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HCT: Subdural hemorrhage.

Radiology

CT Brain: Subdural Hemorrhage.

CC: ,Difficulty with speech.,HX:, This 84 y/o RHF presented with sudden onset word finding and word phonation difficulties. She had an episode of transient aphasia in 2/92 during which she had difficulty with writing, written and verbal comprehension, and exhibited numerous semantic and phonemic paraphasic errors of speech. These problems resolved within 24 hours of onset and she had no subsequent speech problems prior to this presentation. Workup at that time revealed a right to left shunt on trans-thoracic echocardiogram. Carotid doppler studies showed 0-15% BICA stenosis and a LICA aneurysm (mentioned above). Brain CT was unremarkable. She was placed on ASA after the 2/92 event.,In 5/92 she was involved in a motor vehicle accident and suffered a fractured left humerus and left occipital scalp laceration. HCT at that time showed a small area of slightly increased attenuation at the posterior right claustrum only. This was not felt to be a contusion; nevertheless, she was placed on Dilantin seizure prophylaxis. Her left arm was casted and she returned home.,5 hours prior to presentation today, the patient began having difficulty finding words and putting them into speech. She was able to comprehend speech. This continued for an hour; then partially resolved for one hour; then returned; then waxed and waned. There was no reported weakness, numbness, incontinence, seizure-like activity, incoordination, HA, nausea, vomiting, or lightheadedness,MEDS:, ASA , DPH, Tenormin, Premarin, HCTZ,PMH:, 1)transient fluent aphasia 2/92 (which resolved), 2)bilateral carotid endarterectomies 1986, 3)HTN, 4)distal left internal carotid artery aneurysm.,EXAM:, BP 168/70, Pulse 82, RR 16, 35.8F,MS:A & O x 3, Difficulty following commands, Speech fluent, and without dysarthria. There were occasional phonemic paraphasic errors.,CN: Unremarkable.,Motor: 5/5 throughout except for 4+ right wrist extension and right knee flexion.,Sensory: unremarkable.,Coordination: mild left finger-nose-finger dysynergia and dysmetria.,Gait: mildly unsteady tandem walk.,Station: no Romberg sign.,Reflexes: slightly more brisk at the left patella than on the right. Plantar responses were flexor bilaterally.,The remainder of the neurologic exam and the general physical exam were unremarkable.,LABS:, CBC WNL, Gen Screen WNL, , PT/PTT WNL, DPH 26.2mcg/ml, CXR WNL, EKG: LBBB, HCT revealed a left subdural hematoma.,COURSE:, Patient was taken to surgery and the subdural hematoma was evacuated. Her mental status, language skills, improved dramatically. The DPH dosage was adjusted appropriately.

radiology, ct brain, ct, difficulty with speech, hct, subdural hemorrhage, hemorrhage, phonation difficulties, subdural, transient fluent aphasia, phonemic paraphasic errors, hematoma, carotid, speech,

CT Brain to evaluate episodic mental status change, RUE numbness, chorea, and calcification of Basal Ganglia (globus pallidi).

Radiology

CT Brain - Calcification of Basal Ganglia

CC:, Episodic mental status change and RUE numbness, and chorea (found on exam).,HX:, This 78y/o RHM was referred for an episode of unusual behavior and RUE numbness. In 9/91, he experienced near loss of consciousness, generalized weakness, headache and vomiting. Evaluation at that time revealed an serum glucose of >500mg/dL and he was placed on insulin therapy with subsequent resolution of his signs and symptoms. Since then, he became progressively more forgetful, and at the time of evaluation, 1/17/93, had lost his ability to perform his job repairing lawn mowers. His wife had taken over the family finances.,He had also been "stumbling," when ambulating, for 2 months prior to presentation. He was noted to be occasionally confused upon awakening for last several months. On 1/15/93, he was lying on a couch when he suddenly began throwing pillows and blankets for no apparent reason. There had been no change in sleep, appetite, or complaint of depression.,In addition, for two months prior to presentation, he had been experiencing 10-15minute episodes of RUE numbness. There was no face or lower extremity involvement.,During the last year he had developed unusual movements of his extremities.,MEDS:, NPH Humulin 12U qAM and 6U qPM. Advil prn.,PMH:, 1) Traumatic amputation of the 4th and 5th digits of his left hand. 2) Hospitalized for an unknown "nervous" condition in the 1940's.,SHX/FHX:, Retired small engine mechanic who worked in a poorly ventilated shop. Married with 13 children. No history of ETOH, Tobacco or illicit drug use. Father had tremors following a stroke. Brother died of brain aneurysm. No history of depression, suicide, or Huntington's disease in family.,ROS:, no history of CAD, Renal or liver disease, SOB, Chest pain, fevers, chills, night sweats or weight loss. No report of sign of bleeding.,EXAM:, BP138/63 HR65 RR15 36.1C,MS: Alert and oriented to self, season; but not date, year, or place. Latent verbal responses and direction following. Intact naming, but able to repeat only simple but not complex phrases. Slowed speech, with mild difficulty with word finding. 2/3 recall at one minute and 0/3 at 3 minutes. Knew the last 3 presidents. 14/27 on MMSE: unable to spell "world" backwards. Unable to read/write for complaint of inability to see without glasses.,CN: II-XII appeared grossly intact. EOM were full and smooth and without unusual saccadic pursuits. OKN intact. Choreiform movements of the tongue were noted.,Motor: 5/5 strength throughout with Guggenheim type resistance. there were choreiform type movements of all extremities bilaterally. No motor impersistence noted.,Sensory: unreliable.,Cord: "normal" FNF, HKS, and RAM, bilaterally.,Station: No Romberg sign.,Gait: unsteady and wide-based.,Reflexes: BUE 2/2, Patellar 2/2, Ankles Trace/Trace, Plantars were flexor bilaterally.,Gen Exam: 2/6 Systolic ejection murmur in aortic area.,COURSE:, No family history of Huntington's disease could be elicited from relatives. Brain CT, 1/18/93: bilateral calcification of the globus pallidi and a high attenuation focus in the right occipital lobe thought to represent artifact. Carotid duplex, 1/18/93: RICA 0-15%, LICA 16-49% stenosis and normal vertebral artery flow bilaterally. Transthoracic Echocardiogram (TTE),1/18/93: revealed severe aortic fibrosis or valvular calcification with "severe" aortic stenosis in the face of "normal" LV function. Cardiology felt the patient the patient had asymptomatic aortic stenosis. EEG, 1/20/93, showed low voltage Delta over the left posterior quadrant and intermittent background slowing over the same region consistent with focal dysfunction in this quadrant. MRI Brain, 1/22/93: multiple focal and more confluent areas of increased T2 signal in the periventricular white matter, more prominent on the left; in addition, there were irregular shaped areas of increased T2 signal and decreased T1 signal in both cerebellar hemispheres; and age related atrophy; incidentally, there is a cavum septum pellucidum et vergae and mucosal thickening of the maxillary sinuses. Impression: diffuse bilateral age related ischemic change, age related atrophy and maxillary sinus disease. There were no masses or areas of abnormal enhancement. TSH, FT4, Vit B12, VDRL, Urine drug and heavy metal screens were unremarkable. CSF,1/19/93: glucose 102 (serum glucose 162mg/dL), Protein 45mg/dL, RBC O, WBC O, Cultures negative. SPEP negative. However serum and CSF beta2 microglobulin levels were elevated at 2.5 and 3.1mg/L, respectively. Hematology felt these may have been false positives. CBC, 1/17/93: Hgb 10.4g/dL (low), HCT 31% (low), RBC 3/34mil/mm3 (low), WBC 5.8K/mm3, Plt 201K/mm3. Retic 30/1K/mm3 (normal). Serum Iron 35mcg/dL (low), TIBC 201mcg/dL (low), FeSat 17% (low), CRP 0.1mg/dL (normal), ESR 83mm/hr (high). Bone Marrow Bx: normal with adequate iron stores. Hematology felt the finding were compatible with anemia of chronic disease. Neuropsychologic evaluation on 1/17/93 revealed significant impairments in multiple realms of cognitive function (visuospatial reasoning, verbal and visual memory, visual confrontational naming, impaired arrhythmatic, dysfluent speech marked by use of phrases no longer than 5 words, frequent word finding difficulty and semantic paraphasic errors) most severe for expressive language, attention and memory. The pattern of findings reveals an atypical aphasia suggestive of left temporo-parietal dysfunction. The patient was discharged1/22/93 on ASA 325mg qd. He was given a diagnosis of senile chorea and dementia (unspecified type). 6/18/93 repeat Neuropsychological evaluation revealed moderate decline in all areas tested reflecting severe dementia.

radiology, episodic mental status change, huntington's disease, brain ct, transthoracic echocardiogram, carotid duplex, mental status change, ct brain, basal ganglia, mental status, globus pallidi, aortic stenosis, maxillary sinuses, rue numbness, basal, ganglia, globus, pallidi, therapy, chorea, ct, rue, brain,

CT Brain: Suprasellar aneurysm, pre and post bleed.

Radiology

CT Brain - Aneurysm

CC:, Decreasing visual acuity.,HX: ,This 62 y/o RHF presented locally with a 2 month history of progressive loss of visual acuity, OD. She had a 2 year history of progressive loss of visual acuity, OS, and is now blind in that eye. She denied any other symptomatology. Denied HA.,PMH:, 1) depression. 2) Blind OS,MEDS:, None.,SHX/FHX: ,unremarkable for cancer, CAD, aneurysm, MS, stroke. No h/o Tobacco or ETOH use.,EXAM:, T36.0, BP121/85, HR 94, RR16,MS: Alert and oriented to person, place and time. Speech fluent and unremarkable.,CN: Pale optic disks, OU. Visual acuity: 20/70 (OD) and able to detect only shadow of hand movement (OS). Pupils were pharmacologically dilated earlier. The rest of the CN exam was unremarkable.,MOTOR: 5/5 throughout with normal bulk and tone.,Sensory: no deficits to LT/PP/VIB/PROP.,Coord: FNF-RAM-HKS intact bilaterally.,Station: No pronator drift. Gait: ND,Reflexes: 3/3 BUE, 2/2 BLE. Plantar responses were flexor bilaterally.,Gen Exam: unremarkable. No carotid/cranial bruits.,COURSE:, CT Brain showed large, enhancing 4 x 4 x 3 cm suprasellar-sellar mass without surrounding edema. Differential dx: included craniopharyngioma, pituitary adenoma, and aneurysm. MRI Brain findings were consistent with an aneurysm. The patient underwent 3 vessel cerebral angiogram on 12/29/92. This clearly revealed a supraclinoid giant aneurysm of the left internal carotid artery. Ten minutes following contrast injection the patient became aphasic and developed a right hemiparesis. Emergent HCT showed no evidence of hemorrhage or sign of infarct. Emergent carotid duplex showed no significant stenosis or clot. The patient was left with an expressive aphasia and right hemiparesis. SPECT scans were obtained on 1/7/93 and 2/24/93. They revealed hypoperfusion in the distribution of the left MCA and decreased left basal-ganglia perfusion which may represent in part a mass effect from the LICA aneurysm. She was discharged home and returned and underwent placement of a Selverstone Clamp on 3/9/93. The clamp was gradually and finally closed by 3/14/93. She did well, and returned home. On 3/20/93 she developed sudden confusion associated with worsening of her right hemiparesis and right expressive aphasia. A HCT then showed SAH around her aneurysm, which had thrombosed. She was place on Nimodipine. Her clinical status improved; then on 3/25/93 she rapidly deteriorated over a 2 hour period to the point of lethargy, complete expressive aphasia, and right hemiplegia. An emergent HCT demonstrated a left ACA and left MCA infarction. She required intubation and worsened as cerebral edema developed. She was pronounced brain dead. Her organs were donated for transplant.

radiology, ct brain, hct, mri brain, suprasellar, suprasellar aneurysm, aneurysm, cerebral angiogram, craniopharyngioma, internal carotid artery, loss of visual acuity, pituitary adenoma, suprasellar-sellar mass, visual acuity, expressive aphasia, cerebral, ct, hemiparesis, aphasia, brain,

Abdominal pain. CT examination of the abdomen and pelvis with intravenous contrast.

Radiology

CT Abdomen & Pelvis - OB-GYN

EXAM:, CT examination of the abdomen and pelvis with intravenous contrast.,INDICATIONS:, Abdominal pain.,TECHNIQUE: ,CT examination of the abdomen and pelvis was performed after 100 mL of intravenous Isovue-300 contrast administration. Oral contrast was not administered. There was no comparison of studies.,FINDINGS,CT PELVIS:,Within the pelvis, the uterus demonstrates a thickened-appearing endometrium. There is also a 4.4 x 2.5 x 3.4 cm hypodense mass in the cervix and lower uterine segment of uncertain etiology. There is also a 2.5 cm intramural hypodense mass involving the dorsal uterine fundus likely representing a fibroid. Several smaller fibroids were also suspected.,The ovaries are unremarkable in appearance. There is no free pelvic fluid or adenopathy.,CT ABDOMEN:,The appendix has normal appearance in the right lower quadrant. There are few scattered diverticula in the sigmoid colon without evidence of diverticulitis. The small and large bowels are otherwise unremarkable. The stomach is grossly unremarkable. There is no abdominal or retroperitoneal adenopathy. There are no adrenal masses. The kidneys, liver, gallbladder, and pancreas are in unremarkable appearance. The spleen contains several small calcified granulomas, but no evidence of masses. It is normal in size. The lung bases are clear bilaterally. The osseous structures are unremarkable other than mild facet degenerative changes at L4-L5 and L5-S1.,IMPRESSION:,1. Hypoattenuating mass in the lower uterine segment and cervix of uncertain etiology measuring approximately 4.4 x 2.5 x 3.4 cm.,2. Multiple uterine fibroids.,3. Prominent endometrium.,4. Followup pelvic ultrasound is recommended.

radiology, ovaries, pelvic fluid, adenopathy, uterine segment, cervix, hypodense mass, ct examination, fibroids, pelvic, ct, pelvis, isovue, abdomen

Lower quadrant pain with nausea, vomiting, and diarrhea. CT abdomen without contrast and CT pelvis without contrast. Noncontrast axial CT images of the abdomen and pelvis are obtained.

Radiology

CT Abdomen & Pelvis - 7

REASON FOR EXAM: , Lower quadrant pain with nausea, vomiting, and diarrhea.,TECHNIQUE: , Noncontrast axial CT images of the abdomen and pelvis are obtained.,FINDINGS: , Please note evaluation of the abdominal organs is secondary to the lack of intravenous contrast material.,Gallstones are seen within the gallbladder lumen. No abnormal pericholecystic fluid is seen.,The liver is normal in size and attenuation.,The spleen is normal in size and attenuation.,A 2.2 x 1.8 cm low attenuation cystic lesion appears to be originating off of the tail of the pancreas. No pancreatic ductal dilatation is seen. There is no abnormal adjacent stranding. No suspected pancreatitis is seen.,The kidneys show no stone formation or hydronephrosis.,The large and small bowels are normal in course and caliber. There is no evidence for obstruction. The appendix appears within normal limits.,In the pelvis, the urinary bladder is unremarkable. There is a 4.2 cm cystic lesion of the right adnexal region. No free fluid, free air, or lymphadenopathy is detected.,There is left basilar atelectasis.,IMPRESSION:,1. A 2.2 cm low attenuation lesion is seen at the pancreatic tail. This is felt to be originating from the pancreas, a cystic pancreatic neoplasm must be considered and close interval followup versus biopsy is advised. Additionally, when the patient's creatinine improves, a contrast-enhanced study utilizing pancreatic protocol is needed. Alternatively, an MRI may be obtained.,2. Cholelithiasis.,3. Left basilar atelectasis.,4. A 4.2 cm cystic lesion of the right adnexa, correlation with pelvic ultrasound is advised.

radiology, ct abdomen, ct pelvis, neoplasm, lesion, attenuation, hydronephrosis, stone formation, ct images, cystic lesion, abdomen, cystic, pancreatic, ct, pelvis, intravenous, noncontrast

Generalized abdominal pain, nausea, diarrhea, and recent colonic resection. CT abdomen with and without contrast and CT pelvis with contrast. Axial CT images of the abdomen were obtained without contrast. Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.

Radiology

CT Abdomen & Pelvis - 8

CT ABDOMEN WITH AND WITHOUT CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain, nausea, diarrhea, and recent colonic resection in 11/08.,TECHNIQUE:, Axial CT images of the abdomen were obtained without contrast. Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.,FINDINGS: , The liver is normal in size and attenuation.,The gallbladder is normal.,The spleen is normal in size and attenuation.,The adrenal glands and pancreas are unremarkable.,The kidneys are normal in size and attenuation.,No hydronephrosis is detected. Free fluid is seen within the right upper quadrant within the lower pelvis. A markedly thickened loop of distal small bowel is seen. This segment measures at least 10-cm long. No definite pneumatosis is appreciated. No free air is apparent at this time. Inflammatory changes around this loop of bowel. Mild distention of adjacent small bowel loops measuring up to 3.5 cm is evident. No complete obstruction is suspected, as there is contrast material within the colon. Postsurgical changes compatible with the partial colectomy are noted. Postsurgical changes of the anterior abdominal wall are seen. Mild thickening of the urinary bladder wall is seen.,IMPRESSION:,1. Marked thickening of a segment of distal small bowel is seen with free fluid within the abdomen and pelvis. An inflammatory process such as infection or ischemia must be considered. Close interval followup is necessary.,2. Thickening of the urinary bladder wall is nonspecific and may be due to under distention. However, evaluation for cystitis is advised.

radiology, abdominal pain, nausea, diarrhea, colonic resection, axial ct images, ct abdomen, isovue, inflammatory, urinary, bladder, abdominal, colonic, wall, thickening, axial, bowel, contrast, attenuation, pelvis, ct, abdomen

Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism. CT angiography chest with contrast. Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.

Radiology

CT Angiography

CT ANGIOGRAPHY CHEST WITH CONTRAST,REASON FOR EXAM: , Chest pain, shortness of breath and cough, evaluate for pulmonary arterial embolism.,TECHNIQUE: ,Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,FINDINGS: ,There is no evidence for pulmonary arterial embolism.,The lungs are clear of any abnormal airspace consolidation, pleural effusion, or pneumothorax. No abnormal mediastinal or hilar lymphadenopathy is seen.,Limited images of the upper abdomen are unremarkable. No destructive osseous lesion is detected.,IMPRESSION: , Negative for pulmonary arterial embolism.

radiology, airspace consolidation, pleural effusion, pneumothorax, lymphadenopathy, hilar, ct angiography, pulmonary arterial, arterial embolism, angiography, ct, chest, arterial, pulmonary, embolism, isovue,

CT abdomen without contrast and pelvis without contrast, reconstruction.

Radiology

CT Abdomen & Pelvis - 5

EXAM: , CT abdomen without contrast and pelvis without contrast, reconstruction.,REASON FOR EXAM: , Right lower quadrant pain, rule out appendicitis.,TECHNIQUE: ,Noncontrast CT abdomen and pelvis. An intravenous line could not be obtained for the use of intravenous contrast material.,FINDINGS: , The appendix is normal. There is a moderate amount of stool throughout the colon. There is no evidence of a small bowel obstruction or evidence of pericolonic inflammatory process. Examination of the extreme lung bases appear clear, no pleural effusions. The visualized portions of the liver, spleen, adrenal glands, and pancreas appear normal given the lack of contrast. There is a small hiatal hernia. There is no intrarenal stone or evidence of obstruction bilaterally. There is a questionable vague region of low density in the left anterior mid pole region, this may indicate a tiny cyst, but it is not well seen given the lack of contrast. This can be correlated with a followup ultrasound if necessary. The gallbladder has been resected. There is no abdominal free fluid or pathologic adenopathy. There is abdominal atherosclerosis without evidence of an aneurysm.,Dedicated scans of the pelvis disclosed phleboliths, but no free fluid or adenopathy. There are surgical clips present. There is a tiny airdrop within the bladder. If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection.,IMPRESSION:,1.Normal appendix.,2.Moderate stool throughout the colon.,3.No intrarenal stones.,4.Tiny airdrop within the bladder. If this patient has not had a recent catheterization, correlate for signs and symptoms of urinary tract infection. The report was faxed upon dictation.

radiology, reconstruction, appendicitis, urinary tract infection, ct abdomen, abdomen, ct, pelvis, contrast, noncontrast,

Shortness of breath for two weeks and a history of pneumonia. CT angiography chest with contrast. Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.

Radiology

CT Angiography - 1

CT ANGIOGRAPHY CHEST WITH CONTRAST,REASON FOR EXAM: ,Shortness of breath for two weeks and a history of pneumonia. The patient also has a history of left lobectomy.,TECHNIQUE: , Axial CT images of the chest were obtained for pulmonary embolism protocol utilizing 100 mL of Isovue-300.,FINDINGS: , There is no evidence of any acute pulmonary arterial embolism.,The main pulmonary artery is enlarged showing a diameter of 4.7 cm.,Cardiomegaly is seen with mitral valvular calcifications.,Postsurgical changes of a left upper lobectomy are seen. Left lower lobe atelectasis is noted. A 7 mm and a 5 mm pulmonary nodule are seen within the left lower lobe (image #12). A small left pleural effusion is noted.,Right lower lobe atelectasis is present. There is a right pleural effusion, greater than as seen on the left side. A right lower lobe pulmonary nodule measures 1.5 cm. There is a calcified granuloma within the right lower lobe.,IMPRESSION:,1. Negative for pulmonary arterial embolism.,2. Enlargement of the main pulmonary artery as can be seen with pulmonary arterial hypertension.,3. Cardiomegaly with mitral valvular calcifications.,4. Postsurgical changes of a left upper lobectomy.,5. Bilateral pleural effusions, right greater than left with bilateral lower lobe atelectasis.,6. Bilateral lower lobe nodules, pulmonary nodules, and interval followup in three months to confirm stability versus further characterization with prior studies is advised.

radiology, shortness of breath, pneumonia, pulmonary embolism, isovue-300, axial ct images, ct angiography, lower lobe, pulmonary, lobectomy, isovue, angiography, arterial, atelectasis, pleural, ct, embolism,

Right-sided abdominal pain with nausea and fever. CT abdomen with contrast and CT pelvis with contrast. Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.

Radiology

CT Abdomen & Pelvis - 6

REASON FOR EXAM: , Right-sided abdominal pain with nausea and fever.,TECHNIQUE: , Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN: ,The liver, spleen, pancreas, gallbladder, adrenal glands, and kidney are unremarkable.,CT PELVIS: , Within the right lower quadrant, the appendix measures 16 mm and there are adjacent inflammatory changes with fluid in the right lower quadrant. Findings are compatible with acute appendicitis.,The large and small bowels are normal in course and caliber without obstruction. The urinary bladder is normal. The uterus appears unremarkable. Mild free fluid is seen in the lower pelvis.,No destructive osseous lesions are seen. The visualized lung bases are clear.,IMPRESSION: , Acute appendicitis.

radiology, adrenal glands, appendicitis, gallbladder, kidney, liver, pancreas, spleen, acute appendicitis, ct pelvis, ct abdomen, abdominal, contrast, fluid, abdomen, inflammatory, pelvis, ct

CT brain (post craniectomy) - RMCA stroke and SBE.

Radiology

CT Brain

CC:, Left-sided weakness.,HX:, This 28y/o RHM was admitted to a local hospital on 6/30/95 for a 7 day history of fevers, chills, diaphoresis, anorexia, urinary frequency, myalgias and generalized weakness. He denied foreign travel, IV drug abuse, homosexuality, recent dental work, or open wound. Blood and urine cultures were positive for Staphylococcus Aureus, oxacillin sensitive. He was place on appropriate antibiotic therapy according to sensitivity.. A 7/3/95 transthoracic echocardiogram revealed normal left ventricular function and a damaged mitral valve with regurgitation. Later that day he developed left-sided weakness and severe dysarthria and aphasia. HCT, on 7/3/95 revealed mild attenuated signal in the right hemisphere. On 7/4/95 he developed first degree AV block, and was transferred to UIHC.,MEDS: ,Nafcillin 2gm IV q4hrs, Rifampin 600mg q12hrs, Gentamicin 130mg q12hrs.,PMH:, 1) Heart murmur dx age 5 years.,FHX:, Unremarkable.,SHX:, Employed cook. Denied ETOH/Tobacco/illicit drug use.,EXAM:, BP 123/54, HR 117, RR 16, 37.0C,MS: Somnolent and arousable only by shaking and repetitive verbal commands. He could follow simple commands only. He nodded appropriately to questioning most of the time. Dysarthric speech with sparse verbal output.,CN: Pupils 3/3 decreasing to 2/2 on exposure to light. Conjugate gaze preference toward the right. Right hemianopia by visual threat testing. Optic discs flat and no retinal hemorrhages or Roth spots were seen. Left lower facial weakness. Tongue deviated to the left. Weak gag response, bilaterally. Weak left corneal response.,MOTOR: Dense left flaccid hemiplegia.,SENSORY: Less responsive to PP on left.,COORD: Unable to test.,Station and Gait: Not tested.,Reflexes: 2/3 throughout (more brisk on the left side). Left ankle clonus and a Left Babinski sign were present.,GEN EXAM: Holosystolic murmur heard throughout the precordium. Janeway lesions were present in the feet and hands. No Osler's nodes were seen.,COURSE:, 7/6/95, HCT showed a large RMCA stroke with mass shift. His neurologic exam worsened and he was intubated, hyperventilated, and given IV Mannitol. He then underwent emergent left craniectomy and duraplasty. He tolerated the procedure well and his brain was allowed to swell. He then underwent mitral valve replacement on 7/11/95 with a St. Judes valve. His post-operative recovery was complicated by pneumonia, pericardial effusion and dysphagia. He required temporary PEG placement for feeding. The 7/27/95, 8/6/95 and 10/18/96 HCT scans show the chronologic neuroradiologic documentation of a large RMCA stroke. His 10/18/96 Neurosurgery Clinic visit noted that he can ambulate without assistance with the use of a leg brace to prevent left foot drop. His proximal LLE strength was rated at a 4. His LUE was plegic. He had a seizure 6 days prior to his 10/18/96 evaluation. This began as a Jacksonian march of shaking in the LUE; then involved the LLE. There was no LOC or tongue-biting. He did have urinary incontinence. He was placed on DPH. His speech was dysarthric but fluent. He appeared bright, alert and oriented in all spheres.

radiology, ct brain, rmca, anorexia, chills, craniectomy, diaphoresis, fevers, myalgias, stroke, urinary frequency, echocardiogram, holosystolic murmur, pneumonia, pericardial effusion, tongue-biting, sided weakness, mitral valve, rmca stroke, ct, hct, weakness,

Generalized abdominal pain with swelling at the site of the ileostomy. CT abdomen with contrast and CT pelvis with contrast. Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.

Radiology

CT Abdomen & Pelvis - 9

CT ABDOMEN WITH CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain with swelling at the site of the ileostomy.,TECHNIQUE:, Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN: ,The liver, spleen, pancreas, adrenal glands, and kidneys are unremarkable. Punctate calcifications in the gallbladder lumen likely represent a gallstone.,CT PELVIS: ,Postsurgical changes of a left lower quadrant ileostomy are again seen. There is no evidence for an obstruction. A partial colectomy and diverting ileostomy is seen within the right lower quadrant. The previously seen 3.4 cm subcutaneous fluid collection has resolved. Within the left lower quadrant, a 3.4 cm x 2.5 cm loculated fluid collection has not significantly changed. This is adjacent to the anastomosis site and a pelvic abscess cannot be excluded. No obstruction is seen. The appendix is not clearly visualized. The urinary bladder is unremarkable.,IMPRESSION:,1. Resolution of the previously seen subcutaneous fluid collection.,2. Left pelvic 3.4 cm fluid collection has not significantly changed in size or appearance. These findings may be due to a pelvic abscess.,3. Right lower quadrant ileostomy has not significantly changed.,4. Cholelithiasis.

radiology, axial ct images, isovue-300, ct pelvis, ct abdomen, fluid collection, abdomen, obstruction, subcutaneous, abscess, pelvic, fluid, collection, pelvis, ileostomy, ct, isovue,

Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin. CT abdomen without contrast and CT pelvis without contrast.

Radiology

CT Abdomen & Pelvis - 10

CT ABDOMEN WITHOUT CONTRAST AND CT PELVIS WITHOUT CONTRAST,REASON FOR EXAM: , Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin.,CT ABDOMEN: , There is no evidence for a retroperitoneal hematoma.,The liver, spleen, adrenal glands, and pancreas are unremarkable. Within the superior pole of the left kidney, there is a 3.9 cm cystic lesion. A 3.3 cm cystic lesion is also seen within the inferior pole of the left kidney. No calcifications are noted. The kidneys are small bilaterally.,CT PELVIS: , Evaluation of the bladder is limited due to the presence of a Foley catheter, the bladder is nondistended. The large and small bowels are normal in course and caliber. There is no obstruction.,Bibasilar pleural effusions are noted.,IMPRESSION:,1. No evidence for retroperitoneal bleed.,2. There are two left-sided cystic lesions within the kidney, correlation with a postcontrast study versus further characterization with an ultrasound is advised as the cystic lesions appear slightly larger as compared to the prior exam.,3. The kidneys are small in size bilaterally.,4. Bibasilar pleural effusions.

radiology, cystic lesion, superior pole, kidney, ct pelvis, ct abdomen, retroperitoneal hematoma, lesion, kidneys, bladder, bibasilar, pleural, effusions, lesions, pelvis, hematoma, retroperitoneal, cystic, ct, abdomen,

CT abdomen and pelvis without contrast, stone protocol, reconstruction.

Radiology

CT Abdomen & Pelvis - 4

EXAM: , CT abdomen and pelvis without contrast, stone protocol, reconstruction.,REASON FOR EXAM: , Flank pain.,TECHNIQUE: , Noncontrast CT abdomen and pelvis with coronal reconstructions.,FINDINGS: , There is no intrarenal stone bilaterally. However, there is very mild left renal pelvis and proximal ureteral dilatation with a small amount of left perinephric stranding asymmetric to the right. The right renal pelvis is not dilated. There is no stone along the course of the ureter. I cannot exclude the possibility of recent stone passage, although the findings are ultimately technically indeterminate and clinical correlation is advised. There is no obvious solid-appearing mass given the lack of contrast.,Scans of the pelvis disclose no evidence of stone within the decompressed bladder. No pelvic free fluid or adenopathy.,There are few scattered diverticula. There is a moderate amount of stool throughout the colon. There are scattered diverticula, but no CT evidence of acute diverticulitis. The appendix is normal.,There are mild bibasilar atelectatic changes.,Given the lack of contrast, visualized portions of the liver, spleen, adrenal glands, and the pancreas are grossly unremarkable. The gallbladder is present. There is no abdominal free fluid or pathologic adenopathy.,There are degenerative changes of the lumbar spine.,IMPRESSION:,1.Very mild left renal pelvic dilatation and proximal ureteral dilatation with mild left perinephric stranding. There is no stone identified along the course of the left ureter or in the bladder. Could this patient be status post recent stone passage? Clinical correlation is advised.,2.Diverticulosis.,3.Moderate amount of stool throughout the colon.,4.Normal appendix.

radiology, coronal reconstructions, stone protocol, renal pelvic dilatation, proximal ureteral dilatation, ct abdomen and pelvis, stone protocol reconstruction, abdomen and pelvis, perinephric stranding, free fluid, scattered diverticula, renal, dilatation, contrast, ureteral, ct, abdomen, pelvis, stone, noncontrast,

CT scan of the abdomen and pelvis without and with intravenous contrast.

