlkPhos-74 TotBili-0.9
___ 02:10AM BLOOD cTropnT-0.03*
___ 10:45AM BLOOD CK-MB-3 cTropnT-0.01
___ 06:50PM BLOOD cTropnT-0.02*
___ 10:45AM BLOOD Calcium-8.3* Phos-2.3* Mg-2.1
___ 06:25AM BLOOD calTIBC-160* Hapto-310* Ferritn-249*
TRF-123*
___ 05:44AM BLOOD TSH-0.57
___ 05:44AM BLOOD T4-4.9
================================
CXR PA/Lat ___: IMPRESSION: No evidence of acute
cardiopulmonary process. Blunting of the left costophrenic
angle may represent a small left-sided pleural effusion.
.
CT HEAD noncontrast ___: IMPRESSION:
1. No evidence of acute intracranial abnormality.
2. Small sclerotic lesion in the left frontal bone, remodeling
the internal table is unchanged from prior and likely a
non-aggressive process such as an osteoma.
3. Chronic changes, as detailed.
.
EKG on admission: HR 82, sinus, normal axis, TWI in V2-V4
EKG ___ ___: QTc~450.
EKG ___: unchanged TWI in V2&V3; QTc ~457
.
ECHO ___ The left atrium and right atrium are normal in
cavity size. The estimated right atrial pressure is ___ mmHg.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is unusually small. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). No mid-cavitary gradient is identified.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. The end-diastolic pulmonic regurgitation velocity
is increased suggesting pulmonary artery diastolic hypertension.
There is no pericardial effusion.
IMPRESSION: Severe pulmonary artery hypertension. Relatively
small left ventricular cavity with normal regional and
hyperdynamic global systolic function. Moderate to severe
tricuspid regurgitation.
Is there a history to suggest high output syndrome (thiamine
deficiency, anemia, thyrotoxicosis, peripheral shunt, etc.).
MICRO:
-___ CDIFF STOOL NEGATIVE
-___ 5:30 am URINE URINE CULTURE (Final ___: GRAM
POSITIVE BACTERIA. >100,000 ORGANISMS/ML. Alpha hemolytic
colonies consistent with alpha streptococcus or Lactobacillus
sp.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Sotalol 40 mg PO DAILY
RX *sotalol 80 mg one half tablet(s) by mouth once a day Disp
#*15 Tablet Refills:*2
2. Amlodipine 5 mg PO DAILY
to treat your blood pressure.
RX *amlodipine 5 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Levothyroxine Sodium 50 mcg PO DAILY
6. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID
7. Metoprolol Succinate XL 100 mg PO DAILY
to treat your AFib
RX *metoprolol succinate 100 mg 1 tablet extended release 24
hr(s) by mouth once daily Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
UTI
Atrial Fibrillation with RVR
Anemia, normocytic
Secondary:
Hypothyroidisim
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with generalized weakness and near syncope.
Evaluate for infiltrate.
COMPARISON: ___.
TECHNIQUE: PA and lateral chest radiograph.
FINDINGS: The lungs are well expanded and clear. Cardiomediastinal and hilar
contours are unremarkable. Mild calcification is noted in the right lower
paratracheal station, likely representing a calcified lymph node. The aorta
is tortuous. There is no pleural effusion. There is blunting of the left
costophrenic angle which may represent a small pleural effusion.
IMPRESSION: No evidence of acute cardiopulmonary process. Blunting of the
left costophrenic angle may represent a small left-sided pleural effusion.
Radiology Report
INDICATION: ___ female with generalized weakness and syncope.
Evaluate for evidence of acute intracranial process.
COMPARISON: ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the head
without administration of IV contrast. Coronal, sagittal, and thin sliced
bone reformats were generated.
DLP: 897.50 mGy-cm.
CTDI: 63.81 mGy.
FINDINGS: There is no hemorrhage, edema, mass, mass effect, or large
territorial infarction. The ventricles and sulci are prominent, compatible
with age-related atrophy. Periventricular white matter changes suggest
chronic small vessel ischemic disease. A small hypodensity in the left
frontal lobe (2:15) is likely a focus of encephalomalacia from prior infarct.
Otherwise, there is preservation of gray-white matter differentiation in the
unaffected parts of the brain and the basal cisterns are patent.
Mineralization of the bilateral basal ganglia is also present.
No fracture is identified. A 9-mm sclerotic lesion, centered in the right
lateral aspect of the frontal bone with slight convex bowing of the internal
table (3:27) is unchanged from ___. The visualized paranasal
sinuses, mastoid air cells and middle ear cavities are clear. Atherosclerotic
calcification of the carotid siphons is present.
IMPRESSION:
1. No evidence of acute intracranial abnormality.
2. Small sclerotic lesion in the left frontal bone, remodeling the internal
table is unchanged from prior and likely a non-aggressive process such as an
osteoma.
3. Chronic changes, as detailed.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: WEAKNESS
Diagnosed with OTHER MALAISE AND FATIGUE, URIN TRACT INFECTION NOS
temperature: 97.3
heartrate: 82.0
resprate: 16.0
o2sat: 98.0
sbp: 149.0
dbp: 55.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is an ___ F with AFib, HTN, HLD who presents two
recent falls with weakness, ___, TWI's, and mild trop leak in
the setting of UTI.
.
# AFib: CHADS score at least 2. Possible hx of TIA. Admitted off
anticoagulation due to hx of spontaneous subarachnoid
hemorrhage. Stroke team consulted ___ help decide risk of
systemic anticoagulation, and since appears has Amyloid
Angiopathy, will defer anticoagulation. Pt followed by Dr.
___ with ___ cardiology. Admitted in sinus, then went
to AFib RVR to 140's on floor then converted from AFib RVR to
sinus on ___ at 1600 with extra dose of Metoprolol tartrate
50mg po x1. Previously on amiodarone, but stopped in early ___
due to hypothyroidism, bradycardia, and abscence of AFib.
Patient appears to have COPD on CXR and was found to have
pulmonary HTN on echo ___ w/ 3+ TR. GFR is also borderline.
TSH & T4 wnl. Deferred anticoagulation as above. Metoprolol
succinate 100mg daily. Sotalol 40mg daily (started ___:
dose reduced due to GFR <40. Discussed w/ pharmacy re: dose. EKG
___ QTc ~450.
.
# Anemia, Normocytic: Hct 34 on admission, most recent baseline
from ___ ~31. Hct 34 --> 27 w/ fluids then up to 30.
Continued to downtrend to 25.3 on ___. Labs suggest not
hemolysis or iron deficiency. Last colonoscopy ___ per pt.
Retic 1.8% on ___. Guaiac stools: neg x1 on ___.
Consider outpatient colonoscopy and anemia work-up.
.
# Pulmonary Hypertension: Dx as severe on TTE ___ w/ 3+ TR.
No prior dx of this. No sx of RV strain, suggesting is chronic.
EF was hyperdynamic. CXR appears hyperinflated, so may be due to
baseline lung dz. Could be pulmonary arterial. Less likely due
to left heart failure or chronic thromboembolic dz. Recommend
outpatient PFTs and outpatient Pulm f/u.
.
# T-Wave Inversions: She was found to have new t-wave inversion
in V2-V4 when compared to previous EKG's. She was also noted to
have a mildly elevated troponin of 0.03 in the setting of ___.
Second trop was <0.01. Unlikely ACS since trop negative x3, no
chest pain. Repeat EKG ___ showed unchanged TWI in V2&V3.
ASA 81mg daily. Atorvastatin 40mg daily (increased from 20mg on
___. Discontinued Atenolol due to ___. Metoprolol succinate
100mg daily (started on admission).
.
# UTI: Positive U/A with recent rigors and subjective fevers at
home. Ceftriaxone 1g q24 daily x5 day course (D1 = ___. ___
cx growing GPCs: alpha strep.
.
# Diarrhea: Had loose stools ___ AM x4. Resolved ___. CDiff
negative. Guaiac neg x1 ___.
.
# ___: Pt admitted w/ creat 1.4 with baseline ~1.0. Discharge
creat 1.2. FENA 1.1%.
D/c Atenolol as above
.
#CODE: Full- confirmed
#CONTACT: ___ (Son/HCP) ___
#DISPO: ___ cardiology service to home w/ ___ ___
.
### TRANSITIONAL ISSUES ###
- please check EKG at next visit to ensure QTc is not prolonged
with sotalol
- please check Creat and Hct next visit
- please discuss colonoscopy (last was ___ and her normocytic
anemia (Hct 27 on discharge)
- recommend outpatient PFTs and Pulm f/u for severe Pulmonary
HTN seen on echo |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L TKA prosthetic joint infection
Major Surgical or Invasive Procedure:
Left knee irrigation and debridement, spacer and wound VAC
placement ___ (Dr. ___
Left knee irrigation and debridement, spacer, gastrocnemius flap
and wound VAC placement ___ (Drs. ___
History of Present Illness:
___ PMH type II DM, AS, HTN, left TKA in ___ at ___, then
left TKA explant, placement antibiotic spacer by Dr. ___ at
___ in ___ for septic TKA growing MSSA and serratia, now
s/p 6 weeks cefazolin and levaquin. Patient had been doing well
at rehab, recently discharged home. Today he was taking off his
knee immobilizer and noticed purulent drainage from the knee the
inferior aspect of the wound. No recent falls, no recent fevers
or chills, no numbness or tingling.
Past Medical History:
Type 2 diabetes
Aortic stenosis
Hypertension
Osteoarthritis
Social History:
___
Family History:
Non-contributory
Physical Exam:
VS: AFVSS
GENL: NAD
CARD: RRR, systolic murmur
PULM: clear to auscultation bilaterally
ABDM: non-distended; non tender
EXTR: warm and well perfused, no edema on the right, 2+ edema L
decreased sensation to light touch left foot
NPWT in place, drains serosang, clear
Pertinent Results:
___ 06:24AM BLOOD WBC-8.6 RBC-3.07* Hgb-8.2* Hct-26.0*
MCV-85 MCH-26.7 MCHC-31.5* RDW-18.2* RDWSD-55.8* Plt ___
___ 06:35AM BLOOD WBC-9.7 RBC-3.01* Hgb-8.1* Hct-25.8*
MCV-86 MCH-26.9 MCHC-31.4* RDW-18.1* RDWSD-56.1* Plt ___
___ 04:19AM BLOOD WBC-12.6* RBC-3.37* Hgb-9.0* Hct-29.2*
MCV-87 MCH-26.7 MCHC-30.8* RDW-17.7* RDWSD-55.4* Plt ___
___ 06:24AM BLOOD Glucose-81 UreaN-28* Creat-1.1 Na-134*
K-4.4 Cl-99 HCO3-21* AnGap-14
___ 06:35AM BLOOD Glucose-79 UreaN-29* Creat-1.2 Na-135
K-4.7 Cl-100 HCO3-20* AnGap-15
___ 06:35AM BLOOD ALT-<5 AST-33 LD(LDH)-174 AlkPhos-101
TotBili-0.3
___ 06:24AM BLOOD Calcium-8.1* Phos-3.9 Mg-2.1
___ 06:35AM BLOOD Vanco-20.2*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 25 mg PO DAILY
2. Tizanidine 4 mg PO TID
3. Oxybutynin 10 mg PO DAILY
4. Triamcinolone Acetonide 0.025% Cream 1 Appl TP PRN itching
5. Furosemide 20 mg PO DAILY
6. irbesartan 150 mg oral BREAKFAST
7. Verapamil 200 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Apixaban 2.5 mg PO BID
3. Ascorbic Acid ___ mg PO BID
4. Bisacodyl 10 mg PR QHS:PRN constipation
5. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
6. Docusate Sodium 100 mg PO BID
7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate
RX *hydromorphone 2 mg ___ tablet(s) by mouth q3h Disp #*84
Tablet Refills:*0
8. Glargine 28 Units Bedtime
Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
9. Metoprolol Tartrate 12.5 mg PO BID
10. Milk of Magnesia 30 mL PO Q6H:PRN constipation
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Senna 8.6 mg PO BID
13. Tamsulosin 0.4 mg PO QHS
14. Vancomycin 1000 mg IV Q48H
RX *vancomycin 1 gram 1000 mg IV q48h Disp #*25 Vial Refills:*0
15. Zinc Sulfate 220 mg PO DAILY
16. Furosemide 40 mg PO BID
17. Tizanidine 4 mg PO TID
RX *tizanidine 4 mg 1 tablet(s) by mouth three times a day Disp
#*42 Tablet Refills:*0
18. Triamcinolone Acetonide 0.025% Cream 1 Appl TP PRN itching
19. HELD- Oxybutynin 10 mg PO DAILY This medication was held.
Do not restart Oxybutynin until Foley out and voiding
spontaneously
20.Outpatient Lab Work
WEEKLY: CBC with differential, BUN, Cr, Vancomycin
trough, crp
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L TKA prosthetic joint infection
Discharge Condition:
VS: AFVSS
GENL: NAD
CARD: RRR, systolic murmur
PULM: clear to auscultation bilaterally
ABDM: non-distended; non tender
EXTR: warm and well perfused, no edema on the right, 2+ edema L
decreased sensation to light touch left foot
NPWT in place, drains serosang, clear
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with new numbness s/p knee spacer placement// new
a-fib...fluid overload?
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The size of the cardiac silhouette is enlarged in comparison to prior. Small
bilateral pleural effusions are present with subjacent atelectasis. There is
no evidence of pulmonary edema. No pneumothorax.
IMPRESSION:
Enlarged cardiac silhouette in comparison to prior.
Small bilateral pleural effusions with subjacent atelectasis. No evidence of
pulmonary edema.
Radiology Report
EXAMINATION: KNEE (2 VIEWS) LEFT
INDICATION: ___ year old man with new numbness s/p knee spacer placement//
Nerve compression from spacer Nerve compression from spacer
TECHNIQUE: Frontal, lateral, and sunrise view radiographs of the left knee.
COMPARISON: ___.
IMPRESSION:
Interval placement of new antibiotic spacer of the tibiofemoral joint. Screws
are again seen through the distal femur and proximal tibia. Alignment appears
relatively well maintained. Surgical drains are seen surrounding the knee as
well as skin staples anteriorly. Wound VAC is seen anteriorly.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with low albumin
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is trace perihepatic ascites. There are small
bilateral pleural effusions.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 10 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 14.7 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Normal sonographic appearance of liver.
2. Mildly dilated common bile duct measuring up to 10 mm. No cholelithiasis
or choledocholithiasis. Consider correlation with LFTs and if there is
concern for biliary obstruction, further assessment with MRCP can be obtained.
3. Small bilateral pleural effusions and trace perihepatic ascites.
4. Mild splenomegaly.
RECOMMENDATION(S): Mildly dilated common bile duct measuring up to 10 mm. No
cholelithiasis or choledocholithiasis. Consider correlation with LFTs and if
there is concern for biliary obstruction, further assessment with MRCP can be
obtained.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new R PICC// 48 cm R brachial SL PICC-
___ ___ Contact name: ___: ___ cm R brachial SL
PICC- ___ ___
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
New right PIC line ends at the level of the superior cavoatrial junction.
Small bilateral pleural effusions, severe left lower lobe atelectasis and
moderate enlargement of cardiac silhouette are stable. No pulmonary edema.
No pneumonia.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Knee pain, L Knee swelling, Transfer
Diagnosed with Other specified soft tissue disorders
temperature: 98.1
heartrate: 80.0
resprate: 18.0
o2sat: 99.0
sbp: 125.0
dbp: 76.0
level of pain: 5
level of acuity: 2.0 | SURGICAL COURSE: The patient was transferred with a worsening of
his L knee infection and was admitted to the orthopedic surgery
service. The patient was taken to the operating room on ___
for L knee I&D, spacer placement and VAC placement and on ___
for L knee I&D, spacer placement, coverage with a gastrocnemius
flap and VAC placement, both of which the patient tolerated
well. For full details of the procedures please see the
separately dictated operative report. 3 JP drains were placed
during the latter case, as well as an HVAC. One JP was pulled on
___ and another on ___ the HVAC and JP will stay until
follow-up. The wound VAC was changed at bedside on ___ at
which time there was noted to be 100% take of the graft, with
plan for another graft assessment/VAC change in clinic on ___.
He was transfused 2u on ___ for Hct 24 and 1u on ___ for Hct
24. Hct on discharge was 26.
INFECTIOUS DISEASE COURSE: Cultures x6 from the initial washout
on ___ grew out MSSA. Cultures from the ___ case grew out
MSSA as well as coagulase-negative staph, which was
methicillin-resistant. Given this finding, antibiotics were
transitioned from cefazolin to vancomycin, with a plan for
ongoing vancomycin therapy until ___. Infectious Disease
follow-up plans are in the Discharge Worksheet. To summarize his
antibiotic course:
-Cefazolin/Levofloxacin ___
-Vanc/Cefepime ___
-Cefazolin 2 g q8h ___ - ___
-Vanc ___
The patient was also noted to have a new reduction in sensation
in the LLE which was felt to be likely due to a neuropraxia and
which was beginning to improve at the time of discharge.
MEDICAL COURSE: The patient was noted to be in atrial
fibrillation on ___ with ventricular response to the 130s.
This was easily rate controlled with metoprolol and he converted
back to sinus rhythm that afternoon and did not go back into
fibrillation for the rest of his stay. Medicine was consulted
and felt that discharge on metoprolol 12.5mb BID was
appropriate. He was started on apixaban for anticoagulation;
currently at 2.5mg BID with plans to increase to 5mg BID once
his risk of graft loss from a hematoma is decreased. He was also
noted to be fluid overloaded and was given 80mg IV Lasix on both
___ and ___ with some improvement. His standing PO dose was
increased from 20mg qd to 40mg qd to 40mg BID on discharge, with
a plan for continued net fluid goal of negative 0.5-1L daily.
The patient also developed ___ of unclear etiology (to Cr 1.3
from baseline 0.6; 1.1 on discharge); for which his home
irbesartan was held. Verapamil was also held and continues to be
so. Other home medications continued throughout his stay.
