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 #: Discharge Documentation 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 #: Discharge Documentation 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 #: 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 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. 2. Metastatic uterine leiomyosarcoma. 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 #: 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 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; ELECTRONICALLY REVIEWED AND SIGNED ON: 21:44 ELECTRONICALLY SIGNED 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. ELECTRONICALLY REVIEWED AND SIGNED ON: 18:04 ELECTRONICALLY SIGNED 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. PAST MEDICAL HISTORY: 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. PHYSICAL EXAMINATION: 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 # ELECTRONICALLY REVIEWED AND SIGNED (NEUR) MD, ELECTRONICALLY SIGNED 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: Emergency Documentation 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: Emergency Documentation 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 /# ELECTRONICALLY REVIEWED AND SIGNED ON: 12:13 ELECTRONICALLY SIGNED ON: 12:13 (EMER) MD, (EMER) MD, Patient Name: FIN: Page Number: 22 MRN: Facility: Emergency Documentation 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. PAST MEDICAL 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: Emergency Documentation Document Name: Document Status: Performed By: Authenticated By: ED Note-Physician Signed (EMER) MD, (EMER) MD, 18:05 EDT 11:04 EDT PHYSICAL EXAMINATION: 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: Authenticated By: 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: Performed By: Authenticated By: 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 Progress Note-Physician 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 ELECTRONICALLY REVIEWED AND SIGNED ON: 10:58 ELECTRONICALLY SIGNED ON: 10:58 Document Name: Document Status: Performed By: Authenticated By: (INTE) NP, (INTE) NP, Progress Note-Physician 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 Progress Note-Physician 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 ELECTRONICALLY REVIEWED AND SIGNED ON: 10:39 ELECTRONICALLY SIGNED ON: 16:20 Document Name: Document Status: Performed By: Authenticated By: (HEMA) NP, (HEMA) MD, Progress Note-Physician 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 Progress Note-Physician 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. 4. Metastatic uterine leiomyosarcoma. -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: Progress Note-Physician Signed Jr., (INTE) MD, Jr., (INTE) MD, 08:55 EDT 08:55 EDT No 24 Hour Lab Data ELECTRONICALLY REVIEWED AND SIGNED ON: 08:55 ELECTRONICALLY SIGNED ON: 08:55 Document Name: Document Status: Performed By: Authenticated By: Jr., (INTE) MD, Jr., (INTE) MD, Progress Note-Physician 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: Progress Note-Physician Signed (INTE) NP, (INTE) NP, 17:55 EDT 17:55 EDT No 24 Hour Lab Data ELECTRONICALLY REVIEWED AND SIGNED ON: 17:55 ELECTRONICALLY SIGNED ON: 17:55 Document Name: Document Status: Performed By: Authenticated By: (INTE) NP, (INTE) NP, Progress Note-Physician 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 Abdomen: Soft, nontender, nondistended, NABS 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: Progress Note-Physician 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 ELECTRONICALLY REVIEWED AND SIGNED ON: 11:02 ELECTRONICALLY SIGNED 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. ELECTRONICALLY REVIEWED AND SIGNED ON: 13:20 Document Name: Document Status: Performed By: Authenticated By: Progress Note-Physician 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 1. R hemiplegia, L basal ganglia stroke 2/2 thrombus. 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. -Continue statin for elevated LDL. Patient Name: Progress Notes Progress Note-Physician 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. Likely from fever as well as some volume depletion. 4. Metastatic uterine leiomyosarcoma. -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. 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 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: 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: Progress Note-Physician Signed (INTE) MD, (INTE) MD, 07:57 EDT 07:57 EDT No 24 Hour Lab Data ELECTRONICALLY REVIEWED AND SIGNED ON: 07:57 ELECTRONICALLY SIGNED ON: 07:57 Document Name: Document Status: Performed By: Authenticated By: ., (INTE) MD, , (INTE) MD, Progress Note-Physician 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: Progress Note-Physician 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 Abdomen: Soft, nontender, nondistended, NABS 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: Progress Note-Physician Signed (HEMA) MD, (HEMA) MD, 14:10 EDT 14:10 EDT No 24 Hour Lab Data ELECTRONICALLY REVIEWED AND SIGNED ON: 14:10 ELECTRONICALLY SIGNED ON: 14:10 Document Name: Document Status: Performed By: Authenticated By: (HEMA) MD, (HEMA) MD, Progress Note-Physician 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 1. R hemiplegia, L basal ganglia stroke 2/2 thrombus. 