Radiology

CT Abdomen & Pelvis - 2

EXAM: , CT scan of the abdomen and pelvis without and with intravenous contrast.,CLINICAL INDICATION: , Left lower quadrant abdominal pain.,COMPARISON: , None.,FINDINGS: , CT scan of the abdomen and pelvis was performed without and with intravenous contrast. Total of 100 mL of Isovue was administered intravenously. Oral contrast was also administered.,The lung bases are clear. The liver is enlarged and decreased in attenuation. There are no focal liver masses.,There is no intra or extrahepatic ductal dilatation.,The gallbladder is slightly distended.,The adrenal glands, pancreas, spleen, and left kidney are normal.,A 12-mm simple cyst is present in the inferior pole of the right kidney. There is no hydronephrosis or hydroureter.,The appendix is normal.,There are multiple diverticula in the rectosigmoid. There is evidence of focal wall thickening in the sigmoid colon (image #69) with adjacent fat stranding in association with a diverticulum. These findings are consistent with diverticulitis. No pneumoperitoneum is identified. There is no ascites or focal fluid collection.,The aorta is normal in contour and caliber.,There is no adenopathy.,Degenerative changes are present in the lumbar spine.,IMPRESSION: , Findings consistent with diverticulitis. Please see report above.

radiology, extrahepatic ductal dilatation, gallbladder, glands, pancreas, spleen, kidney, adrenal, abdomen and pelvis, ct scan, intravenous, abdomen,

Abnormal liver enzymes and diarrhea. CT pelvis with contrast and ct abdomen with and without contrast.

Radiology

CT Abdomen & Pelvis - 11

EXAM: , CT pelvis with contrast and ct abdomen with and without contrast.,INDICATIONS: ,Abnormal liver enzymes and diarrhea.,TECHNIQUE: , CT examination of the abdomen and pelvis was performed after 100 mL of intravenous contrast administration and oral contrast administration. Pre-contrast images through the abdomen were also obtained.,COMPARISON: ,There were no comparison studies.,FINDINGS: ,The lung bases are clear.,The liver demonstrates mild intrahepatic biliary ductal dilatation. These findings may be secondary to the patient's post cholecystectomy state. The pancreas, spleen, adrenal glands, and kidneys are unremarkable.,There is a 13 mm peripheral-enhancing fluid collection in the anterior pararenal space of uncertain etiology. There are numerous nonspecific retroperitoneal and mesenteric lymph nodes. These may be reactive; however, an early neoplastic process would be difficult to totally exclude.,There is a right inguinal hernia containing a loop of small bowel. This may produce a partial obstruction as there is mild fluid distention of several small bowel loops, particularly in the right lower quadrant. The large bowel demonstrates significant diverticulosis coli of the sigmoid and distal descending colon without evidence of diverticulitis.,There is diffuse osteopenia along with significant degenerative changes in the lower lumbar spine.,The urinary bladder is unremarkable. The uterus is not visualized.,IMPRESSION:,1. Right inguinal hernia containing small bowel. Partial obstruction is suspected.,2. Nonspecific retroperitoneal and mesenteric lymph nodes.,3. Thirteen millimeter of circumscribed fluid collection in the anterior pararenal space of uncertain etiology.,4. Diverticulosis without evidence of diverticulitis.,5. Status post cholecystectomy with mild intrahepatic biliary ductal dilatation.,6. Osteopenia and degenerative changes of the spine and pelvis.

radiology, pre-contrast images, contrast, biliary ductal dilatation, pancreas, spleen, adrenal glands, kidneys, mesenteric lymph nodes, fluid collection, inguinal hernia, ct abdomen, hernia, diverticulosis, diverticulitis, osteopenia, degenerative, spine, bowel, pelvis, ct, abdomen,

CT of the abdomen and pelvis without contrast.

Radiology

CT Abdomen & Pelvis - 3

EXAM: , CT of the abdomen and pelvis without contrast.,HISTORY: , Lower abdominal pain.,FINDINGS:, Limited views of the lung bases demonstrate linear density most likely representing dependent atelectasis. There is a 1.6 cm nodular density at the left posterior sulcus.,Noncontrast technique limits evaluation of the solid abdominal organs. Cardiomegaly and atherosclerotic calcifications are seen.,Hepatomegaly is observed. There is calcification within the right lobe of the liver likely related to granulomatous changes. Subtle irregularity of the liver contour is noted, suggestive of cirrhosis. There is splenomegaly seen. There are two low-attenuation lesions seen in the posterior aspect of the spleen, which are incompletely characterized that may represent splenic cyst. The pancreas appears atrophic. There is a left renal nodule seen, which measures 1.9 cm with a Hounsfield unit density of approximately 29, which is indeterminate.,There is mild bilateral perinephric stranding. There is an 8-mm fat density lesion in the anterior inner polar region of the left kidney, compatible in appearance with angiomyolipoma. There is a 1-cm low-attenuation lesion in the upper pole of the right kidney, likely representing a cyst, but incompletely characterized on this examination. Bilateral ureters appear normal in caliber along their visualized course. The bladder is partially distended with urine, but otherwise unremarkable.,Postsurgical changes of hysterectomy are noted. There are pelvic phlebolith seen. There is a calcified soft tissue density lesion in the right pelvis, which may represent an ovary with calcification, as it appears continuous with the right gonadal vein.,Scattered colonic diverticula are observed. The appendix is within normal limits. The small bowel is unremarkable. There is an anterior abdominal wall hernia noted containing herniated mesenteric fat. The hernia neck measures approximately 2.7 cm. There is stranding of the fat within the hernia sac.,There are extensive degenerative changes of the right hip noted with changes suggestive of avascular necrosis. Degenerative changes of the spine are observed.,IMPRESSION:,1. Anterior abdominal wall hernia with mesenteric fat-containing stranding, suggestive of incarcerated fat.,2. Nodule in the left lower lobe, recommend follow up in 3 months.,3. Indeterminate left adrenal nodule, could be further assessed with dedicated adrenal protocol CT or MRI.,4. Hepatomegaly with changes suggestive of cirrhosis. There is also splenomegaly observed.,5. Low-attenuation lesions in the spleen may represent cyst, that are incompletely characterized on this examination.,6. Fat density lesion in the left kidney, likely represents angiomyolipoma.,7. Fat density soft tissue lesion in the region of the right adnexa, this contains calcifications and may represent an ovary or possibly dermoid cyst.

radiology, abdominal pain, cardiomegaly, atherosclerotic calcifications, hepatomegaly, perinephric stranding, low attenuation lesions, abdominal, calcifications, lesions, abdomen,

CT Abdomen and Pelvis with contrast

Radiology

CT Abdomen & Pelvis - 1

EXAM: , CT Abdomen and Pelvis with contrast ,REASON FOR EXAM:, Nausea, vomiting, diarrhea for one day. Fever. Right upper quadrant pain for one day. ,COMPARISON: , None. ,TECHNIQUE:, CT of the abdomen and pelvis performed without and with approximately 54 ml Isovue 300 contrast enhancement. ,CT ABDOMEN: , Lung bases are clear. The liver, gallbladder, spleen, pancreas, and bilateral adrenal/kidneys are unremarkable. The aorta is normal in caliber. There is no retroperitoneal lymphadenopathy. ,CT PELVIS: , The appendix is visualized along its length and is diffusely unremarkable with no surrounding inflammatory change. Per CT, the colon and small bowel are unremarkable. The bladder is distended. No free fluid/air. Visualized osseous structures demonstrate no definite evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1. Unremarkable exam; specifically no evidence for acute appendicitis. ,2. No acute nephro-/ureterolithiasis. ,3. No secondary evidence for acute cholecystitis.,Results were communicated to the ER at the time of dictation.

radiology, liver, gallbladder, spleen, pancreas, adrenal, kidneys, lymphadenopathy, abdomen and pelvis, contrast, ct

A 62-year-old male with a history of ischemic cardiomyopathy and implanted defibrillator.

Radiology

Coronary CT Angiography (CCTA) - 5

COMPARISON STUDIES:, None.,MEDICATION: , Lopressor 5 mg IV.,HEART RATE AFTER MEDICATION:, 64bpm,EXAM:,TECHNIQUE: Tomographic images were obtained of the heart and chest with a 64 detector row scanner using slice thicknesses of less than 1 mm. 80cc’s of Isovue 370 was injected in the right arm.,TECHNICAL QUALITY:,Examination is limited secondary to extensive artifact from defibrillator wires.,There is good demonstration of the coronary arteries and there is good bolus timing.,FINDINGS:,LEFT MAIN CORONARY ARTERY:,The left main coronary artery is a moderate-sized vessel with a normal ostium. There is no calcific or non-calcific plaque. The vessel bifurcates into a left anterior descending artery and a left circumflex artery.,LEFT ANTERIOR DESCENDING ARTERY:,The left anterior descending artery is a moderate-sized vessel, with a small first diagonal branch and a large second diagonal branch. The vessel continues as a small vessel, tapering at the apex of the left ventricle. There is calcific plaque within the mid vessel, with dense calcific plaque at the bifurcation of the second diagonal branch. This limits evaluation of the vessel lumen, and although a flow-limiting lesion cannot be excluded, there is no evidence of a high-grade stenosis. There is ostial calcification within the second diagonal branch as well. The LAD distal to the second diagonal branch is small relative to the more proximal vessel, and this is worrisome for a proximal flow-limiting lesion.,In addition, there is marked tapering of the D2 branch distal to the proximal and ostial calcific plaque. This is worrisome for either occlusion or a high-grade stenosis. There is only minimal contrast that is identified in the distal vessel.,LEFT CIRCUMFLEX ARTERY:,The left circumflex artery is a moderate-sized vessel with a patent ostium. There is calcific plaque within the proximal vessel. There is dense calcific plaque at the bifurcation of the OM1, and the AV groove branch. The AV groove branch tapers as a small vessel at the base of the heart. The dense calcific plaque within the bifurcation of the OM1 and the AV groove branch limits evaluation of the vessel lumen. There is no demonstrated high-grade stenosis, but a flow-limiting lesion cannot be excluded here.,RIGHT CORONARY ARTERY:,The right coronary artery is a moderate-sized vessel with a patent ostium. There is proximal mixed calcific and non-calcific plaque, but there is no flow-limiting lesion. The vessel continues as a moderate-sized vessel to the crux of the heart, supplying a small posterior descending artery and moderate to large posterolateral ventricular branches.,There is scattered calcific plaque within the mid vessel and there is also calcific plaque within the distal vessel at the origin of the posterior descending artery. There is no flow-limited lesion demonstrated.,The right coronary artery is dominant.,NONCORONARY CARDIAC STRUCTURE:,CARDIAC CHAMBERS:, There is diffuse myocardial thinning within the left ventricle, particularly within the apex where there is subendocardial calcification, consistent with chronic infarction. There is ventricular enlargement. There is no demonstrated aneurysm or pseudoaneurysm.,CARDIAC VALVES: ,There is calcification within the left aortic valve cusp. The aortic valve is tri-leaflet. Normal mitral valve.,PERICARDIUM:, Normal.,GREAT VESSELS: ,There are atherosclerotic changes within the aorta.,VISUALIZED LUNG PARENCHYMA, MEDIASTINUM AND CHEST WALL: ,Normal.,IMPRESSION:,Limited examination secondary to extensive artifact from the pacemaker wires.,There is extensive calcific plaque within the left anterior descending artery as well as within the proximal second diagonal branch. There is marked tapering of the LAD distal to the bifurcation of the D1 and this is worrisome for a flow-limiting lesion, but there is no evidence of occlusion.,There is marked tapering of the D1 branch distal to the calcific plaque and occlusion cannot be excluded.,There is dense calcific plaque within the left circumflex artery, and although a flow-limiting lesion cannot be excluded here, there is no evidence of an occlusion or high-grade stenosis.,There is mixed soft and calcific plaque within the proximal RCA, but there is no flow limiting lesion demonstrated.,There is diffuse thinning of the left ventricular wall, most focal at the apex where there is also dense calcification, consistent with chronic infarction. There is no demonstrated aneurysm or pseudoaneurysm.

CT Abdomen & Pelvis W&WO Contrast

Radiology

CT Abdomen & Pelvis

EXAM:, CT Abdomen & Pelvis W&WO Contrast, ,REASON FOR EXAM: , Status post aortobiiliac graft repair. , ,TECHNIQUE: , 5 mm spiral thick spiral CT scanning was performed through the entire abdomen and pelvis utilizing intravenous dynamic bolus contrast enhancement. No oral or rectal contrast was utilized. Comparison is made with the prior CT abdomen and pelvis dated 10/20/05. There has been no significant change in size of the abdominal aortic aneurysm centered roughly at the renal artery origin level which has dimensions of 3.7 cm transversely x 3.4 AP. Just below this level is the top of the endoluminal graft repair with numerous surrounding surgical clips. The size of the native aneurysm component at this level is stable at 5.5 cm in diameter with mural thrombus surrounding the enhancing endolumen. There is no abnormal entrance of contrast agent into the mural thrombus to indicate an endoluminal leak. Further distally, there is extension of the graft into both proximal common iliac arteries without evidence for endoluminal leak at this level either. No exoluminal leakage is identified at any level. There is no retroperitoneal hematoma present. The findings are unchanged from the prior exam. ,The liver, spleen, pancreas, adrenals and right kidney are unremarkable with moderate diffuse atrophy of the pancreas present. There is advanced atrophy of the left kidney. No hydronephrosis is present. No acute findings are identified elsewhere in the abdomen. ,The lung bases are clear. ,Concerning the remainder of the pelvis, no acute pathology is identified. There is prominent streak artifact from the left total hip replacement. There is diffuse moderate sigmoid diverticulosis without evidence for diverticulitis. The bladder grossly appears normal. A hysterectomy has been performed. ,IMPRESSION:,1. No complications identified regarding endoluminal aortoiliac graft repair as described. The findings are stable compared to the study of 10/20/04. ,2. Stable mild aneurysm of aortic aneurysm, centered roughly at renal artery level. ,3. No other acute findings noted. ,4. Advanced left renal atrophy.

radiology, aortobiiliac graft repair, renal atrophy, ct abdomen & pelvis, w&wo contrast, aortic aneurysm, renal artery, mural thrombus, endoluminal leak, ct abdomen, ct, contrast, pelvis, abdomen,

CCTA with Cardiac Function/Calcium Scoring

Radiology

Coronary CT Angiography (CCTA) - 2

CARDIAC CT INCLUDING CORONARY CT ANGIOGRAPHY,PROCEDURE: , Breath hold cardiac CT was performed using a 64-channel CT scanner with a 0.5-second rotation time. Contrast injection was timed using a 10 mL bolus of Ultravist 370 IV. Then the patient received 75 mL of Ultravist 370 at a rate of 5 mL/sec.,Retrospective ECG gating was performed. The patient received 0.4 milligrams of sublingual nitroglycerin prior to the to the scan. The average heart rate was 62 beats/min.,The patient had no adverse reaction to the contrast. Multiphase retrospective reconstructions were performed. Small field of view cardiac and coronary images were analyzed on a 3D work station. Multiplanar reformatted images and 3D volume rendering was performed by the attending physician for the purpose of defining coronary anatomy and determining the extent of coronary artery disease.,CORONARY CTA:,1. The technical quality of the scan is adequate.,2. The coronary ostia are in their normal position. The coronary anatomy is right dominant.,3. LEFT MAIN: The left main coronary artery is patent without angiographic stenosis.,4. LEFT ANTERIOR DESCENDING ARTERY: The proximal aspect of the left anterior descending artery demonstrates a mixed plaque consisting of both calcified and noncalcified lesion which is less than 30% in stenosis severity. Diagonal 1 and diagonal 2 branches of the left anterior descending artery demonstrate mild irregularities.,5. The ramus intermedius is a small vessel with minor irregularities.,6. LEFT CIRCUMFLEX: The left circumflex and obtuse marginal 1 and obtuse marginal 2 branches of the vessel are patent without significant stenosis.,7. RIGHT CORONARY ARTERY: The right coronary artery is a large and dominant vessel. It demonstrates within its mid-segment calcified atherosclerosis, less than 50% stenosis severity. Left ventricular ejection fraction is calculated to be 69%. There are no wall motion abnormalities.,8. Coronary calcium score was calculated to be 79, indicating at least mild atherosclerosis within the coronary vessels.,ANCILLARY FINDINGS: , None.,FINAL IMPRESSION:,1. Mild coronary artery disease with a preserved left ventricular ejection fraction of 69%.,2. Recommendation is aggressive medical management consisting of aggressive lifestyle modifications and statin therapy.,Thank you for referring this patient to us.

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Coronary Artery CTA with Calcium Scoring and Cardiac Function

Radiology

Coronary CT Angiography (CCTA) - 3

EXAM: , Coronary artery CTA with calcium scoring and cardiac function.,HISTORY: , Chest pain.,TECHNIQUE AND FINDINGS: , Coronary artery CTA was performed on a Siemens dual-source CT scanner. Post-processing on a Vitrea workstation. 150 mL Ultravist 370 was utilized as the intravenous contrast agent. Patient did receive nitroglycerin sublingually prior to the contrast.,HISTORY: , Significant for high cholesterol, overweight, chest pain, family history,Patient's total calcium score (Agatston) is 10. his places the patient just below the 75th percentile for age.,The LAD has a moderate area of stenosis in its midportion due to a focal calcified plaque. The distal LAD was unreadable while the proximal was normal. The mid and distal right coronary artery are not well delineated due to beam-hardening artifact. The circumflex is diminutive in size along its proximal portion. Distal is not readable.,Cardiac wall motion within normal limits. No gross pulmonary artery abnormality however they are not well delineated. A full report was placed on the patient's chart. Report was saved to PACS.

radiology, coronary artery cta, calcium scoring, cardiac function, coronary artery, ct, scoring, lad, midportion, cta, calcium, cardiac, coronary, artery, angiography,

Conformal simulation with coplanar beams. This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated.

Radiology

Conformal Simulation

CONFORMAL SIMULATION WITH COPLANAR BEAMS,This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated. It allows us to highly focus the beam of radiation and shape the beam to the target volume, delivering a homogenous dosage through it while sparing the surrounding, more radiosensitive, normal tissues. This will allow us to give the optimum chance of tumor control while minimizing the acute and long-term side effects.,A conformal simulation is a simulation which involves extended physician, therapist, and dosimetrist time and effort. The patient is initially taken into a conventional simulator room, where appropriate markers are placed, and the patient is positioned and immobilized. One then approximates the field sizes and arrangements (gantry angles, collimator angles, and number of fields). Radiographs are taken, and these fields are marked on the patient's skin. The patient is then transferred to the diagnostic facility and placed on a flat CT scan table. Scans are then performed through the targeted area. The CT scans are evaluated by the radiation oncologist, and the tumor volume, target volume, and critical structures are outlined on each slice of the CT scan. The dosimetrist then evaluates each individual slice in the treatment planning computer with the appropriately marked structures. This volume is then reconstructed in 3-dimensional space. Utilizing the beam's-eye view features, the appropriate blocks are designed. Multiplane computerized dosimetry is performed throughout the volume. Field arrangements and blocking are modified as necessary to provide homogenous coverage of the target volume while minimizing the dose to normal structures. Once all appropriate beam parameters and isodate distributions have been confirmed on the computer scan, each individual slice is then reviewed by the physician. The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician. Once these are approved, Cerrobend blocks will be custom fabricated.,If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where the computer-designed fields are re-simulated.

radiology, coplanar beams, ct scan, target volume, conformal simulation, beamsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

A 51-year-old male with chest pain and history of coronary artery disease.

Radiology

Coronary CT Angiography (CCTA) - 4

COMPARISON:, None.,MEDICATIONS:, Lopressor 5mg IV at 0920 hours.,HEART RATE: ,Recorded heart rate 55 to 57bpm.,EXAM:,Initial unenhanced axial CT imaging of the heart was obtained with ECG gating for the purpose of coronary artery calcium scoring (Agatston Method) and calcium volume determination.,18 gauge IV Intracath was inserted into the right antecubital vein.,A 20cc saline bolus was injected intravenously to confirm vein patency and adequacy of venous access.,Multi-detector CT imaging was performed with a 64 slice MDCT scanner with images obtained from the mid ascending aorta to the diaphragm at 0.5mm slice thickness during breath-holding.,95 cc of Isovue was administered followed by a 90cc saline “bolus chaser”. Image reconstruction was performed using retrospective cardiac gating. Calcium scoring analysis (Agatston Method and volume determination) was performed.,FINDINGS:,CALCIUM SCORE: The patient's total Agatston calcium score is: 115. The Agatston score for the individual vessels are: LM: 49. RCA: 1. LAD: 2. CX: 2. Other: 62. The Agatston calcium score places the patient in the 90th percentile, which means 10 percent of the male population in this age group would have a higher calcium score.,QUALITY ASSESSMENT:, Examination is of good quality with good bolus timing and good demonstration of coronary arteries.,LEFT MAIN CORONARY ARTERY:, The left main coronary artery has a posteriorly positioned take-off from the valve cusp, with a patent ostium, and it has an extramural (non-malignant) course. The vessel is of moderate size. There is an apparent second ostium, in a more normal anatomic location, but quite small. This has an extramural (non-malignant) course. There is mixed calcific/atheromatous plaque within the distal vessel, as well as positive remodeling. There is no high grade stenosis but a flow-limiting lesion can not be excluded. The vessel trifurcates into a left anterior descending artery, a ramus intermedius and a left circumflex artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:, The left anterior descending artery is a moderate-size vessel, with ostial calcific plaque and soft plaque without a high-grade stenosis, but there may be a flow-limiting lesion here. There is a moderate size bifurcating first diagonal branch with ostial calcification, but no flow-limiting lesion. LAD continues as a moderate-size vessel to the posterior apex of the left ventricle.,Ramus intermedius branch is a moderate to large-size vessel with extensive calcific plaque, but no ostial stenosis. The dense calcific plaque limits evaluation of the vessel lumen, and a flow-limiting lesion within the proximal vessel cannot be excluded. The vessel continues as a small vessel on the left lateral ventricular wall.,LEFT CIRCUMFLEX CORONARY ARTERY:, The left circumflex artery is a moderate-size vessel with a normal ostium giving rise to a small OM1 branch and a large OM2 branch supplying much of the posterolateral wall of the left ventricular. The AV-groove branch tapers at the base of the heart. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting stenosis.,RIGHT CORONARY ARTERY:, The right coronary artery is a large vessel with a normal ostium giving rise to a moderate-size acute marginal branch and continuing as a large vessel to the crux of the heart supplying a left posterior descending artery and small posterolateral ventricular branches. There is minimal calcific plaque within the mid vessel, but there is no flow-limiting lesion.,Coronary circulation is right dominant.,FUNCTIONAL ANALYSIS:, End diastolic volume: 106ml End systolic volume: 44ml Ejection fraction: 58 percent,ANATOMIC ANALYSIS:,Normal heart size with no demonstrated ventricular wall abnormalities. There are no demonstrated myocardial,bridges. Normal left atrial appendage with no evidence of thrombosis.,Cardiac valves are normal.,The aortic diameter measures 33mm just distal to the sino-tubular junction. The visualized thoracic aorta appears normal in size.,Normal pericardium without pericardial thickening or effusion.,There is no demonstrated mediastinal or hilar adenopathy. The visualized lung parenchyma is unremarkable.,There are two left and two right pulmonary veins.,IMPRESSION:,Ventricular function: Normal.,Single vessel coronary artery analysis:,LM: There is a posterior origin from the valve cusp. There is mixed calcific/atheromatous plaque and positive remodeling plaque within the LM, and although there is no high grade stenosis, a flow-limiting lesion can not be excluded. In addition, there is an apparent second ostium of indeterminate significance, but both ostia have extramural (non-malignant) courses.,LAD: Dense calcific plaque within the proximal vessel with ostial calcification and possible flow-limiting proximal lesion. There is a ramus branch with dense calcific plaque limiting evaluation of the vessel lumen, but a flow-limiting lesion cannot be excluded here.,CX: Minimal calcific plaque with no flow-limiting lesion.,RCA: Minimal calcific plaque with no flow-limiting lesion.,Coronary artery dominance: Right.

CCTA with cardiac function and calcium scoring.

Radiology

Coronary CT Angiography (CCTA) - 1

HISTORY: , Coronary artery disease.,TECHNIQUE AND FINDINGS: ,Calcium scoring and coronary artery CTA with cardiac function was performed on Siemens dual-source CT scanner with postprocessing on Vitrea workstation. Patient received oral Metoprolol 100 milligrams. 100 ml Ultravist 370 was utilized as the contrast agent. 0.4 milligrams of nitroglycerin was given.,Patient's calcium score 164, volume 205; this places the patient between the 75th and 90th percentile for age. There is at least moderate atherosclerotic plaque with mild coronary artery disease and significant narrowings possible.,Cardiac wall motion was within normal limits. Left ventricular ejection fraction calculated to be 82%. End-diastolic volume 98 mL, end-systolic volume calculated to be 18 mL.,There is normal coronary artery origins. There is codominance between the right coronary artery and the circumflex artery. There is mild to moderate stenosis of the proximal LAD with mixed plaque. Mild stenosis mid LAD with mixed plaque. No stenosis. Distal LAD with the distal vessel becoming diminutive in size. Right coronary artery shows mild stenosis proximally and in the midportion due to calcified focal plaque. Once again the distal vessel becomes diminutive in size. Circumflex shows mild stenosis due to focal calcified plaque proximally. No stenosis is seen involving the mid or distal circumflex. The distal circumflex also becomes diminutive in size. The left main shows small amount of focal calcified plaque without stenosis. Myocardium, pericardium and wall motion was unremarkable as seen.,IMPRESSION:,1. Atherosclerotic coronary artery disease with values as above. There are areas of stenosis most pronounced in the LAD with mild to moderate change and mild stenosis involving the circumflex and right coronary artery.,2. Consider cardiology consult and further evaluation if clinically indicated.,3. Full report was sent to the PACS. Report will be mailed to Dr. ABC.

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Chest PA & Lateral to evaluate shortness of breath and pneumothorax versus left-sided effusion.

Radiology

Chest PA & Lateral

EXAM: , Chest PA & Lateral.,REASON FOR EXAM: , Shortness of breath, evaluate for pneumothorax versus left-sided effusion.,INTERPRETATION: ,There has been interval development of a moderate left-sided pneumothorax with near complete collapse of the left upper lobe. The lower lobe appears aerated. There is stable, diffuse, bilateral interstitial thickening with no definite acute air space consolidation. The heart and pulmonary vascularity are within normal limits. Left-sided port is seen with Groshong tip at the SVC/RA junction. No evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1. Interval development of moderate left-sided pneumothorax with corresponding left lung atelectasis.,2. Rest of visualized exam nonacute/stable.,3. Left central line appropriately situated and stable.,4. Preliminary report was issued at time of dictation. Dr. X was called for results.

radiology, effusion, interstitial thickening, chest pa & lateral, shortness of breath, chest, pneumothorax,

Cerebral Angiogram and MRA for bilateral ophthalmic artery aneurysms.

Radiology

Cerebral Angiogram & MRA

CC:, Transient visual field loss.,HX: ,This 58 y/o RHF had a 2 yr h/o increasing gait difficulty which she attributed to generalized weakness and occasional visual obscurations. She was evaluated by a local physician several days prior to this presentation (1/7/91), for clumsiness of her right hand and falling. HCT and MRI brain revealed bilateral posterior clinoid masses.,MEDS:, Colace, Quinidine, Synthroid, Lasix, Lanoxin, KCL, Elavil, Tenormin.,PMH: ,1) Obesity. 2) VBG, 1990. 3) A-Fib. 4) HTN. 5) Hypothyroidism. 6) Hypercholesterolemia. 7) Briquet's syndrome: h/o of hysterical paralysis. 8) CLL, dx 1989; in 1992 presented with left neck lymphadenopathy and received 5 cycles of chlorambucil/prednisone chemotherapy; 10/95 parotid gland biopsy was consistent with CLL and she received 5 more cycles of chlorambucil/prednisone; 1/10/96, she received 3000cGy to right parotid mass. 9) SNHL,FHX:, Father died, MI age 61.,SHX:, Denied Tobacco/ETOH/illicit drug use.,EXAM:, Vitals were unremarkable.,The neurologic exam was unremarkable except for obesity and mild decreased PP about the right upper and lower face, diffusely about the left upper and lower face, per neurosurgery notes. The neuro-ophthalmologic exam was unremarkable, per Neuro-ophthalmology.,COURSE:, She underwent Cerebral Angiography on 1/8/91. This revealed a 15x17x20mm LICA paraclinoid/ophthalmic artery aneurysm and a 5x7mm RICA paraclinoid/ophthalmic artery aneurysm. On 1/16/91 she underwent a left frontotemporal craniotomy and exploration of the left aneurysm. The aneurysm neck went into the cavernous sinus and was unclippable so it was wrapped. She has complained of headaches since.

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Chest CT - Thymoma and history of ocular myasthenia gravis.