Patient had elevated LFTs with unclear etiology; RUQUS showed a
dilated CBD with no evidence of stone disease; this warrants
follow-up on an outpatient basis; MRCP could be considered for
further work-up.
DIABETES COURSE: The ___ Diabetes service was consulted for
assistance in managing his diabetes; his blood glucose well
controlled by the time of discharge and he was discharged on a
stable insulin regimen.
OTHER COURSE: The patient worked with ___ who determined that
discharge to rehab was appropriate. At the time of discharge the
patient's pain was well controlled with oral medications. The
patient is non-weight bearing in the left lower extremity, and
will be discharged on apixaban for anticoagulation. The patient
will follow up with Dr. ___. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hematuria
Major Surgical or Invasive Procedure:
Renal transplant graft biopsy
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
___ gentleman with a past medical history of ESRD
secondary to fibrillary glomerulonephritis status post SCD
kidney ___ on tacrolimus and mycophenolate presents with
hematuria for 3 days. The patient notes that he started having
clear dark red urine starting on ___ that has since progressed
to become lighter in color. he reports some increased cough and
mild shortness of breath, but otherwise, he denies any
associated symptoms with the hematuria, such as fevers, chills,
nausea, vomiting, abdominal pain, diarrhea, or dysuria. In the
ED, initial vitals were: 97.2 88 ___ 97% RA.
Labs were notable for Cr 1.7 with baseline of ___. UA showed
41 WBC, >182 RBC, Lg Bld, Sm Leuk, and Neg Neg. Renal graft
ultrasound showed "1. Normal arterial waveforms in the
transplanted kidney. 2. Unchanged 7 mm nonobstructing stone. New
5 mm nonobstructing stone in the upper pole. No hydronephrosis."
He was started on maintenance IV fluid per Renal fellow and
admitted.
On the floor, the patient reports feeling ok. He does mention
that with palpation over his surgical scar from his transplant,
he does have pain.
Past Medical History:
- ESRD ___ fibrillary GN, IgA immune complex GN
- Acute humoral graft rejection ___
- h/o Hepatitis A and B
- Chronic Hepatitis C, genotype 1B, treated in ___ without
response
- Hypertension
- Depression
- Obstructive sleep apnea on CPAP
- h/o CVA ___ w/ mild residual weakness
- h/o EtOH abuse, sober ___ years
PSH:
- renal transplant ___
- thrombectomy of LUE AV graft ___
- attempted thrombectomy of LUE AV graft ___
- placement of LUE AV graft ___
Social History:
___
Family History:
No family hx of kidney disease, several members with DM II and
heart disease
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T 98.1, BP 160/74, HR 84, RR 24, SAT 99%RA
General: Elderly gentleman lying comfortably in bed, in no acute
distress HEENT: EOMI, PERRL, sclerae anicteric
Neck: supple, no JVD
CV: RRR, no M/R/G
Lungs: Significantly diminished breath sounds throughout, no
wheezes Abdomen: tenderness over graft site, no flank pain,
soft, nondistended, +BS Ext: 2+ lower extremity pulses with no
edema
Neuro: grossly nonfocal and moving all extremities symmetrically
Skin: no rashes
DISCHARGE EXAM:
VS: 97.4 ___ 18 100% RA
I/O: 360/550 (8); 1320/900+ x4 (24)
Wt: 95.2 <- 96.7 <- 97.2 <- 97.3 <- 97.7
BS: ___
General: Elderly gentleman lying comfortably in bed, in no acute
distress
HEENT: NCAT, sclerae anicteric, wears dentures
Neck: supple, no JVD
CV: RRR, no M/R/G noted but exam limited by body habitus
Lungs: CTAB.
Abdomen: No tenderness over graft site, soft, nondistended,
tympanitic, obese
Ext: no edema
Neuro: grossly nonfocal and moving all extremities symmetrically
Skin: no rashes
Psych: Pleasant & energetic
Pertinent Results:
ADMISSION LABS:
___ 05:40PM BLOOD ___
___ Plt ___
___ 05:40PM BLOOD ___
___ Im ___
___
___ 11:03PM BLOOD ___ ___
___ 05:40PM BLOOD ___
___
___ 05:20AM BLOOD ___
___ 05:40PM BLOOD ___
___ 05:47AM BLOOD ___
___ 06:02PM BLOOD ___
DISCHARGE LABS:
___ 05:30AM BLOOD ___
___ Plt ___
___ 04:41AM BLOOD ___ ___
___ 05:30AM BLOOD ___
___
___ 05:30AM BLOOD ___
___ 04:41AM BLOOD ___
___ 05:30AM BLOOD ___
___ 04:41AM BLOOD ___
___ 05:27AM BLOOD ___
___ 05:30AM BLOOD ___
___ 04:41AM BLOOD ___
___ 01:23PM BLOOD ___
MICRO:
___ 5:27 am IMMUNOLOGY
**FINAL REPORT ___
HBV Viral Load (Final ___:
HBV DNA not detected.
Performed using the Cobas Ampliprep / Cobas Taqman HBV
Test v2.0.
Linear range of quantification: 20 IU/mL - 170 million
IU/mL.
Limit of detection: 20 IU/mL.
__________________________________________________________
___ 11:05 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 5:40 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
RUQ ___:
IMPRESSION:
No concerning focal liver lesions. No biliary obstruction.
Heterogeneous appearance of the liver parenchyma may be
artifactual in the setting of poor acoustic windows, or less
likely could reflect new development of steatosis since MR of
___.
GU MRI ___:
IMPRESSION:
1. Mild hydronephrosis of the renal transplant kidney. No focal
mass. A small stone seen on prior ultrasound examinations is
not visualized on MRI. There is no hydroureter, or ureteral or
bladder stone.
2. Nonspecific diffuse minimal thickening of the renal
transplant urothelium, possibly the sequela of prior
inflammation or infection. No fluid collection or perinephric
edema to suggest acute or active inflammation.
3. Markedly atrophic native kidneys, without focal mass.
Abd US ___:
IMPRESSION:
1. No bladder stone or suspicious bladder mass visualized.
2. The native kidneys cannot be identified.
Renal Graft Ultrasound ___:
IMPRESSION:
1. Normal arterial waveforms in the transplanted kidney.
2. Unchanged 7 mm nonobstructing stone. New 5 mm nonobstructing
stone in the upper pole. No hydronephrosis.
PATHOLOGY:
RENAL ALLOGRAFT, CORE BIOPSY ___:
1. BORDERLINE ACUTE ___ MEDIATED REJECTION, SEE NOTE.
2. ___ REJECTION, (NEGATIVE C4D), SEE NOTE.
3. NO SIGNIFICANT CHRONIC CHANGES.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with HCV, renal transplant, rising LFTs in the
setting of pred for rejection // ?biliary obstruction or other acute process
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: MRI abdomen and pelvis ___ and the prior abdominal
ultrasound dated ___.
FINDINGS:
Note is made that the patient was not in the fasting state for this exam
therefore views of the midline are extremely limited.
LIVER: Portions of the liver is appear diffusely echogenic with areas of
patchy heterogeneity, however it is noted that the exam was limited by poor
acoustic windows and these findings could very well be artifactual. No
steatosis was noted on the recent MRI of ___. The contour of the liver
is smooth. There is no focal liver mass. The main portal vein is patent with
hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 8.8 cm.
IMPRESSION:
No concerning focal liver lesions. No biliary obstruction. Heterogeneous
appearance of the liver parenchyma may be artifactual in the setting of poor
acoustic windows, or less likely could reflect new development of steatosis
since MR of ___.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with hx renal xplant now rfank hematuria x 5 days,
SOB // eval ? edema
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Platelike atelectasis is seen at the left lung base. A adjacent area of
lingular airspace opacity may relate to atelectasis however, consolidation due
to pneumonia is not excluded in the appropriate clinical setting. The right
lung is clear. No pleural effusion or pneumothorax is seen. The cardiac and
mediastinal silhouettes are unremarkable. No pulmonary edema is seen.
IMPRESSION:
Left basilar platelike atelectasis. Adjacent airspace opacity may relate to
atelectasis however, consolidation due to pneumonia is not excluded in the
appropriate clinical setting.
No pulmonary edema.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ year old man s/p RLQ kidney allograft w/ 5 days frank
hematuria, evaluate right lower quadrant transplant kidney.
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Transplant renal ultrasound from ___
FINDINGS:
The right iliac fossa transplant renal morphology is normal. Specifically,
the cortex is of normal thickness and echogenicity, pyramids are normal, there
is no urothelial thickening, and renal sinus fat is normal. There is no
hydronephrosis and no perinephric fluid collection. A 7 mm stone is again
identified in interpolar region. In addition, there is a 5 mm echogenic focus
in the upper pole, likely another stone.
The resistive index of intrarenal arteries ranges from 0.63 to 0.9, within the
normal range. The main renal artery shows a normal waveform, with prompt
systolic upstroke and continuous antegrade diastolic flow. Vascularity is
symmetric throughout transplant. The transplant renal vein is patent and shows
normal waveform.
IMPRESSION:
1. Normal arterial waveforms in the transplanted kidney.
2. Unchanged 7 mm nonobstructing stone. New 5 mm nonobstructing stone in the
upper pole. No hydronephrosis.
Radiology Report
EXAMINATION: COMPLETE GU U.S. (BLADDER AND RENAL)
INDICATION: ___ year old man s/p DDRT ___ presenting with hematuria and ___
// Please evaluate for clots in bladder, stones in native kidney, other
lesions in bladder or native kidneys.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
Despite effort the atrophic native kidneys cannot be identified.
The bladder is minimally distended and normal in appearance. No bladder stone
or suspicious bladder mass is visualized. The patient was not willing to
attempt to void.
IMPRESSION:
1. No bladder stone or suspicious bladder mass visualized.
2. The native kidneys cannot be identified.
Radiology Report
INDICATION: ___ year old man s/p renal transplant, with hematuria and ___, low
tacro levels // Needs renal bx to r/o rejection
COMPARISON: Complete GU ultrasound ___.
PROCEDURE: Sonographic guidance for transplant renal biopsy by nephrologist.
OPERATORS: Dr. ___ Dr. ___ sonographic guidance for biopsy
that was performed by the Nephrology team. Dr. ___ radiologist,
was present and supervising throughout the guidance and reviewed and agrees
with the trainee's findings.
TECHNIQUE: Ultrasound guidance by the radiologist was provided to
nephrologist for biopsy of the lower pole of the the transplanted kidney
located in the right lower quadrant. Two passes were made. Please refer to
nephrologist note for details of the procedure.
SEDATION: No moderate sedation was administered.
FINDINGS:
Survey view of the transplanted kidney shows no hydronephrosis or perinephric
collection.
IMPRESSION:
Sonographic guidance for biopsy of the rightlower quadrant transplant kidney
by nephrologist.
Radiology Report
EXAMINATION: MRI of the abdomen and pelvis.
INDICATION: ___ year old man s/p renal transplant, here w/ hematuria // Pls
evaluate native and transplanted kidneys for masses or other parenchymal
abnormalities
TECHNIQUE: T1 and T2 weighted multiplanar images of the abdomen and pelvis
were acquired within a 1.5 Tesla magnet without the use of IV contrast.
COMPARISON: Ultrasound examinations from ___ through ___.
FINDINGS:
MRI OF THE ABDOMEN AND PELVIS WITHOUT IV CONTRAST:
Included views of the lung bases are clear. There is no pericardial pleural
effusion. The heart size is normal.
The hepatic parenchyma demonstrates normal signal intensity on T1 and T2
weighted sequences. No focal hepatic lesion is detected. There is no intra
or extrahepatic bile duct dilation. The gallbladder is normal. No ductal
stone is detected.
The pancreas demonstrates normal signal intensity and bulk. The main
pancreatic duct is normal in caliber.
The spleen size is normal. No focal splenic lesion is seen.
The adrenal glands are normal.
The stomach and intra-abdominal and intrapelvic loops of small and large bowel
are normal in caliber. No focal gastrointestinal mass is seen.
The adrenal glands are normal.
The native kidneys are markedly atrophic (series 3, image 16), without
hydronephrosis or focal mass.
A right lower quadrant renal transplant demonstrates mild hydronephrosis
(series 17, image 17). The urothelium appears slightly thickened diffusely
(series 17, image 18, 19). Previously-seen stone on the prior ultrasound
examinations from ___ and ___ is not visualized with MR.
___ flow voids are demonstrated within the transplanted renal artery and
vein and segmental branches on T2 weighted sequences (series 15, image 25).
No focal mass is seen. There is no perinephric fluid collection or edema. No
ureteral mass or stone is detected.
The bladder is under distended, but appears normal. No focal bladder mass or
bladder stone is seen.
Trace intrapelvic free fluid is incidentally noted (series 15, image 30).
Multiple pelvic sidewall lymph nodes remain well under cross-sectional
criteria for adenopathy (series 15, image 27, 23).
There are no osseous lesions concerning for malignancy or infection.
IMPRESSION:
1. Mild hydronephrosis of the renal transplant kidney. No focal mass. A
small stone seen on prior ultrasound examinations is not visualized on MRI.
There is no hydroureter, or ureteral or bladder stone.
2. Nonspecific diffuse minimal thickening of the renal transplant urothelium,
possibly the sequela of prior inflammation or infection. No fluid collection
or perinephric edema to suggest acute or active inflammation.
3. Markedly atrophic native kidneys, without focal mass.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the ___ ___ at 4:10 ___, 5 minutes after discovery of the
findings.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Hematuria
Diagnosed with Right lower quadrant pain, Acute kidney failure, unspecified
temperature: 97.2
heartrate: 88.0
resprate: 16.0
o2sat: 97.0
sbp: 112.0
dbp: 80.0
level of pain: 8
level of acuity: 2.0 | Mr. ___ is a ___ gentleman with a past medical
history of Hepatitis C, ESRD secondary to fibrillary
glomerulonephritis status post SCD kidney ___ on
tacrolimus and mycophenolate who presented with hematuria and
was found to have ___ with graft biopsy positive for acute
humoral rejection, possible cellular rejection as well.
# ESRD s/p Kidney Transplant c/b acute rejection (___): s/p
DDRT in ___ for fibrillary GN. Patient has baseline Cr ___
with presentation elevation to 1.7. Tacrolimus level was low on
admission (goal ___, concern for missed doses at home. Biopsy
c/w humoral with features of cellular rejection. He was
continued on tacro (goal ___ and Cellcept. He received a
steroid pulse and IVIG for four days and is now on a prednisone
taper. He was also started on nystatin x 1 mo and Valgancyclovir
x 6 weeks. He was also prophylaxed with Bactrim and a PPI. His
acidosis was managed with PO bicarbonate. His mental status was
monitored as prednisone can cause changes, but he tolerated it
well. Patient will use pill box to help ensure med compliance. A
___ may be helpful with medication organization.
# Hematuria: Differential given the hematuria includes
rejection, kidney stones, and recurrence of previous
glomerulonephritis. BK virus was negative and he had no evidence
of infection. Kidney stones were seen on transplant US. Renal US
of native kidneys and bladder was unable to locate kidneys and
otherwise showed no concerning lesions. Mild hydronephrosis of
the renal transplant kidney was seen on GU MRI. Hematuria slowly
improved during his hospitalization. His lisinopril was held.
# Transaminitis: Uptrend in liver panel after initiation of
___ meds. Concern for worsening of Hep C vs
medication effect. RUQ US showed no concerning lesions. He will
need labs + tacro trough checked weekly and sent to renal
transplant clinic
# Hyperkalemia: Likely ___ Bactrim and type IV RTA. He was
treated with a ___ diet and Bicarbonate supplementation.
# Leukocytosis: ___ steroids most likely as has no signs/sx of
infection. Downtrended as steroid dose decreased.
# Hepatitis C: Will see outpatient hepatologist to eval for tx
# Hepatitis B exposure: Previously positive HBsAb and Hbcore Ab.
HBsAg negative and HBV viral load not detectable. A course of
lamivudine was not indicated as he was not treated with
Rituximab.
# Depression: Continued Seroquel 400 mg QHS, sertraline 100 mg
daily, clonazepam 0.5 mg PRN
# Chronic Pain: Reduced gabapentin to 100 mg TID given ___. He
was on tapentadol [Nucynta] at home (nonformulary) and was
monitored for withdrawal, restarted on discharge
# HTN: Held home lisinopril given renal injury. Started
amlodipine for BP control.
# COPD: Albuterol, tiotropium
# Diabetes: He was on metformin at home, which has been
discontinued given renal impairment. He will start glipizide on
discharge
# Dispo: Patient has stuggled with showing up to appointments,
does not have strong understanding of medications although
appears to be filling them. He now lives alone with his wife in
a nursing home. Also has probation officer, and needs to check
in while inpatient.
================================ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Celebrex
Attending: ___.
Chief Complaint:
hyponatremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo woman with hx HTN, MR ___ repair, low
back pain who was recently diagnosed with nephrolithiasis (small
bilateral, nonobstructing) and hyponatremia Na 122 earlier this
month at ___. During that hospitalization ___,
she presented with left flank pain, nausea, episodes of
vomiting, poor po intake. Prior to that presentation she had
also been seen as an outpt for microscopic hematuria and
possible UTI, was briefly on Cipro prior to being admitted. We
do not have full records from this ___, but
she reportedly had normalized Na when discharged (per ___
clinic notes)
She was admitted again to ___ ___ for
recurrent hyponatremia (Na 121) and ongoing flank pain from
known kidney stones. She was felt to have SIADH, ?suspected
secondary to meds? Oxycodone was d/c. Appears losartan was
also changed to amlodipine. She was maintained on 1200 ml fluid
restriction. Her Na remained essentially unchanged at 122 when
she was discharged on ___ with instructions to have f/u labs
from PCP.
She is now readmitted after her outpt labs returned with Na 120.
