Document 6424963

Transcription

Document 6424963

Patient Name:
MR #:
FIN #:
Discharge Documentation
Document Name:
Document Status:
Performed By:
Authenticated By:
11.
12.
13.
14.
Discharge Summary
Signed
06:12 EDT
21:58 EDT
Flonase 1 spray both nares once a day as needed for allergy symptoms.
Zofran 8 mg oral every 8 hours as needed for nausea and vomiting.
Oxycodone 5 mg tablet 1-2 tablets every 4 hours as needed for pain.
Compazine 10 mg oral every 6 hours as needed for nausea and vomiting.
DISCONTINUED MEDICATIONS:
1. Dexamethasone 1 mg once a day as needed for nausea, vomiting
2. Votrient 200 mg 4 tablets once a day.
DISCHARGE DIET:
speech therapy.
Dysphagia 2 with nectar thick liquids and may advance or adjust per
Mighty Shake supplements or other nutritional supplement is recommended.
DISCHARGE ACTIVITY: She needs to be helped out of bed with assistance only. Otherwise
she should be on bed rest until her activity improves enough to function independently.
DISCHARGE FOLLOWUP: She will need to follow up Dr.
Hematology/Oncology after discharge from rehab.
HISTORY OF PRESENT ILLNESS:
of
See dictated H and P.
IMAGING:
1. CT of the head without contrast on
showed asymmetry in the sulci at the
vertex with effacement of the left sulci which may represent early ischemic change.
2. One view chest on
showed extensive lung mass at right perihilum with an
associated pleural effusion and atelectasis. There are some bilateral lung nodules
consistent with metastatic disease.
3. MRA of brain without and with contrast
showed large region of acute
infarction involving the left basal ganglia with two tiny additional infarcts in left
cerebral cortex. There is abrupt termination of the left middle cerebral artery
consistent with thrombosis.
4. Carotid Dopplers done on
showed no significant bilateral internal carotid
artery stenoses.
5. Dopplers of the lower extremities on
showed no evidence of DVT.
6. Echocardiogram on
was normal with an EF of 50% with diastolic dysfunction.
Normal RV. No signs of interatrial shunt. No pericardial effusion.
7. MRA of the head on
showed abrupt termination of the left M1 segment
consistent with thrombosis corresponding to the findings on her MRI. There is acute
subacute infarct at the left basal ganglia with effacement of the left lateral ventricle.
There is a fetal origin of the right posterior cerebral artery with a dominant left
vertebral artery. Fetal origin of the right posterior cerebral artery is a developmental
variation. There is a 2 mm aneurysm at the tip of the basilar artery.
8. One view of the chest on
showed stable mass of the right chest with no
acute findings.
LABORATORY DATA:
1. Cholesterol 236, triglycerides 150, HDL 86, LDL 120. Most recent labs are actually
from admission with a sodium of 135, potassium 3.9, chloride 101, bicarbonate 21, BUN 13,
Page 2 of 177
Patient Name:
MR #:
FIN #:
Document Name:
Document Status:
Performed By:
Authenticated By:
Discharge Summary
Signed
(INTE)
(INTE)
06:12 EDT
21:58 EDT
creatinine 0.62, glucose 124, alkaline phosphatase of 110, T bili 0.4, albumin 2.9, total
protein 7.1, ALT 32, AST 39. WBC 10.2, hemoglobin 13.2, hematocrit 39.1, platelets 274.
2. ESR was 27.
3. Antithrombin III level was normal at 111%. Antiphospholipid antibodies, IgG and IgM
are negative. Protein C antigen level was actually higher than normal, which is of no
significance at 164%. Protein S antigen was 99%, which is normal. She was negative for
factor V Leiden and prothrombin mutations.
4. Urine culture from
showed coag-negative staphylococcus sensitive to
fluoroquinolones, nitrofurantoin, oxacillin, tetracycline, trimethoprim sulfa and
vancomycin.
HOSPITAL COURSE:
1. Stroke. The patient is likely hypercoagulable in the setting of active cancer. She
has a history of a thrombus at the junction of the IVC and left renal vein in 2010 per
UNC records and had to be on enoxaparin at that time that was also in the setting of her
cancer. She had her stroke workup as above. She was started on aspirin. I did send off
a hypercoagulable panel which is essentially negative with the results as above. Her
Votrient which is for her metastatic uterine leiomyosarcoma has been held as it has been
reported to cause thromboses, especially DVTs and PEs. She will not be able to restart
this ever again. She was not a candidate for TPA given the uncertainty about whether she
may have small metastases that would predispose her to intracerebral bleeding. This had
been discussed with neurology as well in the emergency room. She had no findings of
atrial fibrillation during this hospital stay. She was placed on DVT prophylaxis with
enoxaparin. LDL was checked with the results as above and she is being discharged on
Lipitor. Stroke education was done. She was seen by PT, OT and speech therapy and
deemed an acute rehab candidate and she will be discharged to
acute rehab. Her
neurologic exam here has not changed and consists of right-sided hemiplegia with
decreased gross sensation on the right side, in both the arm and leg. She has weakness
of her right face as well with difficulty closing her right eye against resistance so she
does have some upper facial deficits on the right, but she has not had sensory deficits
of her right face.
2. Urinary tract infection. The patient became more tachycardic and had a fever. Her
chest x-ray was negative for pneumonia, but given that she was bedbound I suspected an
element of atelectasis. She also appears to have a urinary tract infection as well. I
am not sure whether the coagulase-negative staphylococcus is actually colonization of her
Foley catheter but I did have the Foley catheter replaced and I have decided to err on
the conservative side given her debilitated state and treat her for a urinary tract
infection without sepsis. She will complete a total of 7 days of treatment with
Levaquin.
3. Metastatic uterine leiomyosarcoma. She has talked with palliative care as well as
Dr.
who will assume her care at this point. Her prognosis is poor, the family and
the patient are not ready for hospice yet and would like to try rehab first before
deciding further action.
CODE STATUS:
The patient has been made DNR/DNI.
Greater than 30 minutes spent on discharge.
Page 3 of 177
Patient Name:
MR #:
FIN #:
Document Name:
Document Status:
Performed By:
Authenticated By:
Discharge Summary
Signed
, (INTE) MD,
INTE) MD,
06:12 EDT
21:58 EDT
, MD
DD:
DT:
06:12:54
06:42:49
/#
ELECTRONICALLY REVIEWED AND SIGNED
ON:
21:58
ELECTRONICALLY SIGNED
ON:
21:58
Jr., (INTE) MD,
Jr., (INTE) MD,
Page 4 of 177
Patient Name:
MR #:
FIN #:
History and Physical Reports
Document Name:
Document Status:
Performed By:
Authenticated By:
History & Physical
Signed
(INTE) MD,
(INTE) MD,
20:37 EDT
21:44 EDT
History & Physical
HIM Hospitalist History and Physical
DATE OF ADMISSION:
PRIMARY CARE PHYSICIAN: None
PRIMARY ONCOLOGIST: Dr.
at
.
CHIEF COMPLAINT: Difficulty speaking and right-sided weakness.
HISTORY OF PRESENT ILLNESS: Ms. is a 49-year-old female receiving treatment for metastatic leiomyosarcoma at
, history
of pleural effusion related to metastatic liposarcoma with the Pleurx catheter on the right side. No history of stroke. No history of
diabetes. Patient presents with a change in mental status and demonstrated aphasia and right-sided weakness. The patient has no
history of seizures. She was reportedly well when she was dropped off at home at 2:00 p.m. after lunch with her daughter. The
patient called by different daughter at 4:05 p.m. and does not sound right on telephone.
Husband subsequently called the patient at 4:30 p.m., patient incoherent and then discovered at home confused, unable to speak with
right-sided weakness. 911 was called and arrived at the emergency room at 5:31 p.m. today, again last well known at 2:00 p.m.
awake and alert. In the emergency room, she is aphasic and not able to provide any other history. Has obvious right-sided facial
droop and right-sided weakness. The patient indicating she is not experiencing any pain by sign language. Unable to obtain any other
history per husband at bedside.
PAST MEDICAL HISTORY:
1. Metastatic uterine leiomyosarcoma.
2. History of pleural effusion related to metastatic leiomyosarcoma.
3. History of hysterectomy.
4. Hypertension.
SOCIAL HISTORY: Does not smoke, never smoked as per husband. Does not have a primary care doctor. No alcohol use.
HOME MEDICATIONS:
1. Oxycodone 1-2 tablets p.o. q.4h. p.r.n. pain.
2. Flonase 1 spray both nares daily p.r.n. allergy symptoms.
3. Zofran 8 mg p.o. q.8h. p.r.n.
4. Dexamethasone 1 mg p.o. daily p.r.n.
5. Pepcid 20 mg p.o. daily p.r.n. indigestion.
6. Compazine 10 mg p.o. q.6h. p.r.n. nausea, vomiting.
7. Votrient 200 mg 4 tablets p.o. daily.
8. Lotrel 5/20 mg 1 capsule p.o. daily.
PRIMARY ONCOLOGIST: Dr.
.
FAMILY HISTORY: No history of stroke or MI in immediate family member.
REVIEW OF SYSTEMS: The patient aphasic, unable to provide any other history. History provided by her husband. Blood sugar
prior to arrival was 116.
Page 10 of 177
Patient Name:
MR #:
FIN #:
Document Name:
Document Status:
Performed By:
Authenticated By:
History & Physical
Signed
(INTE) MD,
(INTE) MD,
20:37 EDT
21:44 EDT
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 132/73, pulse 66, respirations 16, saturating 96% on room air, temperature 36.6 degrees centigrade.
EYES: Pupils are reactive. Unable to do extraocular movement.
ENT/MOUTH: Obvious facial asymmetry with right facial weakness, no difficulty breathing. She is aphasic. Tongue protrudes in
midline. Oral mucosa moist, no hearing loss.
RESPIRATORY: Bilateral clear with fair air entry. No rales, rhonchi or wheezes.
CARDIOVASCULAR: S1, S2, regular rate and rhythm, no rubs or gallops.
GASTROINTESTINAL: Abdomen soft, nontender, nondistended. No guarding. Bowel sounds present.
MUSCULOSKELETAL: No deformities. No edema. Distal extremities well perfused. No spontaneous movement of the right arm
or right leg.
NEUROLOGIC: The patient is awake, she has expressive aphasia, facial asymmetry with right facial weakness, dense right-sided
weakness, cannot raise her right arm or move right leg. Cannot squeeze the right hand and motor function preserved on left side. The
patient indicates decrease in sensation at the right side.