Radiology

Chest CT - Myasthenia Gravis

CC:, Intermittent binocular horizontal, vertical, and torsional diplopia.,HX: ,70y/o RHM referred by Neuro-ophthalmology for evaluation of neuromuscular disease. In 7/91, he began experiencing intermittent binocular horizontal, vertical and torsional diplopia which was worse and frequent at the end of the day, and was eliminated when closing one either eye. An MRI Brain scan at that time was unremarkable. He was seen at UIHC Strabismus Clinic in 5/93 for these symptoms. On exam, he was found to have intermittent right hypertropia in primary gaze, and consistent diplopia in downward and rightward gaze. This was felt to possibly represent Grave's disease. Thyroid function studies were unremarkable, but orbital echography suggested Graves orbitopathy. The patient was then seen in the Neuro-ophthalmology clinic on 12/23/92. His exam remained unchanged. He underwent Tensilon testing which was unremarkable. On 1/13/93, he was seen again in Neuro-ophthalmology. His exam remained relatively unchanged and repeat Tensilon testing was unremarkable. He then underwent a partial superior rectus resection, OD, with only mild improvement of his diplopia. During his 8/27/96 Neuro-ophthalmology clinic visit he was noted to have hypertropia OD with left pseudogaze palsy and a right ptosis. The ptosis improved upon administration of Tensilon and he was placed on Mestinon 30mg tid. His diplopia subsequently improved, but did not resolve. The dosage was increased to 60mg tid and his diplopia worsened and the dose decreased back to 30mg tid. At present he denied any fatigue on repetitive movement. He denied dysphagia, SOB, dysarthria, facial weakness, fevers, chills, night sweats, weight loss or muscle atrophy.,MEDS: , Viokase, Probenecid, Mestinon 30mg tid.,PMH:, 1) Gastric ulcer 30 years ago, 2) Cholecystectomy, 3) Pancreatic insufficiency, 4) Gout, 5) Diplopia.,FHX:, Mother died age 89 of "old age." Father died age 89 of stroke. Brother, age 74 with CAD, Sister died age 30 of cancer.,SHX:, Retired insurance salesman and denies history of tobacco or illicit drug us. He has no h/o ETOH abuse and does not drink at present.,EXAM: ,BP 155/104. HR 92. RR 12. Temp 34.6C. WT 76.2kg.,MS: Unremarkable. Normal speech with no dysarthria.,CN: Right hypertropia (worse on rightward gaze and less on leftward gaze). Minimal to no ptosis, OD. No ptosis, OS. VFFTC. No complaint of diplopia. The rest of the CN exam was unremarkable.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,SENSORY: No deficits appreciated on PP/VIB/LT/PROP/TEMP testing.,Coordination/Station/Gait: Unremarkable.,Reflexes: 2/2 throughout. Plantar responses were flexor on the right and withdrawal on the left.,HEENT and GEN EXAM: Unremarkable.,COURSE:, EMG/NCV, 9/26/96: Repetitive stimulation studies of the median, facial, and spinal accessory nerves showed no evidence of decrement at baseline, and at intervals up to 3 minutes following exercise. The patient had been off Mestinon for 8 hours prior to testing. Chest CT with contrast, 9/26/96, revealed a 4x2.5x4cm centrally calcified soft tissue anterior mediastinal mass adjacent to the aortic arch. This was highly suggestive of a thymoma. There were diffuse emphysematous disease with scarring in the lung bases. A few nodules suggestive of granulomas and few calcified perihilar lymph nodes. He underwent thoracotomy and resection of the mass. Pathologic analysis was consistent with a thymoma, lymphocyte predominant type, with capsular and pleural invasion, and extension to the phrenic nerve resection margin. Acetylcholine Receptor-binding antibody titer 12.8nmol/L (normal<0.7), Acetylcholine receptor blocking antibody <10% (normal), Acetylcholine receptor modulating antibody 42% (normal<19), Striated muscle antibody 1:320 (normal<1:10). Striated muscle antibody titers tend to be elevated in myasthenia gravis associated with thymoma. He was subsequently treated with XRT and continued to complain of fatigue at his 4/18/97 Oncology visit.

radiology, diplopia, neuromuscular disease, muscle antibody titers, chest ct, intermittent binocular, rightward gaze, striated muscle, myasthenia gravis, intermittent, torsional, binocular, myasthenia, chest, thymoma, ophthalmology, antibody,

Cerebral Angiogram - Lobulated aneurysm of the supraclinoid portion of the left internal carotid artery close to the origin of the left posterior communicating artery.

Radiology

Cerebral Angiogram - Left ICA/PCA Aneurysm

CC:, Fluctuating level of consciousness.,HX:, 59y/o male experienced a "pop" in his head on 10/10/92 while showering in Cheyenne, Wyoming. He was visiting his son at the time. He was found unconscious on the shower floor 1.5 hours later. His son then drove him Back to Iowa. Since then he has had recurrent headaches and fluctuating level of consciousness, according to his wife. He presented at local hospital this AM, 10/13/92. A HCT there demonstrated a subarachnoid hemorrhage. He was then transferred to UIHC.,MEDS:, none.,PMH:, 1) Right hip and clavicle fractures many years ago. 2) All of his teeth have been removed., ,FHX:, Not noted.,SHX:, Cigar smoker. Truck driver.,EXAM: , BP 193/73. HR 71. RR 21. Temp 37.2C.,MS: A&O to person, place and time. No note regarding speech or thought process.,CN: Subhyaloid hemorrhages, OU. Pupils 4/4 decreasing to 2/2 on exposure to light. Face symmetric. Tongue midline. Gag response difficult to elicit. Corneal responses not noted.,MOTOR: 5/5 strength throughout.,Sensory: Intact PP/VIB.,Reflexes: 2+/2+ throughout. Plantars were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, The patient underwent Cerebral Angiography on 10/13/92. This revealed a lobulated aneurysm off the supraclinoid portion of the left internal carotid artery close to the origin of the posterior communication artery. The patient subsequently underwent clipping of this aneurysm. He recovery was complicated severe vasospasm and bacterial meningitis. HCT on 10/19/92 revealed multiple low density areas in the left hemisphere in the LACA-LPCA watershed, left fronto-parietal area and left thalamic region. He was left with residual right hemiparesis, urinary incontinence, some (unspecified) degree of mental dysfunction. He was last seen 2/26/93 in Neurosurgery clinic and had stable deficits.

radiology, consciousness, level of consciousness, hct, subhyaloid hemorrhages, cerebral angiography, carotid artery, communication artery, laca-lpca, fluctuating level of consciousness, internal carotid artery, lobulated aneurysm, lobulated, supraclinoid, cerebral, aneurysm, artery, angiogram,

Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.

Radiology

Chest Pulmonary Angio

EXAM: , CTA chest pulmonary angio.,REASON FOR EXAM: , Evaluate for pulmonary embolism.,TECHNIQUE: , Postcontrast CT chest pulmonary embolism protocol, 100 mL of Isovue-300 contrast is utilized.,FINDINGS: , There are no filling defects in the main or main right or left pulmonary arteries. No central embolism. The proximal subsegmental pulmonary arteries are free of embolus, but the distal subsegmental and segmental arteries especially on the right are limited by extensive pulmonary parenchymal, findings would be discussed in more detail below. There is no evidence of a central embolism.,As seen on the prior examination, there is a very large heterogeneous right chest wall mass, which measures at least 10 x 12 cm based on axial image #35. Just superior to the mass is a second heterogeneous focus of neoplasm measuring about 5 x 3.3 cm. Given the short interval time course from the prior exam, dated 01/23/09, this finding has not significantly changed. However, there is considerable change in the appearance of the lung fields. There are now bilateral pleural effusions, small on the right and moderate on the left with associated atelectasis. There are also extensive right lung consolidations, all new or increased significantly from the prior examination. Again identified is a somewhat spiculated region of increased density at the right lung apex, which may indicate fibrosis or scarring, but the possibility of primary or metastatic disease cannot be excluded. There is no pneumothorax in the interval.,On the mediastinal windows, there is presumed subcarinal adenopathy, with one lymph node measuring roughly 12 mm suggestive of metastatic disease here. There is aortic root and arch and descending thoracic aortic calcification. There are scattered regions of soft plaque intermixed with this. The heart is not enlarged. The left axilla is intact in regards to adenopathy. The inferior thyroid appears unremarkable.,Limited assessment of the upper abdomen discloses a region of lower density within the right hepatic lobe, this finding is indeterminate, and if there is need for additional imaging in regards to hepatic metastatic disease, follow up ultrasound. Spleen, adrenal glands, and upper kidneys appear unremarkable. Visualized portions of the pancreas are unremarkable.,There is extensive rib destruction in the region of the chest wall mass. There are changes suggesting prior trauma to the right clavicle.,IMPRESSION:,1. Again demonstrated is a large right chest wall mass.,2. No central embolus, distal subsegmental and segmental pulmonary artery branches are in part obscured by the pulmonary parenchymal findings, are not well assessed.,3. New bilateral pleural effusions and extensive increasing consolidations and infiltrates in the right lung.,4. See above regarding other findings.

radiology, chest pulmonary embolism, chest pulmonary embolism protocol, bilateral pleural effusions, chest wall mass, metastatic disease, pulmonary, isovue, subsegmental, metastatic, disease, mass, lung, embolism, chest, angio

Cerebral Angiogram - Lateral medullary syndrome secondary to left vertebral artery dissection.

Radiology

Cerebral Angiogram - Lateral Medullary Syndrome

CC: ,Falling to left.,HX:, 26y/oRHF fell and struck her head on the ice 3.5 weeks prior to presentation. There was no associated loss of consciousness. She noted a dull headache and severe sharp pain behind her left ear 8 days ago. The pain lasted 1-2 minutes in duration. The next morning she experienced difficulty walking and consistently fell to the left. In addition the left side of her face had become numb and she began choking on food. Family noted her pupils had become unequal in size. She was seen locally and felt to be depressed and admitted to a psychiatric facility. She was subsequently transferred to UIHC following evaluation by a local ophthalmologist.,MEDS:, Prozac and Ativan (both recently started at the psychiatric facility).,PMH: ,1) Right esotropia and hyperopia since age 1year. 2) Recurrent UTI.,FHX:, Unremarkable.,SHX:, Divorced. Lives with children. No spontaneous abortions. Denied ETOH/Tobacco/Illicit Drug use.,EXAM:, BP 138/110. HR 85. RR 16. Temp 37.2C.,MS: A&O to person, place, time. Speech fluent and without dysarthria. Intact naming, comprehension, repetition.,CN: Pupils 4/2 decreasing to 3/1 on exposure to light. Optic Disks flat. VFFTC. Esotropia OD, otherwise EOM full. Horizontal nystagmus on leftward gaze. Decreased corneal reflex, OS. Decreased PP/TEMP sensation on left side of face. Light touch testing normal. Decreased gag response on left. Uvula deviates to right. The rest of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: Decreased PP and TEMP on right side of body. PROP/VIB intact.,Coord: Difficulty with FNF/HKS/RAM on left. Normal on right side.,Station: No pronator drift. Romberg test not noted.,Gait: unsteady with tendency to fall to left.,Reflexes: 3/3 throughout BUE and Patellae. 2+/2+ Achilles. Plantar responses were flexor, bilaterally.,Gen Exam: Obese. In no acute distress. Otherwise unremarkable.,HEENT: No carotid/vertebral/cranial bruits.,COURSE:, PT/PTT, GS, CBC, TSH, FT4 and Cholesterol screen were all within normal limits. HCT on admission was negative. MRI Brain (done locally 2/2/93) was reviewed and a left lateral medullary stroke was appreciated. The patient underwent a cerebral angiogram on 2/3/93 which revealed significant narrowing of the left vertebral artery beginning at C2 and extending to and involving the basilar artery. There is severe, irregular narrowing of the horizontal portion above the posterior arch of C1. The findings were felt consistent with a left vertebral artery dissection. Neuro-opthalmology confirmed a left Horner's pupil by clinical exam and history. Cookie swallow study was unremarkable. The Patient was placed on Heparin then converted to Coumadin. The PT on discharge was 17.,She remained on Coumadin for 3 months and then was switched to ASA for 1 year. An Otolaryngologic evaluation on 10/96 noted true left vocal cord paralysis with full glottic closure. A prosthesis was made and no surgical invention was done.

radiology, horner's pupil, mri brain, otolaryngologic, cerebral angiogram, cerebral angiogram lateral, medullary syndrome, vertebral artery, angiogram, syndrome, falling, narrowing, medullary, vertebral, cerebral,

Concomitant chemoradiotherapy for curative intent patients.

Radiology

Concomitant Chemoradiotherapy

CONCOMITANT CHEMORADIOTHERAPY FOR CURATIVE INTENT PATIENTS,This patient is receiving combined radiotherapy and chemotherapy in an effort to maximize the chance of control of this cancer. The chemotherapy is given in addition to the radiotherapy, not only to act as a cytotoxic agent on its own, but also to potentiate and enhance the effect of radiotherapy on tumor cells. It has been shown in the literature that this will maximize the chance of control.,During the course of the treatment, the patient's therapy must be closely monitored by the attending physician to be sure that the proper chemotherapy drugs are given at the proper time during the radiotherapy course. It is also important to closely monitor the patient to know when treatment with either chemotherapy or radiotherapy needs to be held. This combined treatment usually produces greater side effects than either treatment alone, and these need to be constantly monitored and treatment initiated on a timely basis to minimize these effects. In accordance, this requires more frequency consultation and coordination with the medical oncologist. Therefore, this becomes a very time intensive treatment and justifies CPT Code 77470.

radiology, tumor cells, concomitant chemoradiotherapy, chemotherapy, radiotherapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

Patient with chest pains, CAD, and cardiomyopathy.

Radiology

Cardiac Radionuclide Stress Test

INDICATION FOR STUDY: , Chest pains, CAD, and cardiomyopathy.,MEDICATIONS:, Humulin, lisinopril, furosemide, spironolactone, omeprazole, carvedilol, pravastatin, aspirin, hydrocodone, and diazepam.,BASELINE EKG: , Sinus rhythm at 71 beats per minute, left anterior fascicular block, LVBB.,PERSANTINE RESULTS: , Heart rate increased from 70 to 72. Blood pressure decreased from 160/84 to 130/78. The patient felt slightly dizziness, but there was no chest pain or EKG changes.,NUCLEAR PROTOCOL: , Same day rest/stress protocol was utilized with 12 mCi for the rest dose and 33 mCi for the stress test. 53 mg of Persantine were used, reversed with 125 mg of aminophylline.,NUCLEAR RESULTS:,1. Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition. The resting images are normal. The post Persantine images show mildly decreased uptake in the septum. The sum score is 0.,2. The Gated SPECT shows enlarged heart with a preserved EF of 52%.,IMPRESSION:,1. Mild septal ischemia. Likely due to the left bundle-branch block.,2. Mild cardiomyopathy, EF of 52%.,3. Mild hypertension at 160/84.,4. Left bundle-branch block.,

radiology, cardiac radionuclide, spect, sinus rhythm, cardiac radionuclide stress test, bundle branch block, stress test, bundle branch, chest pains, stress, test, cardiomyopathy, nuclear

Carotid and cerebral arteriogram - abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.

Radiology

Carotid & Cerebral Arteriograms

EXAM: , Carotid and cerebral arteriograms.,INDICATION: , Abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.,IMPRESSION:,1. Complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.,2. Mild stenosis of the right internal carotid artery measured at 20%.,3. Patent bilateral vertebral arteries.,4. No significant disease was identified of the anterior cerebral vessels.,DISCUSSION: ,Carotid and cerebral arteriograms were performed on Month DD, YYYY, previous studies are not available for comparison.,The right groin was sterilely cleansed and draped. Lidocaine 1% buffered with sodium bicarbonate was used as local anesthetic. A 19-French needle was then advanced into the common femoral artery and a wire was advanced. Over the wire, a sheath was placed. A wire was then advanced into the abdominal aorta and over the wire and the flushed catheter was then advanced to the arch of the aorta over a wire. Flushed arteriogram was performed. Arteriogram demonstrated no significant disease of the great vessels at their origins. There is demonstration of complete occlusion of the left common carotid artery approximately 3 cm distal to its origin. The vertebral arteries were widely patent. Following this, the flushed catheter was exchanged for ***** catheter and selective catheterization of the common carotid artery on the right was performed. Carotid and cerebral arteriograms were performed. The carotid arteriograms on the right demonstrated the carotid bulb to be unremarkable. The external carotid artery on the right is quite tortuous in its appearance. The internal carotid artery demonstrates a mild plaque creating stenosis, which is measured approximately 20%. Cerebral arteriogram on the right demonstrated the A1 and M1 segments bilaterally to be normal. No significant stenosis identified. There is complete cross-filling into the left brain via the right. No significant stenosis was appreciated.,Following this, the catheter was parked at the origin of the left common carotid artery and ejection demonstrated complete occlusion.,The patient tolerated the procedure well. No complications occurred during or immediately after the procedure. Stasis was achieved of the puncture site using a VasoSeal. The patient will be observed for at least 2-1/2 hours prior to being discharged to home.

radiology, carotid, arteriogram, bulb, carotid duplex, catheter, cerebral, distal, femoral artery, internal carotid artery, needle, occlusion, sheath, stenosis, vertebral arteries, vessels, cerebral arteriograms, carotid artery, artery, arteriograms, wire,

Cardiolite treadmill exercise stress test. The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS.

Radiology

Cardiolite Treadmill Stress Test

CARDIOLITE TREADMILL EXERCISE STRESS TEST,CLINICAL DATA:, This is a 72-year-old female with history of diabetes mellitus, hypertension, and right bundle branch block.,PROCEDURE:, The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS. There was a normal blood pressure response. The patient did not complain of any symptoms during the test and other than the right bundle branch block that was present at rest, no other significant electrographic abnormalities were observed.,Myocardial perfusion imaging was performed at rest following the injection of 10 mCi Tc-99 Cardiolite. At peak pharmacological effect, the patient was injected with 30 mCi Tc-99 Cardiolite.,Gating poststress tomographic imaging was performed 30 minutes after the stress.,FINDINGS:,1. The overall quality of the study is fair.,2. The left ventricular cavity appears to be normal on the rest and stress studies.,3. SPECT images demonstrate fairly homogeneous tracer distribution throughout the myocardium with no overt evidences of fixed and/or reperfusion defect.,4. The left ventricular ejection fraction was normal and estimated to be 78%.,IMPRESSION: , Myocardial perfusion imaging is normal. Result of this test suggests low probability for significant coronary artery disease.

radiology, peak heart rate, bundle branch block, perfusion imaging, stress test, mci, ventricular, cardiolite, treadmill,

Cerebral Angiogram for avascular mass - cavernous angioma (with hematoma on MRI and Bx).

Radiology

Cerebral Angiogram

CC: ,Headache (HA),HX:, 10 y/o RHM awoke with a bilateral parieto-occipital HA associated with single episode of nausea and vomiting, 2 weeks prior to presentation. The nausea and vomiting resolved and did not recur. However, he continued to experience similar HA 3-4 times per week during the early morning upon awakening. He never felt the HA awakened him from sleep. The HA were partially relieved by Tylenol or Advil, and he distracted himself from the pain by remaining active. One week prior to presentation, he started to experience short episodes of blurred vision and diplopia. He also became fatigued, less active, and frequently yawned.,He had no prior history of HA and he and his family denied any sign or symptom of focal weakness or numbness, dysphagia, dysarthria, or loss of consciousness.,The patient underwent an MRI brain scan prior to transfer to UIHC. This revealed a mass in the left frontal region adjacent to the left temporal horn. The mass was an inhomogeneous blend of signals on T1 and T2 images giving a suggestion of acute bleeding, hemosiderin deposition and multiple vessels within the mass.,MEDS:, None.,PMH:, 1) He was a 7# 15oz. product of a full term, uncomplicated pregnancy and spontaneous vaginal delivery. His post-partum course was unremarkable. 2)Developmental milestones were reached at the appropriate times; though he was diagnosed with dyslexia 4 years ago. 3) No significant illnesses or hospitalizations.,FHX:, MGF (meningioma). PGF (lymphoma). Mother (migraine HA). Father and 22yr old brother are alive and well.,SHX: ,lives with parents and attends mainstream 5th grade classes.,EXAM:, BP124/93 HR96 RR20 37.9C (tympanic),MS: A & O to person, place, time. Cooperative and interactive. Speech fluent and without dysarthria.,CN: EOM intact. VFFTC, Pupils 3/3 decreasing to 2/2 on exposure to light. Fundoscopy: optic disks flat, no evidence of hemorrhage. The rest of the CN exam was unremarkable.,MOTOR: full strength throughout all 4 extremities. Normal muscle tone and bulk.,Sensory: unremarkable.,Coord: unremarkable.,Station: no pronator drift or Romberg sign,Gait: unremarkable.,Reflexes: 2+ in RUE and RLE. 3 in LUE and LLE. Plantar responses were flexor, bilaterally.,HEENT: no meningismus. no cranial bruits. no skull defects palpated.,GEN EXAM: unremarkable.,COURSE:, GS, PT/PTT, CBC were unremarkable. The MRI finding above lead to a differential diagnosis of Venous Angioma, Arteriovenous Malformation, Ependymoma, Neurocytoma, Glioma: all with associated hemorrhage.,He underwent cerebral angiography on 1/25/93. Upon injection of the RCCA an avascular mass was identified in the right temporal lobe displacing the anterior choroidal artery, and temporal branches of the middle cerebral arteries. The internal cerebral vein is displaced to the left suggesting mass effect. There is a hypoplastic A1 segment and fetal origin of the LPCA. The mass was felt by neuroradiology to represent a hematoma.,He underwent a right frontal craniotomy, 1/28/93. Pathological evaluation of the resected tissue was consistent with a vascular malformation with inclusive reactive glial tissue and evidence of recurrent and remote hemorrhage. There were dilated vascular channels having walls of variable thickness, but without evidence of elastic lamina by elastic staining. This was consistent with venous angioma/malformation.

Bilateral carotid ultrasound.

Radiology

Carotid Ultrasound

EXAM:, Bilateral carotid ultrasound.,REASON FOR EXAM: , Headache.,TECHNIQUE: ,Color grayscale and Doppler analysis is employed.,FINDINGS:, On the grayscale images, the right common carotid artery demonstrates patency with mild intimal thickening only. At the level of the carotid bifurcation, there is heterogeneous hard plaque present, but without grayscale evidence of greater than 50% stenosis. Right common carotid waveform is normal with a peak systolic velocity of 0.474 m/second and an end-diastolic velocity of 0.131 m/second. The right ECA is patent as well with the velocity measurement 0.910 m/second.,The right internal carotid artery at the bifurcation demonstrates plaque formation, but no evidence of greater than 50% stenosis. Proximal peak systolic velocity in the internal carotid artery is 0.463 m/second with proximal end-diastolic velocity of 0.170. The mid internal carotid peak systolic velocity is 0.564 m/second, and mid ICA end-diastolic velocity is 0.199 m/second. Right ICA distal PSV 0.580 m/second, right ICA distal EDV 0.204 m/second. Vertebral flow is antegrade on the right at 0.469 m/second.,On the left, the common carotid artery demonstrates intimal thickening, but is otherwise patent. At the level of the bifurcation, however, there is more pronounced plaque formation with approximately 50% stenosis by the grayscale analysis. See the velocity measurements below:,Left carotid ECA measurement 0.938 m/second. Left common carotid PSV 0.686 m/second, and left common carotid end-diastolic velocity 0.137 m/second.,Left internal carotid artery again demonstrates prominent focus of hard plaque with up to at least 50% stenosis. This should be further assessed with CTA for more precise measurement. The left proximal ICA/PSV 0.955 m/second, left proximal ICA/EDV 0.287 m/second. There is spectral broadening in the proximal aspect of the carotid waveform. The left carotid ICA mid PSV 0.895, left carotid ICA mid EDV 0.278 with also spectral broadening present.,The left distal ICA/PSV 0.561, left distal ICA/EDV 0.206, again the spectral broadening present. Vertebral flow is antegrade at 0.468 m/second.,IMPRESSION: , The study demonstrates bilateral hard plaque at the bifurcation, left greater than right. There is at least 50% stenosis of the left internal carotid artery at its bifurcation and a followup CTA is recommended for further assessment.

radiology, doppler analysis, headache, edv, ica, eca, psv, distal ica/edv, hard plaque, bilateral carotid ultrasound, peak systolic velocity, internal carotid artery, plaque formation, carotid ultrasound, carotid artery, carotid, stenosis, proximal, artery, velocity

Carotid Ultrasonic & Color Flow Imaging

Radiology

Carotid Doppler Report

Grade II: Atherosclerotic plaques are seen which appear to be causing 40-60% obstruction.,Grade III: Atherosclerotic plaques are seen which appear to be causing greater than 60% obstruction.,Grade IV: The vessel is not pulsating and the artery appears to be totally obstructed with no blood flow in it.,RIGHT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening with no increase in velocity and no evidence for any obstructive disease. The internal carotid artery shows intimal thickening with some mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease. The external carotid artery shows no disease. The vertebral was present and was antegrade.,LEFT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening, but no increase in velocity and no evidence for any significant obstructive disease. the internal carotid artery shows some intimal thickening with mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease. The external carotid artery shows no disease. The vertebral was present and was antegrade.,IMPRESSION:, Bilateral atherosclerotic changes with no evidence for any significant obstructive disease.

radiology, atherosclerotic, atherosclerotic plaques, obstructive disease, carotid artery, carotid artery and bulb, common carotid artery, mild intimal thickening, external carotid artery, common carotid, internal carotid, external carotid, intimal thickening, carotid, intimal, plaques, artery,

Bilateral Mammogram, (abnormal) additional views requested

Radiology

Bilateral Mammogram

EXAM:, Mammographic screening FFDM,HISTORY: , 40-year-old female who is on oral contraceptive pills. She has no present symptomatic complaints. No prior history of breast surgery nor family history of breast CA.,TECHNIQUE: , Standard CC and MLO views of the breasts.,COMPARISON: , This is the patient's baseline study.,FINDINGS: , The breasts are composed of moderately to significantly dense fibroglandular tissue. The overlying skin is unremarkable.,There are a tiny cluster of calcifications in the right breast, near the central position associated with 11:30 on a clock.,There are benign-appearing calcifications in both breasts as well as unremarkable axillary lymph nodes.,There are no spiculated masses or architectural distortion.,IMPRESSION:, Tiny cluster of calcifications at the 11:30 position of the right breast. Recommend additional views; spot magnification in the MLO and CC views of the right breast.,BIRADS Classification 0 - Incomplete,MAMMOGRAPHY INFORMATION:,1. A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2. Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3. These images were obtained with FDA-approved digital mammography equipment, and iCAD Second Look Software Version 7.2 was utilized.

radiology, ffdm, mammographic screening, tiny cluster of calcifications, bilateral mammogram, additional views, bilateral, mammogram, cluster, breasts, calcifications, mammography,

Carotid artery angiograms.

Radiology

Bilateral Carotid Angiography

PROCEDURE PERFORMED:,1. Selective ascending aortic arch angiogram.,2. Selective left common carotid artery angiogram.,3. Selective right common carotid artery angiogram.,4. Selective left subclavian artery angiogram.,5. Right iliac angio with runoff.,6. Bilateral cerebral angiograms were performed as well via right and left common carotid artery injections.,INDICATIONS FOR PROCEDURE: , TIA, aortic stenosis, postoperative procedure. Moderate carotid artery stenosis.,ESTIMATED BLOOD LOSS:, 400 ml.,SPECIMENS REMOVED:, Not applicable.,TECHNIQUE OF PROCEDURE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state. The right groin was prepped and draped in the usual sterile fashion. Lidocaine 2% was used for infiltration anesthesia. Using modified Seldinger technique, a 6-French sheath was placed into the right common femoral artery and vein without complication. Using injection through the side port of the sheath, a right iliac angiogram with runoff was performed. Following this, straight pigtail catheter was used to advance the aortic arch and aortic arch angiogram under digital subtraction was performed. Following this, selective engagement in left common carotid artery, right common carotid artery, and left subclavian artery angiograms were performed with a V-Tech catheter over an 0.035-inch wire.,ANGIOGRAPHIC FINDINGS:,1. Type 2 aortic arch.,2. Left subclavian artery was patent.,3 Left vertebral artery was patent.,4. Left internal carotid artery had a 40% to 50% lesion with ulceration, not treated and there was no cerebral cross over.,5. Right common carotid artery had a 60% to 70% lesion which was heavily calcified and was not treated with the summed left-to-right cross over flow.,6. Closure was with a 6-French Angio-Seal of the artery, and the venous sheath was sutured in.,PLAN:, Continue aspirin, Plavix, and Coumadin to an INR of 2 with a carotid duplex followup.

radiology, aortic arch angiogram, carotid artery angiogram, artery was patent, common carotid artery, arch angiogram, subclavian artery, aortic arch, carotid artery, carotid, angiography, artery, angiograms, subclavian, catheterization, aortic, angiogram,

Ultrasound BPP - Advanced maternal age and hypertension.

Radiology

Biophysical Profile - 1

HISTORY: , Advanced maternal age and hypertension.,FINDINGS:, There is a single live intrauterine pregnancy with a vertex lie, posterior placenta, and adequate amniotic fluid. The amniotic fluid index is 23.2 cm. Estimated gestational age based on prior ultrasound is 36 weeks 4 four days with an estimated date of delivery of 03/28/08. Based on fetal measurements obtained today, estimated fetal weight is 3249 plus or minus 396 g, 7 pounds 3 ounces plus or minus 14 ounces, which places the fetus in the 66th percentile for the estimated gestational age. Fetal heart motion at a rate of 156 beats per minute is documented. The cord Doppler ratio is normal at 2.2. The biophysical profile score, assessing fetal breathing movement, gross body movement, fetal tone, and qualitative amniotic fluid volume is 8/8.,IMPRESSION:,1. Single live intrauterine pregnancy in vertex presentation with an estimated gestational age of 36 weeks 4 days and established due date of 03/28/08.,2. Biophysical profile (BPP) score 8/8.

radiology, ultrasound, bpp, maternal age, intrauterine pregnancy, biophysical profile, amniotic fluid, gestational age, amniotic, gestational, fetal,

Diagnostic mammogram, full-field digital, ultrasound of the breast and mammotome core biopsy of the left breast.