She is generally feeling 'ok.' Some fatigue and nausea. Denies
vomiting. She still has intermittent flank pain, this morning
it was the right side and now left side. She has been drinking
plenty of fluids, in fact it appears she misinterpreted her
discharge instructions as advising her that she should drink *at
least* 2 L/day. (she had been home only a day and half before
being intructed to return to ED)
ROS otherwise negative for fever, chills, chest pain, shortness
of breath, abdominal pain, diarrhea, rashes, tremors, motor
weakness
+constipation
Past Medical History:
NEPHROLITHIASIS - dx at ___ ___, small bilateral
nonobstructing by CT
MITRAL REGURGITATION
___ mitral repair in ___, normal coronaries, systolic murmur
c/w mitral
___
___
LOW BACK PAIN - L sciatica,herniated discs,steroid injectons at
___ treatment
APPENDECTOMY
TAH/BSO w/bladder susupension___ ___ at ___
OSTEOPOROSIS
COLONIC ADENOMA ___ in ___ - NL ,repeat ___ y
previuosly adenomatous ___
PYELONEPHRITIS ___
BLEPHAROPLASTY
Social History:
___
Family History:
denies any significant family hx of cardiac, DM, malignancy
Physical Exam:
97.4 BP 160/101 HR 67 RR 18 100%RA
well nourished appearing woman, no distress, fatigued appearing
but easily engages in conversation
MMM, neck supple, sclera, anicteric
irregularly irregular
Lungs clear bilaterally
Abd soft, nontender
Flank - very mild tenderness to palpation bilaterally
Extrem - no edema
Neuro: oriented x 3, nonfocal, face symmetric, moving all
extremities well
Psych: pleasant, fluent speech
Pertinent Results:
___ 04:56PM UREA N-17 CREAT-0.6 SODIUM-120* POTASSIUM-3.6
CHLORIDE-85* TOTAL CO2-23 ANION GAP-16
___ 04:56PM OSMOLAL-251*
___ 01:01AM ALBUMIN-4.4
___ 01:01AM WBC-7.5 RBC-3.73* HGB-12.1 HCT-32.9* MCV-88
MCH-32.4*
proBNP-430
LIPASE-33
TSH 1.1
___ 01:01AM GLUCOSE-119* UREA N-18 CREAT-0.5 SODIUM-121*
POTASSIUM-3.7 CHLORIDE-85* TOTAL CO2-24 ANION GAP-16
___ 01:01AM ALT(SGPT)-23 AST(SGOT)-24 ALK PHOS-90 TOT
BILI-0.6
___ 05:00AM TSH-1.1
___ 05:00AM OSMOLAL-251*
___ 05:00AM GLUCOSE-127* UREA N-14 CREAT-0.5 SODIUM-121*
POTASSIUM-3.6 CHLORIDE-84* TOTAL CO2-24 ANION GAP-17
___ 04:45AM URINE HOURS-RANDOM CREAT-109 SODIUM-40
POTASSIUM-42 CHLORIDE-43
___ 04:45AM URINE OSMOLAL-606
___ 04:45AM URINE COLOR-Yellow APPEAR-Cloudy SP ___
___ 04:45AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-LG
___ 04:45AM URINE RBC-6* WBC-14* BACTERIA-FEW YEAST-NONE
EPI-1
EKG: Afib rates 70, no sign of acute ___ CT scan ___ - small nonobstructing calculi
in both kidneys 2 mm in the right mid kidney and two 3-4 mm
calculi in the mid-to-lower left kidney; no hydronephrosis or
perinephric stranding
___ 05:00AM
___ CT scan ___
Small nonobstructing renal calculi No evidence of acute urinary
tract obstruction.
CT head noncontrast ___
IMPRESSION:
1. No acute intracranial process.
2. Please note MRI of the brain is more sensitive for the
detection of acute
infarct.
3. Paranasal sinus disease as described.
CXR ___
IMPRESSION:
No acute cardiopulmonary process.
Discharge Labs:
___ 06:11AM BLOOD WBC-9.6 RBC-3.24* Hgb-10.5* Hct-30.1*
MCV-93 MCH-32.4* MCHC-34.9 RDW-12.8 RDWSD-43.7 Plt ___
___ 03:30PM BLOOD Na-128* K-3.7 Cl-93*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4-6H: PRN wheeze
2. Amlodipine 5 mg PO DAILY
3. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
4. Aspirin EC 81 mg PO DAILY
5. Calcium 500 + D (calcium carbonate-vitamin D3) unknown oral
DAILY
6. Vitamin D ___ UNIT PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Calcium 500 + D (calcium carbonate-vitamin D3) 1 tab ORAL
DAILY
4. Multivitamins 1 TAB PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
7. Bisacodyl 10 mg PO/PR DAILY constipation
8. Furosemide 10 mg PO BID
RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth twice a
day Disp #*30 Tablet Refills:*0
9. Gabapentin 300 mg PO QHS
RX *gabapentin 300 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
10. Senna 8.6 mg PO BID:PRN constipation
11. Sodium Chloride 1 gm PO TID
RX *sodium chloride 1 gram 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
12. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
13. Outpatient Lab Work
Please check sodium ___
14. Outpatient Physical Therapy
Thoracolumbar strain
Please assess and treat
Discharge Disposition:
Home
Discharge Diagnosis:
Hyponatremia
Nephrolithiasis
Thoraco-lumbar pain
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ female with weakness, headache, and hypernatremia.
Evaluate for subdural hemorrhage or mass.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 55.2 mGy (Head) DLP =
891.9 mGy-cm.
Total DLP (Head) = 892 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of no evidence of infarction, hemorrhage, edema, or
mass. Prominent ventricles and sulci suggest age related involutional
changes. Periventricular white matter hypodensities are consistent with
chronic small vessel ischemic disease. Atherosclerotic vascular
calcifications are noted of bilateral cavernous portions of internal carotid
arteries.
There is no evidence of fracture. A mucous retention cyst and mucosal
thickening are seen in the right maxillary sinus. Otherwise, the visualized
portion of the paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial process.
2. Please note MRI of the brain is more sensitive for the detection of acute
infarct.
3. Paranasal sinus disease as described.
Radiology Report
EXAMINATION: Chest radiographs
INDICATION: History: ___ with sob, hx of chf // chf?
TECHNIQUE: Upright PA and lateral images of the chest.
COMPARISON: Comparison is made with chest radiographs from ___ and
___.
FINDINGS:
Lungs well expanded and clear. There is no pleural effusion or pneumothorax.
The cardiomediastinal silhouette is top normal in size.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with hx bilateral small nephrolithiasis
(nonobstructing) at OSH CT scan ___, presenting with persistent flank pain,
also noted to have pyuria, ?firm bladder on palpation despite being
straight-cathed. // Please assess for possible bladder mass/wall thickening.
Also rule out hydronephrosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 12.2 cm. The left kidney measures 10.9 cm. Multiple
tiny echogenic foci are noted bilaterally, measuring up to 2- 3 mm in the
lower pole of the left kidney, which may represent nonobstructing renal
calculi. There is no hydronephrosis or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
The bladder is moderately well distended and normal in appearance. A small
amount of debris is noted within the bladder.
IMPRESSION:
1. Multiple punctate bilateral nonobstructing renal calculi without
hydronephrosis.
2. No bladder mass detected.
Radiology Report
EXAMINATION: CT L-SPINE W/O CONTRAST
INDICATION: ___ year old woman with recent diagnosis nonobstructing bilateral
kidney stones at OSH, with persistent bandlike pain in lower thoracic/lumbar
region. Assess lower thoracic T10 through lumbar spine. r/o compression
fracture
TECHNIQUE: Ataxial, helical, MDCT images were acquired through the lumbar
spine without the administration of intravenous contrast. Coronal, sagittal,
and bone algorithm thin section reformatted images were generated.
DOSE: This study involved 4 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) CT Localizer Radiograph
4) Spiral Acquisition 10.5 s, 38.1 cm; CTDIvol = 40.2 mGy (Body) DLP =
1,340.5 mGy-cm.
Total DLP (Body) = 1,341 mGy-cm.
COMPARISON: None available.
FINDINGS:
For the purposes of numbering, the lowest rib was designated T12. This
implies that there is a lumbarized first sacral segment Intervertebral disc
space was designated the
There is mild anterolisthesis of L5 on S1. Alignment is otherwise normal
There is no evidence of fracture. The prevertebral and paraspinal soft tissues
are unremarkable. Multilevel degenerative changes are seen throughout the
thoracolumbar spine with subchondral sclerosis and disc space narrowing most
prominent at T11-T12.
T10-11: Possible small left left-sided disc protrusion (4:7) with mild left
neural foraminal narrowing. No spinal canal narrowing.
T11-T12: Mild degenerative disc disease with loss of height of the disc and
endplate sclerosis. No encroachment on the thecal sac or neural foramina.
T12-L4: Mild degenerative disc disease with loss of height of the disc and
endplate sclerosis. No encroachment on the thecal sac or neural foramina.
L4-L5: Mild thickening of the ligamentum flavum with small disc bulge is seen
causing mild canal narrowing. No neural foraminal narrowing.
L5-S1: Disc bulge in combination with spondylolisthesis and thickening of the
ligamentum flavum produces mild spinal canal narrowing. The disc bulges into
the neural foramina bilaterally, greater on the left than right. In these
locations, it appears to contact and compresses the exiting left L5 nerve root
and contact the right L5 nerve root without compression. There is severe
narrowing of the left lateral recess with compression of the traversing left
S1 nerve root by a a superior facet osteophyte.
Mild degenerative disease of bilateral sacroiliac joints with subchondral
sclerosis an ex vacuo phenomenon. Limited assessment of the intra-abdominal
structures demonstrates a 2 mm nonobstructing stone within the left collecting
system. There are several high intensity lesions in the left kidney,
incompletely evaluated on this study. If further characterization is
indicated, an ultrasound may be helpful.
IMPRESSION:
1. Mild anterolisthesis of L5 on S1.
2. No evidence of fracture.
3. Degenerative disc disease at multiple levels with nerve root compression
at L5-S1.
4. Partially lumbarized first sacral segment.
5. Nonobstructing 2 mm stone within left collecting system.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal sodium level
Diagnosed with HYPOSMOLALITY/HYPONATREMIA
temperature: 97.4
heartrate: 88.0
resprate: 17.0
o2sat: 99.0
sbp: 127.0
dbp: 85.0
level of pain: 4
level of acuity: 2.0 | ___ yo woman with hx HTN, MR ___ repair, low back pain who was
recently diagnosed with nephrolithiasis (small bilateral,
nonobstructing) and hyponatremia, with two hospitalizations at
OSH, thought likely due to SIADH who now presents with
persistent hyponatremia Na 120
#Hyponatremia - Due to SIADH and pain was thought to be the
stimulus. She required hypertonic saline for a sodium of 119.
Nephrology consulted and she was ultimately treated with fluid
restriction, furosemide, and salt tabs. Her sodium was stable at
126-130 for the last 4 days of admission and 128 on discharge.
She will follow-up on ___ for a sodium check.
#Bilateral flank pain and nephrolithiasis - Her pain was
multifactorial and included renal colic, MSK reproducible pain
with thoracolumbar strain. She also had CT which demonstrated
nerve compression of the L5-S1 nerve root. Over the past several
days of her admission her pain was not severe, though it was
would wake her from sleep as an annoying pain that would make
for a difficult night of rest. She had tenderness to palpation
over the paraspinal muscles which reproduced her pain. She was
treated with gabapentin, lidocaine patch, heating pad and
oxycodone. Flexeril was tried x1, but it made her drowsy and she
was slightly confused on waking up. She was discharged with a
script for outpatient ___. She will need to follow-up with
Urology for her nephrolithiasis.
#Pyuria - suspect due to stone. Denied dysuria and her culture
was mixed flora.
#Atrial fibrillation - newly noted on this admission, though her
EKG looks to be an ectopic atrial focus vs. very prolonged PR
(1st degree block). She should be re-evaluated with EKG in the
office in follow-up. Appears CHADS2 score is 2 and CHA2DS2-VASc
score of 4. If true afib, her cumulative risk over time will
warrant anticoagulation. For now, she was increased to a full
dose ASA.
#HTN - continued amlodipine |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ambien
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
intercostal nerve block
History of Present Illness:
CC: Right-sided chest pain
HPI: Ms. ___ is a ___ y/o woman with a pmhx. of tobacco abuse
(40 pack/yr,) and chronic pain syndrome, with recent diagnosis
of
stage IV NSCL, now C2D5 of ___, presenting with
acute on chronic right-sided chest pain consistent with previous
cancer pain.
Ms. ___ first presented in the ___ with right-sided
mid-back and shoulder discomfort, with imaging in ___
revealing right lung mass. As per outpatient oncology notes,
Ms.
___ underwent bronchoscopy at ___ in early ___, with
biopsy of right hilar mass positive for malignant cells
consistent with non-small cell; IHC showed CK7 positive, TTF-1
cositive, napsin A, EPCAM, and focal positivity for CD56. Tumor
cells were negative for P63, CD45, and synaptophysin and
chromogranin. It was felt that the staining favored
adenocarcinoma, although focal CD56 positivity raised question
of
neuroendocrine differentiation. There were insufficient material
for mutation studies.
She had a PET CT on ___, which showed a large
FDG-avid
right hilar mass, with several avid lymph nodes on the right.
There was a moderate right pleural effusion and several areas of
increased avidity along the posterior right pleura. Multiple
additional lung nodules were noted on the right that were not
avid, but borderline size. In the abdomen and pelvis, multiple
foci of avidity including along the right liver capsule, right
retrocrural area. Multiple foci of FDG avidity were seen
throughout the skeleton including T12, L2, S1, left iliac, right
acetabulum, right sacrum, left sacrum, and right ribs (none with
evidence of spinal invasion). There was a mixed lytic and
sclerotic lesion in the left aspect of L2. An MRI of her brain
to
complete staging showed the severe motion artifact with no
definite mets.
Ms. ___ was admitted with acute pain on ___ and had
confirmatory biopsies of malignant right pleural effusion at
that
time as well (demonstrated adenocarcinoma). She underwent her
first cycle of ___ on ___ during admission. Then
she underwent intercostal nerve block on ___ with minimal
relief.
Mr. ___ received her second cycle of ___ as an
outpatient on ___. She states that last night she developed
acute pain, consistent with prior cancer-associated pain, not
responsive to home pain regimen. However, Ms. ___ states that
she is not entirely clear about what medications she is taking
at
home; her daughter fills her pill box. She thinks she may be
running out of her medication a bit too quickly. She denies any
chest pressure, worsening shortness of breath, current nausea,
vomiting, diarrhea, fevers, or chills. A complete 12-point
review of systems is negative aside from what is described
above.
Past Medical History:
PAST MEDICAL HISTORY:
--Ankle fracture
--Depression
--Fibromyalgia
--GERD
--Hyperlipidemia
--Insomnia
--OSA
--H.Pylori
--RLS
--Tobacco abuse
--Stage IV NSCLC
AST ONCOLOGIC HISTORY:
She presented several times in the late ___ with
right-sided and mid back discomfort and right shoulder pain and
SOB. At the end of ___, chest x-ray showed right-sided lung
mass and pulmonary nodules for which she was sent to ___
___.
She underwent bronchoscopy at ___ in early ___.
Bronch of the right upper lobe showed atypical cells and FNA of
her right hilar mass was felt positive for malignant cells
consistent with non-small cell, the impact showed the CK7
positive, TTF-1 positive, napsin A, EPCAM, and focal positivity
for CD56. Tumor cells were negative for P63, CD45, and
synaptophysin and chromogranin. It was felt that the staining
favored adenocarcinoma, although focal CD56 positivity raised
question of neuroendocrine differentiation. There were
insufficient material for mutation studies. She had a PET CT on
___, which showed a large FDG-avid right hilar mass,
several avid lymph nodes were noted on right. There was a
moderate right pleural effusion and several areas of increased
avidity along the posterior right pleura. Multiple additional
lung nodules were noted on the right that were not avid, but
borderline size. In the abdomen and pelvis, multiple foci of
avidity including along the right liver capsule, right
retrocrural area. Multiple foci of FDG avidity were seen
throughout the skeleton including T12, L2, S1, left
iliac, right acetabulum, right sacrum, left sacrum, and right
ribs (none with evidence of spinal invasion). There was a mixed
lytic and sclerotic lesion in the left aspect of L2. An MRI of
her brain to complete staging showed the severe motion artifact
with no definite mets.
PAST MEDICAL HISTORY:
COPD (not on home O2), fibromyalgia, depression
Social History:
___
Family History:
No family history of lung cancer. Cirrhosis in her father.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.3, 107/76, 116, 18, 95% RA
ECOG: 2
GENERAL: Chronically ill appearing, no acute distress, lying in
bed
HEENT: Mucous membranes dry, no oral lesions, poor dentition
CHEST: Decreased breath sounds at bases, no wheezes, rales, or
rhonchi
CARDIAC: Tachycardic, no murmurs, rubs, or gallops
ABDOMEN: +BS, soft, non-tender, non-distended
EXTREMITIES: No edema bilaterally
SKIN: Very dry, no obvious rash
NEURO: Pupils miotic but reactive, appropriate
DISCHARGE Exam:
VITALS: 98.2 114/57 ___ R18
Gen: breathing comfortably, mild distress due to pain, sleeping
soundly, appears comfortable this morning
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, full pulses, no edema
Resp: normal effort, no accessory muscle use, decreased breath
sounds on the R
GI: ab is nondistended, soft, NT, ND, BS+
Neuro: AAOx3.
Psych: Full range of affect
Pertinent Results:
LABS:
132 92 12 140 AGap=21
------------------
4.0 23 0.6
Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional
Diabetes
ALT: 16 AP: 79 Tbili: 0.8 Alb: 4.0
AST: 15 LDH: Dbili: TProt:
___: Lip: 14
WBC: 9.6
Hgb: 11.7
Hct: 34.9
Plt: 340
MCV: 83
N:88.3 L:8.9 M:1.2 E:1.0 Bas:0.3 ___: 0.3 Absneut: 8.50
___ Abslymp: 0.86 Absmono: 0.12 Abseos: 0.10 Absbaso: 0.03
PATHOLOGY:
___: Pleural Biopsy
Right parietal pleural, biopsy:
Positive for adenocarcinoma, consistent with lung o
rigin.