In the emergency room course, patient was immediately attended by Dr.
and neurology was consultant Dr.
who
suggested no TPA since patient was out of the window and metastatic leiomyosarcoma. Patient had a CT head performed.
LABORATORY DATA: WBC 10.2, hemoglobin 13.2, hematocrit 39.1, neutrophils 87%. PT/INR normal. Sodium 135, potassium
3.9, chloride 101, CO2 21, glucose 124, BUN 13, creatinine 0.62, calcium 8.5, alkaline phosphatase 110, total bilirubin 0.4, albumin
low at 2.9, total protein 7.1, ALT 32, AST 39. Total CK 56, CK-MB 4% is high troponin negative 0.018. TSH 2.8.
EKG: Normal sinus rhythm, no obvious ST elevation or ST depression, rate 79 beats per minute.
RADIOLOGY: Chest x-ray: Extensive lung mass at right perihilar region associated pleural effusion, left basilar atelectasis.
CT head asymmetry and effacement of sulci on the left, early changes of ischemia, no hemorrhage.
IMPRESSION:
1. Acute stroke likely left MCA stroke with right hemiplegia.
3. Hypertension, controlled.
4. History of malignant pleural effusion, status post Pleurx catheter.
PLAN:
1. In view of patient above symptoms and sign will admit to neuro step down. Neurology has been consulted.
2. Check PTT.
3. Check ESR, RPR, ANA, homocysteine level.
4. Check carotid Doppler, venous carotid Doppler, MRI brain without contrast and 2D echo with bubble study.
5. Bilateral lower extremity swelling, which seems to be chronic as per husband, after she has been started on chemo for three years.
We will do a venous Doppler to rule out deep venous thrombosis.
6. If patient has a PFO or lower extremity deep venous thrombosis, she may need a hypercoagulable panel.
7. The patient is on Votrient. Will obtain an oncology consult in a.m. since she took this morning her medication and would like to
obtain expert opinion to evaluate if she should take Votrient or not. At this time, she failed dysphagia screen. She is n.p.o., will get
speech therapy evaluation in a.m.
8. PT, OT and speech therapy to see patient in a.m.
Page 11 of 177
Patient Name:
MR #:
FIN #:
Document Name:
Document Status:
Performed By:
Authenticated By:
History & Physical
Signed
(INTE) MD,
(INTE) MD,
20:37 EDT
21:44 EDT
9. Aspirin rectal 300 mg rectal 1 now, which is given in the emergency room. We will check a fasting lipid profile in a.m. as a core
measure.
10. Deep venous thrombosis and gastrointestinal prophylaxis with IV Pepcid and Lovenox subcutaneous.
MD
DD:
DT:
20:37:15
07:36:45
/#
cc:
MD;
ON:
21:44
ON:
21:44
(INTE) MD,
(INTE) MD,
Page 12 of 177
Patient Name:
MR #:
FIN #:
Consultation Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Consultation Note
Signed
(INTE) NP,
(INTE) NP,
Palliative Care Consult
Requesting Provider: Dr.
Reason for consult: Patient and family support
Code Status: DNR/DNI Advance Directives:
Authorized representative(s): Husband
18:04 EDT
18:04 EDT
-
or
-
Impressions: 49yo woman with metastatic uterine leiomyosarcoma left MCA stroke and right hemiplegia.
I have met with the patient and her daughter, as well as social work and the Hospice of Wake representative
The current plan is for the patient to either have a short stay at
Rehab and then go home with Hospice or to go
home with
Palliative Care, receive PT/OT in the home and then convert to Hospice.
The patient hopes to go home but I will speak with her husband tomorrow about which plan he is most agreeable to.
Recommendations:
1. Continue emotional support for patient and family
2. Finalize a plan for D/C
3. Provide Palliative Care counseling for patient and her family. I will ask them to visit tomorrow.
Past, Social and Family history: Reviewed in chart
Thank you for consult. Will follow closely.
30 min spent, >50% of this time in counseling and coordinating care.
ON:
18:04
ON:
18:04
(INTE) NP,
(INTE) NP,
Page 15 of 177
Patient Name:
MR #:
FIN #:
Consultation Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Consultation Note
Signed
T.
T.
14:01 EDT
10:40 EDT
Consultation Note
HIM Consultation Report
DATE OF CONSULTATION:
REQUESTING PHYSICIAN: Dr.
CHIEF COMPLAINT AND REASON FOR CONSULTATION:
leiomyosarcoma who was evaluated at the request of Dr.
and right hemiparesis.
is a pleasant 49-year-old female with metastatic
for specific advice for evaluation and management of aphasia
HISTORY OF PRESENT ILLNESS:
is a pleasant 49-year-old female with history of metastatic leiomyosarcoma who
was evaluated at the request of Dr.
following acute onset of aphasia and right hemiparesis. The patient presented to
the emergency department at 3 hours and 31 minutes with obvious aphasia and right hemiparesis. An intracranial CT suggested some
mild asymmetry but followup MRI suggested a large area of acute infarction involving the left basal ganglia with additional tiny
infarctions involving the left cerebral cortex. Carotid duplex suggests minimal bilateral internal carotid artery stenosis. Transthoracic
echocardiogram suggests no obvious cardiac source of emboli.
MEDICATIONS: Oxycodone, Flonase, Zofran, dexamethasone, Pepcid, Compazine, Votrient, Lotrel.
ALLERGIES: No known drug allergies.
1. History of metastatic uterine leiomyosarcoma.
2. History of pleural effusion related to metastatic leiomyosarcoma.
3. History of hypertension.
SOCIAL HISTORY: The patient lives with her husband. No history of tobacco or alcohol abuse.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: A complete 10-point review attempted and the pertinent review as best obtained from the husband outlined
above but otherwise negative.
VITAL SIGNS: Temperature 36.5, pulse 90, respirations 18, blood pressure 142/100. CONSTITUTIONAL:
is a
pleasant 49-year-old female in no acute distress.
HEAD, EARS, NOSE AND THROAT: Normocephalic.
CARDIOVASCULAR: Regular rate and rhythm.
RESPIRATORY: Clear to auscultation.
ABDOMEN: Soft, nontender to palpation.
MUSCULOSKELETAL: Muscle bulk and tone
PSYCHIATRIC: The patient awake, alert, and completely oriented.
NEUROLOGIC: There is obvious flattening of the right nasolabial fold, obvious expressive aphasia, no receptive component, flaccid
right hemiparesis. The patient denies sensory changes on the right when compared to the left.
Page 16 of 177
Patient Name:
MR #:
FIN #:
Consultation Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Consultation Note
Signed
T.
T.
14:01 EDT
10:40 EDT
MEDICAL DECISION MAKING, LABORATORY AND DIAGNOSTIC REVIEW: I reviewed the actual report of the intracranial
MRI and I agree with radiologist's interpretation which suggests a large 5.1 x 2.5 cm well defined focus of restricted diffusion
involving the left caudate head, left internal capsule, putamen, globus pallidus and periventricular white matter consistent with an
acute infarction. There are also two additional foci restricted effusion involving the left cerebral cortex of the parietal lobe, no
associated enhancement, no hemorrhage. There is abrupt termination of the signal void in the left middle cerebral artery consistent
with thrombus. Carotid duplex suggests minimal stenosis involving the left and right internal carotid artery. Transthoracic
echocardiogram suggests no obvious cardiac source of emboli. Fasting lipid panel pending at the time of consultation.
IMPRESSION:
1. Acute left middle cerebral artery distribution infarction, probable hypercoagulable state secondary to leiomyosarcoma.
2. History of uterine leiomyosarcoma.
3. History of hypertension.
DISCUSSION/RECOMMENDATIONS: I agree with aspirin for secondary prevention with a statin. The patient will need aggressive
inpatient rehabilitation following discharge. I have discussed the results of the diagnostic studies in detail with husband at the bedside.
I will continue to follow. The husband appears to agree with this management plan and has no further questions or concerns.
Dictated for Dr.
PA
DD:
DT:
14:01:13
16:34:08
#
(NEUR) MD,
ON:
10:40
Page 17 of 177
Patient Name:
MR #:
FIN #:
Emergency Documentation
Document Name:
Document Status:
Performed By:
Authenticated By:
ED Note-Physician
Signed
Scanned, Documents
10:21 EDT
of 177
Patient Name:
FIN:
Page Number: 20
MRN:
Facility:
Document Name:
Document Status:
Performed By:
Authenticated By:
ED Note-Physician
Signed
(EMER) MD,
(EMER) MD,
10:55 EDT
12:13 EDT
ED Note-Physician
ED Emergency Room Report
DATE OF SERVICE:
ADDENDUM:
PRESENTING COMPLAINT:
weakness.
Change in mental status.
Difficulty speaking and right-sided
Please see the previous dictation for history and for physical examination.
MEDICATIONS: Oxycodone, Flonase nasal spray, Zofran, dexamethasone, Pepcid, Compazine,
____, Lotrel.
LABORATORY AND X-RAY RESULTS: White blood count 10.2, hemoglobin 13.2, hematocrit 39
with 274,000 platelets, 87% neutrophils, 7% lymphocytes, 6% monocytes. PT 12.8, INR
0.95, PTT 31. Sodium 135, potassium 3.9, chloride 101, CO2 of 21, BUN 13, creatinine
0.62, glucose 124, calcium 8.5, alkaline phosphatase 110, bilirubin 0.4, total protein
7.1, ALT 32, AST 39. Total CK 56, CK-MB 4, CK-MB index 7.1%, ED troponin I 0.018. TSH
2.800.
EKG reveals normal sinus rhythm, ventricular rate 79 beats per minute, PR interval 122
msec, QRS duration 78 msec, QT interval 384 msec, R axis 81 degrees, possible old
anterior infarction. No old EKG available for comparison.
CT scan of the head demonstrates asymmetry in the sulci at the vertex with effacement of
the sulci on the left. This may represent early change from ischemia in the correct
clinical setting. No associated hemorrhage and no cortical low density identified at
this time. Chest x-ray demonstrates findings consistent with extensive lung mass at
right perihilar region, associated pleural effusion and atelectasis/infiltrate.
Bilateral lung nodules most consistent with metastatic disease. Left basilar atelectasis
or infiltrate. All radiographic findings are according to the reviewing radiologist.