Radiology

Breast Ultrasound & Biopsy

EXAM: ,Bilateral diagnostic mammogram, left breast ultrasound and biopsy.,HISTORY: , 30-year-old female presents for digital bilateral mammography secondary to a soft tissue lump palpated by the patient in the upper right shoulder. The patient has a family history of breast cancer within her mother at age 58. Patient denies personal history of breast cancer.,TECHNIQUE AND FINDINGS: ,Craniocaudal and mediolateral oblique projections of bilateral breasts were obtained on mm/dd/yy. An additional lateromedial projection of the right breast was obtained. The breasts demonstrate heterogeneously-dense fibroglandular tissue. Within the upper outer aspect of the left breast, there is evidence of a circumscribed density measuring approximately 1 cm x 0.7 cm in diameter. No additional dominant mass, areas of architectural distortion, or malignant-type calcifications are seen. Multiple additional benign-appearing calcifications are visualized bilaterally. Skin overlying both breasts is unremarkable.,Bilateral breast ultrasound was subsequently performed, which demonstrated an ovoid mass measuring approximately 0.5 x 0.5 x 0.4 cm in diameter located within the anteromedial aspect of the left shoulder. This mass demonstrates isoechoic echotexture to the adjacent muscle, with no evidence of internal color flow. This may represent benign fibrous tissue or a lipoma.,Additional ultrasonographic imaging of the left breast demonstrates a complex circumscribed solid and cystic lesion with hypervascular properties at the 2 o'clock position, measuring 0.7 x 0.7 x 0.8 cm in diameter. At this time, the lesion was determined to be amenable by ultrasound-guided core biopsy.,The risks and complications of the procedure were discussed with the patient for biopsy of the solid and cystic lesion of the 2 o'clock position of the left breast. Informed consent was obtained. The lesion was re-localized under ultrasound guidance. The left breast was prepped and draped in the usual sterile fashion. 2% lidocaine was administered locally for anesthesia. Additional lidocaine with epinephrine was administered around the distal aspect of the lesion. A small skin nick was made. Color Doppler surrounding the lesion demonstrates multiple vessels surrounding the lesion at all sides. The lateral to medial approach was performed with an 11-gauge Mammotome device. The device was advanced under ultrasound guidance, with the superior aspect of the lesion placed within the aperture. Two core biopsies were obtained. The third core biopsy demonstrated evidence of an expanding hypoechoic area surrounding the lesion, consistent with a rapidly-expanding hematoma. Arterial blood was visualized exiting the access site. A biopsy clip was attempted to be placed, however could not be performed secondary to the active hemorrhage. Therefore, the Mammotome was removed, and direct pressure over the access site and biopsy location was applied for approximately 20 minutes until hemostasis was achieved. Postprocedural imaging of the 2 o'clock position of the left breast demonstrates evidence of a hematoma measuring approximately 1.9 x 4.4 x 1.3 cm in diameter. The left breast was re-cleansed with a ChloraPrep, and a pressure bandage and ice packing were applied to the left breast. The patient was observed in the ultrasound department for the following 30 minutes without complaints. The patient was subsequently discharged with information and instructions on utilizing the ice bandage. The obtained specimens were sent to pathology for further analysis.,IMPRESSION:,1. A mixed solid and cystic lesion at the 2 o'clock position of the left breast was accessed under ultrasound guidance utilizing a Mammotome core biopsy instrument, and multiple core biopsies were obtained. Transient arterial hemorrhage was noted at the biopsy site, resulting in a localized 4 cm hematoma. Pressure was applied until hemostasis was achieved. The patient was monitored for approximately 30 minutes after the procedure, and was ultimately discharged in good condition. The core biopsies were submitted to pathology for further analysis.,2. Small isoechoic ovoid mass within the anteromedial aspect of the left shoulder does not demonstrate color flow, and likely represents fibrotic changes or a lipoma.,3. Suspicious mammographic findings. The circumscribed density measuring approximately 8 mm at the 2 o'clock position of the left breast was subsequently biopsied. Further pathologic analysis is pending.,BIRADS Classification 4 - Suspicious findings.,MAMMOGRAPHY INFORMATION:,1. A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2. Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3. These images were obtained with FDA-approved digital mammography equipment, and iCAD SecondLook Software Version 7.2 was utilized.

radiology, mammotome core biopsy, diagnostic mammogram, breast cancer, bilateral breasts, circumscribed density, ovoid mass, breast ultrasound, core biopsy, lesion, biopsy, breast, hematoma, mammotome, mammography, ultrasound,

BPP of Gravida 1, para 0 at 33 weeks 5 days by early dating. The patient is developing gestational diabetes.

Radiology

Biophysical Profile

CLINICAL HISTORY:, Gravida 1, para 0 at 33 weeks 5 days by early dating. The patient is developing gestational diabetes.,Transabdominal ultrasound examination demonstrated a single fetus and uterus in vertex presentation. The placenta was posterior in position. There was normal fetal breathing movement, gross body movement, and fetal tone, and the qualitative amniotic fluid volume was normal with an amniotic fluid index of 18.2 cm.,The following measurements were obtained: Biparietal diameter 8.54 cm, head circumference 30.96 cm, abdominal circumference 29.17 cm, and femoral length 6.58 cm. These values predict a fetal weight of 4 pounds 15 ounces plus or minus 12 ounces or at the 42nd percentile based on gestation.,CONCLUSION:, Normal biophysical profile (BPP) with a score of 8 out of possible 8. The fetus is size appropriate for gestation.

radiology, biophysical profile, gestational diabetes, amniotic fluid, bpp, gravida, para, diabetes, fetus, fetalNOTE

Brain CT and MRI - suprasellar mass (pituitary adenoma)

Radiology

Brain MRI - Pituitary Adenoma

CC:, Orthostatic lightheadedness.,HX:, This 76 y/o male complained of several months of generalized weakness and malaise, and a two week history of progressively worsening orthostatic dizziness. The dizziness worsened when moving into upright positions. In addition, he complained of intermittent throbbing holocranial headaches, which did not worsen with positional change, for the past several weeks. He had lost 40 pounds over the past year and denied any recent fever, SOB, cough, vomiting, diarrhea, hemoptysis, melena, hematochezia, bright red blood per rectum, polyuria, night sweats, visual changes, or syncopal episodes.,He had a 100+ pack-year history of tobacco use and continued to smoke 1 to 2 packs per day. He has a history of sinusitis.,EXAM:, BP 98/80 mmHg and pulse 64 BPM (supine); BP 70/palpable mmHG and pulse 84BPM (standing). RR 12, Afebrile. Appeared fatigued.,CN: unremarkable.,Motor and Sensory exam: unremarkable.,Coord: Slowed but otherwise unremarkable movements.,Reflexes: 2/2 and symmetric throughout all 4 extremities. Plantar responses were flexor, bilaterally.,The rest of the neurologic and general physical exam was unremarkable.,LAB:, Na 121 meq/L, K 4.2 meq/L, Cl 90 meq/L, CO2 20meq/L, BUN 12mg/DL, CR 1.0mg/DL, Glucose 99mg/DL, ESR 30mm/hr, CBC WNL with nl WBC differential, Urinalysis: SG 1.016 and otherwise WNL, TSH 2.8 IU/ML, FT4 0.9ng/DL, Urine Osmolality 246 MOSM/Kg (low), Urine Na 35 meq/L,,COURSE:, The patient was initially hydrated with IV normal saline and his orthostatic hypotension resolved, but returned within 24-48hrs. Further laboratory studies revealed: Aldosterone (serum)<2ng/DL (low), 30 minute Cortrosyn Stimulation test: pre 6.9ug/DL (borderline low), post 18.5ug/DL (normal stimulation rise), Prolactin 15.5ng/ML (no baseline given), FSH and LH were within normal limits for males. Testosterone 33ng/DL (wnl). Sinus XR series (done for history of headache) showed an abnormal sellar region with enlarged sella tursica and destruction of the posterior clinoids. There was also an abnormal calcification seen in the middle of the sellar region. A left maxillary sinus opacity with air-fluid level was seen. Goldman visual field testing was unremarkable. Brain CT and MRI revealed suprasellar mass most consistent with pituitary adenoma. He was treated with Fludrocortisone 0.05 mg BID and within 24hrs, despite discontinuation of IV fluids, remained hemodynamically stable and free of symptoms of orthostatic hypotension. His presumed pituitary adenoma continues to be managed with Fludrocortisone as of this writing (1/1997), though he has developed dementia felt secondary to cerebrovascular disease (stroke/TIA).

radiology, brain ct, goldman, mri, orthostatic, adenoma, generalized weakness, hypotension, lightheadedness, malaise, pituitary, sinus opacity, suprasellar mass, brain ct and mri, orthostatic hypotension, pituitary adenoma, brain, sinusitis, sellar,

Barium enema - history of encopresis and constipation.

Radiology

Barium Enema

EXAM: , Barium enema.,CLINICAL HISTORY: , A 4-year-old male with a history of encopresis and constipation.,TECHNIQUE: ,A single frontal scout radiograph of the abdomen was performed. A rectal tube was inserted in usual sterile fashion, and retrograde instillation of barium contrast was followed via spot fluoroscopic images. A post-evacuation overhead radiograph of the abdomen was performed.,FINDINGS:, The scout radiograph demonstrates a nonobstructive gastrointestinal pattern. There are no suspicious calcifications seen or evidence of gross free intraperitoneal air. The visualized lung bases and osseous structures are within normal limits.,The rectum and colon is of normal caliber throughout its course. There is no evidence of obstruction, as contrast is seen to flow without difficulty into the right colon and cecum. A small amount of contrast is seen to opacify small bowel loops on the post-evacuation image. There is also opacification of a normal-appearing appendix documented.,IMPRESSION: , Normal barium enema.

radiology, encopresis and constipation, scout radiograph, post evacuation, barium enema, encopresis, constipation, evacuation, colon, radiograph, contrast, enema, barium,

Arterial imaging of bilateral lower extremities.

Radiology

Arterial Imaging

INDICATIONS:, Peripheral vascular disease with claudication.,RIGHT:, ,1. Normal arterial imaging of right lower extremity.,2. Peak systolic velocity is normal.,3. Arterial waveform is triphasic.,4. Ankle brachial index is 0.96.,LEFT:,1. Normal arterial imaging of left lower extremity.,2. Peak systolic velocity is normal.,3. Arterial waveform is triphasic throughout except in posterior tibial artery where it is biphasic.,4. Ankle brachial index is 1.06.,IMPRESSION,:,Normal arterial imaging of both lower extremities.

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MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement.

Radiology

Alzheimer Disease

CC:, Memory difficulty.,HX: ,This 64 y/o RHM had had difficulty remembering names, phone numbers and events for 12 months prior to presentation, on 2/28/95. This had been called to his attention by the clerical staff at his parish--he was a Catholic priest. He had had no professional or social faux pas or mishaps due to his memory. He could not tell whether his problem was becoming worse, so he brought himself to the Neurology clinic on his own referral.,MEDS:, None.,PMH: ,1)appendectomy, 2)tonsillectomy, 3)childhood pneumonia, 4)allergy to sulfa drugs.,FHX:, Both parents experienced memory problems in their ninth decades, but not earlier. 5 siblings have had no memory trouble. There are no neurological illnesses in his family.,SHX:, Catholic priest. Denied Tobacco/ETOH/illicit drug use.,EXAM:, BP131/74, HR78, RR12, 36.9C, Wt. 77kg, Ht. 178cm.,MS: A&O to person, place and time. 29/30 on MMSE; 2/3 recall at 5 minutes. 2/10 word recall at 10 minutes. Unable to remember the name of the President (Clinton). 23words/60 sec on Category fluency testing (normal). Mild visual constructive deficit.,The rest of the neurologic exam was unremarkable and there were no extrapyramidal signs or primitive reflexes noted.,COURSE:, TSH 5.1, T4 7.9, RPR non-reactive. Neuropsychological evaluation, 3/6/95, revealed: 1)well preserved intellectual functioning and orientation, 2) significant deficits in verbal and visual memory, proper naming, category fluency and working memory, 3)performances which were below expectations on tests of speed of reading, visual scanning, visual construction and clock drawing, 4)limited insight into the scope and magnitude of cognitive dysfunction. The findings indicated multiple areas of cerebral dysfunction. With the exception of the patient's report of minimal occupational dysfunction ( which may reflect poor insight), the clinical picture is consistent with a progressive dementia syndrome such as Alzheimer's disease. MRI brain, 3/6/95, showed mild generalized atrophy, more severe in the occipital-parietal regions.,In 4/96, his performance on repeat neuropsychological evaluation was relatively stable. His verbal learning and delayed recognition were within normal limits, whereas delayed recall was "moderately severely" impaired. Immediate and delayed visual memory were slightly below expectations. Temporal orientation and expressive language skills were below expectation, especially in word retrieval. These findings were suggestive of particular, but not exclusive, involvement of the temporal lobes.,On 9/30/96, he was evaluated for a 5 minute spell of visual loss, OU. The episode occurred on Friday, 9/27/96, in the morning while sitting at his desk doing paperwork. He suddenly felt that his gaze was pulled toward a pile of letters; then a "curtain" came down over both visual fields, like "everything was in the shade." During the episode he felt fully alert and aware of his surroundings. He concurrently heard a "grating sound" in his head. After the episode, he made several phone calls, during which he reportedly sounded confused, and perseverated about opening a bank account. He then drove to visit his sister in Muscatine, Iowa, without accident. He was reportedly "normal" when he reached her house. He was able to perform Mass over the weekend without any difficulty. Neurologic examination, 9/30/96, was notable for: 1)category fluency score of 18items/60 sec. 2)VFFTC and EOM were intact. There was no RAPD, INO, loss of visual acuity. Glucose 178 (elevated), ESR ,Lipid profile, GS, CBC with differential, Carotid duplex scan, EKG, and EEG were all normal. MRI brain, 9/30/96, was unchanged from previous, 3/6/95.,On 1/3/97, he had a 30 second spell of lightheadedness without vertigo, but with balance difficulty, after picking up a box of books. The episode was felt due to orthostatic changes.,1/8/97 neuropsychological evaluation was stable and his MMSE score was 25/30 (with deficits in visual construction, orientation, and 2/3 recall at 1 minute). Category fluency score 23 items/60 sec. Neurologic exam was notable for graphesthesia in the left hand.,In 2/97, he had episodes of anxiety, marked fluctuations in job performance and resigned his pastoral position. His neurologic exam was unchanged. An FDG-PET scan on 2/14/97 revealed decreased uptake in the right posterior temporal-parietal and lateral occipital regions.

radiology, dementia, a&o to person, alzheimer's disease, alzheimer's type, mmse, mmse score, mri brain, memory difficulty, neuropsychological, balance difficulty, category fluency, faux pas, minimal occupational dysfunction, parieto-occipital, progressive dementia syndrome, visual acuity, visual loss, visual memory, pet scan, neuropsychological evaluation, alzheimer's, neurological, memory,

Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.

Radiology

Angiogram & StarClose Closure

EXAM: , Left heart cath, selective coronary angiogram, right common femoral angiogram, and StarClose closure of right common femoral artery.,REASON FOR EXAM: , Abnormal stress test and episode of shortness of breath.,PROCEDURE: , Right common femoral artery, 6-French sheath, JL4, JR4, and pigtail catheters were used.,FINDINGS:,1. Left main is a large-caliber vessel. It is angiographically free of disease,,2. LAD is a large-caliber vessel. It gives rise to two diagonals and septal perforator. It erupts around the apex. LAD shows an area of 60% to 70% stenosis probably in its mid portion. The lesion is a type A finishing before the takeoff of diagonal 1. The rest of the vessel is angiographically free of disease.,3. Diagonal 1 and diagonal 2 are angiographically free of disease.,4. Left circumflex is a small-to-moderate caliber vessel, gives rise to 1 OM. It is angiographically free of disease.,5. OM-1 is angiographically free of disease.,6. RCA is a large, dominant vessel, gives rise to conus, RV marginal, PDA and one PL. RCA has a tortuous course and it has a 30% to 40% stenosis in its proximal portion.,7. LVEDP is measured 40 mmHg.,8. No gradient between LV and aorta is noted.,Due to contrast concern due to renal function, no LV gram was performed.,Following this, right common femoral angiogram was performed followed by StarClose closure of the right common femoral artery.,IMPRESSION:,1. 60% to 70% mid left anterior descending stenosis.,2. Mild 30% to 40% stenosis of the proximal right coronary artery.,3. Status post StarClose closure of the right common femoral artery.,PLAN: ,Plan will be to perform elective PCI of the mid LAD.

radiology, heart cath, selective coronary angiogram, common femoral angiogram, abnormal stress test, common femoral artery, starclose closure, femoral artery, angiogram, angiographically, artery, femoral,

CT Brain - arachnoid cyst Arachnoid cyst diagnosed by CT brain.

Radiology

Arachnoid Cyst

CC:, Seizures.,HX: ,The patient was initially evaluated at UIHC at 7 years of age. He had been well until 7 months prior to evaluation when he started having spells which were described as "dizzy spells" lasting from several seconds to one minute in duration. They occurred quite infrequently and he was able to resume activity immediately following the episodes. The spell became more frequent and prolonged, and by the time of initial evaluation were occurring 2-3 times per day and lasting 2-3 minutes in duration. In addition, in the 3 months prior to evaluation, the right upper extremity would become tonic and flexed during the episodes, and he began to experience post ictal fatigue.,BIRTH HX:, 32 weeks gestation to a G4 mother and weighed 4#11oz. He was placed in an incubator for 3 weeks. He was jaundiced, but there was no report that he required treatment.,PMH: ,Single febrile convulsion lasting "3 hours" at age 2 years.,MEDS: ,none.,EXAM:, Appears healthy and in no acute distress. Unremarkable general and neurologic exam.,Impression: Psychomotor seizures.,Studies: Skull X-Rays were unremarkable.,EEG showed "minimal spike activity during hyperventilation, as well as random sharp delta activity over the left temporal area, in drowsiness and sleep. This record also showed moderate amplitude asymmetry ( left greater than right) over the frontal central and temporal areas, which is a peculiar finding.",COURSE:, The patient was initially treated with Phenobarbital; then Dilantin was added (early 1970's); then Depakene was added ( early 1980's) due to poor seizure control. An EEG on 8/22/66 showed "Left mid-temporal spike focus with surrounding slow abnormality, especially posterior to the anterior temporal areas (sparing the parasagittal region). In addition, the right lateral anterior hemisphere voltage is relatively depressed. ...this suggests two separate areas of cerebral pathology." He underwent his first HCT scan in Sioux City in 1981, and this revealed an right temporal arachnoid cyst. The patient had behavioral problems throughout elementary/junior high/high school. He underwent several neurosurgical evaluations at UIHC and Mayo Clinic and was told that surgery was unwarranted. He was placed on numerous antiepileptic medication combinations including Tegretol, Dilantin, Phenobarbital, Depakote, Acetazolamide, and Mysoline. Despite this he averaged 2-3 spells a month. He was last seen, 6/19/95, and was taking Dilantin and Tegretol. His typical spells were described as sudden in onset and without aura. He frequently becomes tonic or undergoes tonic-clonic movement and falls with associated loss of consciousness. He usually has rapid recovery and can return to work in 20 minutes. He works at a Turkey packing plant. Serial HCT scans showed growth in the arachnoid cyst until 1991, when growth arrest appeared to have occurred.

radiology, arachnoid cyst, hct scan, seizures, serial hct scans, dizzy spells, drowsiness, hyperventilation, loss of consciousness, moderate amplitude asymmetry, temporal area, tonic-clonic movement, phenobarbital, dilantin, cyst, temporal, arachnoid

Adenosine with nuclear scan as the patient unable to walk on a treadmill. Nondiagnostic adenosine stress test. Normal nuclear myocardial perfusion scan.

Radiology

Adenosine Nuclear Scan

INDICATION: , Chest pain.,TYPE OF TEST: , Adenosine with nuclear scan as the patient unable to walk on a treadmill.,INTERPRETATION:, Resting heart rate of 67, blood pressure of 129/86. EKG, normal sinus rhythm. Post-Lexiscan 0.4 mg, heart rate was 83, blood pressure 142/74. EKG remained the same. No symptoms were noted.,SUMMARY:,1. Nondiagnostic adenosine stress test.,2. Nuclear interpretation as below.,NUCLEAR INTERPRETATION:, Resting and stress images were obtained with 10.4, 33.1 mCi of tetrofosmin injected intravenously by standard protocol. Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect. Gated SPECT revealed normal wall motion, ejection fraction of 58%. End-diastolic volume of 74, end-systolic volume of 31.,IMPRESSION:,1. Normal nuclear myocardial perfusion scan.,2. Ejection fraction 58% by gated SPECT.

radiology, adenosine nuclear myocardial perfusion scan, chest pain, adenosine stress test, nuclear myocardial perfusion scan, gated spect, spect, mci, myocardial perfusion scan, myocardial, perfusion, adenosine, nuclear,

MRI - Intracerebral hemorrhage (very acute clinical changes occurred immediately prior to scan).

Radiology

Acute Intracerebral Hemorrhage

CC: ,Left hand numbness on presentation; then developed lethargy later that day.,HX: ,On the day of presentation, this 72 y/o RHM suddenly developed generalized weakness and lightheadedness, and could not rise from a chair. Four hours later he experienced sudden left hand numbness lasting two hours. There were no other associated symptoms except for the generalized weakness and lightheadedness. He denied vertigo.,He had been experiencing falling spells without associated LOC up to several times a month for the past year.,MEDS:, procardia SR, Lasix, Ecotrin, KCL, Digoxin, Colace, Coumadin.,PMH: ,1)8/92 evaluation for presyncope (Echocardiogram showed: AV fibrosis/calcification, AV stenosis/insufficiency, MV stenosis with annular calcification and regurgitation, moderate TR, Decreased LV systolic function, severe LAE. MRI brain: focal areas of increased T2 signal in the left cerebellum and in the brainstem probably representing microvascular ischemic disease. IVG (MUGA scan)revealed: global hypokinesis of the LV and biventricular dysfunction, RV ejection Fx 45% and LV ejection Fx 39%. He was subsequently placed on coumadin severe valvular heart disease), 2)HTN, 3)Rheumatic fever and heart disease, 4)COPD, 5)ETOH abuse, 6)colonic polyps, 7)CAD, 8)CHF, 9)Appendectomy, 10)Junctional tachycardia.,FHX:, stroke, bone cancer, dementia.,SHX: ,2ppd smoker since his teens; quit 2 years ago. 6-pack beer plus 2 drinks per day for many years: now claims he has been dry for 2 years. Denies illicit drug use.,EXAM: ,36.8C, 90BPM, BP138/56.,MS: Alert and oriented to person, place, but not date. Hypophonic and dysarthric speech. 2/3 recall. Followed commands.,CN: Left homonymous hemianopia and left CN7 nerve palsy (old).,MOTOR: full strength throughout.,SENSORY: unremarkable.,COORDINATION: dysmetric FNF and HKS movements (left worse than right).,STATION: RUE pronator drift and Romberg sign present.,GAIT: shuffling and bradykinetic.,REFLEXES: 1+/1+ to 2+/2+ and symmetric throughout. Plantar responses were flexor bilaterally.,HEENT: Neck supple and no carotid bruits.,CV: RRR with 3/6 SEM and diastolic murmurs throughout the precordium.,Lungs: bibasilar crackles.,LABS:, PT 19 (elevated) and PTT 46 (elevated).,COURSE:, Coumadin was discontinued on admission as he was felt to have suffered a right hemispheric stroke. The initial HCT revealed a subtle low density area in the right occipital lobe and no evidence of hemorrhage. He was scheduled to undergo an MRI Brain scan the same day, and shortly before the procedure became lethargic. By the time the scan was complete he was stuporous. MRI Scan then revealed a hypointense area of T1 signal in the right temporal lobe with a small foci of hyperintensity within it. The hyperintense area seen on T1 weighted images appeared hypointense on T2 weighted images. There was edema surrounding the lesion The findings were consistent with a hematoma. A CT scan performed 4 hours later confirmed a large hematoma with surrounding edema involving the right temporal/parietal/occipital lobes. The patient subsequently died.

MRI - Arteriovenous malformation with hemorrhage.

Radiology

AVM with Hemorrhage

CC:, Headache.,HX:, 63 y/o RHF first seen by Neurology on 9/14/71 for complaint of episodic vertigo. During that evaluation she described a several year history of "migraine" headaches. She experienced her first episode of vertigo in 1969. The vertigo (clockwise) typically began suddenly after lying down, and was not associated with nausea/vomiting/headache. The vertigo had not been consistently associated with positional change and could last hours to days.,On 3/15/71, after 5 day bout of vertigo, right ear ache, and difficulty ambulating (secondary to the vertigo) she sought medical attention and underwent an audiogram which reportedly showed a 20% decline in low tone acuity AD. She complained of associated tinnitus which she described as a "whistle." In addition, her symptoms appeared to worsen with changes in head position (i.e. looking up or down). The symptoms gradually resolved and she did well until 8/71 when she experienced a 19-day episode of vertigo, tinnitus and intermittent headaches. She was seen 9/14/71, in Neurology, and admitted for evaluation.,Her neurologic exam at that time was unremarkable except for prominent bilateral systolic carotid bruits. Cerebral angiogram revealed an inoperable 7 x 6cm AVM in the right parietal region. The AVM was primarily fed by the right MCA. Otolaryngologic evaluation concluded that she probably also suffered from Meniere's disease.,On 10/14/74 she underwent a 21 day admission for SAH secondary to right parietal AVM.,On 11/23/91 she was admitted for left sided weakness (LUE > LLE), headache, and transient visual change. Neurological exam confirmed left sided weakness, and dysesthesia of the LUE only. Brain CT confirmed a 3 x 4 cm left parietal hemorrhage. She underwent unsuccessful embolization. Neuroradiology had planned to do 3 separate embolizations, but during the first, via the left MCA, they were unable to cannulate many of the AVM vessels and abandoned the procedure. She recovered with residual left hemisensory loss.,In 12/92 she presented with an interventricular hemorrhage and was managed conservatively and refused any future neuroradiologic intervention.,In 1/93 she reconsidered neurointerventional procedure and was scheduled for evaluation at the Barrows Neurological Institute in Phoenix, AZ.

radiology, arteriovenous malformation, avm, brain ct, cerebral angiogram, headache, neurology, audiogram, carotid bruits, difficulty ambulating, hemorrhage, interventricular hemorrhage, migraine, tinnitus, vertigo, visual change, weakness, episode of vertigo, evaluation,

MRI - Right temporal lobe astrocytoma.

Radiology

Astrocytoma

CC: ,Episodic confusion.,HX: ,This 65 y/o RHM reportedly suffered a stroke on 1/17/92. He presented locally at that time with complaint of episodic confusion and memory loss lasting several minutes per episode. The "stroke" was reportedly verified on MRI scan dated 1/17/92. He was subsequently placed on ASA and DPH. He admitted that there had been short periods (1-2 days duration) since then, during which he had forgotten to take his DPH. However, even when he had been taking his DPH regularly, he continued to experience the spells mentioned above. He denied any associated tonic/clonic movement, incontinence, tongue-biting, HA, visual change, SOB, palpitation, weakness or numbness. The episodes of confusion and memory loss last 1-2 minutes in duration, and have been occurring 2-3 times per week.,PMH:, Bilateral Hearing Loss of unknown etiology, S/P bilateral ear surgery many years ago.,MEDS:, DPH and ASA,SHX/FHX:, 2-4 Beers/day. 1-2 packs of cigarettes per day.,EXAM:, BP 111/68, P 68BPM, 36.8C. Alert and Oriented to person, place and time, 30/30 on mini-mental status test, Speech fluent and without dysarthria. CN: Left superior quandranopia only. Motor: 5/5 strength throughout. Sensory: unremarkable except for mild decreased vibration sense in feet. Coordination: unremarkable. Gait and station testing were unremarkable. He was able to tandem walk without difficulty. Reflexes: 2+ and symmetric throughout. Flexor plantar responses bilaterally.,LAB:, Gen Screen, CBC, PT, PTT all WNL. DPH 4.6mcg/ml.,Review of outside MRI Brain done 1/17/92 revealed decreased T1 and increased T2 signal in the Right temporal lobe involving the uncus and adjacent hippocampus. The area did not enhance with gadolinium contrast.,CXR:, 8/31/92: 5 x 6 mm spiculated opacity in apex right lung.,EEG:, 8/24/92: normal awake and asleep,MRI Brain with/without contrast: 8/31/92: Decreased T1 and increased T2 signal in the right temporal lobe. The lesion increased in size and enhances more greatly when compared to the 1/17/92 MRI exam. There is also edema surrounding the affected area and associated mass effect.,NEUROPSYCHOLOGICAL TESTING:, Low-average digit symbol substitution, mildly impaired verbal learning, and severely defective delayed recall. There was relative preservation of other cognitive functions. The findings were consistent with left mesiotemporal dysfunction.,COURSE: ,Patient underwent right temporal lobectomy on 9/16/92 following initial treatment with Decadron. Pathologic analysis was consistent with a Grade 2 astrocytoma. GFAP staining positive. Following surgery he underwent 5040 cGy radiation therapy in 28 fractions to the tumor bed.

radiology, confusion, gfap, gfap staining, mri scan, astrocytoma, hippocampus, memory loss, palpitation, signal, stroke, temporal lobe, tongue-biting, tonic/clonic movement, weakness, increased t signal, mri brain, mri, temporal,

2-D Echocardiogram

Radiology

2-D Echocardiogram - 2

1. The left ventricular cavity size and wall thickness appear normal. The wall motion and left ventricular systolic function appears hyperdynamic with estimated ejection fraction of 70% to 75%. There is near-cavity obliteration seen. There also appears to be increased left ventricular outflow tract gradient at the mid cavity level consistent with hyperdynamic left ventricular systolic function. There is abnormal left ventricular relaxation pattern seen as well as elevated left atrial pressures seen by Doppler examination.,2. The left atrium appears mildly dilated.,3. The right atrium and right ventricle appear normal.,4. The aortic root appears normal.,5. The aortic valve appears calcified with mild aortic valve stenosis, calculated aortic valve area is 1.3 cm square with a maximum instantaneous gradient of 34 and a mean gradient of 19 mm.,6. There is mitral annular calcification extending to leaflets and supportive structures with thickening of mitral valve leaflets with mild mitral regurgitation.,7. The tricuspid valve appears normal with trace tricuspid regurgitation with moderate pulmonary artery hypertension. Estimated pulmonary artery systolic pressure is 49 mmHg. Estimated right atrial pressure of 10 mmHg.,8. The pulmonary valve appears normal with trace pulmonary insufficiency.,9. There is no pericardial effusion or intracardiac mass seen.,10. There is a color Doppler suggestive of a patent foramen ovale with lipomatous hypertrophy of the interatrial septum.,11. The study was somewhat technically limited and hence subtle abnormalities could be missed from the study.,

radiology, 2-d, doppler, echocardiogram, annular, aortic root, aortic valve, atrial, atrium, calcification, cavity, ejection fraction, mitral, obliteration, outflow, regurgitation, relaxation pattern, stenosis, systolic function, tricuspid, valve, ventricular, ventricular cavity, wall motion, pulmonary artery

3-Dimensional Simulation. This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures.