Note: The tumor is moderately to poorly differentia
___. Tumor cells are diffusely and strongly positive
for CK7, Napsin and TTF1. There is also cytoplasmic positivity
for WT1. Cells are negative for calretinin, CK20 and CDX2. The
findings are consistent with an adenocarcinoma of lung origin
___: Pleural Fluid
CYTOLOGY REPORT
Final
SPECIMEN(S) SUBMITTED:
PLEURAL FLUID, right pleural effusion
DIAGNOSIS:
PLEURAL FLUID, RIGHT:
POSITIVE FOR MALIGNANT CELLS.
Metastatic lung adenocarcinoma.
Note: By immunohistochemistry, tumor cells are positive for
TTF-1
and Napsin A. No staining is seen for p63. The cellblock shows
high tumor cellularity.
___: EBUS FNA 4R
Metastatic Lung Adenocarcinoma
CXR ___:
PA and lateral views of the chest provided. Multiple known
lung
nodules are better visualized on prior CT chest. There is no
convincing evidence of pneumonia or edema. Cardiomediastinal
silhouette appears similar with mediastinal prominence
reflecting
known right hilar and suprahilar mass. Aortic calcifications
again noted. Bony structures appear grossly intact.
EKG: Sinus tachycardia with rate of 128, motion artifact, no
concerning ST abnormalities
NERVE BLOCK PROCEDURE NOTE ___: Chief Complaint: Right
sided chest/ chest wall pain
History/Statement of Medical Necessity: ___ year old female with
metastatic non-small cell lung cancer, who was recently
re-admitted for intractable pain at the right chest wall
radiating to her back and to the anterior chest. She is on high
doses of opioids with significant breakthrough pain, exacerbated
with movement. She received a diagnostic intercostal block of
the
___ to ___ intercostal nerves on the right side on ___ with
minimal relief of her symptoms. She is currently admitted for
pain and has been transported to clinic in order to recieve
paravertebral blocks on the right at the level of the ___ and ___ level as well as neurolysis of the ___ and ___
intercostal nerves on the right in an effort to improve pain
control and decrease the need for opioid use.
Interval changes in history/medications/system review:
Unchanged since last seen as inpatient this morning.
Allergies: reviewed and updated as needed in OMR
Medications: reconciled in OMR
Pertinent Labs:
139/3.8 ___ <101
Ca: 8.6 Mg: 1.6 P: 3.1
4.3 > 10.3/32.6 < 217
___: 12.1 INR: 1.1
Anticoagulants: Reviewed with patient, notable for xSubQ Heparin
as an inpatient that was held this am.
Focused Examination:
Ax3
Mood and affect are normal
Vital Signs sheet entries for ___:
BP: 103/56. Heart Rate: 70. Weight: 185 (With Clothes) (___ Plan
of Care: Education). Height: 60 (With Shoes). BMI: 36.1.
Temperature: 96.8. Resp. Rate: 18. Pain Score: 7. O2
Saturation%:
100.
Pre Procedure Diagnosis: Right chest wall pain
Post Procedure Diagnosis: Right chest wall pain, intercostal
neuralgia
Procedure Performed by: ___
___ Physician: ___
___: Verbal and written informed consent was
obtained/reviewed with the patient. Risks, benefits,
alternatives
discussed in detail. All questions were answered.
Site was then marked.
Position: prone
Anesthesia: Monitored Anesthesia Care
Monitoring: NIBP, Pulse oximetry
Antibiotics: None
The skin was prepped with chloraprep (chlorhexidine and alcohol)
and then draped in a sterile fashion
Time out was then performed as per protocol
Procedure - Thoracic Paravertebral Block
The patient was prepped with aseptic technique and was prepped
with a sterile ultrasound sleeve in aseptic technique.
Needle used: 22 GA 3.5 in Spinal
Contrast: Omnipaque
Injectate: Dexamethasone 14mg 2ml and Bupivicaine 0.5% 14 ml
total 16ml divided into 4 levels
Technique:
Under live ultrasound guidance, a 25 G needle
was introduced in-plane to the area of the right paraverterbral
space by locating the spinous process at the ___ thoracic
vertebral level and moving lateral past the transverse process.
The needle was advanced to the praravertebral space just before
the pleura. The tip of the needle was visualized at all times
and during injection. After negative aspiration, the above
mentioned injectate was administered 4 mL was injected. There
was
no evidence of intravascular or intraneural or intra-arterial
injection.
1 ml of omnipaque was then administered with confirmation of
appropriate spread consistent with intercostal nerve block and
without evidence for intravascular uptake
The needle was then withdrawn. The
patient tolerated the procedure well and there were no
complications.
The same procedure was done at the level of ___ and ___
paravertebral levels.
EBL: less than 1 ml
Complications: None
Specimen: None
Fluids: None
Procedure - Intercostal Neurolysis
Needle entry site was then infiltrated with lidocaine 1% using
25G 1.5 inch needle 1ml
Needle used: 22 GA 3.5 in Spinal
Contrast: Omnipaque
Injectate: Lidocaine 2% 15 ml total Phenol 6% 6 ml total
Technique:
The posterior angle of the ribs was identified, in line
vertically with the lateral aspect of the scapula on right side.
The needle was then advanced until it contacted the 5th rib.
The needle was then carefully walked off the inferior margin of
the rib and into the intercostalis groove, at a distance no
greater than 3 mm.
1 ml of omnipaque was then administered with confirmation of
appropriate spread consistent with intercostal nerve block and
without evidence for intravascular uptake
After negative aspiration for air or blood, 5 ml of the 2%
lidocaine was administered and allowed to take effect for 60 sec
at which time the administration of phenol 6% 2ml was
adminstered
into each level. No paresthesias were produced. The needle was
withdrawn.
The same procedure was done at the level of ___ and 7th rib.
EBL: less than 1 ml
Complications: None
Specimen: None
Fluids: None
Post Procedure: see OMR.
Patient was taken to the recovery and monitored. Patient was
stable upon transfer back to the hospital.
Detailed post procedure instructions were provided. Patient was
asked to call in the event of worsening pain, shortnrss of
breath, fever, weakness or numbness.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO TID
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
3. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
abdominal discomfort
4. BuPROPion (Sustained Release) 150 mg PO QAM
5. Docusate Sodium 200 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Escitalopram Oxalate 20 mg PO DAILY
8. Gabapentin 1200 mg PO TID
9. Nicotine Patch 21 mg TD DAILY
10. OxyCODONE SR (OxyconTIN) 80 mg PO Q8H
11. Polyethylene Glycol 17 g PO DAILY for no bowel movement
12. Senna 17.2 mg PO BID
13. Dexamethasone 4 mg PO BID
14. Cyanocobalamin 1000 mcg IM/SC EVERY 9 WEEKS
15. Lactulose 30 mL PO DAILY
16. Lidocaine 5% Patch 1 PTCH TD QAM
17. Lorazepam 0.5 mg PO Q4H:PRN anxiety/agitation
18. Naproxen 500 mg PO Q12H
19. OxycoDONE (Immediate Release) 20 mg PO Q6H:PRN Pain
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
abdominal discomfort
3. BuPROPion (Sustained Release) 150 mg PO QAM
4. Docusate Sodium 200 mg PO BID
5. Escitalopram Oxalate 20 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Gabapentin 1200 mg PO TID
8. Lactulose 30 mL PO DAILY
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Lorazepam 0.5 mg PO Q4H:PRN anxiety/agitation
11. Nicotine Patch 21 mg TD DAILY
12. OxycoDONE (Immediate Release) 20 mg PO Q6H:PRN Pain
13. OxyCODONE SR (OxyconTIN) 80 mg PO Q8H
14. Polyethylene Glycol 17 g PO DAILY for no bowel movement
15. Senna 17.2 mg PO BID
16. Acetaminophen 650 mg PO TID
17. Cyanocobalamin 1000 mcg IM/SC EVERY 9 WEEKS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cancer-related chest pain
Discharge Condition:
stable
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with metastatic lung cancer, nausea/vomiting, on chemo //
Eval for infection
COMPARISON: CTA chest from ___ and chest radiograph from ___.
FINDINGS:
PA and lateral views of the chest provided. Multiple known lung nodules are
better visualized on prior CT chest. There is no convincing evidence of
pneumonia or edema. Cardiomediastinal silhouette appears similar with
mediastinal prominence reflecting known right hilar and suprahilar mass.
Aortic calcifications again noted. Bony structures appear grossly intact.
IMPRESSION:
Findings as stated above.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Nausea, Body aches
Diagnosed with Other chronic pain
temperature: 96.8
heartrate: 114.0
resprate: 18.0
o2sat: 97.0
sbp: 119.0
dbp: 79.0
level of pain: 8
level of acuity: 3.0 | Ms ___ is a pleasant ___ y/o woman with a pmhx. significant for
stage IV NSCLC with large R sided hilar mass c/b malignant
pleural effusion, recently started on chemo s/p C2D5 of
___ most recently on ___, with significant
cancer-associated chest pain (including recent admission
___ s/p intercostal nerve block done on ___ without much
effect), admitted for management of acute on chronic right-sided
chest pain. Symptoms were most consistent with continued
cancer-related pain. No concerning features for ACS or PE. She
was sating well on room air.
Pain management consulted and she underwent a right sided ___,
___ and ___ intercostal neurolysis and right sided paravertebral
block at the ___ and ___ levels on the right side with
benzocaine and dexamethasone injections on ___ with
improvement in her pain (particularly in the area towards her
back) but with some residual anterior pain was noted.
She developed with post-procedure nausea so remained inpatient
an additional overnight for monitoring. She felt much better the
following day and was discharged home with services.
#Nausea: I discussed with the pain management team whether any
of the injected drugs may have contributed to her nausea and
they couldn't think of any identifiable causes relating to the
procedure. Perhaps she was nauseated in response to the sedation
she was given prior to the procedure? the Dexamethasone would be
thought to have improved her nausea. Regardless, she was feeling
much better the following morning and tolerated good pO intake
before going home.
#RIGHT-SIDED CHEST PAIN: Patient stated that pain was
worsening
of her chronic cancer-associated pain with no changes in the
character or quality of the pain. She is usually on oxycontin
80mg tid and oxycodone 20mg Q6 at home however, she admits that
she was unclear to her exactly what she is taking (since someone
else fills her pill box). Initially there was a concern that her
daughter may be handling her narcotics but it was confirmed with
case management that the ___ service is in charge of this aspect
of her care.
-We continued her home oxycontin 80mg tid + oxycodone 20mg Q6
unchanged
-she was also given Toradol 15mg Q6 x3 days
-notably CT angiogram done when she had the same type of pain on
___ that showed no PE. CXR ___ showed known multiple
metastases but no significant recurrence of effusion. No e/o
pneumonia or edema were seen. The previously seen R sided hilar
mass was still present.
-Consider Radiation Oncology consult in the future to determine
utility and
feasibility of palliative radiation in case her pain continues
-Pain management inpatient consult service was enlisted to help
manage her pain and on ___, underwent Right sided ___
and ___ intercostal neurolysis and right sided paravertebral
block at the ___ and ___ levels on the right side with
benzocaine and dexamethasone injections.
#TACHYCARDIA: up to 110s in ED in setting of discomfort,
improved with IV morphine and IVF (rates of 130s in the ED, 110
on the floor). Now resolved, PE unlikely as above. She remained
sating well on room air.
#METASTATIC LUNG CANCER: C2D5 of ___. Further
treatment as per outpatient physicians. Patient is receiving
B12
and dex as an outpatient. She states that she only takes the
dexamethasone right before her chemotherapy so this was held on
her discharge and can be restarted by her outpatient oncology
team as needed. She continues on folic acid.
#Hyponatremia: Na 132 which is slightly reduced from her
baseline around 137, now resolved.
#CONSTIPATION: Continue miralax, senna, Colace, lactulose PRN
#DEPRESSION: Continued home escitalopram and buproprion
#FEN/GI/PPX:
-Aggressive bowel regimen with large dose narcotics
#CODE STATUS: FULL CODE (confirmed by me with the patient
however she seemed a little confused as to what Full code
entails as she later wanted to "just be made comfortable" in
case she were to decompensate). I tried to pursue this further
but she said she would rather discuss this with her daughter
first. She remained full code for this admission and will
discuss with her daughter as an outpatient.
#TRANSITIONAL ISSUES:
-outpt ___ with her oncologist Dr. ___ and in pain
management clinic.
-PCP ___ appointment for goals of care planning
-if pain continues, can consider Radiation Oncology consult to
determine utility and feasibility of palliative radiation if
pain continues |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Flagyl / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
dyspnea x 2 days
lower leg swelling x 3 weeks
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with COPD, HFpEF (TTE
___, EF>65%, dry weight: 135lbs), mild-moderate AR,
mild-moderate TR, thoracic + abd aortic aneurysm with h/o Type A
thoracic dissection s/p repair (___), Crohn's disease s/p
colostomy + subsequent reversal ___, not on any medications),
Bell's palsy w/ R facial droop, HTN, and hypothyroidism who is
being admitted from ___ clinic on ___ for worsening dyspnea.
The pt was recently hospitalized from ___ for concomitant
COPD and CHF exacerbation. For her COPD exacerbation, she
received a 5-day course of prednisone/AZT with plans to f/u with
Pulm as outpatient, although never did. Regarding her acute
HFpEF
exacerbation, on admission her BNP was ~11,000 (baseline 3000)
with mild interstitial edema on CXR. At the time of discharge,
she had 1+ edema above the ankles and demanded to be discharged
home despite recommendation for further diuresis (d/c weight:
142.8lbs, above dry weight: 135lbs). Her home Lasix was
increased
to 40mg bid prior to discharge. She did not keep her f/u PCP apt
after leaving the hospital.
However since discharge, the pt said she felt better than
before,
but never returned to baseline. Over the next several weeks she
complained of progressive shortness of breath with exertion.
Also
w/ increasing ___ edema. Orthopnea at baseline without PND.
Otherwise she also continued to have chronic cough productive of
small amounts of white sputum. No fevers, chills, chest pain,
n/v
or abdominal pain. Says that her scale at home is broken, so
could not comment on possible weight gain. Notably, the pt does
admit to occasionally missing doses of Lasix bc of the
inconvenience of frequent urination.
She presented to clinic on ___ after calling the clinic with
complaints of the above symptoms. Her weight there was recorded
143lbs, 8lbs above presumed dry weight. She was seen by Dr.
___ at referred her to the ED due to concern for concurrent
CHF/COPD exacerbation.
Past Medical History:
CHF (dx ___, EF 35-40%, mild LVH, mod AR, mod TR; TTE ___
with EF 65% Mild-mod AR, Mild-mod)
Hypertension
Hypothyroid
Crohn's disease, not on any maintenance medications
Diverticulosis
Bell's palsy-R facial droop
Thoracic Type A aortic dissection s/p repair
Thoracic and abdominal aortic aneurysm
Colostomy and reversal for Crohn's
Open cholecystectomy
C-Section
Hysterectomy
Social History:
___
Family History:
Mother: Died at age ___ in her sleep. She had colon cancer s/p
resection and heart disease
Father: Died at age ___, DM and heart disease
Brother: Died at age ___, he had CHF, DM, and aneurysms
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
VITALS: T 97.7, BP 118/71, HR 89, RR 20, O2 93% on RA
GENERAL: Alert and interactive, eating dinner, NAD
HEENT: NCAT. Sclera anicteric and without injection.
NECK: Supple, JVD 13cm, +HJR
CARDIAC: RRR, no m/r/g
LUNGS: Decreased breath sounds, diffuse wheezes and rhonchi
ABDOMEN: Soft, non tender, non distended BS+
EXTREMITIES: 2+ ___ edema to knees bilaterally
SKIN: Warm and well perfused
NEUROLOGIC: CN2-12 grossly intact, AOx3
DISCHARGE PHYSICAL EXAM:
==========================
VITALS: ___ 1140 Temp: 97.5 PO BP: 120/70 HR: 78 RR: 18 O2
sat: 93% O2 delivery: Ra
GENERAL: Alert and interactive, sitting in bed in NAD
HEENT: NCAT. Sclera anicteric and without injection.