TREATMENT COURSE: Initial patient assessment is performed at 5:31 p.m. This is 3-1/2
hours after last known well time. I discuss the case with the on-call neurologist, Dr.
at 5:45 p.m. Given the time course of symptoms, and given the history of
metastatic leiomyosarcoma with extensive lung mass identified on chest x-ray and
potential other etiologies for symptoms, it is determined the patient would not be a
thrombolytic candidate. The patient remains hemodynamically stable during her initial
period of treatment in the emergency department. I request dysphagia screening. I
request administration of aspirin suppository. No other acute intervention is initially
required. Repeat vital signs: Blood pressure 138/80, pulse 68, respirations 16, pulse
oximetry 97% room air.
DISCUSSION: The patient presents today with change in mental status. The patient
demonstrates aphasia and right-sided weakness. Last known well time 2:00 p.m. today.
Patient Name:
FIN:
Page Number: 21
MRN:
Facility:
Document Name:
Document Status:
Performed By:
Authenticated By:
ED Note-Physician
Signed
(EMER) MD,
(EMER) MD,
10:55 EDT
12:13 EDT
Initial patient assessment occurs 3-1/2 hours after last known well time. The symptoms
are consistent with stroke involving the left brain. There is history of metastatic
leiomyosarcoma. Chest x-ray demonstrates a large lung mass. Case is discussed with the
on-call neurologist, Dr.
at 5:45 p.m. Given the time course of symptoms and the
history of metastatic leiomyosarcoma with large lung mass, it is determined the patient
would not be a thrombolytic candidate. The patient remains hemodynamically stable during
her initial period of observation in the emergency department. After initial
stabilization, the patient is referred to the medical service for admission. The patient
is examined by Dr.
Additional treatment of this patient and final patient
disposition will be determined by the hospitalist.
ASSESSMENT:
1. Aphasia and right side weakness. Likely acute stroke involving the left brain.
Initial patient assessment performed 3-1/2 hours after last known well time.
2. History of metastatic leiomyosarcoma with extensive lung mass.
3. Pleural effusion.
PLAN:
Medical consultation.
Neurology consultation.
I am continuously involved in the care of Mrs.
from 5:31 p.m. until 6:10 p.m.
Thirty-nine minutes of critical care time confirmed by the clock in the emergency
department. Critical care time includes direct patient management. Also consultations
with neurologist and admitting physician and discussions with family members. While I am
initially involved in the care of Mrs.
I am unable to care for other patients in
the emergency department.
MD
:
DD:
DT:
10:55:39
11:11:07
/#
ON:
12:13
ON:
12:13
(EMER) MD,
(EMER) MD,
Patient Name:
FIN:
Page Number: 22
MRN:
Facility:
Document Name:
Document Status:
Performed By:
Authenticated By:
ED Note-Physician
Signed
(EMER) MD,
(EMER) MD,
18:05 EDT
11:04 EDT
ED Note-Physician
ED Emergency Room Report
DATE OF SERVICE:
DATE OF BIRTH:
CHIEF COMPLAINT:
Difficulty speaking, right-sided weakness.
HISTORY OF PRESENT ILLNESS: Mrs.
is a 49-year-old female. The patient is
receiving treatment for metastatic leiomyosarcoma. There is history of pleural effusions
related to metastatic leiomyosarcoma. There is no history of stroke. No history of
diabetes. No history of hypertension. The patient presents this afternoon with altered
mental status. The patient demonstrates aphasia and right-sided weakness.
As previously discussed, the patient has metastatic leiomyosarcoma. The patient is
receiving chemotherapy at
Hospital
. According to husband, there is no
known history of brain metastases. There is no history of stroke. There is no history
of seizure. No history of diabetes. The patient is reportedly "well" when she is
dropped off at home at 2:00 p.m. after lunch with daughter. The patient is called by a
different daughter at 4:05 p.m. and the patient does not sound right on the telephone.
Husband subsequently calls the patient on the phone at 4:30 p.m. The patient is
incoherent. The patient is then discovered at home confused and unable to speak with
right side weakness. 911 is called.
The patient arrives at the emergency department at 5:31 p.m. Again, the last known well
time is 2:00 p.m. The patient is awake and alert when she arrives at the emergency
department. The patient demonstrates aphasia. There is obvious right facial weakness
and right-sided weakness. The patient indicates she is not experiencing any acute pain.
Given the aphasia at presentation, the patient cannot provide further history.
metastatic cancer.
ALLERGIES:
MEDICATIONS:
Metastatic leiomyosarcoma, history of pleural effusions related to
None.
See addendum.
SOCIAL HISTORY: The patient does not smoke.
a primary care provider.
ONCOLOGIST:
MD at
No alcohol use.
Hospital
The patient does not have
.
REVIEW OF SYSTEMS: The patient is aphasic when she arrives at the emergency department.
The patient cannot perform a review of systems. History is provided by the husband.
Please see HPI. Blood sugar prior to arrival 116.
Patient Name:
FIN:
Page Number: 23
MRN:
Facility:
Document Name:
Document Status:
Performed By:
Authenticated By:
ED Note-Physician
Signed
(EMER) MD,
(EMER) MD,
18:05 EDT
11:04 EDT
VITAL SIGNS: Blood pressure 125/80, pulse 74, respirations 18, temperature 36.6 degrees,
pulse oximetry 95%.
GENERAL: Mrs.
is a 49-year-old female. The patient is awake. The patient is
aphasic. No difficulty breathing is observed. There is obvious facial asymmetry with
right facial weakness.
SKIN: Warm and dry.
HEENT: NC. There is right facial weakness. PERRL. EOMI. Tongue protrudes in the
midline. Oral mucosa is moist.
LUNGS: Grossly clear, breath sounds are symmetric.
CARDIAC: Heart rhythm is regular. I do not appreciate a murmur.
ABDOMEN: Soft, bowel sounds present, no involuntary guarding, no intraabdominal masses
are palpated. No peritoneal signs. No localized abdominal tenderness.
EXTREMITIES: No deformity. No edema. The distal extremities are well perfused. There
is no spontaneous movement of the right arm or right leg.
NEUROLOGIC: The patient is awake. There is expressive aphasia. There is facial
asymmetry with right facial weakness. There is dense right-sided weakness. The patient
cannot raise her right arm from the bed. The patient cannot raise her right leg from the
bed. The patient cannot squeeze with her right hand. Motor function is preserved left
side. The patient does indicate decrease in light touch sensation at her right side.
TREATMENT COURSE: I attend this patient immediately when she arrives at the emergency
department. Initial assessment performed at 5:31 p.m. Last known well time is 2:00 p.m.
Appropriate laboratory and x-ray studies are requested. Urgent CT scan of the head is
performed.
This is a partial treatment summary on
addendum for laboratory and x-ray results.
for final patient disposition.
MD
:
DD:
DT:
18:05:58
19:19:07
/#
record #
Please see
Please see addendum for treatment course and
Patient Name:
Facility:
Page Number: 117
Orders
Order Date/Time
17:39 EDT
Mnemonic
Action
Order
EKG 12 Lead REMA Adult
ED
Ordering Physician
(EMER) MD,
Review Information
Nurse Review, Accepted RN,
,
Order Details
17:39:00 EDT, Stat, once, Stretcher
Order Status
Completed
Type of Order
Cardiology
Order Placed By
jr,
23:01 EDT
Progress Notes
Document Name:
Document Status:
Performed By:
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Automatic IV to PO conversion
Signed
Rph,
01:16 EDT
Rph,
01:16 EDT
AUTOMATIC IV TO PO CONVERSION
This patient meets
Pharmacy and Therapeutics Committee approved criteria for automatic IV to PO
conversion of the following medication(s): Pepcid
This (these) medication(s) is/are highly bioavailable and should provide an equally efficacious mode of therapy
for qualifying patients. Thank you.
Document Name:
Document Status:
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Progress Note-Physician
Signed
(INTE) NP,
(INTE) NP,
10:58 EDT
10:58 EDT
PALLIATIVE CARE PROGRESS NOTE
Assessment/Plan
Due for D/C to
Rehab this AM. Family in the room.
No complaints at present.
The Palliative Care counselor will follow-up later in the week.
Code Status:
DNR/DNI
Time spent for prolonges service (if applicable)
In: 10:15
Out: 10:30
>50% time spent on counseling, education and coordinating care.
Most Recent Vitals
08:06
Patient Name:
Facility:
Page Number: 118
Progress Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Temp
37.0
Signed
(INTE) NP,
(INTE) NP,
BP
108/74
Pulse
128
24 Hr Tmax: 38.2 at
Intake
1220
Totals
10:58 EDT
10:58 EDT
RR
20
SPO2
96%
O2 Therapy
00:10
Output
675
Balance
545
No 24 Hour Lab Data
ON:
10:58
ON:
10:58
Document Name:
Document Status:
Performed By:
Authenticated By:
(INTE) NP,
(INTE) NP,
Signed
(HEMA) NP,
(HEMA) MD,
1
10:36 EDT
16:20 EDT
Subjective
Pt. awake, alert, oriented. Laying in bed eating breakfast. Did not sleep well last night. Denies
pain or SOB.
Assessment/Plan
Left basal ganglia infarct with right sided hemiplegia and expressive aphasia. Will be transferred
later today to
Med Rehab.Continue Lovenox and ASA.
Metastatic uterine leiomyosarcoma- s/p treatment with Cisplatin/gemzar, Ifex/Mesna/Adria, DTIC, and
most recently Votrient, which was d/c upon admission due to the possibility of this med increasing
risk for DVT/ PE.No more chemotherapy planned at this time. Pt. will follow up with Dr.
after
discharge from rehab.
DNR- out of facility form given to discharge planner.
Pt. examined in collaboration with
absence.
Physical Exam
Chest:
Clear, diminished on right.
Dr.
available for consultation in Dr.
Patient Name:
Progress Notes
Signed
(HEMA) NP,
(HEMA) MD,
Document Name:
Document Status:
Performed By:
Authenticated By:
10:36 EDT
16:20 EDT
CV: tachycardia. Apical rate 130. No rubs, murmurs or gallops
Abdomen: Soft, nontender, nondistended, NABS
Extremities: No clubbing, cyanosis . Mild edema bilat. LEs.
Neuro:AA & Ox3. Right sided facial droop and hemiplegia. strength on left 5/5.
Objective
Vitals
Temp
37.0
BP
108/74
Pulse
128
24 Hr Tmax: 38.2 at
Totals
Intake
1220
RR
20
SPO2
95%
O2 Therapy
Room Air
00:10
Output
675
Balance
545
No 24 Hour Lab Data
ON:
10:39
ON:
16:20
Document Name:
Document Status:
Performed By:
Authenticated By:
(HEMA) NP,
(HEMA) MD,
Signed
Jr., (INTE) MD,
Jr., (INTE) MD,
08:55 EDT
08:55 EDT
Subjective
No complaints.