Radiology

3-Dimensional Simulation

3-DIMENSIONAL SIMULATION,This patient is undergoing 3-dimensionally planned radiation therapy in order to adequately target structures at risk while diminishing the degree of exposure to uninvolved adjacent normal structures. This optimizes the chance of controlling tumor while diminishing the acute and long-term side effects. With conformal 3-dimensional simulation, there is extended physician, therapist, and dosimetrist effort and time expended. The patient is initially taken into a conventional simulator room where appropriate markers are placed and the patient is positioned and immobilized. Preliminary filed sizes and arrangements, including gantry angles, collimator angles, and number of fields are conceived. Radiographs are taken and these films are approved by the physician. Appropriate marks are placed on the patient's skin or on the immobilization device.,The patient is transferred to the diagnostic facility and placed on a flat CT scan table. Scans are performed through the targeted area. The scans are evaluated by the radiation oncologist and the tumor volume, target volume, and critical structures are outlined on the CT images. The dosimetrist then evaluates the slices in the treatment-planning computer with appropriately marked structures. This volume is reconstructed in a virtual 3-dimensional space utilizing the beam's-eye view features. Appropriate blocks are designed. Multiplane computerized dosimetry is performed throughout the volume. Field arrangements and blocking are modified as necessary to provide coverage of the target volume while minimizing dose to normal structures.,Once appropriate beam parameters and isodose distributions have been confirmed on the computer scan, the individual slices are then reviewed by the physician. The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician. Once these are approved, physical blocks or multi-leaf collimator equivalents will be devised. If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where computer designed fields are re-simulated.,In view of the extensive effort and time expenditure required, this procedure justifies the special procedure code, 77470.

radiology, 3-dimensional simulation, planned radiation therapy, ct scan, ct images, beam's eye view, field arrangements, normal structures, therapy, dimensional, simulationNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

2-D Echocardiogram

Radiology

2-D Echocardiogram - 3

2-D ECHOCARDIOGRAM,Multiple views of the heart and great vessels reveal normal intracardiac and great vessel relationships. Cardiac function is normal. There is no significant chamber enlargement or hypertrophy. There is no pericardial effusion or vegetations seen. Doppler interrogation, including color flow imaging, reveals systemic venous return to the right atrium with normal tricuspid inflow. Pulmonary outflow is normal at the valve. Pulmonary venous return is to the left atrium. The interatrial septum is intact. Mitral inflow and ascending aorta flow are normal. The aortic valve is trileaflet. The coronary arteries appear to be normal in their origins. The aortic arch is left-sided and patent with normal descending aorta pulsatility.

radiology, 2-d echocardiogram, cardiac function, doppler, echocardiogram, multiple views, aortic valve, coronary arteries, descending aorta, great vessels, heart, hypertrophy, interatrial septum, intracardiac, pericardial effusion, tricuspid, vegetation, venous, pulmonaryNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

Echocardiogram and Doppler

Radiology

2-D Echocardiogram - 4

DESCRIPTION:,1. Normal cardiac chambers size.,2. Normal left ventricular size.,3. Normal LV systolic function. Ejection fraction estimated around 60%.,4. Aortic valve seen with good motion.,5. Mitral valve seen with good motion.,6. Tricuspid valve seen with good motion.,7. No pericardial effusion or intracardiac masses.,DOPPLER:,1. Trace mitral regurgitation.,2. Trace tricuspid regurgitation.,IMPRESSION:,1. Normal LV systolic function.,2. Ejection fraction estimated around 60%.,

radiology, ejection fraction, lv systolic function, cardiac chambers, regurgitation, tricuspid, normal lv systolic function, normal lv systolic, ejection fraction estimated, normal lv, lv systolic, systolic function, function ejection, echocardiogram, doppler, lv, systolic, ejection, mitral, valve

A 6-year-old male with attention deficit hyperactivity disorder, doing fairly well with the Adderall.

Psychiatry / Psychology

Recheck of ADHD Meds

SUBJECTIVE:, This is a 6-year-old male who comes in rechecking his ADHD medicines. We placed him on Adderall, first time he has been on a stimulant medication last month. Mother said the next day, he had a wonderful improvement, and he has been doing very well with the medicine. She has two concerns. It seems like first thing in the morning after he takes the medicine and it seems like it takes a while for the medicine to kick in. It wears off about 2 and they have problems in the evening with him. He was initially having difficulty with his appetite but that seems to be coming back but it is more the problems early in the morning after he takes this medicine than in the afternoon when the thing wears off. His teachers have seen a dramatic improvement and she did miss a dose this past weekend and said he was just horrible. The patient even commented that he thought he needed his medication.,PAST HISTORY:, Reviewed from appointment on 08/16/2004.,CURRENT MEDICATIONS:, He is on Adderall XR 10 mg once daily.,ALLERGIES: , To medicines are none.,FAMILY AND SOCIAL HISTORY:, Reviewed from appointment on 08/16/2004.,REVIEW OF SYSTEMS:, He has been having problems as mentioned in the morning and later in the afternoon but he has been eating well, sleeping okay. Review of systems is otherwise negative.,OBJECTIVE:, Weight is 46.5 pounds, which is down just a little bit from his appointment last month. He was 49 pounds, but otherwise, fairly well controlled, not all that active in the exam room. Physical exam itself was deferred today because he has otherwise been very healthy.,ASSESSMENT:, At this point is attention deficit hyperactivity disorder, doing fairly well with the Adderall.,PLAN:, Discussed with mother two options. Switch him to the Ritalin LA, which I think has better release of the medicine early in the morning or to increase his Adderall dose. As far as the afternoon, if she really wanted him to be on the medication, we will do a small dose of the Adderall, which she would prefer. So I have decided at this point to increase him to the Adderall XR 15 mg in the morning and then Adderall 5 mg in the afternoon. Mother is to watch his diet. We would like to recheck his weight if he is doing very well, in two months. But if there are any problems, especially in the morning then we would do the Ritalin LA. Mother understands and will call if there are problems. Approximately 25 minutes spent with patient, all in discussion.

psychiatry / psychology, adhd, attention deficit hyperactivity disorder, adderall xr, recheck, medicines, adderall,

2-D M-Mode. Doppler.

Radiology

2-D Echocardiogram - 1

2-D M-MODE: , ,1. Left atrial enlargement with left atrial diameter of 4.7 cm.,2. Normal size right and left ventricle.,3. Normal LV systolic function with left ventricular ejection fraction of 51%.,4. Normal LV diastolic function.,5. No pericardial effusion.,6. Normal morphology of aortic valve, mitral valve, tricuspid valve, and pulmonary valve.,7. PA systolic pressure is 36 mmHg.,DOPPLER: , ,1. Mild mitral and tricuspid regurgitation.,2. Trace aortic and pulmonary regurgitation.

radiology, 2-d m-mode, doppler, aortic valve, atrial enlargement, diastolic function, ejection fraction, mitral, mitral valve, pericardial effusion, pulmonary valve, regurgitation, systolic function, tricuspid, tricuspid valve, normal lv

Comprehensive Clinical Psychological Evaluation as part of a Disability Determination action.

Psychiatry / Psychology

Psychological Evaluation

COMPREHENSIVE CLINICAL PSYCHOLOGICAL EVALUATION,CURRENT MEDICATIONS:, Nexium 4 mg 4 times per day, Propanolol 10 mg 4 times a day, Spironolactone 100 mg 3 times per day, Lactulose 60 cc's 3 times a day.,GENERAL OBSERVATIONS: ,Mr. Abc, a 54-year-old black married male who was referred for a Comprehensive Clinical Psychological Evaluation as part of a Disability Determination action. Mr. Abc arrived five minutes late for his scheduled appointment. He was accompanied to the office by his sister-in-law who drove him to the appt. Mr. Abc currently does not receive Disability benefits. This is the first time he has filed for Disability. The Authorization form listed Mr. Abc's current complaints as "cirrhosis of the liver and mental issues." Mr. Abc was well groomed and wore casual attire. He looked older than his stated age. The whites of his eyes were very jaundiced. His posture was slightly stooped and his gait was slow. He was winded after walking up the stairs. Psychomotor activity was retarded. Mr. Abc was cooperative throughout the interview. Although he appeared to be answering most questions to the best of his ability, he appeared to be minimizing his emotional distress. ,PRESENT ILLNESS: , Most information was provided by Mr. Abc who appeared to be a fairly reliable source. His information was supplemented by review of his medical records. Mr. Abc has applied for Federal Disability benefits believing that he qualifies based on his cirrhosis of the liver and his cognitive dysfunction. Mr. Abc was diagnosed with cirrhosis in 1991. His condition has worsened to the point that he is experiencing liver failure and is awaiting a liver transplant. He stated that his main symptom is extreme fatigue. He has no energy and is unable to engage in many activities. Over the past year he was admitted to the hospital four times for confusion and bizarre behavior. He stated that his sister-in-law and his wife told him that he had become violent and he fought with the Sherriff who was trying to take him to the hospital. He has no memory of this. Mr. Abc stated that he was hospitalized one time. Actually he had begun having problems with confusion in July of 2004 and he has been treated four times since that time. According to his medical records, he was found wandering outside of his home. He was apparently delusional believing that a tree branch was a doorknob. Mr. Abc also suffers from edema and swelling in his legs and his feet. Mr. Abc attempted to return to work and found that he was unable to do his job due to the necessity of walking one-quarter mile from the front to the back of the plant. He was unable to walk very far without becoming fatigued. He had instances where he had passed out after becoming faint. He had trouble at work sitting for very long because his feet swelled. He was unable to lift the required 10 pounds of medication boxes. When he found himself unable to do his regular job, he tried another job at the same plant but was unable to do that job. He also became confused easily at work. His doctor advised him to quit and then he did so in March of this year. In addition to his cognitive symptoms, Mr. Abc has had some disturbance in mood as well. He related that he feels very sad since he lost his job. A lot of his self-esteem came from working. He worries about financial problems. His sleep has been disturbed. He sleeps four to five hours a night with trouble falling asleep and frequent awakening in the middle of the night. His appetite is fair. ,PERSONAL, FAMILY AND SOCIAL HISTORY:, Mr. Abc completed the 11th grade. He went on to get his GED in 1971. He stated that he has never failed a grade and he has no history of a learning disability. He received no special education services. His grades were Bs and Cs. He stated that he was suspended from school one time for fighting but got along well in general. Mr. Abc is currently unemployed. His last job was at Baxter Health Care where he worked for four years. It was his longest place of employment. He quit in March of 2005 because of fatigue and inability to perform the necessary job duties. He denies that he was ever fired from a job and he reported good work relationships. Mr. Abc has been married for two years. He has no prior marriages. He has one daughter age 13. He currently lives with his wife. Has been at his current address for four years. ,HISTORY OF OTHER PERTINENT MEDICAL EVENTS: , Mr. Abc has cirrhosis of the liver, hepatitis C, hepatic encephalopathy, and gastroesophageal reflux disease, and hypertension. Surgeries include a cardiac catheterization in 2001, a liver biopsy in 2003. Over the past year he has been hospitalized four times due to confusion and bizarre behaviors stemming from his liver failure. ,DAILY ACTIVITIES AND FUNCTIONING: ,Mr. Abc stated that he tries to do things but he has been severely restricted due to his extreme fatigue. He enjoys reading and does it regularly. He tries to help his wife with the household chores as he can. He has washed dishes, cooked, mopped, dusted, vacuumed and has done laundry occasionally over the past month but not as much as he used to. He stated that he used to mow the yard and do yard work but he can no longer do it because of his extreme fatigue. He has given up driving all together and he no longer goes out alone. He spends most days at home. He enjoys going to church and he prays daily. ,MENTAL HEALTH HISTORY: , Mr. Abc has never been diagnosed or treated for a mental health disorder. He denied any history of mental health problems in his family. He stated that he was evaluated one time earlier this year by a psychiatrist to determine his suitability for a liver transplant. He was approved and he is now on the waiting list to receive a liver. ,SUBSTANCE USE HISTORY: ,Mr. Abc has a history of substance use beginning in his teenage years. He has used alcohol, marijuana and cocaine. He stated that he only used the marijuana and cocaine a few times when he was young but he continued using alcohol until recently. His alcohol use became problematic and he was arrested for DWI three times. He attended AA and the DART program. Mr. Abc stated that he has been clean for eight years and five months.

Psychosocial Evaluation of patient before kidney transplant.

Psychiatry / Psychology

Psychosocial Eval for Kidney Transplant

HISTORY OF PRESENT ILLNESS:, In 2002, the patient had a blood test during her routine screening, which revealed anemia and an elevated creatinine. Two weeks later she saw a nephrologist at ABCDE were she worked at that time. An ultrasound revealed that she had Parenchymal disease in which tissue around the kidney is diseased. No particular treatment was advised. She was laid off 6 months later. In 2004, she began working at The ABCD Hospital and began seeing Dr. A. She was put on Procrit, but could not keep the stringent appointment scheduled for the injection because of her work. She began seeing Dr. B and was put on Procrit and Renagel. She was advised to go on dialysis, but she felt she did not have enough information to such a drastic step. She saw an endocrinologist for some thyroid problem and her blood work showed that her creatinine was now at 7. She was referred to Dr. Xyz who found after a parathyroid scan that she may have an adenoma. Her creatinine is now 7.4.,TREATMENT AND IMPACT OF DISEASE:, She is on several medications. She is not on a renal diet yet. Her energy is good and she is still working full time.,TRANSPLANT FIRST MENTIONED AS TREATMENT OPTION: , She has wanted to transplant ever since dialysis was first mentioned.,EMOTIONAL REACTION TO DIAGNOSIS AND TREATMENT COURSE:, She is frustrated by the lack of information about what exactly has caused her renal failure and has had a real feeling of helplessness in her efforts to pursue this understanding.,OTHER SIGNIFICANT MEDICAL HISTORY/SURGERIES:, She had a Bartholin cyst removed in 2002.,PSYCHIATRIC HISTORY:, None.,COPING STRATEGIES:, She used to exercise vigorously, but has stopped at this time. She enjoys watching movies with her children.,COMPLIANCE:, She feels she watches her diet and medication regimen very closely. She said she communicates daily with Dr. Xyz,PAST AND PRESENT SMOKING:, She began smoking 2 cigarettes a day when she was 22, but stopped after a year.,PAST AND PRESENT ALCOHOL USE:, None.,PAST AND PRESENT DRUG USE:, None.,LEGAL ISSUES:, None.,TATTOOS:, None.,MARITAL STATUS: LENGTH OF THE TIME MARRIED:, She has been married for 25 years.,AGE AND HEALTH OF SPOUSE:, Xyz is 62 and in good health.,CHILDREN:, Four, all are in good health.,FATHER:, Father died in 2001, at the age of 62 of cardiac cancer.,MOTHER:, Dolorous Massey is 63 and in good health.,SIBLINGS:, Ben Doherty died in 1984 at the age of 26 in an automobile accident; Steven Doherty is 46 and is in good health.,PREVIOUS MARRIAGES AND DURATION OF EACH:, None.,PERSONS LIVING IN HOUSEHOLD:, Six.,RELATIONSHIP WITH FAMILY MEMBERS/IDENTIFIED PRIMARY SUPPORT SYSTEM:, She is close to her brother.,HIGHEST LEVEL OF EDUCATION:, She has 2 years of college at ABCD College. She is a licensed LVN.,MILITARY SERVICE:, None.

Psychological Testing for ADHD

Psychiatry / Psychology

Psychological Testing

REFERRAL QUESTIONS:, Mr. Abcd was referred for psychological assessment by his primary medical provider, to help clarify his diagnosis, especially with respect to Attention Deficit Hyperactivity Disorder, a depression, or a Bipolar Spectrum Disorder. The information will be used for treatment planning.,BACKGROUND INFORMATION:, Mr. Abcd is a 33-year-old married man who lives with his wife and three children. He has been married since 1995 and lost a son to SIDS over seven years ago. He served in the army for two years, and did attend some college at UAA. He still wants to get a degree in engineering. Mr. Abcd indicated that he did use THC at the time of his initial intake with me in January 2006, but there are no other substance abuse issues as an adult so far as I am aware. He has had multiple stressors, including a bankruptcy in 2000, as well as his wife's significant health problems. He also reported having herniated discs incurred in an injury over a year ago. He has received counseling in the past, and did try both Lexapro and Wellbutrin, which he stopped taking in October 2005. He indicated these medications tended to decrease libido and flatten all of his emotions. He indicated that he thought he might have Attention Deficit Hyperactivity Disorder, but that this had not been formally evaluated or treated. There is no reported bipolar illness in his immediate family, but there is some depression. A recent stressor involved OCS involvement, apparently because his infant child tested positive for THC. So far as I am aware, this case is closed at this time. ,BEHAVIORAL OBSERVATIONS:, Mr. Abcd arrived on time for his testing session dressed casually and with good hygiene and grooming. Mood is reported to be generally okay, though with some stress. Affect was bright and appropriate to the situation. Speech was a little pressured, but was of normal content and was at all times coherent and goal directed. He was a very pleasant and cooperative testing subject, who appeared to give a good effort on the tasks requested of him. The results appear to provide a useful sample of his current attitudes, opinions, and functional levels in the areas assessed.,ASSESSMENT RESULTS:, Mr. Abcd's responses to a brief self-report instrument given to him by Dr. Starks was suggestive of symptoms that could be consistent with Attention Deficit Hyperactivity Disorder. I therefore had him complete the Conners CPT-II, which showed good performance and no indications of attention problems. The Confidence Index associated with ADHD was over 58 percent that no clinical attention problems are present. While a diagnosis of Attention Deficit Hyperactivity Disorder should not unequivocally be ruled out based on the results of this test, there is nothing in the CPT-II measures indicating attention problems, and that diagnosis appears to be unlikely. The MMPI-2 profile is a technically valid and interpretable one. The Modified Welsh Code is as follows: 49+86-231/570: F'+-/:LK#. The high F scale may reflect some moodiness, restlessness, dissatisfaction, and changeableness in his typical behavior. The Basic Clinical Profile is similar to persons who tend to get into trouble for violating social norms and rules. Such persons are more likely to experience conflicts with authority. They also are prone to impulsivity, self-indulgence, problems with delay of gratification, exercise problematic judgment, and often have low frustration tolerance. Those with similar scores tend to be moody, irritable, extraverted, and often do not trust others very much. Mr. Abcd may tend to keep others at a distance, yet feel rather insecure and dependent. A bipolar diagnosis is a possibility, and an antisocial personality disorder cannot be entirely ruled out either, though I am less confident that that is correct. The MMPI-2 Content Scale scores indicate some mild depression and family stressors, and the Supplementary Scales has a single clinical elevation on Addiction Admission, which is entirely consistent with his interview data. Posttraumatic stress scales are not elevated at a clear clinical level on the MMPI-2.,SUMMARY AND RECOMMENDATIONS:,

psychiatry / psychology, psychological testing, adhd, attention deficit hyperactivity disorder, bipolar spectrum disorder, cpt-ii, mmpi-2, posttraumatic stress disorder, welsh code, depression, psychological assessment, personality disorder, family stressors, posttraumatic stress, disorder, attention, psychological,

Psychosocial donor evaluation. Following questions are mostly involved in a psychosocial donor evaluation.

Psychiatry / Psychology

Psychosocial Eval - Donor - 1

PSYCHOSOCIAL DONOR EVALUATION,Following questions are mostly involved in a psychosocial donor evaluation:,A. DECISION TO DONATE,What is your understanding of the recipient's illness and why a transplant is needed?,When and how did the subject of donation arise?,What was the recipient's reaction to your offer?,What are your family's feelings about your being a donor?,How did you arrive at the decision to be a donor?,How would your family and friends react if you decided not to be a donor?,How would you feel if you cannot be the donor for any reason?,What is your relationship to the recipient?,How will your relationship with the recipient change if you donate your kidney?,Will your being a donor affect any other relationships in your life?,B. TRANSPLANT ISSUES,Do you have an understanding of the process of transplant?,Do you understand the risk of rejection of your kidney by the recipient at some point after transplant?,Have you thought about how you might feel if the kidney/liver is rejected?,Do you have any doubts or concerns about donating?,Do you understand that there will be pain and soreness after the transplant?,What are your expectations about your recuperation?,Do you need to speak further to any of the transplant team members?,C. MEDICAL HISTORY,What previous illnesses or surgeries have you had? ,Are you currently on any medications?,Have you ever spoken with a counselor, a therapist or a psychiatrist?,Do you smoke?,In a typical week, how many drinks do you consume? What drink do you prefer?,What kinds of recreational drugs have you tried? Have you used any recently?,D. FAMILY AND SUPPORT SYSTEM,With whom do you live? ,If you are in a relationship:,- length of the relationship: ,- name of spouse/partner: ,- age and health of spouse/partner: ,- children: ,E. POST-SURGICAL PLANS,With whom will you stay after discharge? ,What is your current occupation: ,Do you have the support of your employer?

Psychosocial evaluation of kidney donor. Questions - Answers

Psychiatry / Psychology

Psychosocial Eval - Donor

DONOR'S PERCEPTION OF RECIPIENT'S ILLNESS:,What is your understanding of the recipient's illness and why they need a kidney - "This kidney is for my mother who is on dialysis and my mother has been suffering long enough, and I want to relieve the suffering so that she is able to have a kidney transplant.",When and how did subject of donation arise - "My mom and I talked about it together as a family.",RECIPIENT'S REACTION TO OFFER:,What was the recipient's reaction to your offer: "I would rather not go there. Well, since we were talking, "I will tell you that my mother really does not understand. She is very worried. She is very afraid that something might happen to me, and she would feel terrible if I had any problems as a result of being a donor. I don't think my mom really understands, and I know that she really needs a kidney. I think she is coming around to accepting.",FAMILY'S REACTION TO OFFER:,What are your family feelings about your being a donor - "Well, my children are fine and my husband is very supportive.",CANDIDATE'S MOTIVATION TO DONATE:,How did you arrive at the decision to be a donor - "My brothers and sisters and I got together and we all decided since my schedule was the most flexible and I was used to traveling, I seem like to the best candidate.",How would your family and friends react if you decided not to be a donor - "I don't think that is going to happen.",CANDIDATE'S MOTIVATION TO DONATE:,How would you feel if you cannot be the donor for any reason - "I would feel very upset because I know that this is the best for my mother, and I want to do this very badly for my mother. I am hoping my headache is away and my blood pressure comes down so that I will start to feel better during this workup.",CANDIDATE'S DESCRIPTION OF RELATIONSHIP WITH RECIPIENT:,What is your relationship to the recipient - "That is my mother.",How your relationship with the recipient change if you donate your kidney - "I am not sure that it will change at all. I know that I will feel better about doing this for my mother, because my mother is always sacrificing and helping others.",With your being a donor affect any other relationships in your life - No, I don't think it will have that much of an impact. I am away from my children and my husband a lot because of I travel with my job. So I don't think being donor will really have that dramatic affect.,Do you have an understanding of the process of transplant - "Yes, I have a very good understanding of the transplant process. I work as a contract nursing all over the country. I am able to see patients doing different things in different places and so I feel like I have a very realistic perceptive on the process.",CANDIDATE'S UNDERSTANDING OF TRANSPLANTATION AND RISK OF REJECTION:,Do you understand the risk of rejection of your kidney by the recipient - "Yes, I do understand all the risks. I have had a long conversation with the coordinator and we have talked about these things.",Have you thought about how you might feel if the kidney is rejected - "I guess, I am just sure that I won't be rejected and I am just sure that everything will be fine. It is a part of the way I am managing my stress about this.",Do you have any doubts or concerns about donating - "No, I don't have any doubts or any concerns right now. I just wish this headache would go away.,Do you understand that there will be pain after the transplant - "Of course, I do.",What are your expectations about your recuperation - "I am planning on staying with my mom for three months in the Houston area after the transplant. We live outside of Tampa, Florida; so this will be an adventure for both of us.",Do you need to speak further to any of the transplant team members - "No, I have had a long talk with ABC. I feel pretty comfortable about my conversation with her as well as my conversation with the Nephrologist.,MEDICAL HISTORY:,What previous illnesses or surgeries have you had - "I had a one cesarian section, and I also suffered from asthma as a child. I am in otherwise good health.",Are you currently on any medication - "Yes, I am on Folic acid.",PSYCHIATRIC HISTORY:,Have you ever spoken with a counselor, therapist, or psychiatrist - "No, I have not. I have a good supportive system and a lot of people that I can talk to when I need to.",ALCOHOL, NICOTINE, DRUG USE:,Do you smoke - "No.",Any typical drinks you prefer - "I am a nondrinker.",What kinds of recreational drugs have you tried? Have you used any recently - "None.",FAMILY AND SUPPORT SYSTEMS:,MARITAL STATUS: LENGTH OF TIME MARRIED: "I live with my family, my husband, and my two children with good relationship. We have been married for 29 years.",NAME OF SPOUSE/PARTNER: "His name is Xyz.",AGE AND HEALTH OF SPOUSE/PARTNER: He is in his 40s and he is healthy and lives outside of Tampo with our 6-year-old daughter. Our elder child has just finished college.",CHILDREN: I have two children; ages 28 and also 6.,POST-SURGICAL HOUSING PLAN:,With whom will you stay after discharge - "I will stay with a friend. He lives in the Houston area. I am staying with that friend right now, while I am here for my workup.",CURRENT OCCUPATION:,What is your current occupation - "I currently work on a contract basis as a nurse. I go on assignments all over the country, and I work until the contract is over. This allowed me to be flexible and the best candidate for donation to mom.",Do you have the support of your employer - "Absolutely.",PAID OFF TIME:,Paid leave - "None.",Disability coverage: "None.",SUPPORTIVE ENVIRONMENT:, "Yes."

Normal left ventricle, moderate biatrial enlargement, and mild tricuspid regurgitation, but only mild increase in right heart pressures.

Radiology

2-D Doppler

2-D STUDY,1. Mild aortic stenosis, widely calcified, minimally restricted.,2. Mild left ventricular hypertrophy but normal systolic function.,3. Moderate biatrial enlargement.,4. Normal right ventricle.,5. Normal appearance of the tricuspid and mitral valves.,6. Normal left ventricle and left ventricular systolic function.,DOPPLER,1. There is 1 to 2+ aortic regurgitation easily seen, but no aortic stenosis.,2. Mild tricuspid regurgitation with only mild increase in right heart pressures, 30-35 mmHg maximum.,SUMMARY,1. Normal left ventricle.,2. Moderate biatrial enlargement.,3. Mild tricuspid regurgitation, but only mild increase in right heart pressures.

radiology, 2-d study, doppler, tricuspid regurgitation, heart pressures, stenosis, ventricular, heart, ventricle, tricuspid, regurgitation,

She was admitted following an overdose of citalopram and warfarin. The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage.

Psychiatry / Psychology

Psychiatric Consult - 2

HISTORY OF PRESENT ILLNESS:, This is a 41-year-old registered nurse (R.N.). She was admitted following an overdose of citalopram and warfarin. The patient has had increasing depression and has been under stress as a result of dissolution of her second marriage. She notes starting in January, her husband of five years seemed to be quite withdrawn. It turned out, he was having an affair with one of her best friends and he subsequently moved in with this woman. The patient is distressed, as over the five years of their marriage, she has gotten herself into considerable debt supporting him and trying to find a career that would work for him. They had moved to ABCD where he had recently been employed as a restaurant manager. She also moved her mother and son out there and is feeling understandably upset that he was being dishonest and deceitful with her. She has history of seasonal affective disorder, winter depressions, characterized by increased sleep, increased irritability, impatience, and fatigue. Some suggestion on her part that her father may have had some mild bipolar disorder and including the patient has a cyclical and recurrent mood disorder. In January, she went on citalopram. She reports since that time, she has lost 40 pounds of weight, has trouble sleeping at night, thinks perhaps her mood got worse on the citalopram, which is possible, though it is also possible that the progressive nature of getting divorce than financial problems has contributed to her worsening mood.,PAST AND DEVELOPMENTAL HISTORY: , She was born in XYZ. She describes the family as being somewhat dysfunctional. Father was a truckdriver. She is an only child. She reports that she had a history of anorexia and bulimia as a teenager. In her 20s, she served six years in Naval Reserve. She was previously married for four years. She described that as an abusive relationship. She had a history of being in counseling with ABC, but does not think this therapist, who is now by her estimate 80 years old, is still in practice.,PHYSICAL EXAMINATION: ,GENERAL: This is an alert and cooperative woman.,VITAL SIGNS: Temperature 98.1, pulse 60, respirations 18, blood pressure 95/54, oxygen saturation 95%, and weight is 132.,PSYCHIATRIC: She makes good eye contact. Speech is normal in rate, volume, grammar, and vocabulary. There is no thought disorder. She denies being suicidal. Her affect is appropriate for material being discussed. She has a sense of future, wants to get back to work, has plans to return to counseling. She appeared to have normal orientation, concentration, memory, and judgment.,Medical history is notable for factor V Leiden deficiency, history of pulmonary embolus, restless legs syndrome. She has been off her Mirapex. I did encourage her to go back on the Mirapex, which would likely lead to some improvement in mood by facilitating better sleep.,The patient at this time can contract for safety. She has made plans for outpatient counseling this Saturday and we will get a referral to a psychiatrist for which she is agreeable to following up with.,LABORATORY DATA: , INR, which is still 8.8. In 1998, she had a normal MRI. Electrolytes, BUN, creatinine, and CBC were all normal.,DIAGNOSES: ,1. Seasonal depressive disorder.,2. Restless legs syndrome.,3. Overdose of citalopram and warfarin.,RECOMMENDATIONS: , The patient reports she has been feeling better since discontinuing antidepressants. I, therefore, recommend she stay off antidepressants at present. If needed, she can take Prozac, which has been effective for her in the past and she plans to see a psychiatrist for consultation. She does give a fairly good history of seasonal depression and given that her mood has improved in the past with Prozac, this will be an appropriate agent to try as needed in the future, but given the situational nature of the depression, she primarily appears to need counseling.,Please feel free to contact me at digital pager if there is additional information I can provide.

psychiatry / psychology, citalopram, depressive disorder, overdose, warfarin, restless legs syndrome, disorder, mood

Discharge summary of a patient with depression and high risk behavior.

Psychiatry / Psychology

Psychiatric Discharge Summary - 2

DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:, This discharge is at the family's request.,IDENTIFIED PROBLEMS/OUTCOMES:,1.

Psychiatric evaluation for major depression without psychotic features.

Psychiatry / Psychology

Psychiatric Evaluation - 2

IDENTIFICATION OF PATIENT: , The patient is a 34-year-old Caucasian female.,CHIEF COMPLAINT:, Depression.,HISTORY OF PRESENT ILLNESS:, The patient's depression began in her teenage years. Sleep has been poor, for multiple reasons. She has obstructive sleep apnea, and has difficulties with a child who has insomnia related to medications that he takes. The patient tends to feel irritable, and has crying spells. She sometimes has problems with motivation. She has problems with memory, and energy level is poor. Appetite has been poor, but without weight change. Because of her frequent awakening, her CPAP machine monitor has indicated she is not using it enough, and Medicaid is threatening to refuse to pay for the machine. She does not have suicidal thoughts. ,The patient also has what she describes as going into a "panic mode." During these times, she feels as if her whole body is going to explode. She has a hard time taking a deep breath, her heart rate goes up, blood pressure is measured as higher shortly afterward, and she gets a sense of impending doom. These spells may last a couple of hours, but once lasted for about two day. She does not get chest pain. These attacks tend to be precipitated by bills that cannot be paid, or being on a "time crunch." ,PSYCHIATRIC HISTORY:, The patient's nurse practitioner had started her on Cymbalta, up to 60 mg per day. This was helpful, but then another physician switched her to Wellbutrin in the hope that this would help her quit smoking. Although she was able to cut down on tobacco usage, the depression has been more poorly controlled. She has used Wellbutrin up to 200 mg b.i.d. and Cymbalta up to 60 mg per day, at different times. At age 13, the patient cut her wrists because of issues with a boyfriend, and as she was being sutured she realized that this was a very stupid thing to do. She has never been hospitalized for psychiatric purposes. She did see a psychologist at age 16 briefly because of prior issues in her life, but she did not fully reveal information, and it was deemed that she did not need services. She has not previously spoken with a psychiatrist, but has been seeing a therapist, Stephanie Kitchen, at this facility.,SUBSTANCE ABUSE HISTORY:,Caffeine: The patient has two or three drinks per day of tea or Diet Pepsi.,Tobacco: She smokes about one pack of cigarettes per week since being on Wellbutrin, and prior to that time had been smoking one-half pack per day. She is still committed to quitting.,Alcohol: Denied.,Illicit drugs: Denied. In her earlier years, someone once put some unknown drug in her milk, and she "came to" when she was dancing on the table in front of the school nurse.,MEDICAL HISTORY/REVIEW OF SYSTEMS:,Constitutional: See History of Present Illness. No recent fever or sweats.