CARDIAC: RRR, no m/r/g
LUNGS: Wheezes audible without stethoscope. Air movement poor,
with diffuse wheezes in all lung fields and delayed expiration
ABDOMEN: Soft, non tender, non distended BS+
EXTREMITIES: 2+ ___ edema to thighs, L>R
SKIN: Warm and well perfused; mild venous stasis changes at
ankles; poor toenail hygeine
NEUROLOGIC: Mild right upper and lower facial droop (chronic);
otherwise CN2-12 grossly intact, AAOx3
Pertinent Results:
ADMISSION LABS:
===================
___ 12:05PM BLOOD WBC-8.6 RBC-4.68 Hgb-12.0 Hct-39.3 MCV-84
MCH-25.6* MCHC-30.5* RDW-16.5* RDWSD-50.9* Plt ___
___ 12:05PM BLOOD Neuts-77.6* Lymphs-13.1* Monos-4.9*
Eos-3.4 Baso-0.7 Im ___ AbsNeut-6.70* AbsLymp-1.13*
AbsMono-0.42 AbsEos-0.29 AbsBaso-0.06
___ 12:05PM BLOOD Glucose-143* UreaN-36* Creat-1.7* Na-145
K-4.6 Cl-103 HCO3-24 AnGap-18
___ 12:05PM BLOOD CK-MB-7 cTropnT-0.02* proBNP-7739*
___ 12:05PM BLOOD cTropnT-0.02*
___ 04:50PM BLOOD cTropnT-0.01
___ 07:00AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.1
___ 07:00AM BLOOD TSH-6.5*
___ 12:25PM BLOOD ___ pO2-34* pCO2-51* pH-7.33*
calTCO2-28 Base XS-0
DISCHARGE LABS:
==================
___ 07:54AM BLOOD WBC-11.4* RBC-4.66 Hgb-11.9 Hct-38.4
MCV-82 MCH-25.5* MCHC-31.0* RDW-16.7* RDWSD-49.3* Plt ___
___ 07:54AM BLOOD Glucose-102* UreaN-66* Creat-2.0* Na-142
K-4.2 Cl-97 HCO3-27 AnGap-18
___ 07:54AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Budesonide 0.25 mg/2 mL inhalation BID
2. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation
inhalation DAILY
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
4. Furosemide 40 mg PO BID
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
6. amLODIPine 5 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES QHS
9. Rosuvastatin Calcium 5 mg PO QPM
10. Carvedilol 12.5 mg PO BID
11. Levothyroxine Sodium 75 mcg PO DAILY
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 3 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth Daily Disp #*1
Tablet Refills:*0
2. Ipratropium-Albuterol Neb 1 NEB NEB Q4H
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1
nebulizer inhaled Every 4 horus Disp #*1 Ampule Refills:*0
3. PredniSONE 10 mg PO DAILY Duration: 3 Doses
RX *prednisone 10 mg 4 tablet(s) by mouth Daily Disp #*16 Tablet
Refills:*0
4. Torsemide 60 mg PO DAILY
RX *torsemide 20 mg 3 tablet(s) by mouth Daily Disp #*21 Tablet
Refills:*0
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
7. amLODIPine 5 mg PO DAILY
8. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25
mcg/actuation inhalation DAILY
9. Aspirin 81 mg PO DAILY
10. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES QHS
11. Budesonide 0.25 mg/2 mL inhalation BID
Start once finish the prednisone
12. CARVedilol 12.5 mg PO BID
13. Levothyroxine Sodium 75 mcg PO DAILY
14. HELD- Furosemide 40 mg PO BID This medication was held. Do
not restart Furosemide until you finish the torsemide.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
----------
Chronic pulmonary obstructive disease exacerbation
Diastolic Heart Failure exacerbation
Secondary:
----------
Tobacco dependence
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 sob// r/o infection r/o infection
IMPRESSION:
Compared to chest radiographs ___ most recently one ___.
Moderate cardiomegaly is stable. Severe upper mediastinal widening due to
generalized aortic ectasia and arterial enlargement has not progressed. Lungs
are grossly clear and there is no pleural abnormality.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Dyspnea, unspecified
temperature: 98.9
heartrate: 88.0
resprate: 28.0
o2sat: 100.0
sbp: 131.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | PATIENT SUMMARY:
Ms. ___ is a ___ year old female with COPD, HFpEF (TTE
___, EF>65%, dry weight: 135lbs), mild-moderate AR,
mild-moderate TR, thoracic + abd aortic aneurysm with h/o Type A
thoracic dissection s/p repair (___), Crohn's disease s/p
colostomy + subsequent reversal ___, not on any medications),
Bell's palsy w/ R facial droop, HTN, and hypothyroidism who was
admitted ___ from ___ clinic for dyspnea x 2 days and ___ edema
2 weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ___
Allergies:
Levaquin / Sulfa (Sulfonamide Antibiotics) / Ceftriaxone /
Dilaudid / Aspirin
Attending: ___.
Chief Complaint:
presyncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo w/ovarian cyst, SLE, prior PE on coumadin presents as
transfer from ___ with presyncope. Today pt felt cold and
dizzy for several minutes and then nearly lost consciousness.
She was helped to the floor. She did not hit her head. She sat
for about 30min and felt better until she stood up again. Denies
CP, palp, SOB. She has had vaginal bleeding, one pad per day
over the past week. One week ago she was admitted to the
hospital for a ruptured ovarian cyst. She has not had any chest
pain, SOB, palpitations.
In ___ pt had US which showed hemoperitoneum, found to
have INR of 4.6. BP 95/50. Given 2L ns, 1u FFP, 10mg IV VitK.
Seen by OB who recommended transfer to BID for further work up.
Upon arrival to BID ___ pt BP improved to 114/70, repeat INR 1.7.
Past Medical History:
SLE: followed by Dr. ___ at ___.
Ovarian cyst
PE, on coumadin
Social History:
___
Family History:
no history of SLE
Physical Exam:
Admission Exam
VS: 97.9 127/83 72 18 100%ra
Pain: 0
Gen: nad, lying in bed
Heent: mmm
Skin: multiple ecchymosis
Resp: ctab
CV: rrr
Abd: nabs, soft, nt/nd
Ext: no e/c/c
Neuro: alert, follows commands, answering questions
approrpriately
Discharge Exam:
VS: 98.2 ___ 16 96% RA
Pain: 0
Gen: NAD, sitting in chair
Resp: CTAB
CV: RR, nl rate, no r/g/m
Abd: soft, nt/nd
Ext: No edema
Pertinent Results:
___:
Transvaginal US Impression:
1. Large amount of hypoechoic somewhat well-organized complex
material
in the right adnexal area adjacent to a remnant of ovarian
tissue
medially. Most likely blood clot related to a ruptured/rupture
rain
ovarian cyst. Echogenic debris is seen around this and
dependently in
the pelvis consistent with blood. No free fluid is seen in the
upper
abdomen.
MCV: 75.0*, HGB: 11.1 (Delta), WBC: 13.8*, PLT: 297 (Delta),
HCT: 35.5 (Delta)
___ URINE PREGNANCY TEST (QUAL): Neg
URINALYSIS W/REFLEX MIC CUL, information as of ___,
12:04 pm
Color: DK YELLOW Clarity: CLOUDY SpecGr: 1.024 pH:
6.5 Urobil: 0.2 Bili: NEGATIVE Leuk: NEGATIVE Bld:
LARGE Nitr: NEGATIVE Prot: TRACE Glu: NEGATIVE
Ket: NEGATIVE
BID Results:
___ 06:20PM WBC-11.9*# RBC-4.26 HGB-9.9* HCT-31.7*
MCV-74* MCH-23.2* MCHC-31.1 RDW-16.5*
___ 06:20PM ___ PTT-58.7* ___
___ 06:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 06:20PM GLUCOSE-83 UREA N-7 CREAT-0.3* SODIUM-139
POTASSIUM-3.6 CHLORIDE-108 TOTAL CO2-23 ANION GAP-12
___ 06:30AM BLOOD WBC-19.1* RBC-4.44 Hgb-10.5* Hct-33.2*
MCV-75* MCH-23.6* MCHC-31.6 RDW-17.0* Plt ___
___ 03:30PM BLOOD Neuts-89* Bands-2 Lymphs-3* Monos-2 Eos-0
Baso-0 ___ Metas-4* Myelos-0
___ 06:20PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 06:20PM URINE RBC-11* WBC-0 Bacteri-NONE Yeast-NONE
Epi-1
Pelvic u/s: Impression: 6.4 cm right ovarian hemorrhagic cyst,
with mild complex free fluid suggesting rupture. Arterial and
venous waveforms seen in the right ovary, although given
enlarged size of the ovary (with hemorrhagic cyst), intermittent
torsion can not be excluded.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 3 mg PO 2X/WEEK (MO,TH)
2. Warfarin 4 mg PO 5X/WEEK (___)
3. Hydroxychloroquine Sulfate 100 mg PO BID
4. Methylprednisolone 30 mg PO DAILY
5. Calcium Carbonate 500 mg PO BID
Discharge Medications:
1. Enoxaparin Sodium 70 mg SC Q12H
RX *enoxaparin 80 mg/0.8 mL please take 70 mg twice per day Disp
#*20 Syringe Refills:*0
2. Calcium Carbonate 500 mg PO BID
3. Hydroxychloroquine Sulfate 100 mg PO BID
4. Methylprednisolone 30 mg PO DAILY
5. Warfarin 4 mg PO DAILY16
this will need to be adjusted with your ___ clinic.
Do not get pregnant while on this medication.
6. Acetaminophen 325-650 mg PO Q4H:PRN Pain
Discharge Disposition:
Home
Discharge Diagnosis:
ruptured hemorrhagic ovarian cyst
acute blood loss anemia
presyncope/hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Coumadin with INR of 4.6, near syncope and known persistently
bleeding ovarian cyst.
No prior examinations for comparison.
LMP: ___.
PELVIC ULTRASOUND: Transabdominal and transvaginal images were acquired, the
latter for further characterization of the uterus and adnexa.
The uterus measures 6.3 x 6 x 2.8 cm. Endometrial stripe measures 3 mm, and
there is a small amount of fluid in the endometrial cavity. No detectable
endometrial flow.
There is a large hemorrhagic cyst within the right ovary measuring 6.4 x 4.6 x
3.3 cm. This has a heterogeneously hypoechoic appearance, with multiple
internal reticulations and no internal vascularity. Surrounding right ovarian
tissue has normal arterial and venous Doppler waveforms. Left ovary is normal
in size, with preserved vascular waveforms.
There is mild complex free fluid in the pelvis.
IMPRESSION: 6.4 cm right ovarian hemorrhagic cyst, with mild complex free
fluid suggesting rupture. Arterial and venous waveforms seen in the right
ovary, although given enlarged size of the ovary (with hemorrhagic cyst),
intermittent torsion can not be excluded.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: SYNCOPE/PRESYNCOPE
Diagnosed with OVARIAN CYST NEC/NOS
temperature: 97.7
heartrate: 71.0
resprate: 16.0
o2sat: 100.0
sbp: 107.0
dbp: 57.0
level of pain: 3
level of acuity: 2.0 | ___ with ovarian cyst, SLE, prior PE on warfarin p/w presyncope,
hypotension and anemia. She was treated with fluids without
further decrease in hematocrit. Her pain improved and her
hypotension/presyncope resolved. She was restarted on
anticoagulation (lovenox and warfarin) without evidence of
further bleed. She was discharged with close follow up.
# Ruptured ovarian hemorrhagic cysts: Her hct was trended and
was stable. Gynecology consulted and felt there was no need for
surgical intervention or need for lupron at this time. She did
not require blood transfusion. She was restarted on lovenox and
warfarin and monitored for 24 to make sure her hematocrit and
hemodynamics were stable. She was discharged with a hematocrit
of 33.2. She will have follow up early next week including INR
draw and hematocrit. She will follow up with gynecology next
week for further assessment of the cyst.
# Prior PE: She was admitted with supratherapeutic INR. She was
given s/p FFP and vitamin K. Her warfarin was restarted along
with a lovenox bridge (she was monitored to make sure she did
not have any bleeding prior to discharge. She will have close
follow up.
# SLE: her home medications were continued.
# Leukocytosis: This was thought to be due to a stress response.
However, she will need follow up to make sure this, along with
the atypical cells in her blood resolve. This was discussed with
her PCP.
# Hematuria: Likely secondary from vaginal bleeding. Will need
follow up to ensure resolution.
# Anemia: acute blood loss and Fe deficiency. Will be followed
by PCP.
# Routine health care: due for pap smear. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Major Surgical or Invasive Procedure:
T9 bone biopsy
attach
Pertinent Results:
NOTABLE LABS:
___ 07:14AM BLOOD WBC-6.6 RBC-4.57 Hgb-10.8* Hct-36.0
MCV-79* MCH-23.6* MCHC-30.0* RDW-16.5* RDWSD-47.2* Plt ___
___ 04:20AM BLOOD Glucose-93 UreaN-10 Creat-0.8 Na-140
K-4.1 Cl-104 HCO3-24 AnGap-12
___ 07:14AM BLOOD ALT-14 AST-18 AlkPhos-96 TotBili-0.4
___ 07:14AM BLOOD Albumin-3.3* Calcium-9.4 Phos-3.7 Mg-2.3
IMAGING:
MRI Mediastinum
IMPRESSION:
1. A slightly heterogenous T2 hyperintense lesion in the
pre-vascular mediastinum corresponds to recent CT findings, and
shows no evidence of associated contrast enhancement. Findings
are suggestive of a benign etiology, likely related to a
congenital cyst rather than transformation.
2. Nonocclusive filling defect in the left brachiocephalic vein
confluence is concerning for thrombus.
3. Enhancing lesion in likely the T9 vertebral body correlates
with a rim sclerotic lesion on recent CT and is concerning for
metastatic disease.
4. Partially visualized right breast tissue shows non
circumscribed cystic areas with associated ill-defined
enhancement.
RECOMMENDATION(S): 1. CTV neck is recommended for further
evaluation of vascular findings.
2. Clinical correlation and possible biopsy is suggested for
enhancing lesion in thoracic vertebral body.
3. Breast followup as planned for further evaluation of right
breast findings.
CTV Neck
IMPRESSION:
1. Thrombus within the left superior intercostal vein with
partial extension into the left brachiocephalic vein.
2. Heterogeneous sclerosis of the C2 through C6 vertebrae, which
may represent metastatic disease.
3. Periapical lucencies involving several right mandibular and
maxillary teeth, which is concerning for periodontal and
periapical infection.
OTHER DATA:
Imaging at ___
___ Chest:
IMPRESSION:
1. No PE.
2. 3.5 cm near water density cystic mass in the left superior
mediastinum. Limited differential diagnosis includes patulous
pericardial recess, pericardial cyst and cystic neoplasm.
CT A/P:
IMPRESSION:
1. Slight fullness of the right pelvicalyceal system. No
obstructing stone or obvious lesion. Otherwise, no acute
intra-abdominal/pelvic pathology identified.
2. Uterine fibroid.
Right breast US
CONCLUSION: 4.5 x 4.1 x 1.7 cm thin-walled simple benign cyst.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Apixaban 5 mg PO BID
Take 2tabs (10mg) for the next 8 doses followed by 1tab (5mg)
twice daily
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Superior intercostal vein thrombus
Periapical lucencies concern for periodontal disease
Discharge Condition:
Discharge condition: stable
Mental status: ANOX3
Ambulatory
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with mediastinal mass noted, per ___ would need
mediastinal MRI before any procedural planning // assess mediastinal mass
TECHNIQUE: Multiplanar multisequence MRI of the mediastinum/lung performed
before and after intravenous administration of 9 mL of Gadavist contrast
medium.
Motion artifact degrades quality of the examination.
COMPARISON: Correlated with outside CT examination of ___
FINDINGS:
LUNGS: No gross abnormality is identified within the lungs. No evidence of an
enhancing pulmonary mass or nodule. There is no evidence of a significant
pneumothorax. Trace left pleural effusion is noted.
VASCULATURE: The thoracic aorta and pulmonary vessels show normal
configuration and contrast an 8 mm filling defect is identified at the left
brachiocephalic vein confluence (___), demonstrating STIR hyperintensity.
Apparent enhancement within the lesion is questionable, and may be
artifactual.
HEART AND MEDIASTINUM: The heart is normal in size. There is no pericardial
effusion. The recently described cystic lesion in the upper mediastinum
correlates with a slightly heterogenous T2 hyperintense 1.9 cm region in the
pre-vascular space (3: 13), without evidence of associated enhancement.
UPPER ABDOMEN: No gross abnormalities identified. Valuation once markedly
limited by motion artifact.
OSSEOUS STRUCTURES: 1.6 cm ill-defined T2 hyperintense lesion is identified
in the left aspect of likely the T9 vertebral body (8:26), demonstrating
enhancement on post-contrast images. There is no evidence of macroscopic fat
to suggest a hemangioma. This lesion corresponds to a sclerotic rim lesion on
recent CT of ___. No other focus of enhancement is identified in
the included osseous structures.
SOFT TISSUES: Ill-defined geographic areas of T2 hyperintensity are identified
in the partially visualized right breast tissues, demonstrating associated
enhancement. Few prominent right axillary lymph nodes are identified, the
largest measuring up to 1 cm in short axis.
IMPRESSION:
1. Cystic structure in the mediastinum without worrisome features corresponds
to recent CT findings, favoring congenital cyst rather than transformation.
2. Nonocclusive filling defect in the left brachiocephalic vein confluence,
concerning for thrombus.
3. Enhancing lesion in likely the T9 vertebral body correlates with a rim
sclerotic lesion on recent CT, concerning for metastatic disease.
4. Partially visualized right breast tissue shows non circumscribed cystic
areas with associated ill-defined enhancement. Further evaluation with
dedicated breast imaging is recommended.
RECOMMENDATION(S): 1. CTV neck is recommended for further evaluation of
vascular findings.
2. Clinical correlation and possible biopsy is suggested for enhancing lesion
in thoracic vertebral body.
3. Breast followup as planned for further evaluation of right breast
findings.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:30 pm, 20 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK
INDICATION: ___ year old woman with unremarkable PMHx who p/w right sided back
pain and new breast lesion, found to have cystic lesion in R breast a/w
abnormal enhancement, as well as MRI mediastinum showing left brachiocephalic
vein confluence concerning for thrombus. CTV for further assessment of
thrombus. Note finding in L brachiocephalic vein on MRI. Please go down to
aortic arch. // CTV neck for assessment of left brachiocephalic vein
thrombus.
TECHNIQUE: Imaging was performed after administration of Omnipaque350
intravenous contrast material.
MDCT acquired helical axial images were obtained from the thoracic inlet
through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.5 s, 29.2 cm; CTDIvol = 17.2 mGy (Body) DLP = 491.8
mGy-cm.
Total DLP (Body) = 492 mGy-cm.
COMPARISON: MR ___ ___. Outside reference CT chest ___.
FINDINGS:
Evaluation of the aerodigestive tract demonstrates no mass and no areas of
focal mass effect.
The salivary glands enhance normally and are without mass or adjacent fat
stranding. The thyroid gland appears normal.There are several prominent lymph
nodes within the bilateral submandibular space but no cervical lymphadenopathy
by size criteria.The bilateral carotid arteries and internal jugular veins are
patent. Of note, the right internal jugular vein is diminutive.
Periapical lucencies are seen involving ___ teeth 3, 5, 28, and 30 (3:28, 21,
30, 31). There are small retention cysts in the bilateral maxillary sinuses.
There is a well delineated rounded a centrally located filling defect within
the left brachiocephalic vein (3:66), which does not appear to extend into the
left subclavian vein, left internal jugular vein, or to the superior vena
cava. Contrast is seen within the left subclavian vein and refluxing to the
left internal jugular vein, however, there is a lack of reflux into the left
superior intercostal vein (3:68), suspicious for extension of thrombus.