No SOB, no pain.
Assessment/Plan
1. R hemiplegia, L basal ganglia stroke 2/2 thrombus.
Likely thrombophilia given h/o thrombus at
junction of IVC/L renal vein and active cancer. Votrient also reported to cause DVT/PE. No
evidence for BLE DVT's. TTE, carotid U/S NL. Hypercoag panel NL.
-Continue ASA 325mg qday.
-Holding Votrient.
-ST/PT/OT.
-Continue statin for elevated LDL.
Patient Name:
Progress Notes
Signed
Jr., (INTE) MD,
Jr., (INTE) MD,
Document Name:
Document Status:
Performed By:
Authenticated By:
2. UTI, CoNS.
-Continue Levaquin (started
3. Tachycardia.
-Fever control.
-IVF.
08:55 EDT
08:55 EDT
).
Likely from fever as well as some volume depletion.
-Dr.
assuming care.
-Palliative care following.
Poor prognosis, sounds like little treatment options left.
5. HTN.
-Continue Norvasc, benazepril.
6. Prophy.
-SCD's, Lovenox given high hypercoagulable risk.
7. Dispo.
Acute rehab today.
Physical Exam
General: Laying comfortably in bed, NAD.
Neck: No JVD.
Chest: CTAB w/o wheezes or crackles.
CV: RRR w/o murmurs. Radial pulses 2+ bilaterally.
Abdomen: Bowel sounds present, soft, nontender, nondistended.
Extremities: No edema.
Neuro: No change from yesterday. Still w expressive aphasia. Intact fine sensation of R face but
weakness of entire R face. No sensation in R arm and R leg. Hemiplegic on R.
Objective
Vitals
Temp
37.0
BP
108/74
Pulse
128
24 Hr Tmax: 38.2 at
Totals
Intake
1220
RR
20
SPO2
95%
00:10
Output
675
Balance
545
O2 Therapy
Room Air
Patient Name:
Progress Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Signed
Jr., (INTE) MD,
Jr., (INTE) MD,
08:55 EDT
08:55 EDT
No 24 Hour Lab Data
ON:
08:55
ON:
08:55
Document Name:
Document Status:
Performed By:
Authenticated By:
Jr., (INTE) MD,
Jr., (INTE) MD,
Signed
(INTE) NP,
(INTE) NP,
17:55 EDT
17:55 EDT
PALLIATIVE CARE PROGRESS NOTE
Brief visit with the patient and her mother.
Up in a chair and looks great!
Phone conversation with
NP.
Due to go out to
Rehab for a short time to establish baseline. Will continue to support.
Code Status:
DNR/DNI
Time spent for prolonges service (if applicable)
In: 14:00
Out: 14:15
>50% time spent on counseling, education and coordinating care.
Most Recent Vitals
Temp
BP
36.9
117/65
24 Hr Tmax: 38.2 at
Totals
Intake
1228
15:53
Pulse
RR
121
18
SPO2
95%
02:12
Output
800
Balance
428
O2 Therapy
Patient Name:
FIN:
Page Number: 122
MRN:
Facility:
Progress Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Signed
(INTE) NP,
(INTE) NP,
17:55 EDT
17:55 EDT
No 24 Hour Lab Data
ON:
17:55
ON:
17:55
Document Name:
Document Status:
Performed By:
Authenticated By:
(INTE) NP,
(INTE) NP,
Modified
(HEMA) NP,
(HEMA) MD,
11:02 EDT
13:14 EDT
Subjective
More verbal today. Answering questions appropriately with 1-2 word answers. Visiting with her
daughter and brother. Ate some eggs for breakfast.
Assessment/Plan
1.Hx. of metastatic leiomyosarcoma.
2.s/p left basal ganglia infarct with right sided hemiplegia on
No further chemotherapy appropriate at this time.Votrient d/c upon admission.
Palliative care consulted yesterday however pt. and family have decided that they wish for her to
go to an inpatient rehab facility upon discharge from
hospital.Discharge planner is aware and
working on getting pt. a bed at
Med Rehab.From an oncology standpoint, she is stable for
discharge to rehab.
Dr.
discussed code status with pt. and her husband yesterday- DNR ordered
Pt. was seen and examined in collaboration with
today in Dr.
absence.
NP. Dr.
.
will see pt. later
Physical Exam
Chest: Clear.
CV: RRR, No rubs, murmurs or gallops
Extremities: No clubbing, cyanosis or edema.
Neuro:AA&Ox3.right sided facial droop persists. Expressive aphasia improving.Right upper and lower
extremities flaccid.No sensation.
Objective
Vitals
Temp
37
BP
109/67
Pulse
109
RR
18
SPO2
95%
O2 Therapy
Room Air
Patient Name
Facility:
Page Number: 123
Progress Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Modified
(HEMA) NP,
(HEMA) MD,
24 Hr Tmax: 38.2 at
Totals
Intake
1228
11:02 EDT
13:14 EDT
02:12
Output
800
Balance
428
No 24 Hour Lab Data
ON:
11:02
ON:
13:14
Addendum by
(HEMA) MD,
(HEMA) NP,
(HEMA) MD,
on
13:20 EDT
Pt seen and examined. Agree with plan of care as outlined above. Patient's mother and husband are
at her bedside. She denies any problems currently; appetite good. Participated with PT this
morning. I discussed plans for palliation with patient and her husband, and both are in agreement.
Will proceed with plans for discharge to rehab, in order help her recover as much function as
possible from her recent stroke.
ON:
13:20
Document Name:
Document Status:
Performed By:
Authenticated By:
Signed
, (INTE) MD,
(INTE) MD,
(HEMA) MD,
07:57 EDT
07:57 EDT
Subjective
Seems a little more down this AM.
No acute events overnight. Met w SW and palliative care
yesterday, plans to discuss long-term goals more w husband today.
Assessment/Plan
Likely has some thrombophilia given h/o
thrombus at junction of IVC/L renal vein and active cancer. Votrient also reported to cause
DVT/PE. No evidence for BLE DVT's. TTE, carotid U/S NL.
-Continue ASA 325mg qday.
-Hypercoag panel (although hypercoagulability in this case likely 2/2 cancer).
-Holding Votrient.
-ST/PT/OT.
Patient Name:
Progress Notes
Signed
(INTE) MD,
(INTE) MD,
Document Name:
Document Status:
Performed By:
Authenticated By:
07:57 EDT
07:57 EDT
2. UTI, CoNS.
-Continue Levaquin
3. Tachycardia.
-Fever control.
-IVF.
-Dr.
assuming care.
-Palliative care following.
Poor prognosis, sounds like little treatment options left.
5. HTN.
6. Prophy.
7. Dispo. Pt and family to think about goals of care today. Acute rehab still not ruled out
apparently by pt and family. Home w hospice also a consideration.
Physical Exam
Neck: No JVD.
Neuro: Alert. Did not do full neuro exam today. Still w no movement of R arm or R leg.
some mixed expressive and receptive aphasia.
Objective
Vitals
Temp
37
BP
109/67
Pulse
109
24 Hr Tmax: 38.2 at
Totals
Intake
1228
RR
18
SPO2
95%
02:12
Output
800
Balance
428
O2 Therapy
Room Air
Still w
Patient Name:
Facility:
Page Number: 125
Progress Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Signed
(INTE) MD,
(INTE) MD,
07:57 EDT
07:57 EDT
No 24 Hour Lab Data
ON:
07:57
ON:
07:57
Document Name:
Document Status:
Performed By:
Authenticated By:
., (INTE) MD,
, (INTE) MD,
Signed
(HEMA) MD,
(HEMA) MD,
14:10 EDT
14:10 EDT
Subjective
Ms
dtr is an OCN/ChemoTx RN in our practice. Mr and Ms
have a desire to have one
Oncology provider, and since she has had a major CVA, she ll not return to Pazopanib (Votrient) Tx
now or in future. She has been followed for 2 yrs at
, under Dr
Following an uncomplicated TAH/BSO in Dec of
, she was found to harbor metastatic high
grade Uterine Sarcoma, w/ bilat pulm nodules evident on Chest CT.
She was initially Tx d at
w/ Docetaxel/Gemcitabine until Fall 2010, when she underwent L
thoracotomy and a left sided thoracic metastectomy, at
By late
she had developed new liver and new Right lung metastases, and she was begun on
Adriamycin. Initial partial response changed to stable dz and then she went on to have a Left
partial hepatectomy/metastectomy.
She was begun on Ifex/Mesnex in
and had minimal to stable response until
2012 when
pulmonary mets worsened. Several attempts at inclusion on clinical trial were unsuccessful for
candidacy reasons, and ultimately in
, she started DTIC.
Her breathing worsened and CT scans showed dramatic progression in Rt and left lung (R>>L) and she
was begun on Pazopanib. She then developed an ischemic CVA in left pontine region 7 wks later.
She remains w/ a dense Rt hemiparesis and expressive aphasia.
She is aware of her dx, stage, relapses, tx courses and prognosis.
She does not wish any heroic
efforts
Assessment/Plan
Widely metastatic high grade uterine sarcoma, w/ progression of dz in the face of 1st/2nd and 3rd
line conventional cytotoxic chemoRx. Date of Dx:
Recent Ischemic L CVA w/ residual dense R hemiplegia and expressive aphasia, possibly resulting
from adverse effects of Pazopanib (w/possible VEGF inhib effects?-- as reported).
I do not have a reasonable alternative for palliative anti neoplastic therapy at this time. I feel
that the best approach is palliative, and since there is a small but possible chance of some
Patient Name:
Facility:
Page Number: 126
Progress Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Signed
(HEMA) MD,
(HEMA) MD,
14:10 EDT
14:10 EDT
recovery of motor skills and speech w/ Speech/Physical/Occupational Therapies.... I would recommend
first ....a) referral to Palliative Care service here at
b) arrange outpt palliative care /
home care w/
to perhaps have some chance of regaining some neuro fxns before committing to
Hospice of
I have told them of my assessment that her prognosis is less than 10-12 mos and that recovery is
unlikely w/ any available conventional txs .
She and her husband agree.
UTI-- C and S pending .... on abx.
DNR/DNI ordered.
palliative care consult requested
care w/ PT/OT/ST requested.