Admission Psychiatric Evaluation

Psychiatry / Psychology

Psychiatric Evaluation - 4

ADMISSION PSYCHIATRIC EVALUATION,IDENTIFYING INFORMATION/REFERRAL DATA: ,This is a 16-year-old Caucasian adolescent female who is going into ninth grade and lives with her mother, the mother's boyfriend, and a 12, 11, and 10-year-old sister. She also has a stepsister that is 8 years old. The patient was brought in by her mother after being picked up by Anchorage Police Department (APD). She was brought to our institution for an assessment. ,REASON FOR ADMISSION/CHIEF COMPLAINT: ,The patient ran away in the middle of the night on Sunday, 07/19/04, and she has been on the run since then. Her friends report to the parents that she is suicidal and that she had a knife. A friend took a knife away from her to keep her from cutting herself. ,HISTORY OF PRESENT ILLNESS: ,This is a 16-year-old Caucasian adolescent girl who was brought in by APD and her parents. This is her first admission. APD picked her up from a runaway and brought her at her mother's request after some friends told the mother that she was suicidal. The mother found journals in her room talking about suicide, and that she has been raped. There were no details and the client denies that she was raped. She is sexually active with one boyfriend, also 16 years old, that she met while going to school in Ketchican in the last school year. She has been with the mother only the last two months and the same Ketchican boyfriend, Michael, followed her to Anchorage. She reports symptoms of depression, no energy, initial and middle insomnia, eating more. She is very irritable and has verbal altercations wither sister who is 14. She admits to being sad and also having poor concentration. She had marked drop in school functioning in the last year, and will need to repeat the ninth grade. The mother is very concerned with the patent's safety and feels she is not able to control her. She lived with her stepfather when she was 8 to 9 years old, but she was too problematic and not successful living there in Ketchican. She went to live with her dad up to age 16. Now she is living with her mother and her mother's boyfriend for the last two months. In December, her grandmother passed away and she was with her grandmother and her mother during all this process, which is when she started feeling depressed.,LEGAL HISTORY: ,No legal history.,TREATMENT/PSYCHIATRIC HISTORY: ,The patient was evaluated once at XYZ when she was 14 due to depression, also when she was 3 years old when a new sibling came into the family. ,FAMILY PSYCHIATRIC HISTORY: ,The patient has three siblings with ADHD (Attention Deficit Hyperactivity Disorder) and two of her siblings are in an RTC (Residential Treatment Center) Program, one with the diagnosis of Bipolar Disorder, and the other with ADHD and bipolar condition.,PERTINENT MEDICAL HISTORY: ,She was born with some eczema. At age 4 she was involved in an accident where she cut one of her legs and needed sutures. There is no history of seizure or head injury. She reports loss of consciousness. This will be investigated; there are no details about it. She admits to being sexually active, protecting herself using condoms. Her last menstruation period was 07/20/04. ,ALLERGIES: ,No allergies.,DEVELOPMENT AGE FACTORS: , The mother reports she was born with some jaundice and eczema. Early milestones walk and talk. The patient appears to function at the expected age level. ,PERTINENT PSYCHOSOCIAL DATA: ,Complete pertinent psychosocial will be obtained by our clinician. The patient admits witnessing seeing some domestic violence when she was small, around five years old. There is an allegation of a rape that the mother found in her journal, but this is going to be investigated. ,SCHOOL HISTORY:

Patient with a long history of depression and attention deficits.

Psychiatry / Psychology

Psychiatric Evaluation - 1

IDENTIFYING DATA:, The patient is a 36-year-old Caucasian male.,CHIEF COMPLAINT:, The patient relates that he originally came to this facility because of failure to accomplish task, difficulty saying what he wanted to say, and being easily distracted.,HISTORY OF PRESENT ILLNESS:, The patient has been receiving services at this facility previously, under the care of ABC, M.D., and later XYZ, M.D. Historically, he has found it very easy to be distracted in the "cubicle" office setting where he sometimes works. He first remembers having difficulty with concentration in college, but his mother has pointed out to him that at some point in his early education, one teacher commented that he may have problems with attention-deficit hyperactivity disorder. Symptoms have included difficulty sustaining attention (especially in reading), not seeming to listen one spoke into directly, failure to finish task, difficulty with organization, avoiding task requiring sustained mental effort, losing things, being distracted by extraneous stimuli, being forgetful. In the past, probably in high school, the patient recalled being more figidity than now. He tensed to feel anxious. Sleep has been highly variable. He will go for perhaps months at a time with middle insomnia and early morning awakening (3:00 a.m.), and then may sleep well for a month. Appetite has been good. He has recently gained about 15 pounds, but notes that he lost about 30 pounds during the time he was taking Adderall. He tends to feel depressed. His energy level is "better now," but this was very problematic in the past. He has problems with motivation. In the past, he had passing thoughts of suicide, but this is no longer a problem.,PSYCHIATRIC HISTORY:, The patient has never been hospitalized for psychiatric purposes. His only treatment has been at this facility. He tried Adderall for a time, and it helped, but he became hypertensive. Lunesta is effective for his insomnia issues. Effexor has helped to some degree. He has been prescribed Provigil, as much as 200 mg q.a.m., but has been cutting it down to 100 mg q.a.m. with some success. He sometimes takes the other half of the tablet in the afternoon.

The patient was discharged by court as a voluntary drop by prosecution.

Psychiatry / Psychology

Psychiatric Discharge Summary

DISCHARGE DISPOSITION:, The patient was discharged by court as a voluntary drop by prosecution. This was AMA against hospital advice.,DISCHARGE DIAGNOSES:,AXIS I: Schizoaffective disorder, bipolar type.,AXIS II: Deferred.,AXIS III: Hepatitis C.,AXIS IV: Severe.,AXIS V: 19.,CONDITION OF PATIENT ON DISCHARGE: , The patient remained disorganized. The patient was suffering from prolactinemia secondary to medications.,DISCHARGE FOLLOWUP: ,To be arranged per the patient as the patient was discharged by court.,DISCHARGE MEDICATIONS: , A 2-week supply of the following was phoned into the patient's pharmacy: Seroquel 25 mg p.o. nightly. Zyprexa 5 mg p.o. b.i.d.,MENTAL STATUS AT THE TIME OF DISCHARGE:, Attitude was cooperative. Appearance showed fair hygiene and grooming. Psychomotor behavior showed restlessness. No EPS or TD was noted. Affect was restricted. Mood remained anxious and speech was pressured. Thoughts remained tangential, and the patient endorsed paranoid delusions. The patient denied auditory hallucinations. The patient denied suicidal or homicidal ideation, was oriented to person and place. Overall, insight into her illness remained impaired.,HISTORY AND HOSPITAL COURSE: , The patient is a 22-year-old female with a history of bipolar affective disorder, was initially admitted for evaluation of increasing mood lability, disorganization, and inappropriate behaviors. The patient reportedly was asking her father to have sex with her and tried to pull down her mother's pants. The patient took her clothing off, was noted to be very disorganized sexually, and religiously preoccupied, and endorsed auditory hallucinations of voices telling her to calm herself and others. The patient has a history of depression versus bipolar disorder, last hospitalized in Pierce County in 2008, but without recent treatment. The patient on admission interview was noted to be labile and disorganized. The patient was initiated on Risperdal M-Tab 2 mg p.o. b.i.d. for psychosis and mood lability, and also medically evaluated by Rebecca Richardson, MD. The patient remained labile and suspicious during her hospital stay. The patient continued to be sexually preoccupied and had poor insight into her need for treatment. The patient denied further auditory hallucinations. The patient was treated with Seroquel for persistent mood lability and psychosis. The patient was noted to develop prolactinemia with Risperdal and this was changed to Zyprexa prior to discharge. The patient remained disorganized, but was given a voluntary drop by prosecution against medical advice when she went to court on 01/11/2010. The patient was discharged to return home to her parents and was referred to Community Mental Health Agencies. The patient was thus discharged in symptomatic condition.

psychiatry / psychology, schizoaffective disorder, bipolar type, mood lability, disorganization, bipolar affective disorder, voluntary drop, auditory hallucinations, psychiatric, axis,

Psychiatric evaluation for ADHD, combined type.

Psychiatry / Psychology

Psychiatric Evaluation - 3

IDENTIFICATION OF PATIENT: , ABCD is an 8-year-old Hispanic male currently in the second grade.,CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS: , ABCD presents to this visit with his mother, Xyz, and her significant other, Pqr. Circumstances leading to this admission: In the past, ABCD has been diagnosed and treated for ADHD, combined type, and has been on Concerta 54 mg one p.o. q.8h. Since he has been on the 54 mg, mother has concerns because he has not been sleeping well at night, consistently he is staying up until 12:00 or 1:00, and he is not eating the noonday meal and not that much for supper. ABCD is also complaining of headaches when he takes the medication. Mother reports that on the weekends he is off the medication. She does notice that his sisters become more irritated with him and say he is either hitting them or bothering them and he will say, "It's an accident." She sees him as impulsive on the weekends, but is not sure if this just isn't "all boy.",Mother reports ABCD has been on medication since kindergarten. Currently, the teachers say he is able to pay attention and he is well behaved in school. Prior to being on medication, there were issues with the teachers saying he was distractible and had difficulty paying attention.,He had a psychological evaluation done on 07/16/06 by Dr. X, in which he was diagnosed with ADHD, combined type; ODD; rule out depressive disorder, NOS; rule out adjustment disorder with depressed mood; and rule out adjustment disorder with mixed features of conduct. He also has seen XYZ, LCSW, in the past for outpatient therapy.,ABCD's mother, A, as well as her significant other, R, and his teachers are not convinced that he needs his medication and would like to either trial him off or trial him on a lower dose.,REVIEW OF SYSTEMS:,Sleep: As stated before, he is having much difficulty on a consistent basis falling asleep. It is 12:00 to 1:00 a.m. before he falls to sleep. When he was on the 36 mg of Concerta, he was able to fall asleep without difficulty. On the weekends, he is also having difficulty falling asleep, even though he is not taking the medication.,Appetite: He will eat breakfast and supper, but not much lunch, if any at all. He has not lost weight that mother is aware of, nor is he getting more sick than normal.,Mood control: Mother reports he has not been aggressive since he has been on the medication, nor is he getting in trouble at school for aggression or misbehavior. The only exception to this is he gets in occasional fights with his sisters. ABCD denies visual or auditory hallucinations or racing thoughts. He reports his thoughts are sometimes bad because he says sometimes he thinks of the "S" word.,Energy: Mother reports a lot of energy.,Pain: ABCD denies any pain in his body.,Suicidal or homicidal thoughts: He denies suicidal thoughts or plan to hurt himself or anyone else.,PAST TREATMENT AND/OR MEDICATIONS:,ABCD was originally tried on Ritalin in kindergarten, and he has been on Concerta since 07/14/06. He has received outpatient therapy from XYZ, LCSW. He is currently not in outpatient therapy.,FAMILY PSYCHIATRIC HISTORY:,Mother reports that on her side of the family she is currently being assessed for mood disorder/bipolar. She reports she has significant moodiness episodes and believes in the past she has had a manic episode. She is currently not on medication. She does not know of anyone else in her family, with the exception of she said her father's behavior was "weird." Biological father's side of the family, mother reports father was very impulsive. He had anger issues. He had drug and alcohol issues. He was in jail for three years for risky behavior. There was also domestic violence when mother was married to father.,FAMILY AND SOCIAL HISTORY:,Biological mother and father were married for five years. They divorced when ABCD was 2-1/2 years of age. Currently, father has been deported back to Mexico. He last saw ABCD in March 2006 for one day when they went down to AAAA. He does call on special holidays and his birthday. Contact is brief, but so far has been consistent. Mother is currently seeing R, a significant other, and has been seeing him for the last seven months. ABCD had a good relationship with R. ABCD has an older sister, M, age 9, who they describe as very gifted and creative without attention issues or oppositional issues, and a younger sister, S, age 7, who mother describes as "all wisdom.",PREGNANCY:, Mother reports her pregnancy was within normal limits as well as the labor and birth; although, she was exposed to domestic violence while ABCD was in utero. She did not use drugs or alcohol while she was pregnant.,DEVELOPMENTAL MILESTONES:, Developmental milestones were all met on time, although ABCD has had speech therapy since he was young.,PHYSICAL ABUSE:, Mother and ABCD deny any history of physical or sexual abuse or emotional abuse, with the exception of exposure to domestic violence when he was very young, age 2 and before.,DISCIPLINE PROBLEMS:, Mother reports ABCD was a very cuddly infant and could sleep well. As a toddler, he was all over the place, climbing and always busy. Elementary school: In kindergarten, the teacher said it was very emphatic that he needed medication because he could not focus or sit still or listen. ABCD has no history of fire setting or abuse to animals. He does not lie more than other kids his age and he does not have any issues with stealing.,PAST DRUG AND ALCOHOL HISTORY:, Noncontributory.,MEDICAL STATUS AND HISTORY:, ABCD has no known drug allergies. He has no history of heart murmur, heart defect of other heart problems. No history of asthma, seizures or head injuries. He no medical diagnosis and he has ever spent an overnight in a medical hospital.,SCHOOL:, When I asked ABCD whether he likes school, he stated, "No." His grades are okay, per mother. He does have an IEP for the ADHD, but she does not believe he has a learning disability. Behavior problems: He currently is not having any behavior problems in the school. He reports he does not get along with his teachers because they tell him what to do. Strengths: He reports he loves to read and he can focus and concentrate on his reading and he dislikes centers.,RELATIONSHIPS:, He reports he has best friends. He named two, D and B, and he does have a friend that is a girl named Kim. When asked if church or God were important to him, he stated, "God is." He is in a Roman Catholic family and that is an important aspect of his life.,WORK HISTORY:, In the home, he has chores of taking out the trash.,LEGAL:, He has not been involved in the legal system.,SUPPORT SYSTEMS:, When asked if he feels safe in his home, he stated, "Yes." When asked who he talks to if he is hurt or upset, he stated, "Mom." (At first, he said video games, but then he said mom).,TALENTS AND GIFTS:, He is good at basketball, video games, and reading books.,MENTAL STATUS EXAM:, This was a very long appointment, approximately two hours in length, due to mother and significant other had many questions. ABCD kept himself occupied throughout and was very well behaved throughout the session. He had some significant memory responses in that he remembered the last holiday was Martin Luther King Day, which is somewhat unusual for a child his age, but he could only recall one of three items after five minutes. Distractibility and attention: He, at times, was very mildly distracted, but otherwise did not appear hyperactive. His judgment was adequate. When asked what he would do if there was a fire in his house, he said, "Get out!" Insight was poor to adequate. Fund of information was good. When asked who the president was, he said, "George Washington." Intelligence is probably average to above average. Speech was normal. He had some difficulty with abstract thinking. He could not see any similarities between an orange and an apple, but was able to see similarities of wheels between an airplane and a bicycle. On serial 7's he could do 100 minus 7, but then unable to subtract any of the others, but he completed serial 3's very rapidly. When given three commands in a row, he used his left hand instead of his right hand, but followed the last two commands correctly. Appearance was casual. Hygiene was good. Attitude was cooperative. Speech was normal. Psychomotor was between normal and slightly hyperactive. Orientation was x2. Attention/concentration was intact. Memory was intact at times and then had some memory recall problems with three words. Mood was euthymic. Affect was bright. He has no suicidal or homicidal/violence risks. Perceptions were normal. Thought process logical. Thought content normal. Disassociation none. Sleep: He is having some insomnia. Appetite/eating are decreased.,STRENGTHS AND SUPPORTS:, He has a strong support system in his mother, grandmother, and mother's significant other, Richard. He has good health. He has shown gain from past treatment. He has a sense of humor and a positive relationship with his mother and her significant other, as well as good school behavior.

Discharge summary of a patient with mood swings and oppositional and defiant behavior.

Psychiatry / Psychology

Psychiatric Discharge Summary - 1

DISCHARGE SUMMARY,SUMMARY OF TREATMENT PLANNING:,Two major problems were identified at the admission of this adolescent:,1.

Bipolar disorder, apparently stable on medications. Mild organic brain syndrome, presumably secondary to her chronic inhalant, paint, abuse.

Psychiatry / Psychology

Psychiatric Consult - 1

HISTORY OF PRESENT ILLNESS:, This is a 53-year-old widowed woman, she lives at ABC Hotel. She presented with a complaint of chest pain, evaluations revealed severe aortic stenosis. She has been refusing cardiac catheter and she may well need aortic valve replacement. She states that she does not want heart surgery or valve replacement. She has a history of bipolar disorder and has been diagnosed at times with schizophrenia. She is on Depakote 500 mg three times a day and Geodon 80 mg twice a day. The patient receives mental health care through the XYZ Health System and there is a psychiatrist who makes rounds at the ABC Hotel. She denies hallucinations, psychosis, paranoia, and suicidal ideation at this time. States that she does not want surgery because the chest pain that was a presenting complaint has gone away that she did not feel her problem is severe enough to require surgery, and medical records does show in this obese individual that cardiac surgery would present substantial risks and for this individual with the chronic mental illness and behavioral problems of a chronic nature, surgery does present some additional risks. The patient notes that she has a long history of substance abuse, primarily inhalation of paint vapors that she had more than 100 incarcerations in the XYZ County Jail related to offenses related to her lifestyle at that time such as shoplifting, violation of orders to abstain from substance abuse and the longest confinement of these was 100 days.,The patient is able to write a fairly reasonable explanation for why she does not want to pursue medical care.,PAST AND DEVELOPMENTAL HISTORY: , She was born in XYZ. She is a high-school graduate from ABCD High School. She did have an abusive childhood. She is married four times. She notes she developed depression when a number of her children died.,PHYSICAL EXAMINATION: ,GENERAL: , This is an obese woman in bed. She is somewhat restless and moving during the interview.,VITAL SIGNS,: Temperature of 97.3, pulse 70, respirations 18, blood pressure 113/68, and oxygen saturation 94% on 3 L of oxygen.,PSYCHIATRY: ,Speech is normal, rate, volume, grammar, and vocabulary consistent with her educational level. There is no overt thought disorder. She does not appear psychotic. She is not suicidal on formal testing. She gives the date as Sunday, 05/19/2007 when it is the 20th and 207 when it is 2007. She is oriented to place. She can memorize four times, repeats two at five minutes, gets the other two with category hints, this places short-term memory in normal limits. She had difficulty with serial three subtractions, counting on her fingers and had difficulty naming the months in reverse order stating, "December, November, September, October, June, July, August, September," but recognizes this was not right and then said, "March, April, May." She is able to name objects appropriately.,LABORATORY DATA: , Chest x-ray showing no acute changes. Carotid duplex shows no stenosis. Electrolytes and liver function tests are normal. TSH normal. Hematocrit 31%. Triglycerides 152.,DIAGNOSES: ,1. Bipolar disorder, apparently stable on medications.,2. Mild organic brain syndrome, presumably secondary to her chronic inhalant, paint, abuse.,3. Aortic stenosis.,4. Sleep apnea.,5. Obesity.,6. Anemia.,7. Gastroesophageal reflux disease.,RECOMMENDATIONS:, It is my impression at present that the patient retains ability to make decisions on her own behalf. Given this lady's underlying mental problems, I would recommend that her treating physicians discuss her circumstances with physicians who round on her at the ABC Hotel. While she may well need surgery and cardiac catheter, she may be more willing to accept this in the context of some continued encouragement from care providers who usually provide care for her. She clearly at this time wants to leave this hospital; she normally gets her care through XYZ Health. Again, in summary, I would consider her to retain the ability to make decisions on her own behalf.,Please feel free to contact me at digital pager if additional information is needed.

psychiatry / psychology, organic brain syndrom, substance abuse, bipolar disorder, mental, abuse,

Psychiatric Assessment of a patient with bipolar and anxiety disorder having posttraumatic stress syndrome.

Psychiatry / Psychology

Psychiatric Assessment

IDENTIFICATION OF PATIENT: , This is a 31-year-old female who was referred by herself. She was formerly seen at Counseling Center. She is a reliable historian.,CHIEF COMPLAINT:, "I'm bipolar and I have severe anxiety disorder. I have posttraumatic stress syndrome." ,HISTORY OF PRESENT ILLNESS: , At age 19, Ms. Abc had a recurrence of memories. Her father had molested her, and the memories returned. In 1992, at the age of 18, she entered her first abusive marriage. She was beaten and her husband shared her sexually with his friends. This lasted until age 24. The second marriage was age 26, her second husband was a drug abuser and "he slapped me around." She had two children during that marriage. In 2001, she was married in Indiana to a military man. This was her third marriage and she stated, "This marriage is good." She had EMDR in Indiana when she was being treated for Posttraumatic Stress Disorder. ,Historically, her first husband threw her down the stairs at age 21, and she had a miscarriage. Her sexual abuse began at age 5, and at that time she lost interest in other activities that normal school children have. Currently, she is unable to have sex with the lights on. She states, "Sometimes I hurt all over." Her husband was deployed three days ago, on April 21, to a foreign theater of operations. She has panic attacks every day.,Review of symptoms shows her to have physiological distress at the memory of her trauma, she has psychological distress, and this comes about when she smells Old Spice aftershave. She does not avoid thoughts of her trauma, but she avoids the perpetrators and placements. She is not unable to recall details of her trauma. She does feel detached and isolated. She has restrictive range of affect and she had a foreshortened future. She also had a loss of interest in things, starting at age 5. She has anger, which is uncontrollable at times, she has poor sleep, she has nightmares, flashbacks, she is hypervigilant, she has exaggerated startle reflex, and with respect to concentration, she says, "I don't do as good as I can." Further review of symptoms shows her to have periods of constant cleaning and increased sex drive. She also has had euphoria, poor judgment, distractibility, and inability to concentrate. She has been irritable. She has had a decreased need for sleep, which lasts for six or seven days. She had racing thoughts, rapid speech, but has not had grandiosity. These symptoms of mania occurred in the last week of November 2005 and lasted for seven days from, which she was not hospitalized. Furthermore, she endorses the following symptoms: She states, "When I'm depressed, I have neck pain, jaw pain, abdominal pain. I have migraines and urinary tract pain." She also complains of chest pain, pain during sex, and excess pain during her menstrual period. She has an increased gag reflex, which has caused her to have emesis. She states it is easy to choke. She has had physical symptoms, "for as long as I can remember," and she states, "I've felt like crap most of my life," "it affects my marriage." She has also admitted to having nausea and vomiting, with excess gas. She has constipation and she cannot eat certain foods, mainly broccoli and cauliflower, and she does not have diarrhea. She states that sex is only important to her in mania. Otherwise, she has no desire. She has had irregular periods for two or three weeks at a time. She has had no episodes of excess bleeding. She has had no paralysis, no balance issues, no diplopia, no seizures, no blindness, no deafness, no amnesia, no loss of consciousness, but she does have a lump in her throat on occasion. Currently, she is sleeping from 10 p.m. to 3 a.m., and that is under the influence of Lunesta. Her energy is "not good. Her appetite is "I'm craving crap," stating that she wants to eat carbohydrates. Concentration is poor today. She feels worthless, hopeless, and guilty. Her self-esteem is "I don't have any." She has no anhedonia, and she has no libido. She also has had feelings of chronic emptiness. She feels abandoned. She has had unstable relationships. She self-mutilated, but she stopped at age 22. She has trouble controlling her anger. She did not have stress-related paranoia or dissociative phenomena, but she did have those during the sexual transgressions when she was a child. She has no identity disturbance. ,CURRENT MEDICATIONS: , Seroquel 700 mg p.o. q.d.; Wellbutrin XL 300 mg p.o. q.d.; Desyrel 100 mg p.o. q.h.s.; Ativan p.r.n. dosage unknown. In the past, she has been on Prozac, Paxil, lithium, Depakote, Depakene, and Zoloft. ,PSYCHIATRIC HISTORY: , She saw Dr. B. She saw Chris. She is diagnosed with Posttraumatic Stress Disorder, depression, and Bipolar Disorder. She had counseling in Indiana in 2001. She had inpatient treatment in Indiana in 2001 also, at age 19. She had three suicide attempts. At age 14, she took too many aspirin; the second one was at age 19, she took pain medication and sleep medication; and when she discussed her third suicide attempt, she began to cry and would not speak of it any more. She has had no psychological testing. ,MEDICAL HISTORY: , Significant for migraines, hyperactive and gag reflex. She states she has had cardiovascular workups due to panic disorder, but nothing was found. She also has astigmatism. She states she has stomach pain and may have irritable bowel syndrome, and she had had recurrent kidney infections with a stent in the right kidney during one of her pregnancy. She has no history of head injury or MRI test of the brain. No history of EEG, seizures, thyroid problems, or asthma. There are no drug allergies. She has never had an EKG. She does have musculoskeletal problems and has arthritis-like joint pains on occasion. She has had ear infections and sinus infections intermittently. Hearing test was normal. She is currently not pregnant. She saw her gynecologist four months ago at Elmendorf Air Force Base. ,Surgical history is significant for having a tubal ligation at age 27, an appendectomy at age 19. She had surgery on her right ovary due to pain, a cyst was found; the date on that is unknown. ,She has no hypertension, no diabetes, no glaucoma.,FAMILY HISTORY: , Significant for her paternal grandmother not being mentally competent. Her mother was depressed and was treated. Her mother is currently age 55. She has a paternal grandmother who may have had Schizophrenia. There is also a family history of the paternal grandfather using substance. He was "an extreme alcoholic." She had maternal aunts who used alcohol, and a maternal uncle use alcohol to excess. The maternal uncle committed suicide; he drowned himself. ,There is no family history of bipolar disorder, anxiety, nor attention deficit, mental netardation, Tourette's syndrome, or learning disabilities. ,Medical history in the family is significant for her son, age 4, who is having seizures ruled out. Her mother and two maternal aunts have thyroid disease. She has a brother, age 32, with diabetes, a maternal uncle with heart disease, and several paternal great aunts had breast cancer. There is no family history of hypertension.,ABUSE HISTORY: , Significant for being physically abused by her father, her first husband, and her second husband. She was sexually abused by her father from age 5 to age 18. She states, "my first husband gave me away for four years to his friends to be used sexually." She was emotionally abused by her mother, father, and both of her first two husbands. She was neglected by her mother and her father. She never witnessed domestic violence. She has not witnessed traumatic events. ,SUBSTANCE ABUSE: , Significant for having used nerve pills, but she stated she has not used them excessively, and never had to get her prescription refilled early. She has never used alcohol, tobacco, marijuana, or any other drugs.,PARENT/SIBLING RELATIONSHIP INFORMATION: , She had had a poor relationship with her parents. She has no contact with them. She has no contact with her brother. She was married three times, as stated in the history. She has two children with Asperger's and autism. ,HOBBIES/SPIRITUAL: , She likes to read and write. She likes to cross-stitch, quilt, and do music, and has found a good church in Anchorage. ,EDUCATIONAL:, She states she was teased in school because "I was so depressed." She got good grades otherwise. She finished high school.,WORK HISTORY:, She has worked in the past managing a Dollar General store. She has been a waitress and an executive secretary. ,LEGAL HISTORY:, She has never been arrested.,MENTAL STATUS:, Significant for a well groomed, well kempt young white female who appears her stated age. She has a pierced nose and has a nose ring. She is cooperative, alert, and attentive. She makes good eye contact. Her speech is normal, prosody is normal, and rate and rhythm are normal. Motor is normal. She has no gait abnormalities. No psychomotor retardation or agitation. Her mood is "I'm sad and depressed." Her affect is restricted. She is tearful at times when discussing the sexual traumas, and she became anxious and panicky at certain points during the interviews. Perception is normal. She denies auditory and visual hallucinations. She denies depersonalization and derealization, except that those occurred when the sexual transgressions occurred. Otherwise, she has not had dissociative phenomena. Thought processes are normal. She has no loosening of association, no flight of ideas, no tangentiality, and no circumstantiality. She is goal directed and oriented. Insight and judgment are good. She is alert and oriented to person, place, and time, stating it was 04/18/06, Tuesday, it was Anchorage in the spring. She is able to register three words and recall them at five minutes. She is able to do simple calculations, stating 2x3 is 6, and 1 dollar 15 cents has 23 nickels. She is given a proverb to interpret. She was asked what judging a book by its cover meant. She said, "You can't always tell what a person is by looking at them on the outside." She is appropriate in her abstraction, and is able to identify the last four presidents.,CLINICAL IMPRESSION: ,Abc is a 31-year-old female with a family history of mood disorder, suicide, alcoholism, and possible psychosis. She has had an extensive history of sexual abuse and emotional abuse. She has not used drugs and alcohol, and she has been treated in the past. She was treated with EMDR and stated that she did not benefit from that. She has an extensive medical history and brought her medical records, and they were thoroughly reviewed. She currently has symptoms of dysthymia and she had had a recent bout of bipolar hypomania, which was in November of 2005. She also has symptoms of somatization, but these are not chronic in the fact that they only exist during her dysphoric periods and do not exist when she has mania. Medical records review a history of dysmenorrhea with surgery to the right cystic ovary. The EMDR did not benefit her in the past. She also has not had good psychotherapeutic consultation. ,DIAGNOSES:,AXIS I. 309.81 Posttraumatic Stress Disorder.

Psychiatric consultation for substance abuse.