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. Not considering anti-coag at this point. -Hypercoag panel (although hypercoagulability in this case likely 2/2 cancer). -Holding Votrient. -ST/PT/OT. -Continue statin for elevated LDL. 2. UTI. -Continue CTX (started -F/U urine culture. 3. Tachycardia. -Fever control. -Starting IVF. ). Likely from fever as well as some volume depletion. 4. Metastatic uterine leiomyosarcoma. -Dr. to assume her care. Discussed briefly w him this AM. family later today. He will discuss goals of care w 5. HTN. -Continue Norvasc, benazepril. 6. Prophy. -SCD's, Lovenox given high hypercoagulable risk. 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: Progress Note-Physician 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 ELECTRONICALLY REVIEWED AND SIGNED ON: 07:34 ELECTRONICALLY SIGNED ON: 2 07:34 Addendum by ., (INTE) MD, , (INTE) MD, , (INTE) MD, on 7:36 EDT Physical Exam General: Laying comfortably in bed, NAD. Neck: No JVD. Chest: CTAB w/o wheezes or crackles. CV: Tachycardic, regular rhythym w/o murmurs. Radial pulses 2+ bilaterally. Abdomen: Bowel sounds present, soft, nontender, nondistended. Extremities: No edema. 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. ELECTRONICALLY REVIEWED AND SIGNED ON: , (INTE) MD, Patient Name: Facility: Page Number: 129 Progress Notes Document Name: Document Status: Performed By: Authenticated By: Progress Note-Physician 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: Progress Note-Physician 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, ELECTRONICALLY REVIEWED AND SIGNED ON: 10:22 ELECTRONICALLY SIGNED ON: 13:49 Document Name: Document Status: Performed By: Authenticated By: PA, (NEUR) MD, Progress Note-Physician 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 ELECTRONICALLY REVIEWED AND SIGNED ON: 08:26 ELECTRONICALLY SIGNED ON: 08:26 Document Name: Document Status: Performed By: Authenticated By: (HEMA) MD, (HEMA) MD, Progress Note-Physician 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: Progress Note-Physician Signed , (INTE) MD, (INTE) MD, 06:52 EDT 07:44 EDT Assessment/Plan 1. R hemiplegia, L basal ganglia stroke 2/2 thrombus. 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. Not considering anti-coag at this point. -Hypercoag panel (although hypercoagulability in this case likely 2/2 cancer). -Stopping Votrient (have discussed this w Dr. of ). -ST/PT/OT. -Continue statin for elevated LDL. 2. Fever. Could be atelectasis, UTI. -U/A, CXR. -Incentive spiro. 3. Metastatic uterine leiomyosarcoma. 4. HTN. -Continue Norvasc, benazepril. 5. Prophy. -SCD's. 6. Dispo. Will need rehab on D/C. Physical Exam General: Laying comfortably in bed, NAD. Neck: No JVD. Chest: CTAB w/o wheezes or crackles. CV: Regular rhythm, tachycardic w/o murmurs. Radial pulses 2+ bilaterally. Abdomen: Bowel sounds present, soft, nontender, nondistended. Extremities: No edema. 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: Progress Note-Physician Signed (INTE) MD, (INTE) MD, 06:52 EDT 07:44 EDT No 24 Hour Lab Data ELECTRONICALLY REVIEWED AND SIGNED ON: 07:44 ELECTRONICALLY SIGNED ON: 07:44 Document Name: Document Status: Performed By: Authenticated By: , (INTE) MD, , (INTE) MD, Progress Note-Physician Signed 08:55 EDT . 10:38 EDT Progress Note-Physician 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. PHYSICAL EXAMINATION: 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. Progress Note-Physician 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 # ELECTRONICALLY REVIEWED AND SIGNED (NEUR) MD, ELECTRONICALLY SIGNED ON: 10:38 Document Name: Document Status: Performed By: Authenticated By: Progress Note-Physician 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 1. R hemiplegia, L basal ganglia stroke 2/2 thrombus. 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. -Continue ASA 325mg qday. Not considering anti-coag at this point. -Hypercoag panel (although hypercoagulability in this case likely 2/2 cancer). -Stopping Votrient (have discussed this w ). -ST/PT/OT. -Continue statin for elevated LDL. Patient Name: Facility: Page Number: 134 Progress Notes Document Name: Document Status: Performed By: Authenticated By: Progress Note-Physician Signed , (INTE) MD, (INTE) MD, 08:14 EDT 08:14 EDT 2. Metastatic uterine leiomyosarcoma. 3. HTN. -Continue Norvasc, benazepril. 4. Prophy. -SCD's. 5. Dispo. Will need rehab on D/C. 