The imaged portion of the lung apices are clear and there are no concerning
pulmonary nodules. There is a 1.8 cm nonenhancing rounded low-density
structure within the superior mediastinum, anterior to the aortic arch (3:75),
better characterized on prior MR.
___ is heterogeneous sclerosis of the C2 through C6 vertebrae, which may
represent metastatic disease. No pathological fracture is identified. There
are mild multilevel degenerative changes in the cervical spine.
IMPRESSION:
1. Thrombus within the left superior intercostal vein with partial extension
into the left brachiocephalic vein.
2. Heterogeneous sclerosis of the C2 through C6 vertebrae, which may represent
metastatic disease.
3. Periapical lucencies involving several right mandibular and maxillary
teeth, which is concerning for periodontal and periapical infection.
Radiology Report
EXAMINATION: CT-guided spine biopsy
INDICATION: ___ year old woman with unremarkable PMHx who presents with right
back pain and new right breast lesion, found to have cystic appearing breast
lesion with some abnormal enhancement and a T9 lesion which is concerning for
metastatic spread. Consult for biopsy of this lesion. // T4 lesion c/f met
COMPARISON: CT ___, MRI ___, outside hospital CT ___
PROCEDURE: CT-guided core biopsy of T8 vertebral boy.
OPERATORS: Dr. ___, radiology resident and Drs. ___
___, attending radiologists performed the procedure. Dr. ___
___ supervised the trainee during the key components of the procedure
and reviewed and agrees with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the CT scan table. Limited
preprocedure CT scan of the intended biopsy area was performed. There is
redemonstration a right peripheral breast lesion (series 2, image 7). Based
on the CT findings an appropriate position for the biopsy was chosen. The
site was marked.
The site was prepped and draped in the usual sterile fashion. 1% lidocaine
were administered to the subcutaneous and deep tissues for local anesthetic
effect. 5% bupivacaine was administered along the periosteum. Under CT
guidance, using an Arrow OnControl bone access system, an 11 gauge access
needle was introduced into the lesion. A 13 gauge bone biopsy needle was used
to obtain 3 specimens of the left aspect of the vertebral body at the level of
T8, through a transpedicular approach. The samples were sent for pathology.
A postprocedure spiral CT was obtained, which demonstrated the tract site of
the biopsy without evidence of large hematoma, pneumothorax or fracture.
The procedure was tolerated well and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.0 s, 21.2 cm; CTDIvol = 29.1 mGy (Body) DLP = 624.8
mGy-cm.
2) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
3) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
4) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
5) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
6) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
7) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
8) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
9) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
10) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
11) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
12) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
13) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
14) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
15) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
16) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
17) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
18) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
19) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
20) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
21) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
22) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
23) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
24) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
25) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
26) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
27) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
28) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
29) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
30) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
31) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
32) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
33) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
34) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
35) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
36) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
37) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
38) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
39) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
40) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
41) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
42) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
43) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
44) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
45) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
46) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
47) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
48) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
49) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
50) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
51) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
52) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
53) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
54) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
55) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
56) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
57) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
58) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
59) Spiral Acquisition 3.2 s, 16.7 cm; CTDIvol = 29.1 mGy (Body) DLP = 493.8
mGy-cm.
Total DLP (Body) = 1,358 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of 3
mg Versed and 150 mcg fentanyl throughout the total intra-service time of 45
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
1. Pre and postprocedural CT read demonstrated a sclerotic lesion within the
left lateral aspect of the T8 vertebral body. Additionally, there is a soft
tissue lesion and general nodularity of the right breast, which is
incompletely characterized on this noncontrast CT and would be better
evaluated mammographically.
IMPRESSION:
1. Successful biopsy of the left sided sclerotic T8 vertebral body lesion.
Samples were sent to pathology for review.
2. No immediate complications.
3. Soft tissue mass and nodularity of the right breast, which would be better
characterized mammographically.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: R Breast pain, Transfer
Diagnosed with Unspecified lump in the right breast, unspecified quadrant
temperature: 97.9
heartrate: 96.0
resprate: 20.0
o2sat: 100.0
sbp: 139.0
dbp: 77.0
level of pain: 0
level of acuity: 3.0 | SUMMARY:
___ yo healthy, obese female who presented with R breast pain and
R stabbing back pain, found to have a cystic breast mass,
enhancing sclerotic lesions at C3-C6 and T9 vertebral bodiesm
and a left superior intercostal vein thrombus with extension
into the L brachiocephalic vein. Findings were overall
concerning for underlying malignancy. She underwent an ___
guided T9 spinal bone biopsy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
BuSpar / amoxicillin / salsalate
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization with PCI ___
History of Present Illness:
Ms. ___ is a ___ year old female with mild aortic stenosis
___ 1.2-1.9), hypertension, hyperlipidemia, GERD, and recent
admission for chest pain with negative stress echo, who presents
with substernal chest pain. She describes the chest pain as
substernal, band-like, with some radiation to her back and
teeth. The pain was ___ in severity, similar in character to
that from her last admission but worse. The patient at Maalox at
home with no relief of symptoms. The pain does not get worse
with exertion. She denies shortness of breath and edema.
In the ED, initial vitals were 98 70 160/90 16 99% RA. Labs were
notable for WBC 11.1, Cr 0.8, trop 0.14 -> 0.29. EKG showed SR,
LAD, Q waves in III, aVF, V1-V3 without ST changes. Due to
persistent pain, the patient was given ASA 324mg, nitro SL and
gtt, and heparin gtt. Her pressures dropped to SBP ___ after the
admission of nitro SL. Given her persistent chest pain and
rising troponins, the patient was taken directly to the C. Cath
lab where 2 DES were placed in her RCA. She was loaded with
ticagrelor 180 mg PO once. She tolerated the procedure well and
was admitted to the general cardiology service.
On the floor, the patient feels well. She has no further chest
pain at present. She has no other complaints at present.
Of note, the patient was recently admitted to ___ for chest
pain from ___ to ___. Due to concern for ACS, she was
started on a heparin gtt for 48 hours. TTE showed mild aortic
stenosis with EF 65%. An exercise stress echo was done without
evidence of inducible ischemia. It was felt her pain was
non-cardiac in etiology.
On review of systems, the patient complains of phlebitis on her
right ankle. She denies any prior history of stroke, TIA, deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, hemoptysis, black stools
or red stools. 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 dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
IBS-C
GASTROESOPHAGEAL REFLUX
HYPERTENSION
ELEVATED CHOLESTEROL
ASTHMA
Aortic stenosis ___ 1.2-1.9cm2)
Social History:
___
Family History:
no family history of MI, sudden cardiac death
Physical Exam:
PHYSICAL EXAM:
Vitals: T 98.3, BP 140-84, HR 75, RR 16, O2 98%RA
General: Pleasant woman in bed in NAD.
HEENT: NCAT, MMM, EOMI
Neck: JVP not elevated
CV: ___ systolic murmur strongest at the LUSB, RRR, normal S1S2
Lungs: CTAB, no crackles or wheezes appreciated
Abdomen: soft, nontender, nondistended, +BS
Extr: warm and well-perfused, no cyanosis, clubbing, or edema,
2+ DP pulses bilaterally. Swollen superficial vein near right
ankle.
Neuro: A&Ox3, no gross deficits.
Pertinent Results:
ADMISSION LABS:
___ 02:30AM WBC-11.1* RBC-5.66* HGB-15.7 HCT-47.3* MCV-84
MCH-27.7 MCHC-33.2 RDW-13.2 RDWSD-39.5
___ 02:30AM GLUCOSE-96 UREA N-15 CREAT-0.8 SODIUM-136
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-28 ANION GAP-14
___ 02:30AM LIPASE-26
___ 02:30AM cTropnT-0.14*
TROPONIN TREND:
___ 02:30AM BLOOD cTropnT-0.14*
___ 08:35AM BLOOD cTropnT-0.29*
DISCHARGE LABS:
___ 06:05AM BLOOD WBC-11.1* RBC-5.18 Hgb-14.4 Hct-44.0
MCV-85 MCH-27.8 MCHC-32.7 RDW-13.3 RDWSD-41.0 Plt ___
___ 06:05AM BLOOD Plt ___
___ 06:05AM BLOOD Glucose-72 UreaN-13 Creat-0.6 Na-139
K-3.8 Cl-101 HCO3-25 AnGap-17
___ 06:05AM BLOOD cTropnT-0.17*
___ 06:05AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.5
MICROBIOLOGY:
none
IMAGING/PROCEDURES:
Cardiac cath ___:
The ___ had no angiographically apparent CAD. The LAD had mild
calcification and luminal irregularities. The Cx and OM had mild
luminal irregularities. The RCA was moderately calcified with
irregular, hazy and calcific 60-70% stenoses in the mid and
distal section. Successful PCI of the RCA with two overlapping
stents. Final angiography revealed normal flow, no dissection,
0% residual stenosis.
CXR ___: No acute cardiopulmonary process
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Cetirizine 10 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. linaclotide 290 mcg oral DAILY
5. Omeprazole 20 mg PO BID
6. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
7. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
2. Omeprazole 20 mg PO BID
3. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
4. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
5. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
6. Cetirizine 10 mg PO DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. linaclotide 290 mcg oral DAILY
9. TiCAGRELOR 90 mg PO BID
RX *ticagrelor [BRILINTA] 90 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
10. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
non-ST elevation myocardial infarction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: PA AND LATERAL CHEST RADIOGRAPH
INDICATION: History: ___ with CP, concern for NSTEMI // evidence of
pneumothorax or pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: None
FINDINGS:
The cardiomediastinal and hilar contours are within normal limits. The lungs
are clear without focal consolidation, pleural effusion or pneumothorax. No
pulmonary edema. Linear opacity at the left costophrenic angle corresponds to
scarring when correlated with recent chest CT.
IMPRESSION:
No acute cardiopulmonary process
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Epigastric pain
Diagnosed with SUBENDOCARDIAL INFARCTION, INITIAL EPISODE OF CARE
temperature: 98.0
heartrate: 70.0
resprate: 16.0
o2sat: 99.0
sbp: 160.0
dbp: 90.0
level of pain: 7
level of acuity: 2.0 | ___ year old female with mild aortic stenosis ___ 1.2-1.9),
hypertension, and GERD who presents with substernal chest pain.
Troponins elevated on admission and uptrending. EKG consistent
with NSTEMI.
# NSTEMI: The patient's troponins in the ED uptrended from 0.14
to 0.29. Serial EKGs on admission showed Q waves in III, AVR,
and V1, with T-wave flattening/inversions in V4 and V5, no ST
elevations or depressions. The patient's chest pain persisted
and she patient did not tolerate SL nitro (blood pressures
dropped in ED). The patient was taken to the Cath Lab where they
found one-vessel disease and two overlapping DES were placed in
her RCA. She was loaded with ticagrelor in the cath lab. The
patient tolerated the procedure well and ger chest pain resolved
after PCI. After her PCI, that patient had dual-antiplatelet
therapy with aspirin and ticagrelor. We increased her home
atorvastatin to 80mg. We also started metoprolol tartrate 12.5mg
q6h. We avoided further nitros. After her cath, the patient's
troponins were 0.17. The patient's post-cath course was
uneventful and she was discharged in stable condition on
___.
# HTN: chronic. We started metoprolol as above. We held the
patient's home Triamterene/HCTZ on admission
# GERD: chronic. We continued the patient's home home omeprazole
20mg BID.
# HLD: chronic. We increased the patient;s home atorvastatin
from 40mg to 80mg as above.
# Asthma: chronic
- Home Symbicort not on the formulary, giving Advair during this
admission. Discharged back on home Symbicort.
***Transitional Issues***
[ ] follow up with your PCP
[ ] follow up with your cardiologiest |
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:
___ Celiac plexus neurolysis
History of Present Illness:
___ with Stage IIB pancreatic adenocarcinoma s/p surgery,
chemoXRT, adjuvant SBRT, and gemcitabine, presenting again with
acute on chronic abdominal pain.
Patient states since his cancer diagnosis, he has chronic LUQ,
LLQ, and RLQ pain. He takes oxycodone and oxycontin for this
pain. He has had multiple hospitalizations for this pain. On
___, he was found to have intussusception of his small bowel.
He was treated conservatively and his symptoms improved. He was
again admitted from ___ to ___ for acute on chronic
abdominal pain. CT showed no acute findings. Bowel regimen was
increased and he was discharged home.
Today, he reports epigastric pain and nausea which has
progressively worsened last several days. No vomiting or fevers.
His last bowel movement was reportedly normal. In the ED,
initial vitals were T99.1 59 135/69 18 100RA. Labs were at
baseline except for mild transaminitis, normal AP, TB, lipase.
CT showed stable appearance of pancreatic head mass and
ill-defined soft tissue. No evidence of small-bowel obstruction.
Intact jejunal anastomosis. He was given 1L NS, morphine 5mg IV
x4, Zofran 4mg IV x3, fluoxetine 10mg.
Past Medical History:
==============================================
PAST ONCOLOGIC HISTORY
==============================================
Mr ___ underwent resection in ___ for stage
IIB (pT3, pN1, cM0) 1.5 cm, grade 1 pancreatic ductal
adenocarcinoma with LVI and perineural invasion and positive
margins 1 of 3 lymph nodes positive s/p central pancreatectomy.
Received adjuvant therapy on study ___, a phase 3 study of
chemotherapy and chemoradiotherapy with or without
hyperacute-pancreas immunotherapy in subjects with resected
pancreatic cancer. Randomized to standard of care arm and
completed adjuvant therapy in ___.
.
Surveillance scans in ___ were concerning for local
recurrence which was biopsy proven. Mark started chemotherapy
for local recurrence ___ with gemcitabine, with plan for ___
cycles. Received adjuvant SBRT to the pancreas in ___.
Course complicated by need for dose adjustment due to counts as
well as hospitalization for abdominal pain in ___. Resumed
chemotherapy ___ to finish planned adjuvant course.
- S/p Gemcitabine Cycle 6.
==============================================
PAST MEDICAL HISTORY
==============================================
--CELIAC PLEXUS NEUROLYSIS ___
--GERD
--Chronic back pain
--Cholecystecomy with intraoperative cholangiogram (___)
--Appendectomy
--Tonsillectomy
Social History:
___
Family History:
adopted, family hx unknown
Physical Exam:
===================
ADMISSION PHYSICAL:
===================
GENERAL: NAD
HEENT: NC/AT, EOMI, PERRL, MMM
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
PULSES: 2+DP pulses bilaterally
NEURO: A&O x 3, CN II-XII intact
SKIN: Warm and dry, without rashes
===================
DISCHARGE PHYSICAL:
===================
VS: 98.4 106/56 57 20 98%RA
GENERAL: NAD
HEENT: NC/AT, EOMI, PERRL, MMM
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
PULSES: 2+DP pulses bilaterally
NEURO: A&O x 3, CN II-XII intact
SKIN: Warm and dry, without rashes
Pertinent Results:
================
ADMISSION LABS:
================
___ 03:55AM BLOOD WBC-9.1 RBC-3.76* Hgb-11.6* Hct-36.8*
MCV-98 MCH-30.9 MCHC-31.5* RDW-15.2 RDWSD-55.1* Plt ___
___ 03:55AM BLOOD Neuts-72.5* Lymphs-15.7* Monos-6.9
Eos-4.3 Baso-0.3 Im ___ AbsNeut-6.57* AbsLymp-1.43
AbsMono-0.63 AbsEos-0.39 AbsBaso-0.03
___ 03:55AM BLOOD ___ PTT-30.9 ___
___ 03:55AM BLOOD Glucose-100 UreaN-12 Creat-0.5 Na-138
K-4.2 Cl-104 HCO3-23 AnGap-15
___ 03:55AM BLOOD ALT-64* AST-41* AlkPhos-124 TotBili-0.2
___ 03:55AM BLOOD Lipase-10
___ 03:55AM BLOOD Albumin-3.6 Calcium-8.5 Phos-4.1 Mg-2.1
================
DISCHARGE LABS:
================
___ 04:53AM BLOOD WBC-6.7 RBC-3.66* Hgb-11.4* Hct-35.9*
MCV-98 MCH-31.1 MCHC-31.8* RDW-14.9 RDWSD-53.8* Plt ___
___ 04:53AM BLOOD Plt ___
___ 04:53AM BLOOD Glucose-99 UreaN-12 Creat-0.5 Na-139
K-4.3 Cl-105 HCO3-27 AnGap-11
___ 04:53AM BLOOD ALT-91* AST-28 AlkPhos-218* TotBili-0.2
___ 04:53AM BLOOD Calcium-8.3* Phos-3.9 Mg-2.1
=========
IMAGING:
=========
___ CT ABD/PELVIS:
1. Stable appearance of pancreatic head mass and ill-defined
soft tissue.
2. No evidence of small-bowel obstruction. Intact jejunal
anastomosis.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: +PO contrast; History: ___ with diffuse abdominal pain history of
pancreatic cancer+PO contrast // eval for sbo, worsening cancer
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
IV Contrast: 130 mL Omnipaque.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 600 mGy-cm.
COMPARISON: ___ a
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.
Hypodensity at the liver dome has not changed since the recent examinations.
No other focal hepatic lesions are seen. Minimal intrahepatic biliary ductal
dilatation with focal dilatation of the dome is unchanged since the 2 prior
examinations. The common bile duct measures approximately 9 mm, which is
unchanged since prior examinations. The gallbladder is absent.
PANCREAS: The patient is status post central pancreatectomy and
pancreaticojejunostomy. The pancreatic tail is atrophic. Again seen is a
hypodense lesion in the pancreatic head, not significantly changed since the
prior. Ill-defined soft tissue adjacent to the fiducial markers is also
unchanged (02:23), and is difficult to measure.