Psychiatry / Psychology

Psych Consult - Substance abuse

REASON FOR CONSULT: , Substance abuse.,HISTORY OF PRESENT ILLNESS: , The patient is a 42-year-old white male with a history of seizures who was brought to the ER in ABCD by his sister following cocaine and nitrous oxide use. The patient says he had been sober from any illicit substance for 15 months prior to most recent binge, which occurred approximately 2 days ago. The patient is unable to provide accurate history as to amount use in this most recent binge or time period it was used over. The patient had not used cocaine for 15 years prior to most recent usage but had used alcohol and nitrous oxide up until 15 months ago. The patient says he was depressed and agitated. He says he used cocaine by snorting and nitrous oxide but denies other drug usage. He says he experienced visual hallucinations while intoxicated, but has not had hallucinations since being in the hospital. The patient states he has had cocaine-induced seizures several times in the past but is not able to provide an accurate history as to the time period of the seizure. The patient denies suicidal ideation, homicidal ideation, auditory hallucinations, visual hallucinations, or tactile hallucinations. The patient is A&O x3.,PAST PSYCHIATRIC HISTORY:, Substance abuse as per HPI. The patient went to a well sober for 15 months.,PAST MEDICAL HISTORY:, Seizures.,PAST SURGICAL HISTORY:, Shoulder injury.,SOCIAL HISTORY:, The patient lives alone in an apartment uses prior to sobriety 15 months ago. He was a binge drinker, although unable to provide detail about frequency of binges. The patient does not work since brother became ill 3 months ago when he quit his job to care for him.,FAMILY HISTORY:, None reported.,MEDICATIONS OUTPATIENT:, Seroquel 100 mg p.o. daily for insomnia.,MEDICATIONS INPATIENT:,1. Gabapentin 300 mg q.8h.,2. Seroquel 100 mg p.o. q.h.s.,3. Seroquel 25 mg p.o. q.8h. p.r.n.,4. Phenergan 12.5 mg IV q.4h. p.r.n.,5. Acetaminophen 650 mg q.4h. p.r.n.,6. Esomeprazole 40 mg p.o. daily. ,MENTAL STATUS EXAMINATION: , The patient is a 42-year-old male who appears stated age, dressed in a hospital gown. The patient shows psychomotor agitation and is somewhat irritable. The patient makes fair eye contact and is cooperative. He had answers my questions with "I do not know." Mood "depressed" and "agitated." Affect is irritable. Thought process logical and goal directed with thought content. He denies suicidal ideation, homicidal ideation, auditory hallucinations, visual hallucinations, or tactile hallucinations. Insight and judgment are both fair. The patient seems to understand why he is in the hospital and patient says he will return to Alcoholics Anonymous and will try to stay sober in all substances following discharge. The patient is A&O x3.,ASSESSMENT:,AXIS I: Substance withdrawal, substance abuse, and substance dependence.,AXIS II: Deferred.,AXIS III: History of seizures.,AXIS IV: Lives alone and unemployed.,AXIS V: 55.,IMPRESSION:, The patient is a 42-year-old white male who recently had a cocaine binge following 15 months of sobriety. The patient is experiencing mild symptoms of cocaine withdrawal.,RECOMMENDATIONS:,1. Gabapentin 300 mg q.8h. for agitation and history of seizures.,2. Reassess this afternoon for reduction in agitation and withdrawal seizures.,Thank you for the consult. Please call with further questions.

Psychiatric consultation has been requested as the patient has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior.

Psychiatry / Psychology

Psychiatric Consult

HISTORY OF PRESENT ILLNESS: ,This is a 23-year-old married man who had an onset of aplastic anemia in December, underwent a bone marrow transplant in the end of March, has developed very severe graft-versus-host reaction. Psychiatric consultation has been requested as the patient has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior.,The patient gives a significant history of behavioral problems from late adolescence until the onset of illness, states he had lot of trouble with law, he was convicted of assault, he was also arrested with small amount of cannabis, states he served one year incarcerated in ABCD that was about two years ago. Gives an ongoing history of substance abuse until one year ago when he went into a drug rehabilitation program, he was discharged from that on 05/28/2006 and states he has been clean and sober since then. Prior to going to rehabilitation, he was using intravenous heroin couple of times a week since age 17, which would have been over a period of about five years, reports heavy use of cannabis, smoking pot up to five times a day if he could. He would drink up to half of a fifth of rum on a daily basis when available.,The patient is currently on Lexapro 10 mg in the morning and diazepam 10 mg at bedtime. He complained of some depressive and some anxiety symptoms, but these do not appear to be out of proportion to his medical issues and, for this individual, the frustrations of his treatments. He would have a limited support system here in Colorado. He married in January and states that the marriage is not going particularly well, being young, sick, and hospitalized, has not helped his relationship with his new wife who apparently is expecting a child in July. I would recommend some couples counseling as a part of their treatment here.,The patient was fairly drowsy during the interview and full past and developmental history was not obtained. The patient's comment is that he grew up all over, that his parents had separated, that he lived with his mother, that he dropped out of school in eleventh grade, at that time was living in XYZ area because he did not like school.,PHYSICAL EXAMINATION: ,GENERAL: , This is a cooperative man, speech is soft and difficult to understand. There is no thought disorder and no hallucination. He denies being suicidal, but does express at times feelings about giving up on his treatments and primarily complaints about feeling that he is treated like a child and confined in the hospital.,VITAL SIGNS: , Temperature 97.2, pulse 117, respirations 16, blood pressure 127/74, oxygen saturation 97%, and weight is 154 pounds.,PSYCHIATRY:, There is no thought disorder, no paranoia, no delusions, and no psychotic symptoms. Activities of daily living (ADLs) appear intact. On formal testing, he is oriented to place. He can give a reasonable recitation of his medical history. He is oriented to the year, knows it is the 15th, but gave the month as June instead of May. He can memorize four items, repeats three out of four at five minutes, gives the fourth through the category, which places short-term memory in normal limits. He can do serial three subtractions accurately, can name objects appropriately.,LABORATORY DATA:, Sodium of 135, BUN of 24, and glucose 119. GGT of 355, ALT of 97, LDH of 703, and alk phos of 144. FK506 is 28.8, which is elevated tacrolimus level. Hematocrit 29% and white count is 7000.,DIAGNOSES: ,AXIS I:, Depressive disorder secondary to the underlying medical condition of graft-versus-host reaction.,AXIS II: , Personality disorder, not otherwise specified (NOS).,AXIS III: , History of polysubstance abuse, in remission.,RECOMMENDATIONS: ,1. This patient appears to retain the ability to make decisions on his own behalf. I think he is mentally competent. Unfortunately, his impulsive low frustration personality dynamics do not fit well with the demands and requirements for treatment of this chronic illness. If the patient refuses treatment, he understands that the consequences of this would likely be hastened mortality and he does state that he does not want to die.,2. The patient does complain of depressed mood, also of anxiety. We did discuss medications. He appeared somewhat sedated at the time of my interview. I would recommend that we try Seroquel 25 mg twice daily on an as-needed basis to see if this diminishes anxiety. I will have Dr. X followup with him.,Please feel free to contact me at digital pager if additional information is needed.,My overall recommendation would be that the patient be on some random urine drug screening, that he use cell phone if he goes off the unit, to be called back up when treatments are scheduled, and hopefully he will be agreeable to complying with this.

psychiatry / psychology, noncompliant, confusion, graft versus host reaction, psychiatric consultation, willful behavior, cannabis,

A 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation.

Psychiatry / Psychology

Psych Consult - Paranoia

IDENTIFYING DATA: , The patient is a 30-year-old white male with a history of schizophrenia, chronic paranoid, was admitted for increasing mood lability, paranoia, and agitation.,CHIEF COMPLAINT: , "I am not sure." The patient has poor insight into hospitalization and need for treatment.,HISTORY OF PRESENT ILLNESS: , The patient has a history of schizophrenia and chronic paranoid, for which she has received treatment in Houston, Texas. According to mental health professionals, the patient had been noncompliant with medications for approximately two weeks. The patient had taken an airplane from Houston to Seattle, but became agitated, paranoid, expressing paranoid delusions that the stewardess and pilots were trying to reject him and was deplaned in Seattle. The patient was taken to the local shelter where he remained labile, breaking a window, and was taken to jail. The patient has now been discharged from jail but involuntarily detained for persistent paranoia and disorganization (no jail hold).,PAST PSYCHIATRIC HISTORY: , History of schizophrenia, chronic paranoid. The patient as noted has been treated in Houston but has not had recent treatment or medications.,PAST MEDICAL HISTORY: ,No acute medical problems noted.,CURRENT MEDICATIONS: , None. The patient was most recently treated with Invega and Abilify according to his records.,FAMILY SOCIAL HISTORY: , The patient resides with his father in Houston. The patient has no known history of substances abuse. The patient as noted was in jail prior to admission after breaking a window at the local shelter but has no current jail hold.,FAMILY PSYCHIATRIC HISTORY:, Need to increase database.,MENTAL STATUS EXAMINATION:,Attitude: Calm and cooperative.,Appearance: Shows poor hygiene and grooming.,Psychomotor: Behavior is within normal limits without agitation or retardation. No EPS or TDS noted.,Affect: Is suspicious.,Mood: Anxious but cooperative.,Speech: Shows normal rate and rhythm.,Thoughts: Disorganized,Thought Content: Remarkable for paranoia "they want to hurt me.",Psychosis: The patient endorses paranoid delusions as above. The patient denies auditory hallucinations.,Suicidal/Homicidal Ideation: The patient denies on admission.,Cognitive Assessment: Grossly intact. The patient is alert and oriented x 3.,Judgment: Poor, shown by noncompliance with treatment.,Assets: Include stable physical status.,Limitations: Include recurrent psychosis.,FORMULATION: ,The patient with a history of schizophrenia was admitted for increasing mood lability and psychosis due to noncompliance with treatment.,INITIAL IMPRESSION:,AXIS I: Schizophrenia, chronic paranoid.,AXIS II: None.,AXIS III: None.,AXIS IV: Severe.,AXIS V: 10.,ESTIMATED LENGTH OF STAY: , 12 days.,PLAN: ,The patient will be restarted on Invega and Abilify for psychosis. The patient will also be continued on Cogentin for EPS. Increased database will be obtained.

Psychiatric History and Physical - Patient with schizoaffective disorder.

Psychiatry / Psychology

Psych H&P - 2

HISTORY OF PRESENT ILLNESS:, The patient is a 69-year-old single Caucasian female with a past medical history of schizoaffective disorder, diabetes, osteoarthritis, hypothyroidism, GERD, and dyslipidemia who presents to the emergency room with the complaint of "manic" symptoms due to recent medication adjustments. The patient had been admitted to St. Luke's Hospital on Month DD, YYYY for altered mental status and at that time, the medical team discontinued Zyprexa and lithium. In the emergency room, the patient reported elevated mood, pressured speech, irritability, decreased appetite, and impulsivity. She also added that over the past three days, she felt more confused and reported having blackouts as well as hallucinations about white lines and dots on her arms and face from the medication changes. She was admitted voluntarily to the inpatient unit and medications were not restarted for her. On the unit this morning, the patient is loud and nonredirectable, she is singing loudly and speaking in a very pressured manner. She reports that she would like to speak with Dr. A, the neurologist who saw her at St. Luke's, because she "trust him." The patient is somewhat reluctant to answer questions stating that she has answered enough of people's questions; however, she is talkative and reports that she feels as though she needs a sedative. The patient reports that she is originally from Brooklyn, New York, and she moved down to Houston about a year ago to be with her daughter. She also expressed frustration over the fact that her daughter wanted her removed from the apartment she was in initially and had her placed in a nursing home due to inability to care for herself. The patient also complains that her daughter is "trying to tell me what medications to take." The patient sees Dr. B in the Woodlands for outpatient care.,PAST PSYCHIATRIC HISTORY:, Per chart. The patient has been mentally ill for over 30 years with past diagnoses of bipolar disorder, schizoaffective disorder, and schizophrenia. She has been stable on lithium and Zyprexa according to her daughter and was recently taken off those medications, changed to Seroquel, and the daughter reports that she has decompensated since then. It is not known whether the patient has had prior psychiatric inpatient admissions; however, she denies that she has.,MEDICATIONS: ,1. Seroquel 100 mg, 1 p.o. b.i.d.,2. Risperdal 1 mg tab, 1 p.o. t.i.d.,3. Actos 30 mg, 1 p.o. daily.,4. Lipitor 10 mg, 1 p.o. at bedtime.,5. Gabapentin 100 mg, 1 p.o. b.i.d.,6. Glimepiride 2 mg, 1 p.o. b.i.d.,7. Levothyroxine 25 mcg, 1 p.o. q.a.m.,8. Protonix 40 mg, 1 p.o. daily.,ALLERGIES: , No known drug allergies.,FAMILY HISTORY:, Per chart; her mother died of stroke, father with alcohol abuse and diabetes, one sister with diabetes, and one uncle died of leukemia.,SOCIAL HISTORY:, The patient is from Brooklyn, New York and moved to Houston approximately one year ago. She lived independently in an apartment until about one month ago when her daughter moved her into a nursing home. She has been married once, but her spouse left her when her three children were young. Her children are ages 47, 49, and 51. She had one year of college, and she currently is retired after working in New York public schools for 20 or more years. She reports that her spouse was physically abusive to her. She reports occasional alcohol use and quit smoking 11 years ago.,MENTAL STATUS EXAM: ,GENERAL: The patient is an obese, white female who appears older than stated age, seated in a chair wearing large dark glasses.,BEHAVIOR: The patient is singing loudly and joking with interviewers. She is pleasant, but non-cooperative with interview.,SPEECH: Increased volume, rate, and tone. Normal in flexion and articulation. MOTOR: Agitated.,MOOD: Okay.,AFFECT: Elevated and congruent.,THOUGHT PROCESSES: Tangential and logical at times.,THOUGHT CONTENTS: Denies suicidal or homicidal ideation. Denies auditory or visual hallucination. Positive grandiose delusions and positive paranoid delusions.,INSIGHT: Poor to fair.,JUDGMENT: Impaired. The patient is alert and oriented to person, place, date, year, but not day of the week.,LABORATORY DATA:, Sodium 144, potassium 4.2, chloride 106, bicarbonate 27, glucose 183, BUN 23, creatinine 1.1, and calcium 10.6. Acetaminophen level 3.3 and salicylate level less than 0.14. WBC 7.41, hemoglobin 13.8, hematocrit 43.1, and platelets 229,000. Urinalysis within normal limits.,PHYSICAL EXAMINATION:,GENERAL: Alert and oriented, in no acute distress.,VITAL SIGNS: Blood pressure 152/92, heart rate 81, and temperature 97.2.,HEENT: Normocephalic and atraumatic. PERRLA. EOMI. MMM. OP clear.,NECK: Supple. No LAD, no JVD, and no bruits.,CHEST: Clear to auscultation bilaterally.,CARDIOVASCULAR: Regular rate and rhythm. S1 and S2 heard. No murmurs, rubs, or gallops.,ABDOMEN: Obese, soft, nontender, and nondistended. Positive bowel sounds x4.,EXTREMITIES: No cyanosis, clubbing, or edema.,ASSESSMENT:, This is a 69-year-old Caucasian female with a past medical history of schizoaffective disorder, diabetes, hypothyroidism, osteoarthritis, dyslipidemia, and GERD who presents to the emergency room with complaints of inability to sleep, irritability, elevated mood, and impulsivity over the past 3 days, which she attributes to a recent change in medication after an admission to St. Luke's Hospital during which time the patient was taken off her usual medications of lithium and Zyprexa. The patient is manic and disinhibited and is unable to give a sufficient interview at this time.,AXIS I: Schizoaffective disorder.,AXIS II: Deferred.,AXIS III: Diabetes, hypothyroidism, osteoarthritis, gastroesophageal reflux disease, and dyslipidemia.,AXIS IV: Family strife and recent relocation.,AXIS V: GAF equals 25.,PLAN:

Psychiatric History and Physical - Patient with major depression

Psychiatry / Psychology

Psych H&P - 1

HISTORY OF PRESENT ILLNESS: , This 40-year-old white single man was hospitalized at XYZ Hospital in the mental health ward, issues were filled up by his sister and his mother. The issues involved include the fact that for the last 10 years he has been on disability for psychiatric reasons and has been not working, and in the last several weeks to month he began to call his family talking about the fact that he had been sexually abused by brother. He has been in outpatient therapy with Jeffrey Silverberg for the past 10 years and Mr. Silverberg became concerned about his behavior, called the family and told them to have him put in the hospital, and at one point called the police because the patient was throwing cellphones and having tantrums in his office.,The history includes the fact that the patient is the 3rd of 4 children. A brother who is approximately 8 years older, sexually abused brother who is 4 years older. The brother who is 8 years older lives in California and will contact the family, has had minimal contact for many years.,That brother in California is gay. The brother who is 4 years older, sexually abused, the patient from age 8 to 12 on a regular basis. He said, he told his mother several years ago, but she did nothing about it.,The patient finished high school and with some struggle completed college at the University of Houston. He has a sister who is approximately a year and half younger than he is, who was sexually abused by the brothers will, but only on one occasion. She has been concerned about patient's behavior and was instrumental in having him committed.,Reportedly, the patient ran away from home at the age of 12 or 13 because of the abuse, but was not able to tell his family what happened.,He had no or minimal psychiatric treatment growing up and after completing college worked in retail part time.,He states he injured his back about 10 yeas ago. He told he had disk problems but never had surgery. He subsequently was put on psychiatric disability for depression, states he has been unable to get out of bed at times and isolates and keeps to himself.,He has been on a variety of different medications including Celexa 40 mg and ADD medication different times, and reportedly has used amphetamines in the past, although he denies it at this time. He minimizes any alcohol use which appears not to be a problem, but what does appear to be a problem is he isolates, stays at home, has been in situations where he brings in people he does not know well and he runs the risk of getting himself physically harmed.,He has never been psychiatrically hospitalized before.,MENTAL STATUS EXAMINATION:, Revealed a somewhat disheveled 40-year-old man who was clearly quite depressed and somewhat shocked at his family's commitment. He says he has not seen them on a regular basis because every time he sees them he feels hurt and acknowledged that he called up the brother who abused him and told the brother's wife what had happened. The brother has a child and wife became very upset with him.,Normocephalic. Pleasant, cooperative, disheveled man with about 37 to 40, thoughts were somewhat guarded. His affect was anxious and depressed and he denied being suicidal, although the family said that he has talked about it at times.,Recent past memory were intact.,DIAGNOSES:,Axis I: Major depression rule out substance abuse.,Axis II: Deferred at this time.,Axis III: Noncontributory.,Axis IV: Family financial and social pressures.,Axis V: Global Assessment of Functioning 40.,RECOMMENDATION:, The patient will be hospitalized to assess.,Along the issues, the fact that he is been living in disability in the fact that his family has had to support him for all this time despite the fact that he has had a college degree. He says he has had several part time jobs, but never been able to sustain employment, although he would like to.

psychiatry / psychology, history of present illness:, global assessment of functioning, mental status examination, major depression, psychiatric, abuse, behavior, depression, mental health, mental health ward, psychiatric disability, sexually abused, substance abuse, health,

A 45-year-old white male with a history of schizophrenia and AIDS. He was admitted for disorganized and assaultive behaviors while off all medications for the last six months.

Psychiatry / Psychology

Psych Consult - Schizophrenia

IDENTIFYING DATA:, The patient is a 45-year-old white male. He is unemployed, presumably on disability and lives with his partner.,CHIEF COMPLAINT: , "I'm in jail because I was wrongly arrested." The patient is admitted on a 72-hour Involuntary Treatment Act for grave disability.,HISTORY OF PRESENT ILLNESS: , The patient has minimal insight into the circumstances that resulted in this admission. He reports being diagnosed with AIDS and schizophrenia for some time, but states he believes that he has maintained his stable baseline for many months of treatment for either condition. Prior to admission, the patient was brought to Emergency Room after he attempted to shoplift from a local department store, during which he apparently slapped his partner. The patient was disorganized with police and emergency room staff, and he was ultimately detained on a 72-hour Involuntary Treatment Act for grave disability.,On the interview, the patient is still disorganized and confused. He believes that he has been arrested and is in jail. Reports a history of mental health treatment, but denies benefiting from this in the past and does not think that it is currently necessary.,I was able to contact his partner by telephone. His partner reports the patient is paranoid and has bizarre behavior at baseline over the time that he has known him for the last 16 years, with occasional episodes of symptomatic worsening, from which he spontaneously recovers. His partner estimates the patient spends about 20% of the year in episodes of worse symptoms. His partner states that in the last one to two months, the patient has become worse than he has ever seen him with increased paranoia above the baseline and he states the patient has been barricading himself in his house and unplugging all electrical appliances for unclear reasons. He also reports the patient has been sleeping less and estimates his average duration to be three to four hours a night. He also reports the patient has been spending money impulsively in the last month and has actually incurred overdraft charges on his checking account on three different occasions recently. He also reports that the patient has been making threats of harm to him and that His partner no longer feels that he is safe having him at home. He reports that the patient has been eating regularly with no recent weight loss. He states that the patient is observed responding to internal stimuli, occasionally at baseline, but this has gotten worse in the last few months. His partner was unaware of any obvious medical changes in the last one to two months coinciding with onset of recent symptomatic worsening. He reports of the patient's longstanding poor compliance with treatment of his mental health or age-related conditions and attributes this to the patient's dislike of taking medicine. He also reports that the patient has expressed the belief in the past that he does not suffer from either condition.,PAST PSYCHIATRIC HISTORY: , The patient's partner reports that the patient was diagnosed with schizophrenia in his 20s and he has been hospitalized on two occasions in the 1980s and that there was a third admission to a psychiatric facility, but the date of this admission is currently unknown. The patient was last enrolled in an outpatient mental health treatment in mid 2009. He dropped out of care about six months ago when he moved with his partner. His partner reports the patient was most recently prescribed Seroquel, which, though the patient denied benefiting from, his partner felt was "useful, but not dosed high enough." Past medication trials that the patient reports include Haldol and lithium, neither of which he found to be particularly helpful.,MEDICAL HISTORY: , The patient reports being diagnosed with HIV and AIDS in 1994 and believes this was secondary to unprotected sexual contact in the years prior to his diagnosis. He is currently followed at Clinic, where he has both an assigned physician and a case manager, but treatment compliance has been poor with no use of antiretroviral meds in the last year. The patient is fairly vague on his history of AIDS related conditions, but does identify the following: Thrush, skin lesions, and lung infections; additional details of these problems are not currently known.,CURRENT MEDICATIONS: , None.,ALLERGIES:, No known drug allergies.,SOCIAL AND DEVELOPMENTAL HISTORY: , The patient lives with his partner. He is unemployed. Details of his educational and occupational history are not currently known. His source of finances is also unknown, though social security disability is presumed.,SUBSTANCE AND ALCOHOL HISTORY: , The patient smoked one to two packs per day for most of the last year, but has increased this to two to three packs per day in the last month. His partner reports that the patient consumed alcohol occasionally, but denies any excessive or binge use recently. The patient reports smoking marijuana a few times in his life, but not recently. Denies other illicit substance use.,LEGAL HISTORY: ,Unknown.,GENETIC PSYCHIATRIC HISTORY:, Also unknown.,MENTAL STATUS EXAM:,Attitude: The patient demonstrates only variable cooperation with interview, requires frequent redirection to respond to questions. His appearance is cachectic. The patient is poorly groomed.,Psychomotor: There is no psychomotor agitation or retardation. No other observed extrapyramidal symptoms or tardive dyskinesia.,Affect: His affect is fairly detached.,Mood: Describes his mood is "okay.",Speech: His speech is normal rate and volume. Tone, his volume was decreased initially, but this improved during the course of the interview.,Thought Process: His thought processes are markedly tangential.,Thought content: The patient is fairly scattered. He will provide history with frequent redirection, but he does not appear to stay on one topic for any length of time. He denies currently auditory or visual hallucinations, though his partner says that this is a feature present at baseline. Paranoid delusions are elicited.,Homicidal/Suicidal Ideation: He denies suicidal or homicidal ideation. Denies previous suicide attempts.,Cognitive Assessment: Cognitively, he is alert and oriented to person and year only. His memory is intact to names of his Madison Clinic providers.,Insight/Judgment: His insight is absent as evidenced by his repeated questioning of the validity of his AIDS and mental health diagnoses. His judgment is poor as evidenced by his longstanding pattern of minimal engagement in treatment of his mental health and physical health conditions.,Assets: His assets include his housing and his history of supportive relationship with his partner over many years.,Limitations: His limitations include his AIDS and his history of poor compliance with treatment.,FORMULATION: ,The patient is a 45-year-old white male with a history of schizophrenia and AIDS. He was admitted for disorganized and assaultive behaviors while off all medications for the last six months. It is unclear to me how much his presentation is a direct expression of an AIDS-related condition, though I suspect the impact of his HIV status is likely to be substantial.,DIAGNOSES:,AXIS I: Schizophrenia by history. Rule out AIDS-induced psychosis. Rule out AIDS-related cognitive disorder.,AXIS II: Deferred.,AXIS III: AIDS (stable by his report). Anemia.,AXIS IV: Relationship strain and the possibility that he may be unable to return to his home upon discharge; minimal engagement in mental health and HIV-related providers.,AXIS V: Global Assessment Functioning is currently 15.,PLAN: , I will attempt to increase the database, will specifically request records from the last mental health providers. The Internal Medicine Service will evaluate and treat any acute medical issues that could be helpful to collaborate with his providers at Clinic regarding issues related to his AIDS diagnosis. With the patient's permission, I will start quetiapine at a dose of 100 mg at bedtime, given the patient's partner report of partial, but response to this agent in the past. I anticipate titrating further for effect during the course of his admission.

Patient with a history of PTSD, depression, and substance abuse.

Psychiatry / Psychology

Psych Consult - Psychosis

IDENTIFYING DATA:, Psychosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 28-year-old Samoan female who was her grandmother's caretaker. Her grandmother unfortunately had passed away recently and then the patient had developed erratic behavior. She had lived with her parents and son, but parents removed son from the home, secondary to the patient's erratic behavior. Recently, she was picked up by Kent Police Department "leaping on Highway 99.",PAST MEDICAL HISTORY: , PTSD, depression, and substance abuse.,PAST SURGICAL HISTORY: ,Unknown.,ALLERGIES:, Unknown.,MEDICATIONS: , Unknown.,REVIEW OF SYSTEMS: , Unable to obtain secondary to the patient being in seclusion.,OBJECTIVE:, Vital signs that were previously taken revealed a blood pressure of 152/86, pulse of 106, respirations of 18, and temperature is 97.6 degrees Fahrenheit. General appearance, HEENT, and history and physical examination was unable to be obtained today, as patient was put into seclusion.,LABORATORY DATA: , Laboratory reviewed reveals a BMP, slightly elevated glucose at 100.2. Previous urine tox was positive for THC. Urinalysis was negative, but did note positive UA wbc's. CBC, slightly elevated leukocytosis at 12.0, normal range is 4 to 11.,ASSESSMENT AND PLAN:,AXIS I: Psychosis. Inpatient Psychiatric Team to follow.,AXIS II: Deferred.,AXIS III: We were unable to perform physical examination on the patient today secondary to her being in seclusion. Laboratory was reviewed revealing leukocytosis, possibly secondary to a UTI. We will wait until the patient is out of seclusion to perform examination. Should she have some complaints of dysuria or any suprapubic pain, then we will begin on appropriate antimicrobial therapy. We will followup with the patient should any new medical issues arise.

psychiatry / psychology, ptsd, depression, psychosis, psychiatric, substance abuse, erratic behavior, behavior, axis,

The patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home.

Psychiatry / Psychology

Psych Consult - Psychosis - 1

IDENTIFYING DATA: , This is a 26-year-old Caucasian male of unknown employment, who has been living with his father.,CHIEF COMPLAINT AND/OR REACTION TO HOSPITALIZATION: , The patient is unresponsive.,HISTORY OF PRESENT ILLNESS: , The patient was found by outpatient case manager to be unresponsive and incontinent of urine and feces at his father's home. It is unknown how long the patient has been decompensated after a stay at Hospital.,PAST PSYCHIATRIC HISTORY: , Inpatient ITA stay at Hospital one year ago, outpatient at Valley Cities, but currently not engaged in treatment.,MEDICAL HISTORY: , Due to the patient being unresponsive and very little information available in the chart, the only medical history that we can identify is to observe that the patient is quite thin for height. He is likely dehydrated, as it appears that he has not had food or fluids for quite some time.,CURRENT MEDICATIONS:, Prior to admission, we do not have that information. He has been started on Ativan 2 mg p.o. or IM if he refuses the p.o. and this would be t.i.d. to treat the catatonia.,SOCIAL AND DEVELOPMENTAL HISTORY: ,The patient has been living in his father's home and this is all the information that we have available from the chart.,SUBSTANCE AND ALCOHOL HISTORY: ,It is unknown with the exception of nicotine use.,LEGAL HISTORY: , Unknown.,GENETIC PSYCHIATRIC HISTORY: , Unknown.,MENTAL STATUS EXAM:,Attitude: The patient is unresponsive.,Appearance: He is lying in bed in the fetal position with a blanket over his head.,Psychomotor: Catatonic.,EPS/TD: Unable to assess though his limbs are quite contracted.,Affect: Unresponsive.,Mood: Unresponsive.,Speech: Unresponsive.,Thought Process And Thought Content: Unresponsive.,Psychosis: Unable to elicit information to make this assessment.,Suicidal/Homicidal: Also unable to elicit this information.,Cognitive Assessment: Unable to elicit.,Judgment And Insight: Unable to elicit.,Assets: The patient is young.,Limitations: Severe decompensation.,FORMULATION: ,This is a 26-year-old Caucasian male with a diagnosis of psychosis, NOS, admitted with catatonia.,DIAGNOSES:,AXIS I: Psychosis, NOS.,AXIS II: Deferred.,AXIS III: Dehydration.,AXIS IV: Severe.,AXIS V: 10.,ESTIMATED LENGTH OF STAY: , 10 to 14 days.,RECOMMENDATIONS AND PLAN:,1. Stabilize medically from the dehydration per internal medicine.,2. Medications, milieu therapy to assist with re-compensation.

Psychiatric consultation for management of pain medications.