Physical Exam
Chest: Clear on L but absent Rt BS
CV: RRR, No rubs, murmurs or gallops
Extremities: No clubbing, cyanosis or edema
Neck: No JVD
Neuro: dense Rt hemiparesis
Objective
Vitals
Temp
37.1
BP
107/66
Pulse
114
24 Hr Tmax: 37.8 at
Totals
Intake
1513
RR
18
SPO2
95%
00:14
Output
1250
Balance
263
O2 Therapy
Room Air
Patient Name:
Facility:
Page Number: 127
Progress Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Signed
(HEMA) MD,
(HEMA) MD,
14:10 EDT
14:10 EDT
No 24 Hour Lab Data
ON:
14:10
ON:
14:10
Document Name:
Document Status:
Performed By:
Authenticated By:
(HEMA) MD,
(HEMA) MD,
Modified
Jr., (INTE) MD,
Jr., (INTE) MD,
07:03 EDT
07:34 EDT
Subjective
No prn meds required last night.
night.
No SOB or CP.
Getting tachycardic.
Per RN, very little PO intake.
Low-grade temps.
Didn't sleep well last
Assessment/Plan
-Continue ASA 325mg qday. Not considering anti-coag at this point.
-Holding Votrient.
-ST/PT/OT.
2. UTI.
-Continue CTX (started
-F/U urine culture.
3. Tachycardia.
-Fever control.
-Starting IVF.
).
-Dr.
to assume her care. Discussed briefly w him this AM.
family later today.
He will discuss goals of care w
5. HTN.
6. Prophy.
7. Dispo. If family and Dr.
decide on hospice, won't pursue rehab, but if they choose to
pursue treatment, will probably need some acute rehab.
Patient Name:
Facility:
Page Number: 128
Progress Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Modified
(INTE) MD,
, (INTE) MD,
07:03 EDT
07:34 EDT
Physical Exam
Objective
Vitals
Temp
37.4
BP
126/65
Pulse
125
24 Hr Tmax: 37.8 at
Totals
RR
18
SPO2
95%
O2 Therapy
Room Air
00:14
Intake
1513
Output
1250
Balance
263
No 24 Hour Lab Data
ON:
07:34
ON:
2 07:34
Addendum by
., (INTE) MD,
, (INTE) MD,
, (INTE) MD,
on
7:36 EDT
Physical Exam
Neck: No JVD.
CV: Tachycardic, regular rhythym w/o murmurs. Radial pulses 2+ bilaterally.
Neuro: Decreased strength on entire R side including face. More decreased fine sensation in R arm
today than yesterday. Has some fine sensation in R face and R leg.
ON:
, (INTE) MD,
Patient Name:
Facility:
Page Number: 129
Progress Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Signed
PA,
10:22 EDT
(NEUR) MD,
13:49 EDT
Neurology progress note for stroke
Subjective:
No events
ROS / Fam HX / Soc Hx:
No changes since initial consult
Assessment/Plan:
1. Acute L Basal ganlia CVA with 2 additional smaller infarcts.
hypercoagulable state
2. Metastatic leiomyosarcoma
3. 2 mm, basilar tip aneurysm (no further w/u needed)
supect secondary to
Brain MRI Imaging and Imaging report reviewed
No evidence of Atrial Fibrillation
Therapy Notes reviewed
Carotid Doppler and Echo with bubble study: NML
Labs reviewed
Discussed with family in room
would continue asa and lipitor
Agree with other management
No further inpatient neurology work up needed
Please call if any further questions. Will sign off.
Physical Exam
I was asked to no disturb pt who was sleeping
General appearance: NAD
sleeping soundly
face =
motor: no spontaneous movements, strength not tested
no tremor or involuntary movements,
Objective
Vitals
Temp
36.8
BP
136/90
Pulse
119
24 Hr Tmax: 38.2 at
Totals
Intake
1020
RR
18
SPO2
----
20:14
Output
250
Balance
770
O2 Therapy
Room Air
Patient Name:
Facility:
Page Number: 130
Progress Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Signed
PA,
10:22 EDT
(NEUR) MD,
13:49 EDT
Today's Lab Results
0824
UA Glucose
See Flowsheet,
UA Protein
See Flowsheet,
UA Bili
See Flowsheet,
UA pH
5.5,
UA Blood
See Flowsheet,
UA Ketones
See Flowsheet,
UA Nitrite
See Flowsheet,
UA Leuk Est
See Flowsheet,
UA Clarity
See Flowsheet,
UA Spec Grav
1.020,
UA Color
See Flowsheet,
UA RBC
8 H,
UA WBC
18 H,
UA Bacteria
See Flowsheet,
Urine
Collectio
See Flowsheet,
ON:
10:22
ON:
13:49
Document Name:
Document Status:
Performed By:
Authenticated By:
PA,
(NEUR) MD,
Signed
(HEMA) MD,
(HEMA) MD,
08:26 EDT
08:26 EDT
Oncology:
Called by daughter and family and asked to assume outpt Oncology care, of metastatic Uterine Sarcoma.
I have reviewed the current events at
and I will ask
return at lunch today to talk further w/ pts family.
c and
for their salient records. I will
md
ON:
08:26
ON:
08:26
Document Name:
Document Status:
Performed By:
Authenticated By:
(HEMA) MD,
(HEMA) MD,
Signed
(INTE) MD,
, (INTE) MD,
06:52 EDT
07:44 EDT
Subjective
No prn meds required in last 24 hrs.
Fever up to 38.2, more tachycardic.
No complaints, no SOB.
Patient Name:
Progress Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Signed
, (INTE) MD,
(INTE) MD,
06:52 EDT
07:44 EDT
Assessment/Plan
-Stopping Votrient (have discussed this w Dr.
of
).
-ST/PT/OT.
2. Fever. Could be atelectasis, UTI.
-U/A, CXR.
-Incentive spiro.
4. HTN.
5. Prophy.
-SCD's.
6. Dispo.
Will need rehab on D/C.
Physical Exam
Neck: No JVD.
CV: Regular rhythm, tachycardic w/o murmurs. Radial pulses 2+ bilaterally.
Neuro: Awake, alert. Still w difficulty naming things. No change in strength or sensory exam
from yesterday. No movement at all of R side w decreased fine sensation in R arm and leg.
Objective
Vitals
Temp
36.4
BP
142/85
Pulse
126
24 Hr Tmax: 38.2 at
Totals
Intake
423
RR
18
SPO2
----
20:14
Output
650
Balance
-227
O2 Therapy
-----------
Patient Name:
Facility:
Page Number: 132
Progress Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Signed
(INTE) MD,
(INTE) MD,
06:52 EDT
07:44 EDT
No 24 Hour Lab Data
ON:
07:44
ON:
07:44
Document Name:
Document Status:
Performed By:
Authenticated By:
, (INTE) MD,
, (INTE) MD,
Signed
08:55 EDT
.
10:38 EDT
HIM Progress Note - Physician
DATE OF SERVICE:
PHYSICIAN:
, PA
CHIEF COMPLAINT AND REASON FOR FOLLOWUP:
leiomyosarcoma who is evaluated at the request of Dr.
is a pleasant, 49-year-old female with history of
for acute middle cerebral artery distribution infarction.
PRESENT ILLNESS:
is a pleasant, 49-year-old female with history of metastatic leiomyosarcoma, who is
seen in followup for an acute middle cerebral artery distribution infarction. The patient suggests improvement in speech, but denies
improvement in flaccid, right hemiparesis. The patient denies associated headache.
VITAL SIGNS: 36.9, pulse 113, respiratory rate 18, pressure 146/83.
NEUROLOGIC: Mild flattening of the right nasal labial fold. Obvious expressive aphasia with improved fluency with no receptive
component. No change in flaccid, right hemiparesis.
MEDICAL DECISION MAKING (laboratory and diagnostic review):
1. I reviewed the report of intracranial MRI, which suggests a large, 5.1 x 2.5 cm, well defined focus with restricted effusion
involving the left cauda head, left internal capsule, putamen, the globus pallidus, and periventricular white matter consistent with an
acute infarction. There are also two, additional foci restricted effusion involving the left cerebral cortex of the parietal lobe. No
associated enhancement, no hemorrhage. There is abrupt termination of the signal void in the left middle cerebral artery consistent
with thrombus.
2. Carotid duplex suggest minimal stenosis involving the left and right internal carotid arteries.
3. Transthoracic echocardiogram suggests no obvious cardiac source of emboli.
4. Cholesterol 236, triglycerides 150, HDL 86, LDL 120.
5. Intracranial MR angiogram suggests an acute thrombus in the left M-1 segment. A 2 mm aneurysm noted at the tip of the basilar
artery.
IMPRESSION:
1. A middle cerebral artery distribution infarction, probable hypercoagulable states secondary to metastatic leiomyosarcoma.
Patient Name:
Facility:
Page Number: 133
Progress Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
2.
3.
4.
5.
Signed
T.
08:55 EDT
T.
10:38 EDT
History of metastatic leiomyosarcoma.
Hyperlipidemia.
A 2 mm, basilar tip aneurysm.
History of hypertension.
DISCUSSION AND RECOMMENDATIONS: The patient a bit encouraged about the improvement in speech, but concerned about
the persistent, flaccid, right hemiparesis. I agree with continuation of aspirin for secondary prevention. I would add statin for
hyperlipidemia. No specific recommendations regarding the 2 mm, basilar artery aneurysm. I will continue to follow. The appears to
agree with this management and plan and has no further question or concerns.
Dictated
MD.
, PA
DD:
DT:
2 08:55:59
09:30:44
#
(NEUR) MD,
ON:
10:38
Document Name:
Document Status:
Performed By:
Authenticated By:
Signed
(INTE) MD,
, (INTE) MD,
08:14 EDT
08:14 EDT
Subjective
No prn meds required last night.
Temp of 38.1 early this AM that self-resolved.
No complaints.
Still w no movement of R side.
Assessment/Plan
Likely has some thrombophilia given reported
h/o clot in the past (which I could not find in UNC records) and active cancer. Votrient also
reported to cause DVT/PE. No evidence for BLE DVT's. TTE, carotid U/S NL.
-Stopping Votrient (have discussed this w
).
-ST/PT/OT.
Patient Name:
Facility:
Page Number: 134
Progress Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Signed
, (INTE) MD,
(INTE) MD,
08:14 EDT
08:14 EDT
3. HTN.
4. Prophy.
-SCD's.
5. Dispo.
Will need rehab on D/C.
Physical Exam
Neck: No JVD.
Neuro: Alert, can identify she is in hospital, thought year was
. Still w some Wernickie-like
aphasia. Weakness of entire R face, tongue protrusion to R. 1/5 strength of RUE, RLE. Decreased
fine sensation in RUE and RLE.