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 is a simple cyst in the upper pole of the right kidney. There is
no hydronephrosis or perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. The patient has undergone
prior pancreaticojejunostomy. Right upper quadrant anastomosis is intact,
with contrast material passing past this region, through the entire small
bowel, into the colon. The small bowel is largely unremarkable. A prominent
loop of small bowel in the right upper quadrant measures approximately 3.7 cm
in diameter, and is nonspecific. A decompressed loop of small bowel is seen
in the left lower quadrant (601b:20). The this may be related to peristalsis.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged.
LYMPH NODES: No definite lymphadenopathy is present.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: Degenerative changes are seen throughout the thoracolumbar spine,
particularly at L4 and 5.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Stable appearance of pancreatic head mass and ill-defined soft tissue.
2. No evidence of small-bowel obstruction. Intact jejunal anastomosis.
Radiology Report
INDICATION: ___ year old man with pancreatic cancer and acutely worsening
abdominal pain with guarding and rebound evaluate for perforation or
obstruction.
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: ___ CT of the abdomen and pelvis with contrast.
FINDINGS:
There are no abnormally dilated loops of large or small bowel. There is no
free intraperitoneal air. The clips overlie the right upper quadrant and
upper abdomen. There are mild degenerative changes of the lumbar spine.
IMPRESSION:
No obstruction or pneumoperitoneum.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Nausea
Diagnosed with Lower abdominal pain, unspecified, Malignant neoplasm of pancreas, unspecified
temperature: 99.1
heartrate: 59.0
resprate: nan
o2sat: 100.0
sbp: 135.0
dbp: 69.0
level of pain: 8
level of acuity: 2.0 | ___ with Stage IIB (pT3, pN1, cM0) pancreatic adenocarcinoma s/p
central pancreatectomy, pancreaticojejunostomy w/ adjuvant
chemoradiation with biopsy confirmed local recurrence in ___
s/p adjuvant CK ___ and 6 cycles of Gemcitabine (last dose
___ c/b recent dx of jejunal intussusception presenting
with acute on chronic abdominal pain.
============= |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Keflex / Sulfa(Sulfonamide Antibiotics) / Xanax / Prozac /
vancomycin / lisinopril
Attending: ___.
Chief Complaint:
CC: ___, flank pain and abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Ms. ___ is a ___ female with the past medical
history notable for CHF (LVEF 50%), breast cancer in remission
since ___ s/p chemotherapy/mastectomy/radiation c/b pulmonary
fibrosis and pulmonary hypertension who presented with
complaints of 1 day of diarrhea, nausea, flank pain and
abdominal
pain.
Patient reports she has been having symptoms of diarrhea since
___. She was first admitted on ___ and treated for UTI,
eosinophilia and thrush with unintentional weight loss. She was
recently readmitted from ___ in the setting of nausea,
vomiting and diarrhea after another admission on ___ for
similar
symptoms. On her most recent admission CT scan was negative,
MRCP
had showed intra and extrahepatic bile duct dilation which was
felt due to prior cholecystectomy as EUS and MRCP were
reassuring
and workup for PBC was negative.
She then saw her PCP ___ ___ who had planned to check stool for
cultures, ova and parasites, cdiff giardia, strongyloides
antibodies, schistosoma antibodies, unfortunately stool studies
weren't obtained yet. Patient was found to have H.Pylori IgG
Antibody positive and started on pylera (Bismuth/ Metronidazole
/ Tetracycline with omeprazole for 10 days. She has currently
taken 3 days of the pills.
On ___ she presented again with 1 day of diarrhea overnight (~5
episodes of watery diarrhea), abdominal pain and bilateral flank
pain. She reports chills but denies fevers. Denies any recent
travel. Reports unintentional weight loss of ~11 pounds for the
past few months. She denies urinary symptoms. She reports
diarrhea has improved however she took loperamide on morning
prior to coming to the ED.
In the ED
- Initial vitals: 97.0 74 127/78 18 95% RA
- Exam notable for: minimal epigastric tenderness with no
rebound
or guarding
- Labs:
+ CBC: WBC 8.2 H/H 10.9/33.6 Plt 320
+ Chem 10: Na 132 Creat 1.4, HCO3 24
+ LFTs: ALT 17 AST 60 Alkphos 109, T bili 0.4
+ UA was normal
- Imaging: Cxray showed: No evidence of acute pneumonia or
vascular congestion
- Patient was given: Haldol PO 1.5mg, Erythromycin 250mg and 2L
NS.
- Transfer vitals: 98.0 57 108/38 18 100% RA
On the floor patient reports improvement in symptoms. She
reports
abdominal cramps but denies overt abdominal tenderness. Rest of
history as above. She had half of her dinner and relatively
tolerated it well. She denies any recent travel or exposure to
sick contacts.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
- Congestive Heart Failure: unclear etiology thought to be due
to Adriamycin vs. ischemic cardiomyopathy
- CAD s/p DES placed to RCA in ___ (reports recently
being on 1 month of clopidogrel due to a procedure she had,
ended
___
- Abnormal lung parenchyma, post-radiation changes and COPD
- Cath demonstrated elevated PAsp and elevated PCWP
- GERD
- Depression
- COPD
- Hypertension
- LUE DVT in ___ s/p 3 month Lovenox
- Hx of breast cancer s/p mastectomy/chemo/radiation in
remission
- Cataract surgery
- Hyperlipidemia
- Cholecystectomy in ___
- Hysterectomy age ___
- Multiple thyroid nodules
- Osteoporosis
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization. Mother had CHF. Sister who
was diagnosed with breast cancer at ___.
Physical Exam:
Admission EXAM
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx dry without visible lesion, erythema or exudate
CV: Heart regular, ___ murmur loudest in ___
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation in all
quadrants, though reports lower quadrant cramps. Bowel sounds
present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
Back: Reports CVA tenderness ___
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Discharge Exam
VITALS: 98.1 105 / 60 65 18 96 Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx dry without visible lesion, erythema or exudate
CV: Heart regular, ___ murmur loudest in ___
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation in all
quadrants. No cramps reported today. 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
Back: No CVA tenderness
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
Relevant historical labs:
==========================
Strongyloides (___) negative
IgE ___ High at 4426
Atrius records from ___
- H. Pylori IgG Antibody Positive
Imaging:
========
Chest xray showed: No evidence of acute pneumonia or
vascular congestion
Abdominal xray: ___
IMPRESSION:
No evidence of bowel obstruction
Discharge labs:
===============
___ 07:35AM BLOOD Glucose-77 UreaN-19 Creat-0.9 Na-144
K-4.7 Cl-105 HCO3-25 AnGap-14
___ 07:35AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.3
Microbiology:
=============
___ 1:58 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 11:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 8:25 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
___ 8:25 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
___ 8:19 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
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.
___ 8:17 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
OVA + PARASITES (Pending):
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath
3. LORazepam 0.5 mg PO Q8H:PRN anxiety
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. Pravastatin 40 mg PO QPM
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Omeprazole 20 mg PO BID
8. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shorteness of
breath
10. Clobetasol Propionate 0.05% Cream 1 Appl TP BID eczema
11. Docusate Sodium 100 mg PO BID:PRN constipation
12. Hydrocortisone Cream 1% 1 Appl TP TID vaginal pruritis
13. ipratropium bromide 0.06 % nasal BID
14. Ondansetron 4 mg PO BID:PRN nausea/vomiting
15. Spironolactone 25 mg PO EVERY OTHER DAY
16. Torsemide 20 mg PO EVERY OTHER DAY
17. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID to all
pruritic areas
18. LOPERamide 2 mg PO QID:PRN diarrhea
19. Pylera (bismuth subcit K-metronidz-tcn) ___ mg oral
QID
Discharge Medications:
1. Simethicone 40-80 mg PO QID:PRN gas pains
RX *simethicone 80 mg 1 tablet by mouth four times a day Disp
#*60 Tablet Refills:*0
2. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*3
3. Ondansetron 4 mg PO BID:PRN nausea/vomiting
4. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shorteness of
breath
6. Aspirin 81 mg PO DAILY
7. Clobetasol Propionate 0.05% Cream 1 Appl TP BID eczema
8. Hydrocortisone Cream 1% 1 Appl TP TID vaginal pruritis
9. ipratropium bromide 0.06 % nasal BID
10. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath
11. LOPERamide 2 mg PO QID:PRN diarrhea
12. LORazepam 0.5 mg PO Q8H:PRN anxiety
13. Metoprolol Succinate XL 12.5 mg PO DAILY
14. Multivitamins W/minerals 1 TAB PO DAILY
15. Pravastatin 40 mg PO QPM
16. Pylera (bismuth subcit K-metronidz-tcn) ___ mg oral
QID
17. Spironolactone 25 mg PO EVERY OTHER DAY
18. Torsemide 20 mg PO EVERY OTHER DAY
19. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID to all
pruritic areas
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Intolerance of Fermentable Oligo-, Di-, Mono-saccharides And
Polyols
H. Pylori
___
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 low BP, infectious work-up// evaluate for
infectious process
IMPRESSION:
In comparison with the study ___, the cardiomediastinal silhouette is
stable. No substantial change in the postoperative appearance of the left
upper lung.
No evidence of acute pneumonia or vascular congestion.
Radiology Report
INDICATION: ___ year old woman with diarrhea, abd distension// assess for
dilated loops of bowel, any signs of obstruction
TECHNIQUE: Abdomen supine
COMPARISON: ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
The patient is status post cholecystectomy.
IMPRESSION:
No evidence of bowel obstruction
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, N/V
Diagnosed with Unspecified abdominal pain
temperature: 97.0
heartrate: 74.0
resprate: 18.0
o2sat: 95.0
sbp: 127.0
dbp: 78.0
level of pain: 6
level of acuity: 3.0 | ___ w/ CAD s/p DES ___, HTN/HLD, dCHF, breast CA s/p
mastectomy/chemo/XRT, GERD admitted with diarrhea, nausea,
abdominal pain and bloating. Her symptoms have been intermittent
for the past 2 months, during which time she has had 3
hospitalizations for this problem. She has also had an 11 lb
weight loss over the past 2 months due mainly to decreased PO
intake due to nausea. She also had some ___ on admission that
resolved with PO intake and hydration; her diuretics were held
during this admission. This improved with increasing her
omeprazole to 40 mg PO BID. Her diarrhea resolved with one dose
of immodium, and she was started on a FODMAP elimination diet.
Her case was discussed with gastroenterology, who felt that
since she will undergo a repeat EGD in 4 weeks to assess for H.
pylori resolution, it would be preferable to assess her colon
with a colonoscopy at that time. She was discharged with
gastroenterology follow-up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
L sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ right-handed man with PMH significant
for a heart murmur for which he takes ASA 81mg who was
transferred from ___ for right basal ganglia IPH.
As per the pt's wife, the pt was in his usual state of health
when he awoke this morning, had breakfast and then went to the
bathroom to get cleaned up and start his day. When he returned
from the bathroom he was slipping as he walked toward the bed.
His wife initially thought he was goofing off, so she told him
to
go get dressed, but when he went over to the dresser he
continued
to have difficulty standing and was slipping almost pulling the
dresser down on himself. As he turned to try to walk back
towards the bed, he told his wife that his left-side felt funny
and then he became unable to walk and started crawling towards
the bed. His wife called ___ and she noticed that he had a left
facial droop and started to slur his words.
He was taken by EMS to ___ where a ___ showed a right BG
IPH and he was transferred to ___ for further evaluation. At
the OSH, BP 183/87.
OSH Labs: Chem 142/3.3 ___ Glc 140 Ca 9.5
CBC: 14>13.9/41.7<246
Trop <0.01
He was transferred to ___ for further evaluation. Upon arrival
a CODE STROKE was called. NIHSS 8* and he was taken for CT/CTA
H/N. BP on arrival 172/88.
As per wife, no reported headache, loss of vision, blurred
vision, diplopia, dysphagia, lightheadedness, vertigo, tinnitus
or hearing difficulty. No bowel or bladder incontinence or
retention.
As per wife, no 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:
heart murmur (unspecified valvular disease)
Social History:
___
Family History:
Mother: DM. Maternal side: Strokes with old age
Physical Exam:
ADMISSION EXAM:
Vitals: T:98.6 P: 53 R: 14 BP: 172/88 SaO2:99% RA
General: Awake, right-gaze preference.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to self, hospital and date.
+Dysarthric speech. Right gaze preference with left-sided
neglect. +Inattention requiring repetition and reorientation.
-Cranial Nerves:
PERRL 3 to 2mm and brisk. EOM full horizontal gaze without
nystagmus. Normal saccades. +LNLFF at rest and left droop with
activation. Tongue midline
-Motor: Normal bulk, tone throughout.
Delt Bic Tri IP Quad Ham TA ___ ___
L 5- 4+ ___- 5- 4+ 5- 4+
R 5 5 ___ 5 5 5 5
-Sensory: No deficits to light touch throughout. -DTRs:
___ Pat +crossed adductors b/l
L 2 2 3
R 2 2 3
L toe mute, R toe up
-Coordination: No dysmetria to FNF on right, no gross ataxia on
L
FNF, but hard to assess due to LUE weakness
-Gait: Deferred
========================
DISCHARGE EXAM:
General: Awake, NAD, no gaze preference.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Normal work of breathing
Cardiac: warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented. Language fluent. Dysarthria
resolved.
-Cranial Nerves:
PERRL 3 to 2mm and brisk. EOM full horizontal gaze without
nystagmus. Normal saccades. +LNLFF at rest, symmetric
activation. Tongue midline
-Motor: Normal bulk, tone throughout. Pronator drift LUE
Delt Tri WrExtIP IP Quad Ham TA
L 5 5- 5 5- 5- 5 5
R 5 5 5 ___ 5
-Sensory: decreased sensation on L compared to R for pinprick,
temp, proprioception and vibration
-DTRs:
L toe mute, R toe up
-Coordination: No dysmetria to FNF on right, L side dysmetria
improving
-Gait: wide based
Pertinent Results:
___ 07:00AM BLOOD WBC-6.4 RBC-4.74 Hgb-12.5* Hct-39.6*
MCV-84 MCH-26.4 MCHC-31.6* RDW-14.1 RDWSD-43.4 Plt ___
___ 07:00AM BLOOD Glucose-100 UreaN-12 Creat-1.0 Na-144
K-4.3 Cl-104 HCO3-26 AnGap-14
___ 05:05PM BLOOD ALT-17 AST-23 LD(LDH)-214 CK(CPK)-178
AlkPhos-95 TotBili-0.2
___ 12:29AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.7
___ 05:05PM BLOOD Triglyc-73 HDL-64 CHOL/HD-4.5
LDLcalc-211*
___ 12:38PM BLOOD %HbA1c-5.7 eAG-117
___ 05:05PM BLOOD TSH-0.93
===============
DIAGNOSTIC STUDIES:
CTA ___ ___:
1. Right basal ganglia hemorrhage without mass effect, midline
shift or
significant surrounding edema.
2. Mild atherosclerotic disease both carotid bifurcations
otherwise no
significant abnormalities on CT angiography of the ___ and
neck.
CT ___ ___:
Grossly unchanged 3.5 x 2.3 cm right basal ganglia
intraparenchymal hematoma
with surrounding edema. No evidence of new intracranial
hemorrhage.
MR ___ w/wo contrast ___:
Right basal ganglia hemorrhage is again noted. No other
hemorrhage.
No acute infarct. No abnormal enhancement post-contrast.
Imaging follow-up after resolution advised to exclude an
underlying lesion, if clinically indicated.
(Not indicated given etiology is hypertensive bleed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Lisinopril 10 mg PO DAILY
2. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until minimum 1 month after stroke. Should
be restarted only if physician says it is necessary for treating
an existing condition.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute hemorrhagic stroke
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 ANGIOGRAPHY HEAD AND NECK
INDICATION: History: ___ with L sided weakness, L hemineglect// R basal
ganglia hemorrhage, midline shift, worsening, aneurism?
TECHNIQUE: CT of the head was acquired. Following contrast administration and
departmental protocol CT angiography of the head and neck was obtained. 3D
and curved reformatted images were obtained on the independent workstation.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 7.0 s, 0.5 cm; CTDIvol = 76.2 mGy (Head) DLP =
38.1 mGy-cm.
3) Spiral Acquisition 5.0 s, 39.7 cm; CTDIvol = 31.0 mGy (Head) DLP =
1,231.3 mGy-cm.
Total DLP (Head) = 2,072 mGy-cm.
COMPARISON: None
FINDINGS:
CT head shows a right basal gangliar intraparenchymal bleed that measures up
to 2.1 x 3.6 cm (02:16). There is no shift of normally midline structures. The
basal cisterns are patent.
CT angiography of the neck shows normal appearance of the carotid and
vertebral arteries without stenosis or occlusion or dissection. The distal
right vertebral artery ends in posterior inferior cerebellar artery, a normal
variation.
CT angiography of the head shows normal appearance of the arteries of the
anterior and posterior circulation without stenosis or occlusion or aneurysm
greater than 3 mm in size. Mild atherosclerotic disease seen at both carotid
bifurcations without stenosis.
IMPRESSION:
1. Right basal ganglia hemorrhage without mass effect, midline shift or
significant surrounding edema.
2. Mild atherosclerotic disease both carotid bifurcations otherwise no
significant abnormalities on CT angiography of the head and neck.
Radiology Report
INDICATION: ___ with weakness// ?pna
TECHNIQUE: Single portable view of the chest.
COMPARISON: None
FINDINGS:
Lungs are clear. There is no focal consolidation. There is no effusion or
edema. The cardiomediastinal silhouette is within normal limits. No acute
osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with hypertension and R BG IPH, eval for interval
change and any underlying mass// interval scan and etiology of bleed
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: Prior CT brain done ___
FINDINGS:
The right basal ganglia hemorrhage is again noted being T1 iso to hyperintense
and T2 hyperintense with marked blooming on the gradient echo with surrounding
edema on T2 and FLAIR. The bleed measures approximately 40 x 24 mm in the
axial plane on T2 imaging. There is mass effect on the adjacent left lateral
ventricle with midline shift by 1-2 mm. No abnormal enhancement postcontrast.