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: 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 ELECTRONICALLY REVIEWED AND SIGNED ON: 08:14 ELECTRONICALLY SIGNED 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: Progress Note-Physician 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. -Hypercoag panel (although hypercoagulability in this case likely 2/2 cancer). -Stopping Votrient (reports of DVT/PE w this, have discussed this w Dr. of Onc). -ST/PT/OT. -Continue statin for elevated LDL. -TTE w bubble pending. 2. Metastatic uterine leiomyosarcoma. 3. HTN. -Continue Norvasc, benazepril as BP's are not low. 4. Prophy. -SCD's. Physical Exam General: Laying comfortably in bed, NAD. Neck: No JVD, no bruits, NL carotid upstrokes. 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: 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: Progress Note-Physician 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 Progress Note-Physician Signed , (INTE) MD, (INTE) MD, 0.028 11:24 EDT 11:24 EDT ng/mL ELECTRONICALLY REVIEWED AND SIGNED ON: 11:24 ELECTRONICALLY SIGNED 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 Legend: A=Abnormal, C=Critical, *=Interpretive Data @=Corrected, L=Low, H=High, f=footnotes 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 Legend: A=Abnormal, C=Critical, *=Interpretive Data @=Corrected, L=Low, H=High, f=footnotes Sed Rate mm/hr [0-20] 27 H 27 H@ 21:11 EDT Sed Rate: Corrected from 18 on 22:09 EDT Coagulation Legend: A=Abnormal, C=Critical, *=Interpretive Data @=Corrected, L=Low, H=High, f=footnotes 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 Legend: A=Abnormal, C=Critical, *=Interpretive Data, @=Corrected, L=Low, H=High, f=footnotes 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 Legend: A=Abnormal, C=Critical, *=Interpretive Data, @=Corrected, L=Low, H=High, f=footnotes 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 Legend: A=Abnormal, C=Critical, *=Interpretive Data, @=Corrected, L=Low, H=High, f=footnotes 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 Legend: A=Abnormal, C=Critical, *=Interpretive Data, @=Corrected, L=Low, H=High, f=footnotes 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: A CK must be ordered with this test. 18:10 EDT CK-MB: A CK must be ordered with this test. Endocrinology General Endocrinology Procedure Units Ref Range 18:10 EDT Legend: A=Abnormal, C=Critical, *=Interpretive Data, @=Corrected, L=Low, H=High, f=footnotes TSH mIU/L [0.358-3.740] 2.800 Immunology/Serology/Molecular Testing Legend: A=Abnormal, C=Critical, *=Interpretive Data, @=Corrected, L=Low, H=High, f=footnotes 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 Legend: A=Abnormal, C=Critical, *=Interpretive Data @=Corrected, L=Low, H=High, f=footnotes 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 Legend: A=Abnormal, C=Critical, *=Interpretive Data, @=Corrected, L=Low, H=High, f=footnotes 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 Laboratory Director: , M.D. Protein C Ag-Mayo % [70-150] 164 Hf Patient Name: Facility: Page Number: 143 References Legend: A=Abnormal, C=Critical, *=Interpretive Data, @=Corrected, L=Low, H=High, f=footnotes 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 Laboratory Director: , M.D. 12:15 EDT Fac V Leid (R506Q) : HI Expected Test Result LO Units Values ---------------------------------------------------------------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 Laboratory Director: Fac V Leid (R506Q) - , M.D. SEE COMMENTS f Patient Name: Facility: Page Number: 144 References Legend: A=Abnormal, C=Critical, *=Interpretive Data, @=Corrected, L=Low, H=High, f=footnotes 12:15 EDT Prothrombin G20210A HI Expected Test Result LO Units Values ---------------------------------------------------------------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 Laboratory Director: , 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 25567 (DR Chest 1 View Portable Only) Exam Date/Time 08:01 EDT Ordering Physician (INTE) MD, Patient Name: Facility: Page Number: 148 Diagnostic Radiology Accession Number Exam DR Chest 1 View Portable 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 (Electronic Signature): Signed by: (RAD) MD, Transcribed by: Accession Number 8:07 am Exam DR Chest 1 View Portable Only Exam Date/Time 18:54 EDT CPT4 Codes 71010 (DR Chest 1 View Portable Only) CDM Codes 25567 (DR Chest 1 View Portable Only) 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: Diagnostic Radiology Accession Number Exam DR Chest 1 View Portable 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 (Electronic Signature): 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 Magnetic Resonance Imaging 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 (Electronic Signature): 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 Magnetic Resonance Imaging 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 (Electronic Signature): 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. (Electronically Signed) 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. (Electronically Signed) Final Date: 11:48 ***** Final ***** Signed (Electronic Signature): Signed by: Transcribed by: 11:48 am
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