Objective
Vitals
Temp
36.5
BP
145/81
Pulse
102
24 Hr Tmax: 38.1 at
Totals
Intake
423
RR
16
SPO2
----
00:00
Output
650
Balance
-227
No 24 Hour Lab Data
ON:
08:14
ON:
08:14
, (INTE) MD,
(INTE) MD,
O2 Therapy
-----------
Patient Name:
Facility:
Page Number: 135
Progress Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Signed
, (INTE) MD,
r., (INTE) MD,
11:24 EDT
11:24 EDT
Subjective
No complaints.
Last known to be in her normal state around 3:45p when she talked w her mother-this was not known to ED staff as husband was not aware about this until after her admission.
Noted to be abnormal around 4:30 or so. No h/o TIA's but had a h/o blood clot somewhere in thorax
(not a PE apparently) that was treated w 6 mo of Lovenox; this was all at
, and this was during
her cancer treatment course as well. No real FH of stroke although father may have had it during
his cancer course.
Assessment/Plan
1. R hemiplegia, L basal ganglia stroke.
2 other areas of restricted diffusion in L parietal lobe,
(maybe related to likely clot causing L basal ganglia stroke?) Likely has some thrombophilia given
h/o clot in the past and active cancer.
-Continue ASA.
-Will get MRA to assess for thrombus as anti-coag would make more sense in such situation.
-Stopping Votrient (reports of DVT/PE w this, have discussed this w Dr.
of
Onc).
-ST/PT/OT.
-TTE w bubble pending.
3. HTN.
-Continue Norvasc, benazepril as BP's are not low.
4. Prophy.
-SCD's.
Physical Exam
Neck: No JVD, no bruits, NL carotid upstrokes.
Neuro: Alert, having some expressive aphasia, knows she is in a hospital but thought it was
and said yr was 1496. Has R facial weakness and difficulty keeping R eye closed. Decreased fine
sensation on entire right side and 1/5 strength on entire right side.
Objective
Vitals
Temp
36.6
BP
151/84
24 Hr Tmax: 36.7 at
Pulse
90
08:15
RR
18
SPO2
96%
O2 Therapy
Room Air
Patient Name:
Facility:
Page Number: 136
Progress Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Signed
(INTE) MD,
, (INTE) MD,
Totals
Intake
467
11:24 EDT
11:24 EDT
Output
350
Balance
117
Today's Lab Results
05:42
Procedure
UA Glucose
UA Protein
UA Bili
UA pH
UA Blood
UA Ketones
UA Nitrite
UA Leuk Est
UA Clarity
UA Spec Grav
UA Color
UA RBC
UA WBC
UA Bacteria
Urine Collectio
300 mg/dl
30 mg/dl
Neg
6.5
Neg
Neg
Neg
Neg
Clear
1.019
Yellow
1
1
Rare
Urine, Voided
04:36
Procedure
Total CK
CK MB
% CK MB
Troponin-I
Magnesium
HDL
Chol
Trig
LDL
Chol/HDL
VLDL
Non HDL Chol
50
3.4
6.8 H
0.027
2.1
86 H
236 H
150
120 H
2.7
30
150 H
00:57
Procedure
Total CK
CK MB
% CK MB
51
3.8
7.5 H
Units
Ref Range
Neg
Neg
Neg
5.0 - 8.0
Neg
Neg
Neg
Neg
1.005 - 1.030
/HPF
/HPF
0 - 3
0 - 2
None Seen
Units
U/L
ng/mL
% Index
ng/mL
mg/dL
mg/dL
mg/dL
mg/dL
mg/dL
mg/dL
mg/dL
Ref Range
26 - 192
0.0 - 5.0
0.0 - 3.5
0.000 - 0.045
1.8 - 2.4
40 - 59
120 - 200
40 - 150
40 - 100
1.0 - 4.5
9 - 37
70 - 130
Units
U/L
ng/mL
% Index
Ref Range
26 - 192
0.0 - 5.0
0.0 - 3.5
Patient Name:
Progress Notes
Document Name:
Document Status:
Performed By:
Authenticated By:
Troponin-I
Signed
, (INTE) MD,
(INTE) MD,
0.028
11:24 EDT
11:24 EDT
ng/mL
ON:
11:24
ON:
11:24
Jr., (INTE) MD,
0.000 - 0.045
(INTE) MD,
Facility:
Page Number: 138
Hematology
General Hematology
Procedure
Units
Ref Range
18:10 EDT
Legend: A=Abnormal, C=Critical, *=Interpretive Data @=Corrected, L=Low, H=High, f=footnotes
WBC
k/uL
[3.5-10.5]
10.2
RBC
M/uL
[3.90-5.03]
4.15
Differential
Hgb
g/dL
[12.0-15.5]
13.2
Hct
%
[35.0-44.0]
39.1
Platelet
k/uL
[150-450]
274
RDW
%
[12.0-15.0]
18.5 H
MCV
fL
[82.0-98.0]
94.2
Procedure
Units
Ref Range
18:10 EDT
Neutro
%
[42-78]
87 H
Lymph
%
[16-52]
7 L
Misc Hematology
Procedure
Units
Ref Range
12:15 EDT
21:11 EDT
Mono
%
[1-11]
6
Eos
%
[0-7]
0
Basophil
%
[0-4]
0
Neutro Abs
k/uL
[2.10-6.30]
8.87 H
Sed Rate
mm/hr
[0-20]
27 H
27 H@
21:11 EDT Sed Rate:
Corrected from 18 on
22:09 EDT
Coagulation
Procedure
Units
Ref Range
12:15 EDT
18:10 EDT
18:10 EDT
PT
sec
[11.8-14.8]
INR *
12.8
0.95
PTT
sec
[24-36]
Antithromb III
%
[84-129]
111
31
18:10 EDT INR:
* Therapeutic (Coumadin) Range for INR is 2.00 to 3.00
Chemistry
General Chemistry
Procedure
Units
Ref Range
18:10 EDT
Legend: A=Abnormal, C=Critical, *=Interpretive Data, @=Corrected, L=Low, H=High, f=footnotes
Sodium Lvl
mmol/L
[134-145]
135
Potassium Lvl
mmol/L
[3.5-5.1]
3.9
Chloride
mmol/L
[98-107]
101
CO2
mmol/L
[21.0-32.0]
21.0
BUN
mg/dL
[7-18]
13
Creatinine *
mg/dL
[0.60-1.10]
0.62
Patient Name:
Chemistry
General Chemistry
18:10 EDT Creatinine:
* This creatinine method is traceable to a GC-IDMS method and NIST standard reference material.
Procedure
Units
Ref Range
22:02 EDT
18:10 EDT
eGFR - African
eGFR - Non-African *
Glucose Lvl
mg/dL
[65-99]
>60 f
>60 f
124 H
POC WB Glucose *
mg/dL
[65-99]
136 H
Calcium Lvl
mg/dL
[8.5-10.1]
8.5
18:10 EDT eGFR - Non-African:
The eGFR is calculated using the four parameter MDRD equation for IDMS-traceable creatinine.
eGFR < 60 indicates chronic kidney disease, eGFR < 15 indicates kidney failure.
22:02 EDT POC WB Glucose:
* Point of Care Testing performed by Nursing Services per documented policies.
18:10 EDT eGFR - African:
eGRF calculated by Discern Logic.
18:10 EDT eGFR - Non-African:
eGRF calculated by Discern Logic.
Procedure
Units
Ref Range
04:36 EDT
18:10 EDT
Alk Phos
U/L
[50-136]
Bili Total
mg/dL
[0.2-1.0]
Albumin Lvl
g/dL
[3.4-5.0]
Total Protein
g/dL
[6.4-8.2]
ALT
U/L
[17-65]
AST
U/L
[3-37]
110
0.4
2.9 L
7.1
32
39 H
Chol
mg/dL
[120-200]
236 H
04:36 EDT Lipid:
Patient must fast 12-14 Hours
Procedure
Units
Ref Range
04:36 EDT
04:36 EDT
[1.0-4.5]
LDL
mg/dL
[40-100]
VLDL
mg/dL
[9-37]
Non HDL Chol
mg/dL
[70-130]
2.7
120 H
30
150 H
Trig
mg/dL
[40-150]
HDL
mg/dL
[40-59]
Chol/HDL *
150
86 H
Magnesium
mg/dL
[1.8-2.4]
2.1
Patient Name:
Chemistry
General Chemistry
04:36 EDT Chol/HDL:
*
THERAPY TARGET VALUES BY RISK LEVEL (NCEP ATP III 2004):
Low:
LDL-C < 160; non HDL-C < 190
Moderate:
LDL-C < 130; non HDL-C < 160
High:
LDL-C < 100; non HDL-C < 130
Very High(optional): LDL-C < 70; non HDL-C < 100
Primary target is LDL-C; secondary target is non HDL-C (if trig > 200)
*
PATIENT RISK LEVEL
Low:
No CHD, 0-1 risk factor
Moderate:
No CHD, 2+ risk factors, Framingham 10-year risk < 20%
High:
CHD or equivalents, Framingham 10-year risk >= 20%
*
MAJOR CARDIOVASCULAR RISK FACTORS
Age: male > 45 years, female > 55 years
HDL cholesterol < 40 mg/dL
Active smoking (in the past month)
Hypertension (>= 140/90 or taking antihypertensive medication)
Family history of premature heart disease: male < 55, female < 65
(modified from PocketGuide - Lipid and Lipoprotein Disorders)
Misc Chemistry
Procedure
Units
Ref Range
21:11 EDT
Homocysteine *
umol/L
[3.2-13.0]
8.7
21:11 EDT Homocysteine:
* The reference interval is based on fasting specimens. Homocysteine
may be elevated in malnutrition or folate/vitamin B12 deficiency.
Homocysteine has also been used as a weak predictor of cardiac risk,
as delineated below.
SERUM HOMOCYSTEINE AND CARDIAC RISK
Desirable <= 10
Intermediate > 10 to < 15
High
>= 15 to < 30
Very High >= 30
(from Clinical Chemistry 2009;55:378-384)
Patient Name:
Cardiac Enzymes
Procedure
Units
Ref Range
04:36 EDT
00:57 EDT
18:10 EDT
Total CK
U/L
[26-192]
50
51
56
CK MB
ng/mL
[0.0-5.0]
3.4
3.8
4.0
% CK MB
% Index
[0.0-3.5]
6.8 H
7.5 H
7.1 H
Troponin-I *
ng/mL
[0.000-0.045]
0.027
0.028
ED Troponin-I *
ng/mL
[0.000-0.045]
0.018
18:10 EDT Total CK:
Normal range change on
due to new formulation of reagent.