No other areas of intracranial hemorrhage. No acute infarct. Partially empty
sella. The craniocervical junction appears normal. The intracranial arteries
demonstrate normal T2 flow voids. Mild mucosal thickening involving the
paranasal sinuses. The orbits appear normal.
IMPRESSION:
Right basal ganglia hemorrhage is again noted. No other hemorrhage.
No acute infarct. No abnormal enhancement postcontrast.
Imaging follow-up after resolution advised to exclude an underlying lesion, if
clinically indicated.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: ___ year old man with R BG IPH// Repeat in 24hrs.
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: CTA head and neck dated ___.
FINDINGS:
Again seen is a 3.5 x 2.3 cm intraparenchymal hematoma in the right basal
ganglia with surrounding edema, grossly unchanged compared to ___
given technique differences. No significant midline shift. There is no
evidence ofnew hemorrhage,edema,or mass. Mild effacement of the right lateral
ventricle is unchanged. The sulci are mildly effaced.
There is no evidence of fracture. There is mild mucosal thickening of the
right maxillary sinus. The remaining paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
Grossly unchanged 3.5 x 2.3 cm right basal ganglia intraparenchymal hematoma
with surrounding edema. No evidence of new intracranial hemorrhage.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: L Weakness, Transfer
Diagnosed with Cerebral infarction, unspecified
temperature: 98.6
heartrate: 60.0
resprate: 18.0
o2sat: 99.0
sbp: 148.0
dbp: 82.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ right-handed man with PMH significant for
a heart murmur (unspecified valvular disease) who was
transferred from ___ for right basal ganglia IPH. Etiology
likely hypertensive.
Patient was briefly on nicardipine drip ~5 hours. SBPs was kept
within goal 150mg with PRN antihypertensives. Patient started on
lisinopril with blood pressures sustained systolics 100-150mmHg.
MRI was obtained 24 hours after initial presentation and showed
stable bleeding. No additional intracranial anomalies, signs of
vessel abnormalities, or concerns for cerebral amyloid.
___ evaluated patient and recommended ___
rehabilitation. Patient passed bedside dysphagia screen and
tolerated regular diet.
==================================
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) ___ - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
==================================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ h/o stroke on aggrenox who is s/p fall from standing
around 9:30 pm and transferred from OSH w/ CT findings of L
parietal skull fracture, epidural hematoma, and SAH. He stated
he
slipped on ice on the sidewalk and had likely +LOC. He had
friends who witnessed the fall and stated he hit the back of his
head. He was alert and oriented at the scene and responding to
questions appropriately. He was brought to OSH, where CT Head
showed L parietal bone fracture and a 1.8 x 6 cm epidural
hematoma, as well as frontal contusions and SAH. He was
transferred to ___, hemodynamically stable. He is complaining
of a mild headache as well as nausea, and he has had a few
episodes of emesis.
Past Medical History:
DM2, s/p CVA, HTN, hyperlipidemia, thyroid nodule, erectile
dysfunction
PSH: none
Social History:
___
Family History:
NC
Physical Exam:
Upon admission:
Gen: NAD, A&Ox3
CV: RRR
Pulm: CTAB
Neuro:
CN:
II: Pupils equally round and reactive to light
III, IV, VI: EOMI
V, VII: facial strength/sensation intact symmetric
VIII: intact to voice
IX, X: Palatal elevation symmetrical
XI: intact ___ strength
XII: Tongue midline
Motor: Normal bulk and tone bilaterally. Strength full power ___
throughout.
Sensation: Intact to light touch throughout
Upon discharge:
Awake, alert, oriented x3, MAE full.
Pertinent Results:
___ EKG
Sinus tachycardia. Late R wave progression. Minor lateral
precordial
ST segment depression. No previous tracing available for
comparison. Clinical correlation is suggested.
___ CXR
Left basilar opacity, which may represent atelectasis,
aspiration or
pneumonia. A dedicated PA and lateral view of the chest would be
helpful for further evaluation.
___ CT head
1. Known left epidural hematoma appears slightly larger than on
the prior examination. There is no evidence of midline shifting
of the normally midline structures.
2. Small foci of bilateral subarachnoid hemorrhage, small left
subdural
hemorrhage, and right inferior frontal contusions are stable.
___ CT head
1. No appreciable change in left epidural hematoma and other
small subdural and subarachnoid hemorrhages.
2. Tiny amount of hemorrhage layering dependently in the
occipital horns is more conspicuous.
3. Left subgaleal hemorrhage is improving.
___ CT head:
1. No appreciable change in left epidural and small left
subdural hematomas.
2. No significant change in small intraventricular hemorrhage.
3. Small bilateral subarachnoid hemorrhages are less
conspicuous.
___ 06:52AM BLOOD WBC-13.8* RBC-5.14 Hgb-16.2 Hct-47.3
MCV-92 MCH-31.6 MCHC-34.3 RDW-13.4 Plt ___
___ 04:50AM BLOOD WBC-15.4* RBC-4.86 Hgb-15.0 Hct-44.9
MCV-92 MCH-31.0 MCHC-33.5 RDW-13.9 Plt ___
___ 04:24AM BLOOD WBC-16.1* RBC-4.84 Hgb-15.1 Hct-46.1
MCV-95 MCH-31.2 MCHC-32.8 RDW-13.5 Plt ___
___ 07:26AM BLOOD WBC-17.7* RBC-4.87 Hgb-15.1 Hct-44.8
MCV-92 MCH-31.0 MCHC-33.7 RDW-14.0 Plt ___
___ 01:33AM BLOOD WBC-19.4*# RBC-5.32 Hgb-16.3 Hct-48.6
MCV-91 MCH-30.6 MCHC-33.5 RDW-14.2 Plt ___
___ 01:33AM BLOOD Neuts-85.1* Lymphs-8.9* Monos-5.0 Eos-0.7
Baso-0.5
___ 06:52AM BLOOD ___ PTT-28.8 ___
___ 01:33AM BLOOD ___ PTT-28.9 ___
___ 06:52AM BLOOD Glucose-53* UreaN-21* Creat-1.0 Na-136
K-4.0 Cl-97 HCO3-29 AnGap-14
___ 04:50AM BLOOD Glucose-175* UreaN-19 Creat-0.9 Na-138
K-4.4 Cl-100 HCO3-28 AnGap-14
___ 04:24AM BLOOD Glucose-70 UreaN-16 Creat-0.9 Na-141
K-4.0 Cl-105 HCO3-23 AnGap-17
___ 05:28PM BLOOD Glucose-167* UreaN-16 Creat-1.0 Na-140
K-4.1 Cl-102 HCO3-27 AnGap-15
___ 07:26AM BLOOD Glucose-452* UreaN-19 Creat-1.2 Na-132*
K-4.9 Cl-96 HCO3-24 AnGap-17
___ 01:33AM BLOOD Glucose-251* UreaN-19 Creat-1.1 Na-137
K-4.1 Cl-100 HCO3-25 AnGap-16
___ 06:52AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.2
___ 04:50AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.2
___ 04:24AM BLOOD Calcium-8.1* Phos-3.3 Mg-2.0
___ 05:28PM BLOOD Calcium-8.7 Phos-3.4 Mg-1.9
___ 07:26AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.6
Medications on Admission:
aggrenox ___ BID, atorvastatin 80mg daily, lantus 30u
qAM 8u qpm, humalong SSI, irbesartan 300mg daily, metoprolol 100
BID, nifedipine ER 60mg daily, tadalafil 20mg q72h prn
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN headache
2. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*60 Tablet Refills:*0
3. LeVETiracetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
4. Metoprolol Tartrate 100 mg PO BID
5. NIFEdipine CR 60 mg PO DAILY
6. Glargine 30 Units Breakfast
Glargine 8 Units Bedtime
7. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
8. Outpatient Physical Therapy
Dx: ___
s/p fall with epidural hematoma and skull fx
Discharge Disposition:
Home
Discharge Diagnosis:
Frontal Contusion
Epidural Hematoma
SAH
L parietal skull fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent. Needs some
intermittent supervision for medications and cooking.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with fall, EDH, skull fx, oxygen requirement // ? pneumonia
TECHNIQUE: AP upright view of the chest.
COMPARISON: Chest radiograph ___, chest CT ___.
FINDINGS:
The cardiomediastinal and hilar contours are normal. There is no pneumothorax
or large pleural effusion. Elevation of the right hemidiaphragm is again seen,
with right basilar atelectasis. Heterogeneous left basilar opacities are
noted, which may are present atelectasis, aspiration, or infectious process.
Evidence of right rotator cuff repair is noted. The upper abdomen is
unremarkable.
IMPRESSION:
Left basilar opacity, which may represent atelectasis, aspiration or
pneumonia. A dedicated PA and lateral view of the chest would be helpful for
further evaluation.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 10:14 AM.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man s/p fall w/ L parietal skull fx
epidural/subarachnoid hematoma, on aggrenox at home // eval progression of
epidural hematoma / SAH.
TECHNIQUE: Contiguous axial images images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
CTDIvol: 54.90 mGy
DLP: 1003.42 mGy-cm
COMPARISON: Outside hospital head CT ___.
FINDINGS:
A left frontoparietal epidural hematoma appears slightly larger in size
compared to the prior exam allowing for differences in technique. This
hematoma now has a maximum at 18 mm from the inner table. There is local mass
effect, but no midline shift. Multiple small foci of subarachnoid hemorrhage
in the left frontal and parietal lobes are similar compared to the prior exam.
A small left subdural hematoma is similar, with maximum depth of 4 mm from the
inner table (series 2, image 21). Right parietal subarachnoid hemorrhage is
also now seen. Right frontal intraparenchymal hyperdensities, consistent with
contusion, are slightly more conspicuous than on the prior examination.
Ventricles and sulci are stable in size and configuration. Right frontal lobe
encephalomalacia is stable compared to the prior exam. The basal cisterns are
patent, and there is preservation gray-white matter differentiation.
A nondisplaced left parietal bone fracture is present. No other fractures are
visualized. The mastoid air cells and middle ear cavities are clear. Partial
opacification of the right sphenoid sinus is noted, as well as patchy
opacification of right ethmoid air cells. The visualized portions of the
maxillary sinuses are clear. A left parietal subgaleal hematoma is similar to
prior. The globes are unremarkable.
IMPRESSION:
1. Known left epidural hematoma appears slightly larger than on the prior
examination. There is no evidence of midline shifting of the normally midline
structures.
2. Small foci of bilateral subarachnoid hemorrhage, small left subdural
hemorrhage, and right inferior frontal contusions are stable.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ? enlargement epudral hematoma ___ year old man with Left
parietal skull Fx and epidural hematoma // ? enlargement epudral hematoma
TECHNIQUE: Contiguous axial images images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
DOSE CTDIvol: 533 mGy
DLP: 1003 mGy-cm
COMPARISON: CT head ___ at 04:15 and outside CT of the head ___.
FINDINGS:
Allowing for differences in slice selection and measurement technique left
frontoparietal epidural hemorrhage is unchanged maximally measuring up to 18
mm (02:25). As on the prior study there is local mass effect but no shift of
midline structures. Overlying subgaleal hemorrhage is smaller. Small left
frontal subdural hematoma is unchanged. Tiny amount of hemorrhage layering the
occipital horns is minimally more conspicuous. Multiple small subarachnoid
hemorrhages bilaterally are unchanged. Small right frontal hemorrhagic
contusions are re- demonstrated. Size and configuration of the lateral
ventricles is unchanged. The basal cisterns are patent. Right frontal
encephalomalacia is re- demonstrated.
As before there is a nondisplaced left calvarial fracture involving the
frontal and parietal skull. There is persistent mucosal thickening of the
ethmoidal air cells. There is partial opacification of the right sphenoid
sinus with aerosolized secretions as before. The mastoid air cells and middle
ear cavities are clear.
IMPRESSION:
1. No appreciable change in left epidural hematoma and other small subdural
and subarachnoid hemorrhages.
2. Tiny amount of hemorrhage layering dependently in the occipital horns is
more conspicuous.
3. Left subgaleal hemorrhage is improving.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: Last CT ___ pleae evaluate for evolution ___ year old man
with epidural hematoma // Last CT ___ pleae evaluate for evolution
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
CTDIvol: 55.33 mGy
DLP: 1003.42 mGy-cm
COMPARISON: Head CT ___,
FINDINGS:
Multiple foci of intracranial hemorrhage are present. The largest of these is
a left frontoparietal epidural hematoma measuring 5.5 x 1.7 cm, with local
mass effect. This hemorrhage is not significantly changed in size since the
prior examination. A small amount of left subdural frontal hemorrhage is also
unchanged. Several small right inferior frontal hemorrhagic contusions appear
similar to prior examination. Several foci of subarachnoid hemorrhage
bilaterally are less conspicuous on the prior examination. A small amount of
hemorrhage layering in the occipital horns of the lateral ventricles
bilaterally is stable to slightly increased compared to the prior exam. The
ventricles are stable in size and configuration since the prior examination.
The basal cisterns remain patent. An area of right frontal encephalomalacia is
redemonstrated.
There is no fracture. Bubbly secretions in the right sphenoid sinus are noted.
Patchy opacification bilateral ethmoid air cells is also present. The
remainder of the paranasal sinuses, as well as the mastoid air cells and
middle ear cavities, are clear. Carotid siphon calcifications are again noted.
IMPRESSION:
1. No appreciable change in left epidural and small left subdural hematomas.
2. No significant change in small intraventricular hemorrhage.
3. Small bilateral subarachnoid hemorrhages are less conspicuous.
Gender: M
Race: WHITE
Arrive by HELICOPTER
Chief complaint: ICH
Diagnosed with CL SKL FX NEC/MENING HEM, UNSPECIFIED FALL
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | On ___ Mr. ___ was admitted to the neurosurgical service
after sustaining a fall resulting in EDH, SAH, L parietal bone
fracture. He was admitted to the ICU. He recieved 1 pack plt for
hx of aggrenox. He was neurologically intact.
On ___ Patient underwent repeat head CT which was stable. He
remained in the ICU. Later in the day he reported increasing
nausea, vomiting and headache. A Stat CT head was obtained which
revealed stable hematoma.
On ___ His neurological exam was stable. His blood pressure
goal was liberalized SBP <160. Increased metoprolol to home
dosing. Transfer orders were written to floor
On ___ Patient was neurologically stable. He was awaiting
transfer to the floor. He was evaluated by ___ who recommened ___
more visits prior to making final recommendations.
Mr. ___ was evaluated by ___ and OT on ___. Both services
felt that he would need at least one additional session with
them before he was safely discharged home. Based on their
evaluation, the patient had imbalance issues and slight
difficulty, e.g. slowing, in performing certain mental tasks.
The patient was re-evaluated by ___ and OT on ___ and
discharged home with outpatient ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
codeine / Banana / Gleevec
Attending: ___
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
___: L4-L5 maximal access surgery with posterior lumbar
interbody fusion
History of Present Illness:
Mr. ___ is a ___ male with history of CML on
___ presented to ___ ED with primary complaint of fever.
He is s/p max access posterior lumbar interbody fusion with Dr.
___ on ___ and was discharge home on ___. He represents
with fever to 100.6 at home in addition to chills, sweats and
cough. CXR obtained in ED with possible pneumonia.
Past Medical History:
Seizures (induced by gleevec)
Reflux
CML (dx ___ yrs ago)
Social History:
___
Family History:
Father with leukemia in ___ although unclear what type.
Physical Exam:
Exam at discharge:
Afebrile
Vital signs stable
No apparent distress
Heart rate regular
Respirations non-labored
Abdomen soft, non-tender, non-distended
Back incision clean, dry, intact
Motor ___ throughout
Sensation intact to light touch throughout
Pertinent Results:
___ 06:48AM BLOOD WBC-7.6 RBC-3.21* Hgb-10.3* Hct-30.9*
MCV-96 MCH-32.1* MCHC-33.3 RDW-13.9 RDWSD-49.4* Plt ___
Medications on Admission:
___
Discharge Medications:
1. Diazepam ___ mg PO Q6H:PRN muscle spasm
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 300 mg PO TID
4. Acetaminophen 1000 mg PO Q8H:PRN pain
5. Levofloxacin 750 mg PO Q24H Duration: 4 Doses
RX *levofloxacin 750 mg 1 tablet(s) by mouth Daily Disp #*4
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Lumbar spondylolisthesis
Discharge Condition:
Stable
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with CML, s/p L4/L5 fusion this week, p/w fever; pursuing
infectious work-up. Please eval for PNA.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph of ___ and ___.
FINDINGS:
Compared with the prior studies, new bibasilar opacities, left greater than
right, are concerning for developing infection given the clinical history.
The cardiomediastinal silhouette is within normal limits. No large focal
consolidation, pleural effusion, or pneumothorax.
IMPRESSION:
New bibasilar opacities, left greater than right, are concerning for
developing pneumonia, given the patient's clinical history.
NOTIFICATION: The above findings were communicated via telephone by Dr.
___ to Dr. ___ at 10:35 pm on ___, at the time of his call.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever
Diagnosed with Fever, unspecified
temperature: 99.1
heartrate: 70.0
resprate: 16.0
o2sat: 96.0
sbp: 111.0
dbp: 60.0
level of pain: 10
level of acuity: 2.0 | Mr. ___ is a ___ male with history of CML on
Dastinib who underwent L4-L5 MAS PLIF with Dr. ___ on ___
and discharged home on ___. He presented to the ___ ED on
___ with primary complaint of fever at home to 100.6 in
addition to sweats and chills. Labs were notable for WBC of
13.2. Chest XRAY could not rule out pneumonia and so the patient
was admitted for treatment. The patient was evaluated by the
Medicine service on ___ who recommended treatment with a five
day course of Levaquin. The patient received his first dose of
Levaquin on ___ and was discharged with a prescription for the
remainder of the course. ___ had down-trended to 7.6 on ___.
Per the patient's Oncologist, Dr. ___ was being
held for one week before and after surgery. The patient was
therefore instructed to restart ___ on ___.
At the time of discharge on ___, the patient's pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient will follow up with Dr. ___
routine. The patient expressed readiness for discharge. |