00:57 EDT Troponin-I:
* Values > 0.045 ng/mL suggest myocardial injury. For optimal performance, the pattern of enzyme elevation should be correlated
with the clinical symptoms, ECG findings, and other laboratory data.
18:10 EDT ED Troponin-I:
* Values > 0.045 ng/mL suggest myocardial injury. For optimal performance, the pattern of enzyme elevation should be correlated
with the clinical symptoms, ECG findings, and other laboratory data.
04:36 EDT CK-MB:
A CK must be ordered with this test.
00:57 EDT CK-MB:
18:10 EDT CK-MB:
Endocrinology
General Endocrinology
Procedure
Units
Ref Range
18:10 EDT
TSH
mIU/L
[0.358-3.740]
2.800
Immunology/Serology/Molecular Testing
2
Procedure
Units
Ref Range
21:11 EDT
ANA (Screen)
Syphilis Antibody *
[Neg]
Neg
Negative
21:11 EDT Syphilis Antibody:
Reference range is negative.
Patient Name:
Urinalysis
Procedure
Units
Ref Range
08:24 EDT
05:42 EDT
UA Color
UA Clarity
UA Spec Grav
UA pH
UA Protein *
UA Glucose
Yellow
Yellow
Cloudy
Clear
[1.005-1.030]
1.020
1.019
[5.0-8.0]
5.5
6.5
[Neg]
100 mg/dl A
30 mg/dl A
[Neg]
70 mg/dL A
300 mg/dl A
05:42 EDT UA Protein:
INTERPRETATION OF NUMERIC VALUES FOR URINALYSIS
Protein
Glucose
Ketone
TR = Trace
TR = 100 mg/dL
TR = 5 mg/dL
1+ = 30 mg/dL 1+ = 250 mg/dL 1+ = 15 mg/dL
2+ = 100 mg/dL 2+ = 500 mg/dL 2+ = 40 mg/dL
3+ = 300 mg/dL 3+ = 1000 mgdL 3+ = >80 mg/dL
Procedure
Units
Ref Range
08:24 EDT
05:42 EDT
UA Ketones
UA Bili
UA Blood
UA Nitrite
UA Leuk Est
[Neg]
Trace A
Neg
[Neg]
Neg
Neg
[Neg]
Neg
Neg
[Neg]
Pos A
Neg
[Neg]
Small A
Neg
Procedure
Units
Ref Range
08:24 EDT
05:42 EDT
UA Bacteria
Urine Collection Type
[None Seen]
Moderate A
Rare A
Urine, Cath
Urine, Voided
UA WBC
/HPF
[0-2]
18 H
1
UA RBC
/HPF
[0-3]
8 H
1
References
Procedure
Units
Ref Range
12:15 EDT
12:15 EDT
Phospho IgG-Mayo
GPL
[<10.0 (Negative)]
Phospho IgM-Mayo
MPL
[<10.0 (Negative)]
<4.0 f
<4.0
12:15 EDT Phospho IgGTest Performed by:
Laboratories -
o:
Campus
Laboratory Director:
, M.D.
12:15 EDT Protein C Ag:
Note: Increased Protein C antigen is of unknown hemostatic
significance.
Test Performed by:
Laboratories Campus
, M.D.
Protein C Ag-Mayo
%
[70-150]
164 Hf
Patient Name:
Facility:
Page Number: 143
References
Procedure
Units
Ref Range
12:15 EDT
12:15 EDT
Protein S. Antigen Free, P
Prothrombin G20210A -
SEE COMMENTS f
SEE COMMENTS f
12:15 EDT Protein S. Antigen Free, P
HI
Expected
Test
Result LO Units Values
---------------------------------------------------------------Protein S Ag, P
Protein S Ag, Free, P
99
%
50 - 160
Test Performed by:
Laboratories Campus
, M.D.
12:15 EDT Fac V Leid (R506Q) :
HI
Expected
Test
---------------------------------------------------------------Factor V Leiden (R506Q)
Negative
Negative
Mutation, B
F5DNA Interpretation
SEE COMMENTS
This individual DOES NOT have the factor V Leiden (R506Q)
mutation. Although the factor V Leiden mutation is absent,
the individual may have other genetic and environmental
risk factors for thrombosis. If clinically indicated,
suggest Coagulation Consultation 83093 (Thrombophilia
Profile) to complete the evaluation for an inherited or
acquired thrombosing disorder (i.e., thrombophilia).
This test is a direct mutation analysis of leukocyte
genomic DNA by the Invader Assay system (Invader, Hologic
Inc, Madison, WI).
Analyte Specific Reagent. This test was developed and its
performance characteristics determined by
. It
has not been cleared or approved by the U.S. Food and Drug
Administration.
F5DNA Reviewed By
, M.D., Ph.D.
Test Performed by:
Laboratories Campus
Fac V Leid (R506Q) -
, M.D.
SEE COMMENTS f
Patient Name:
Facility:
Page Number: 144
References
12:15 EDT Prothrombin G20210A HI
Expected
Test
---------------------------------------------------------------Prothrombin G20210A Mutation, B Negative
Negative
PTNT Interpretation
SEE COMMENTS
This individual DOES NOT have the Prothrombin G20210A
mutation. Although the Prothrombin G20210A mutation is
absent, the individual may have other genetic and
environmental risk factors for thrombosis. If clinically
indicated, suggest Coagulation Consultation 83093
(Thrombophilia Profile) to complete the evaluation for an
inherited or acquired thrombosing disorder (i.e.,
thrombophilia). Consider genetic consultation and
counseling of potentially affected family members regarding
laboratory testing.
This test is a direct mutation analysis of leukocyte
genomic DNA by the Invader Assay system (Invader,
WI).
Analyte Specific Reagent. This test was developed and its
performance characteristics determined by
It
has not been cleared or approved by the U.S. Food and Drug
Administration.
PTNT Reviewed By
M.D., Ph.D.
Test Performed by:
Laboratories Campus
, M.D.
Microbiology - Urine Cultures
PROCEDURE: Urine Culture
SOURCE: U Cath
COLLECTED:
STARTED:
ACCESSION:
08:24 EDT
13:13 EDT
*** FINAL REPORT ***
Final Report
Verified:
09:36 EDT
Colony Count >100,000 organisms/mL isolated of Staphylococcus lugdunensis
Patient Name:
Facility:
Page Number: 145
Microbiology - Urine Cultures
PROCEDURE: Urine Culture
SOURCE: U Cath
COLLECTED:
STARTED:
ACCESSION:
08:24 EDT
13:13 EDT
*** SUSCEPTIBILITY RESULTS ***
Staphylococcus lugdunensis
__________________________
MIC(ug/mL)
____________
Ciprofloxacin(1)
<=0.5
Levofloxacin
<=0.12
Nitrofurantoin
<=16
Oxacillin(2)
0.5
Trimethoprim/Sulfa
<=10
Tetracycline
<=1
Vancomycin
1
MIC Interp
____________
S
S
S
S
S
S
S
S=Susceptible, I=Intermediate, R=Resistant, N/A=Not Applicable
*** FOOTNOTES ***
(1)
Levofloxacin is the preferred fluoroquinolone at Rex Healthcare.
(2)
B-lactams (except amoxacillin, ampicillin, and penicillins) are active
against oxacillin susceptible Staph
__________________________________________________________
Radiology - Scanned
Document Name:
Document Status:
Performed By:
Authenticated By:
Scanned Radiology
Signed
Scanned, Documents
12:23 EDT
Patient Name
Facility:
Page Number: 147
Computed Tomography
Accession Number
Exam
CT Head W/O Contrast
Exam Date/Time
17:52 EDT
Ordering Physician
(EMER) MD,
CPT4 Codes
70450 (CT Head W/O Contrast)
CDM Codes
27221 (CT Head W/O Contrast)
Reason For Exam
Acute Stroke
Report
INDICATIONS: Stroke, aphasia, right-sided weakness
Patient arrival to imaging less than 24 hours
COMPARISON: none
FINDINGS: There is mild asymmetry in the appearance of the sulci with
effacement of sulci of the left cerebrum. No associated low density in
the cortex or subcortical white matter is visualized. There is noted
associated hemorrhage or midline shift. There is no mass or mass
effect. No hemorrhage or extra axial fluid collection is identified.
No discrete low-density lesions are identified. The visualized
paranasal sinuses are clear.
IMPRESSION: Asymmetry in the sulci at the vertex with effacement of
the sulci on the left . This may represent early change from ischemia
in the correct clinical setting. No associated hemorrhage and no
cortical low density identified at this time..
***** Final *****
(RAD) MD,
Signed (Electronic Signature):
Signed by:
(RAD) MD,
Transcribed by:
5:53 pm
Diagnostic Radiology
Accession Number
Exam
DR Chest 1 View Portable
Only
CPT4 Codes
71010 (DR Chest 1 View Portable Only)
CDM Codes
Exam Date/Time
08:01 EDT
Ordering Physician
(INTE) MD,
Patient Name:
Facility:
Page Number: 148
Accession Number
Exam
Only
Exam Date/Time
08:01 EDT
Ordering Physician
, (INTE) MD,
Reason For Exam
Shortness of Breath
Report
INDICATION: Shortness of breath, history of cancer
TECHNIQUE: 1 view , portable
FINDINGS: Comparison: And 5
. Port a catheter present over the
right chest with catheter in the SVC. Chest is rotated the left. Heart
is at the upper limits of normal in size. There is a large mass over
the right upper lobe and right mid lung without change from the prior
study. No new infiltrate.
IMPRESSION: Stable mass over right chest. No acute findings.
***** Final *****
(RAD) MD,
Signed by:
(RAD) MD,
Transcribed by:
Accession Number
8:07 am
Exam
Only
Exam Date/Time
18:54 EDT
CPT4 Codes
CDM Codes
Reason For Exam
Stroke
Report
INDICATION: Lung carcinoma, metastatic disease, CVA, chemotherapy.
Upright portable study 1840 hours, no comparison.
Right-sided Port-A-Cath observed, tip at SVC/RA junction. Surgical
clips project at right upper quadrant. Mild thoracic scoliosis
observed. Cardiac silhouette not enlarged. Opacification of the
superior two-thirds of the right hemithorax evident, the without
mediastinal shift. Findings consistent with large lung mass or masses,
associated atelectasis and effusion. Nodular lesions project at right
Ordering Physician
(EMER) MD,
Patient Name:
Accession Number
Exam
Only
Exam Date/Time
18:54 EDT
Ordering Physician
(EMER) MD,
lung base, and left infrahilar region, probable metastatic disease.
Atelectasis or infiltrate observed at left lung base.
IMPRESSION:
Findings consistent with extensive lung mass at right perihilar
region, associated pleural effusion and atelectasis/infiltrate.
Bilateral lung nodules most consistent with metastatic disease.
Left basilar atelectasis or infiltrate.
Chest CT may be helpful to further evaluate.
***** Final *****
(RAD) MD,
Signed by:
(RAD) MD,
Transcribed by:
6:58 pm
Magnetic Resonance Imaging
Accession Number
Exam
MR Angio Head W/O Contrast
Exam Date/Time
16:04 EDT
CPT4 Codes
70544 (MR Angio Head W/O Contrast)
CDM Codes
36217 (MR Angio Head W/O Contrast)
Reason For Exam
L hemisphere stroke, cancer, assess for L MCA thrombus;Non-Hemorrhagic Stroke - TIA
Report
INDICATION: Abnormal MRI, left MCA distribution CVA, thrombus evident
on MRI.
Three D time of flight MRA, correlation with current MRI.
Left vertebral artery is dominant. Both vertebral arteries contribute
to the basilar artery. A very small, 2 mm aneurysm evident, projects
to the right at the tip of the basilar artery. Normal appearing left
posterior cerebral artery. Fetal origin of right posterior cerebral
Ordering Physician
, (INTE) MD,
Patient Name:
Facility:
Page Number: 150
Accession Number
Exam
MR Angio Head W/O Contrast
Exam Date/Time
16:04 EDT
Ordering Physician
(INTE) MD,
artery evident, developmental variation. Normal appearing distal
internal carotid arteries. No abnormality evident at the anterior
cerebral arteries and right middle cerebral artery. Abrupt termination
at M1 segment of the left middle cerebral artery observed,
corresponding to finding on MRI, consistent with thrombosis. On the
axial, source images, abnormal signal intensity observed at left basal
ganglion, corresponding to acute/subacute infarction on MRI, with
effacement of left lateral ventricle.
IMPRESSION:
Abrupt termination of left M1 segment, consistent with thrombosis,
corresponding to finding on current MRI. Acute/subacute infarction at
left basal ganglion, effacement of left lateral ventricle.
Dominant left vertebral artery, fetal origin of right posterior
cerebral artery, developmental variation.
2 mm aneurysm at the tip of basilar artery.
***** Final *****
Signed by:
(RAD) MD,
Transcribed by:
Accession Number
4:21 pm
Exam
MR Brain W/WO Contrast
Exam Date/Time
08:27 EDT
CPT4 Codes
70553 (MR Brain W/WO Contrast)
CDM Codes
36021 (MR Brain W/WO Contrast), 53804 (INJ GADOLINIUM MRI CONTRAST/ML)
Reason For Exam
Stroke/TIA;Other-Please complete Reason For Exam free text
Report
Indication: Right-sided weakness, achalasia; metastatic leiomyosarcoma
TECHNIQUE: Routine multiplanar multisequence imaging of the brain was
performed without and with 17 cc Magnevist.
FINDINGS: Comparison head CT scan of
. There is a 5.1 x
2.5 cm well-defined focus of restricted diffusion involving the left
caudate head, internal capsule, putamen , globus pallidus and
Ordering Physician
(INTE) MD,
Patient Name:
Facility:
Page Number: 151
Accession Number
Exam
MR Brain W/WO Contrast
Exam Date/Time
08:27 EDT
periventricular white matter marginating the lateral ventricle. There
is mild mass effect upon the right lateral ventricle, likely related
to edema. There are 2 additional foci of restricted diffusion
involving the left cerebral cortex of the parietal lobe, measuring
approximately 0.9 cm and 0.5 cm. There is no enhancement in these
regions. There is no hemorrhage, extra-axial fluid collection or
hydrocephalus. The brainstem and cerebellum are normal. There is no
Chiari I. There is abrupt termination of the signal void in the left
middle cerebral artery (see image 11 series 3), consistent with
thrombosis. The other major intracranial vessels are patent. The
paranasal sinuses are clear.
IMPRESSION:
1. Large region of acute infarction involving the left basal ganglia
as described. Two additional tiny infarcts in the left cerebral
cortex.
2. Abrupt termination of the left middle cerebral artery, consistent
with thrombosis. Consider further evaluation with a brain MRA.
The report was called to Dr.
***** Final *****
Signed by:
) MD,
Transcribed by:
9:13 am
Electrocardiograms
Document Name:
Document Status:
Performed By:
Authenticated By:
Electrocardiogram-EKG
Signed
Ordering Physician
(INTE) MD,
Patient Name:
Facility:
Page Number: 153
Electrocardiograms
Document Name:
Document Status:
Performed By:
Authenticated By:
Electrocardiogram-EKG
Signed
EKG 12 Lead REMA Adult ED
Ventricular Rate = 79 BPM
Atrial Rate = 79 BPM
P-R Interval = 122 ms
QRS Duration = 78 ms
Q-T Interval = 384 ms
QTC Calculation(Bezet) = 440 ms
P Axis = 83 degrees
R Axis = 81 degrees
T Axis = 38 degrees
93000
Normal sinus rhythm
Anterior infarct , age undetermined
Abnormal ECG
Patient Name:
Facility:
Page Number: 158
Peripheral Vascular Procedures
Accredited by the Intersocietal Commission for the Accreditation of Vascular Laboratories
Accession Number
Exam
PV Extensive Duplex
Scan/Doppler Bilater
Exam Date/Time
09:10 EDT
Ordering Physician
(INTE) MD,
Report
Carotid Duplex
Report
49
Gender: F
Exam Location:
_Vasc
Referring Physician:
DOB:
EHR CC:
Sonographer:
Procedure CPT:
Indications:
Stroke
ICD-9 Codes:
Risk Factors:
Previous Vascular Surgery:
IMPRESSION
The bilateral carotid systems were scanned in both the longitudinal and transverse planes utilizing real time simultaneous Doppler.
1. Color flow duplex ultrasound of the right cervical carotid system demonstrated no to minimal stenosis of the right internal carotid
artery (0-19% diameter reduction).
2. Color flow duplex ultrasound of the left cervical carotid system demonstrated no to minimal stenosis of the left internal carotid
artery (0-19% diameter reduction).
3. The bilateral external carotid arteries demonstrated normal spectral waveforms with antegrade flow.
4. The bilateral vertebral arteries demonstrated normal spectral waveforms with antegrade flow.
5. The bilateral subclavian arteries demonstrated normal spectral waveforms without evidence of stenosis.
6. There is minimal plaque in the bilateral carotid bifurcations.
Impression - There are no significant bilateral internal carotid artery stenoses, normal bilateral vertebral artery flow, minimal plaque
is
seen in the bilateral carotid bifurcations.
Patient Name:
Facility:
Page Number: 159
Peripheral Vascular Procedures
Accredited by the Intersocietal Commission for the Accreditation of Vascular Laboratories
Accession Number
Exam
PV Extensive Duplex
Scan/Doppler Bilater
Exam Date/Time
09:10 EDT
Ordering Physician
Exam
PV Venous Doppler Lower
Bilateral
Exam Date/Time
09:11 EDT
Ordering Physician
(Electronically Signed)
Final Date:
Accession Number
Report
Lower Extremity
Venous Duplex Report
Indications:
ICD-9 Codes:
Deep Vein Thrombosis
IMPRESSION
High resolution real time venous duplex ultrasonography was performed of the common femoral vein, saphenofemoral junction,
femoral vein, and popliteal vein of the bilateral lower extremities.
1. Normal compressibility was demonstrated in all segments in the transverse plane.
2. Phasic flow with good augmentation was demonstrated in the longitudinal plane in all segments.
3. The posterior tibial veins and peroneal veins were additionally scanned in the longitudinal plane and demonstrated complete
color fill in with augmentation.
Impression:.
No evidence of acute deep vein thrombosis in the bilateral lower extremities. However, venous duplex ultrasonography cannot
with certainty exclude isolated calf vein thrombosis.
Final Date:
13:36
Patient Name:
Facility:
Page Number: 160
Echocardiogram Procedures
Accession Number
Exam
HT Echo Cardiac 2D with
Contrast
Exam Date/Time
10:00 EDT
Ordering Physician
Report
Transthoracic
Echo Report
Procedure CPT: 93306
Indications:
TIA, CVA
ICD-9 Codes:
4359 436.0
Pt. History:
BP: 101
/ 66
HR: 78
Rhythm:
Sinus
Technical Quality: Good
IMPRESSIONS
Normal left ventricular size. Left ventricular wall thickness mildly increased. Interventricular dyssynchrony. Abnormal left
ventricular diastolic filling pattern for age. The ejection fraction is visually estimated at 50%.
The right ventricle is normal in size and function.
An interatrial shunt was not identified with and without valsalva.
Trace aortic regurgitation.
Normal pericardium without effusion.
Normal aortic root dimension. IVC appears normal.
FINDINGS
Left Ventricle
Right Ventricle
Right Atrium
Left Atrium
Mitral Valve
Aortic Valve
Tricuspid Valve
Normal left ventricular size. Left ventricular wall thickness mildly increased. Interventricular
dyssynchrony. Abnormal left ventricular diastolic filling pattern for age. The ejection fraction is visually
estimated at 50%.
The right ventricle is normal in size and function.
The right atrium is normal in size.
The left atrium is normal in size. 30mL of agitated saline were injected into patient's port a cath line by
RN. An interatrial shunt was not identified with and without valsalva.
The mitral valve is normal in mobility and thickness. Mild mitral annular calcification. Trace mitral
regurgitation.
The aortic valve appears normal. Three cusps are identified with normal mobility and function. Trace aortic
regurgitation.
Normal appearance and motion of the tricuspid valve. Trace tricuspid regurgitation.
Patient Name:
Facility:
Page Number: 161
Echocardiogram Procedures
Accession Number
Pulmonic Valve
Pericardium
Vessels
Exam
HT Echo Cardiac 2D with
Contrast
Exam Date/Time
10:00 EDT
Ordering Physician
Normal appearance and motion of the pulmonic valve. Trace pulmonic regurgitation.
Normal pericardium without effusion.
Normal aortic root dimension. IVC appears normal.
Final Date:
11:48
***** Final *****
Signed by:
Transcribed by:
11:48 am

Document 6424963

Transcription

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