Psychiatry / Psychology

Psych Consult - Pain Meds

REASON FOR CONSULTATION: , Management of pain medications.,HISTORY OF PRESENT ILLNESS: , This is a 60-year-old white male with history of coronary artery disease, status post CABG in 1985 with subsequent sternal dehiscence with rewiring in December 2005 and stent placement in LAD region in 2005, who developed sudden chest pain and was taken to San Jacinto via ambulance where he was diagnosed with acute MI and then went into atrial fibrillation. An intraaortic balloon pump was placed for cardiogenic shock, and then he was transferred to the ABCD Hospital on October 22, 2006, for continued critical care. He was in a state of cardiogenic shock and multiorgan system failure including respiratory failure and acute renal insufficiency when he was transferred. He is currently on dialysis due to end-stage renal disease and has a tracheostomy. He is receiving fentanyl since he has been here for back pain, leg pain, abdominal pain, and pain in the feet. He states that he is currently in pain and the fentanyl only helps for about an hour or so before the pain resumes. He currently rates his pain as 7 out of 10. He denies a depressed mood or anxiety and states that he knows he is getting better. He describes his sleep as erratic and states that he will sleep for 1 hour after giving fentanyl IV and then will wake up until he gets another fentanyl. He has PEG for tube feeding. He has weakness on left side of his body as well as both legs since his MI. He has been switched from fentanyl IV q.2h. to the fentanyl patch today. He also has been started on Seroquel 12.5 mg p.o. at bedtime and will receive his first dose on the evening of Monday, February 12, 2007. He denies any other psychiatric symptoms including auditory or visual hallucinations or delusions. His wife was present in the room and both him and his wife seemed to be offended by the suggestion of any psychiatric history or any psychiatric problems.,PAST MEDICAL HISTORY:,1. DVT in December 2005.,2. Three MI's (1996, 2005, and 2006).,3. Diabetes for 5 years.,4. Coronary artery disease for 10 years.,PAST SURGERIES:,1. Appendectomy as a child.,2. CABG x3, November 2005.,3. Sternal rewiring, December 2005.,MEDICATIONS:,1. Restoril 7.5 mg p.o. at bedtime p.r.n.,2. Acetaminophen 650 mg p.o. q.6h. p.r.n. fever.,3. Aspirin 81 mg p.o. daily.,4. Bisacodyl suppository 10 mg per rectum daily.,5. Erythropoietin injection 100 mcg subcutaneously every week at 5 p.m.,6. Esomeprazole 40 mg IV q.12h.,7. Fentanyl patch 25 mcg per hour.,8. Transderm patch every 72 hours.,9. Heparin IV.,10. Lactulose 30 mL p.o. daily p.r.n. constipation.,11. Metastron injection 4 mg IV q.6h. p.r.n. nausea.,12. Seroquel 12 mg p.o. at bedtime.,13. Saliva substitute 30 mL spray p.o. q.3h. p.r.n. dry mouth.,14. Simethicone drops 80 mg per G-tube p.r.n. gas pain.,15. Bactrim suspension p.o. daily.,16. Insulin medium dose sliding scale.,17. Albumin 25% IV p.r.n. hemodialysis.,18. Ipratropium solution for nebulizer.,ALLERGIES:, No known drug allergies.,PAST PSYCHIATRIC HISTORY:, The patient denies any past psychiatric problems. No medications. He denies any outpatient visits or inpatient hospitalizations for psychiatric reasons.,SOCIAL HISTORY:, He lives with his wife in New Jersey. He has 2 children. One son in Texas City and 1 daughter in Florida. He is a master mechanic for a trucking company since 1968. He retired in the May 2006. The highest level of education that he received was 1 year in college.,Ethanol, tobacco, or drugs; he smoked 2 packs per day for 40 years, but quit in 1996. He occasionally has a beer, but denies any continuous use of alcohol. He denies any illicit drug use.,FAMILY HISTORY:, Both parents died with myocardial infarctions. He has 2 sisters and a brother with diabetes mellitus and coronary artery disease. He denies any history of psychiatric problems in family.,MENTAL STATUS EXAMINATION:, The patient was sitting in his bed in hospital gown with tracheostomy and receiving tube feeding. The patient's appearance was appropriate with fair-to-good grooming and hygiene. He had little-to-no psychomotor activity secondary to weakness post MI. He had good eye contact. His speech was of decreased rate volume and flexion secondary to tracheostomy. The patient was cooperative. He described his mood is not good in congruent stable and appropriate affect with decreased range. His thought process is logical and goal directed. His thought content was negative for delusions, phobias, obsessions, suicidal ideation, or homicidal ideation. He denied any perceptional disturbances including any auditory or visual hallucinations. He was alert and oriented x3.,Mini mental status exams not completed.,ASSESSMENT:,AXIS I: Pain with physical symptoms and possibly psychological symptoms.,AXIS II: Deferred.,AXIS III: See above.

Psychiatric Consultation of patient with altered mental status.

Psychiatry / Psychology

Psych Consult - Altered Mental Status

REASON FOR CONSULT:, Altered mental status.,HPI:, The patient is 77-year-old Caucasian man with benign prostatic hypertrophy, status post cardiac transplant 10 years ago who was admitted to the Physical Medicine and Rehab Service for inpatient rehab after suffering a right cerebellar infarct last month. Last night, he became confused and he eloped from the unit. When he was found, he became combative. This a.m., he continued to be aggressive and required administration of four-point soft restraints in addition to Haldol 1 mg intramuscularly. There was also documentation of him having paranoid thoughts that his wife was going out spending his money instead of being with him in the hospital. Given this presentation, Psychiatry was consulted to evaluate and offer management recommendations.,The patient states that he does remember leaving the unit looking for his wife, but does not recall becoming combative, needing restrains and emergency medications. He reports feeling fine currently, denying any complaints. The patient's wife notes that her husband might be confused and disoriented due to being in the hospital environment. She admits that he has some difficulty with memory for sometime and becomes irritable when she is not around. However, he has never become as combative as he has this particular episode.,He negates any symptoms of depression or anxiety. He also denies any hallucinations or delusions. He endorses problems with insomnia. At home, he takes temazepam. His wife and son note that the temazepam makes him groggy and disoriented at times when he is at home.,PAST PSYCHIATRIC HISTORY:, He denies any prior psychiatric treatment or intervention. However, he was placed on Zoloft 10 years ago after his heart transplant, in addition to temazepam for insomnia. During this hospital course, he was started on Seroquel 20 mg p.o. q.h.s. in addition to Aricept 5 mg daily. He denies any history of suicidal or homicidal ideations or attempts.,PAST MEDICAL HISTORY:,1. Heart transplant in 1997.,2. History of abdominal aortic aneurysm repair.,3. Diverticulitis.,4. Cholecystectomy.,5. Benign prostatic hypertrophy.,ALLERGIES:, MORPHINE AND DEMEROL.,MEDICATIONS:,1. Seroquel 50 mg p.o. q.h.s., 25 mg p.o. q.a.m.,2. Imodium 2 mg p.o. p.r.n., loose stool.,3. Calcium carbonate with vitamin D 500 mg b.i.d.,4. Prednisone 5 mg p.o. daily.,5. Bactrim DS Monday, Wednesday, and Friday.,6. Flomax 0.4 mg p.o. daily.,7. Robitussin 5 mL every 6 hours as needed for cough.,8. Rapamune 2 mg p.o. daily.,9. Zoloft 50 mg p.o. daily.,10. B vitamin complex daily.,11. Colace 100 mg b.i.d.,12. Lipitor 20 mg p.o. q.h.s.,13. Plavix 75 mg p.o. daily.,14. Aricept 5 mg p.o. daily.,15. Pepcid 20 mg p.o. daily.,16. Norvasc 5 mg p.o. daily.,17. Aspirin 325 mg p.o. daily.,SOCIAL HISTORY:, The patient is a retired paster and missionary to Mexico. He is still actively involved in his church. He denies any history of alcohol or substance abuse.,MENTAL STATUS EXAMINATION:, He is an average-sized white male, casually dressed, with wife and son at bedside. He is pleasant and cooperative with good eye contact. He presents with paucity of speech content; however, with regular rate and rhythm. He is tremulous which is worse with posturing also some increased motor tone noted. There is no evidence of psychomotor agitation or retardation. His mood is euthymic and supple and reactive, appropriate to content with reactive affect appropriate to content. His thoughts are circumstantial but logical. He defers most of his responses to his wife. There is no evidence of suicidal or homicidal ideations. No presence of paranoid or bizarre delusions. He denies any perceptual abnormalities and does not appear to be responding to internal stimuli. His attention is fair and his concentration impaired. He is oriented x3 and his insight is fair. On mini-mental status examination, he has scored 22 out of 30. He lost 1 for time, lost 1 for immediate recall, lost 2 for delayed recall, lost 4 for reverse spelling and could not do serial 7s. On category fluency, he was able to name 17 animals in one minute. He was unable to draw clock showing 2 minutes after 10. His judgment seems limited.,LABORATORY DATA:, Calcium 8.5, magnesium 1.8, phosphorous 3, pre-albumin 27, PTT 24.8, PT 14.1, INR 1, white blood cell count 8.01, hemoglobin 11.5, hematocrit 35.2, and platelet count 255,000. Urinalysis on January 21, 2007, showed trace protein, trace glucose, trace blood, and small leukocyte esterase.,DIAGNOSTIC DATA:, MRI of brain with and without contrast done on January 21, 2007, showed hemorrhagic lesion in right cerebellar hemisphere with diffuse volume loss and chronic ischemic changes.,ASSESSMENT:,AXIS I:,1. Delirium resulting due to general medical condition versus benzodiazepine ,intoxication/withdrawal.,2. Cognitive disorder, not otherwise specified, would rule out vascular dementia.,3. Depressive disorder, not otherwise specified.

Psychiatric consultation of patient with lethargy.

Psychiatry / Psychology

Psych Consult - Lethargy

REASON FOR CONSULTATION: , Lethargy.,HISTORY OF PRESENT ILLNESS:, The patient is a 62-year-old white female with a past medical history of left frontal glioblastoma with subsequent craniotomy infection for PE, DVT, hyperlipidemia, and hypertension who is according to the patient's daughter expressing signs of depression. Symptoms began on February 5, 2007, upon receiving the unexpected news, the patient would need three to four more days of chemotherapy and radiation therapy for her glioblastoma, described as a sudden onset of symptoms including hypersomnia (18 to 20 hours per day), drastic decrease in energy level, anhedonia, feelings of hopelessness and helplessness, psychomotor retardation, and past history of suicidal ideations. The patient's appetite is unknown since she had been fed by NG tube after being diagnosed with neuromuscular oropharyngeal dysphagia. Prior to receiving the news for needing more cancer therapy, the patient was described as being "fine," participating in physical therapy and talking regularly as she was looking forward to leaving the hospital. Now, the patient has become angry, socially withdrawn, not wanting to see anyone including her own grandchildren, and not participating in physical therapy. Has been on a daily dose of Lexapro since January 08, 2007, was increased from 10 mg to 20 mg on January 24, 2007, which is her current dose. Has been on Provigil 100 mg b.i.d. since February 06, 2007, but has not noticed an impact. Had been on Zyprexa 2.5 mg p.o. q.p.m. from December 20, 2006, to February 01, 2007, but has been discontinued. Currently, the patient has not displayed any manic symptoms, auditory or visual hallucinations, or symptoms of anxiety. Also, denies any homicidal ideations.,PAST PSYCHIATRIC HISTORY:, Was prescribed Prozac for depression, felt during husband's successful battle with prostate cancer. Never been diagnosed with psychiatric illness. Displayed some psychotic symptoms, status post craniotomy while in ICU, treated with Zyprexa and Xanax during hospitalization in 2006.,PAST MEDICAL HISTORY:, Craniotomy November 2006 with subsequent CSF infection of enterobacter, status post glioblastoma multiforme, PE, DVT, hypertension, SIADH, and IVC filter. No history of thyroid problems, seizures, strokes, or traumatic head injuries.,HOME MEDICATIONS:, Norvasc 5 mg daily, TriCor 145 mg daily, aspirin one tablet daily, Tylenol, and glucosamine chondroitin sulfate.,CURRENT MEDICATIONS:, Norvasc 10 mg p.o. daily, Decadron injection 6 mg IV q.12h., Colace 100 mg liquid b.i.d., Cardura 2 mg p.o. daily, Lexapro 20 mg p.o. daily, Lopressor 50 mg p.o. q.12h., Flagyl 500 mg via PEG tube q.8h., modafinil 100 mg p.o. b.i.d., Lovenox 60 mg subcu q.12h., insulin sliding scale, Tylenol suppositories 650 mg rectal q.4h. p.r.n., and Ambien 5 mg p.o. q.h.s. p.r.n.,ALLERGIES:, PHENYTOIN (STEVENS-JOHNSON SYNDROME), CODEINE, NOVOCAIN, UNKNOWN ALLERGY.,FAMILY MEDICAL HISTORY:, Father had lung cancer, was smoker for 40 years. Father's aunt have heart disease.,SOCIAL AND DEVELOPMENTAL HISTORY:, Currently lives with husband of 40 years in League City, has a Masters in Education, is a retired reading specialist which she did it for 33 years. Has one younger brother, one daughter. Denies use of tobacco, alcohol and illicit drugs. The child as per daughter was picked on and has a strained relationship with her mother, but they still are communicating.,MENTAL STATUS EXAMINATION:, The patient is a 62-year-old white female, lying in hospital bed, with gown on, eyes closed, short shaven hair, and golf ball-sized indentation in the anterior fontanelle from craniotomy. Psychomotor retardation, poor eye contact, speech low volume, slow rate, poor flexion, essentially unresponsive, and somnolent during interview. Poor concentration, mood unknown (the patient did not respond to questions), affect flat, thought process logical and goal directed, thought content unable to assess from the patient but the patient's daughter denied delusions and homicidal ideations. Positive for passive suicidal ideations and perceptions. No auditory or visual hallucinations. Sensorium stuporous, did not answer orientation questions. Memory information, intelligence, judgment, and insight unknown.,Mini-Mental status examination unable to be performed.,ASSESSMENT:, A 62-year-old white female status post craniotomy for glioblastoma multiforme with subsequent CNS infection and currently has been displaying symptoms of depression for the past seven days and hence was told she needed more chemotherapy and radiation therapy.,Axis I: Depression, NOS. Rule out depression secondary to general medical condition.,Axis II: Deferred.,Axis III: Craniotomy with subsequent CSF infection, PE, DVT, and hypertension.,Axis IV: Hospitalization.,Axis V: 11.,PLAN:, Continue Lexapro 20 mg p.o. daily. Discontinue Provigil, begin Ritalin 5 mg p.o. q.a.m. and q. noon.,Thank you for the consultation.

Psychiatric Consultation of patient with major depression disorder.

Psychiatry / Psychology

Psych Consult - Depression - 2

REASON FOR CONSULT:, Depression.,HPI:, The patient is an 87-year-old white female admitted for low back pain status post hip fracture sustained a few days before Thanksgiving in 2006. The patient was diagnosed and treated for a T9 compression fraction with vertebroplasty. Soon after discharge, the patient was readmitted with severe mid low back pain and found to have a T8 compression fracture. This was also treated with vertebroplasty. The patient is now complaining of back pain that fluctuates at time, acknowledging her pain medication works but not all the time. Her pain is in her upper back around her shoulder blades. The patient says lying down with the heated pad lessens the pain and that any physical activity increases it. MRI on January 29, 2007, was positive for possible meningioma to the left of anterior box.,The patient reports of many depressive symptoms, has lost all interest in things she used to do (playing cards, reading). Has no energy to do things she likes, but does participate in physical therapy, cries often and what she believes for no reason. Does not see any future for herself. Reports not being able to concentrate on anything saying she gets distracted by thoughts of how she does not want to live anymore. Admits to decreased appetite, feeling depressed, and always wanting to be alone. Claims that before her initial hospitalization for her hip fracture, she was highly active, enjoyed living independently at Terrace. Denies suicidal ideations and homicidal ideations, but that she did not mind dying, and denies any manic symptoms including decreased need to sleep, inflated self-worth, and impulsivity. Denies auditory and visual hallucinations. No paranoid, delusions, or other abnormalities of thought content. Denies panic attacks, flashbacks, and other feelings of anxiety. Does admit to feeling restless at times. Is concerned with her physical appearance while in the hospital, i.e., her hair looking "awful.",PAST MEDICAL HISTORY:, Hypertension, cataracts, hysterectomy, MI, osteoporosis, right total knee replacement in April 2004, hip fracture, and newly diagnosed diabetes. No history of thyroid problems, seizures, strokes, or head injuries.,CURRENT MEDICATIONS:, Norvasc 10 mg p.o. daily, aspirin 81 mg p.o. daily, Lipitor 20 mg p.o. daily, Klonopin 0.5 mg p.o. b.i.d., digoxin 0.125 mg p.o. daily, Lexapro 10 mg p.o. daily, TriCor 145 mg p.o. each bedtime, Lasix 20 mg p.o. daily, Ismo 20 mg p.o. daily, lidocaine patch, Zestril, Prinivil 40 mg p.o. daily, Lopressor 75 mg p.o. b.i.d., Starlix 120 mg p.o. t.i.d., Pamelor 25 mg p.o. each bedtime, polyethylene glycol 17 g p.o. every other day, potassium chloride 20 mEq p.o. t.i.d., Norco one tablet p.o. q.4h. p.r.n., Zofran 4 mg IV q.6h.,HOME MEDICATIONS:, Unknown.,ALLERGIES:, CODEINE (HALLUCINATIONS).,FAMILY MEDICAL HISTORY:, Unremarkable.,PAST PSYCHIATRIC HISTORY:, Unremarkable. Never taken any psychiatric medications or have ever had a family member with psychiatric illness.,SOCIAL/DEVELOPMENTAL HISTORY:, Unremarkable childhood. Married for 40 plus years, widowed in 1981. Worked as administrative assistant in UTMB Hospitals VP's office. Two children. Before admission, lived in the Terrace Independent Living Center. Was happy and very active while living there. Had friends in the Terrace and would not mind going back there after discharge. Occasional glass of wine at dinner. Denies ever using illicit drugs and tobacco.,MENTAL STATUS EXAM:, The patient is an 87-year-old white female with appropriate appearance, wearing street clothes while lying in bed with her eyes tightly closed. Slight decrease in motor activity. Normal eye contact. Speech, low volume and rate. Good articulation and inflexion. Normal concentration. Mood, labile, tearful at times, depressed, then euthymic. Affect, mood congruent, full range. Thought process, logical and goal directed. Thought content, no delusions, suicidal or homicidal ideations. Perception, no auditory or visual hallucinations. Sensorium, alert, and oriented x3. Memory, fair. Information and intelligence, average. Judgment and insight, fair.,MINI MENTAL STATUS EXAM,: A 28/30. Could not remember two out of the three recalled words.,ASSESSMENT:, The patient is an 87-year-old white female with recent history of hip fracture and two thoracic compression fractures. The patient reports being high functioning prior to admission and says her depression symptoms have occurred while being in the hospital.,Axis I: Major depression disorder.,Axis II: Deferred.,Axis III: Osteoporosis, hypertension, hip fracture, possible diabetes, meningioma, MI, and right total knee replacement.,Axis IV: Lives independently at Terrace, difficulty walking, hospitalization.,Axis V: 45.,PLAN:, Continue Lexapro 10 mg daily and Pamelor 25 mg each bedtime monitor for adverse effects of TCA and worsening of depressive symptoms. Discussed about possible inpatient psychiatric care.,Thank you for the consultation.

Psychiatric Consultation of patient with dementia.

Psychiatry / Psychology

Psych Consult - Dementia

REASON FOR CONSULT,: Dementia.,HISTORY OF PRESENT ILLNESS: ,The patient is a 33-year-old black female, referred to the hospital by a neurologist in Tyler, Texas for disorientation and illusions. Symptoms started in June of 2006, when the patient complained of vision problems and disorientation. The patient was seen wearing clothes inside out along with other unusual behaviors. In August or September of 2006, the patient reported having a sudden onset of headaches, loss of vision, and talking sporadically without making any sense. The patient sought treatment from an ophthalmologist. We did not find any abnormality in the Behavior Center in Tyler, Texas. The Behavior Center referred the patient to Dr. Abc, a neurologist in Tyler, who then referred the patient to this hospital.,According to the mother, the patient has had no past major medical or psychiatric illnesses. The patient was functioning normally before June 2006, working as accounting tech after having completed 2 years of college. She reports of worsening in symptoms, mainly unable to communicate about auditory or visual hallucinations or any symptoms of anxiety. Currently, the patient lives with mother and requires her assistance to perform ADLs and the patient has become ataxic since November 2006. Sleeping patterns and the amount is unknown. Appetite is okay.,PAST PSYCHIATRIC HISTORY:, The patient was diagnosed with severe depression in November 2006 at the Behavior Center in Tyler, Texas, where she was given Effexor. She stopped taking it soon after, since they worsened her eye vision and balance.,PAST MEDICAL HISTORY: , In 2001 diagnosed with Meniere disease, was treated such that she could function normally in everyday activities including work. No current medications. Denies history of seizures, strokes, diabetes, hypertension, heart disease, or head injury.,FAMILY MEDICAL HISTORY: ,Father's grandmother was diagnosed with Alzheimer disease in her 70s with symptoms similar to the patient described by the patient's mother. Both, the mother's father and father's mother had "nervous breakdowns" but at unknown dates.,SOCIAL HISTORY: , The patient lives with a mother, who takes care of the patient's ADLs. The patient completed school, up to two years in college and worked as accounting tech for eight years. Denies use of alcohol, tobacco, or illicit drugs.,MENTAL STATUS EXAMINATION: , The patient is 33-year-old black female wearing clean clothes, a small towel on her head and over a wheel chair with her head rested on a pillow and towel. Decreased motor activity, but did blink her eyes often, but arrhythmically. Poor eye contact. Speech illogic. Concentration was not able to be assessed. Mood is unknown. Flat and constricted affect. Thought content, thought process and perception could not be assessed. Sensorial memory, information, intelligence, judgment, and insight could not be evaluated due to lack of communication by the patient.,MINI-MENTAL STATUS EXAM: , Unable to be performed.,AXIS I: Rapidly progressing early onset of dementia, rule out dementia secondary to general medical condition, rule out dementia secondary to substance abuse.,AXIS II: Deferred.,AXIS III: Deferred.,AXIS IV: Deferred.,AXIS V: 1.,ASSESSMENT: , The patient is a 32-year-old black female with rapid and early onset of dementia with no significant past medical history. There is no indication as to what precipitated these symptoms, as the mother is not aware of any factors and the patient is unable to communicate. The patient presented with headaches, vision forms, and disorientation in June 2006. She currently presents with ataxia, vision loss, and illusions.,PLAN: , Wait for result of neurological tests. Thank you very much for the consultation.

psychiatry / psychology, reason for consult:, concentration, dementia, mood, psychiatric consultation, sensorial memory, affect, disorientation, illusions, information, insight, intelligence, judgment, loss of vision, motor activity, neurologist, thought process, unusual behaviors, mental status examination, consultation, headaches,

Psychiatric Consultation of patient with recurring depression.

Psychiatry / Psychology

Psych Consult - Depression - 1

CC: , "Five years ago, I stopped drinking and since that time, I have had severe depression. I was doing okay when I stopped my medications in April for a few weeks, but then I got depressed again. I started lithium three weeks ago.",HPI: ,The patient is a 45-year-old married white female without children currently working as a billing analyst for Northwest Natural. The patient has had one psychiatric hospitalization for seven days in April of 1999. The patient now presents with recurrent depressive symptoms for approximately four months. The patient states that she has decreased energy, suicidal ideation, suicide plan, feelings of guilt, feelings of extreme anger, psychomotor agitation, and increased appetite. The patient states her sleep is normal and her ability to concentrate is normal. The patient states that last night she had an argument with her husband in which he threaten to divorce her. The patient went into the rest room, tried to find a razor blade, could not find one but instead found a scissor and cut her arm moderately with some moderate depth. She felt better after doing so and put a bandage over the wound and did not report to her husband or anybody else what she had done. The patient reports that she has had increased tension with her husband as of recent. She notes that approximately a week ago she struck her husband several times. She states that he has never hit her but instead pushed her back after she was hitting him. She reports no history of abuse in the past. The patient identifies recent stressors as having ongoing conflict at work with her administrator with them "cracking down on me." The patient also notes that her longstanding therapy will be temporarily interrupted by the therapist having a child. She states that her recent depression seems to coincide with her growing knowledge that her therapist was pregnant. The patient states that she has a tremendous amount of anger towards her therapist for discontinuing or postponing treatment. She states that she feels "abandoned." The patient notes that it does raise issues with her past, where she had a child at the age of 17 who she gave away for adoption and a second child that she was pregnant by the age of 42 that she aborted at the request of her husband. The patient states she saw her therapist most recently last Friday. She sees the therapy weekly and indicates the therapy helps, although she is unable to specify how. When asked for specifics of what she has learned from the therapy, the patient was unable to reply. It appears that she is very concrete and has difficulty with symbolization and abstractions and self-observation. The patient reports that at her last visit her therapist was concerned that she may be suicidal and was considering hospitalization. The patient, at that point, stated that she would be safe through Monday despite having made a gesture last night. At present, the patient's mood is reactive and for much of the session she appears angry and irritated with me but at the end of the session, after I have given her my assessment, she appears calmed and not depressed. When asked if she is suicidal at present, she states no. The patient does not want to go into the hospital. The patient also indicates at the end of the session she felt hopeful. The patient reports her current sleep is about eight hours per night. She states that longest she has been able to stay awake in the past has been 24 hours. She states that during periods where she feels up she sleeps perhaps six hours per night. The patient reports no spending sprees and no reports no sexual indiscretions. The patient states that her sexuality does increase when she is feeling better but not enormously so. The patient denies any history of delusions or hallucinations. The patient denies any psychosis. The patient states that she does have mood swings and that the upstate lasts for a couple of weeks at longest. She states that more predominately she has depression. The patient states that she does not engage in numerous projects when she is in an upstate although does imagine doing so. The patient notes that suicidality and depression seems to often arise around disputes with her husband and/or feelings of abandonment. The patient indicates some satisfaction when she is called on her behavior "I need to answer for my actions." The patient gives a substantial history of alcohol abuse lasting up to about five years ago when she was hospitalized. Most typically, the patient will drink at least a bottle of wine per day. The patient has attended AA but at present going once a week, although she states that she is not engaged as she has been in the past; and when asked if she may be in early relapse, she indicates that yes that is a very real possibility. The patient states she is not working through any of the steps at present.,PPH: , The patient denies any sexual abuse as a child. She states that she was disciplined primarily by her father with spankings. She states that on occasion her mother would use a belt to spank her or with her hand or with a spoon. The patient has been seeing Dr. A for the past five years. Prior to that she was admitted to a hospital for her suicide attempt. The patient also has one short treatment experienced with the Day Treatment Program here in Portland. The patient states that it was not useful as it focused on group work with pts that she did not feel any similarity with. The patient, also as a child, had a history of cutting behaviors. The patient was admitted to the hospital after lacerating her arm.,MEDICAL HISTORY: ,The patient has hypothyroidism and last had her TSH drawn a week ago but does not know the results. Janet Green is her primary physician. The patient also has had herniated disc in the neck and a sinus inflammation, both of which were treated surgically.,CURRENT MEDICATIONS: , The patient currently is taking Synthroid 75 mcg per day and lithium 1200 mg p.o. q.d. The patient started the lithium approximately three weeks ago and has not had a recent lithium level or kidney function test.,ALLERGIES: , No known drug allergies.,SUBSTANCE HISTORY: , The patient has been sober for five years. She drank one bottle of wine per day as per HPI. History of drinking for approximately 25 years. The patient does not currently have a sponsor. The patient experimented with amphetamines, cocaine, marijuana approximately 16 years ago.,SOCIAL HISTORY: , The patient's mother is age 66, father is age 70, and she has a brother age 44. Her brother has been incarcerated numerous times for assaults and has difficulty with anger and rage. He made a suicide attempt at age 17. The patient's father is a machinist who she describes as somewhat narcissistic and with alcohol abuse problem. He also has arthritis. The patient's mother is arthritic. She states that her mother stopped working at middle age after being laid off and appears somewhat reclusive.,EDUCATIONAL HISTORY: , The patient was educated through high school and has two years of Night College. The patient states that she grew up and was raised in Portland but notes her childhood was primarily lonely. She states she was unliked and unpopular child because she was "shy" and "not smart enough." The patient denies having secrets. The patient reports that this is her second marriage, which has lasted two years. Her first marriage lasted I believe it was five years. The patient also had a relationship in recovery for four years, which ended after they went "different directions.",MSE:, The patient is middle-aged white female, dressed in a red sweater with a white shirt, full patterned skirt, and open sandals. The patient is suspicious and somewhat confrontative early in the session. She asked me regarding my cancellation policy, why I require seven days and not 24 hours. The patient also is irritated with paper required of her. Psychomotor is increased slightly. The patient makes strong eye contact. Speech is normal rate, rhythm, and volume. Mood is "irritated." Affect is irritated, angry, demanding, attempting to wrest control from me, depressed, frustrated. Thought is directed. Content is nondelusional. There are no auditory and no visual hallucinations. The patient has no homicidal ideation. The patient does endorse suicidal ideations. Regarding plan, the patient notes that cutting herself hurts too much therefore she would like to take some benzodiazepines or barbiturates but has access to none. The patient states that she will not try to hurt herself currently and that she poses no risk at present. The patient notes that she does not want to go to the hospital at present. The patient is alert and oriented x 3. Recall is three for three at five minutes. Proverbs are concrete. She has fair impulse control, poor judgment, and poor insight.,FORMULATION: ,The patient is a 45-year-old married white female with no children now presenting with recurrent depressive symptoms and active suicidal ideation and planning. The patient reports longstanding depressive symptoms that were subthreshold punctuated by periods of more severe depression. The patient also reports some up periods, which do not meet most criteria for a bipolar disorder or manic states. The patient notes that current depression started with approximately the same time that she became aware that her therapist was pregnant. She notes that the current depression is atypical in that it is primarily anger based and she does not have the typical hypersomnia that she gets. The patient reports being unable to express anger to her therapist and being unable to discuss her feeling regarding the pregnancy. The patient also states that she feels abandoned with the upcoming discontinuation of treatment while the therapist is giving birth and thereafter. Symptoms are consistent with a longstanding dysthymia and reoccurring depression. In addition, diagnosis is highly complicated by presence of a strong personality disorder component, most likely borderline personality disorder. This latter diagnosis seems to be the most active at this time with the patient acutely reacting to perceived therapist's absence and departure. This is exacerbated by instability in the patient's marital life.,DIAGNOSIS:,Axis I: Dysthymia. Major depression, moderate severity, recurrent, with partial remission.,Axis II: Borderline personality disorder.,Axis III: Hypothyroidism and cervical disc herniation and sinus surgery.,Axis IV: Medical access. Marital discord.,Axis V: A GAF of 30.,PLAN: ,The patient is unlikely to have bipolar disorder. We will recommend the patient's thyroid be rechecked to ensure she is currently euthymic. We would recommend continued weekly or twice weekly insight oriented psychotherapy with aggressive exploration of the patient's reaction to her therapist's departure. We would also recommend dialectical behavioral therapy while the therapist is on leave. We would recommend continued treatment with SSRIs for dysthymia and depression. We would suggest prescribing long acting antidepressant such as Prozac, given the patient's ambivalence regarding medications. Prozac should be pushed to minimum of 40 mg, which the patient has already tolerated in the past, but most likely up to 60 or 80 mg. We might also supplement the Prozac with a (anti-sleep medication).,Time spent with the patient was 1.5 hours.

A 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.

Psychiatry / Psychology

Psych Consult - Bipolar Affective Disorder

IDENTIFYING DATA: , The patient is a 41-year-old African-American male with a history of bipolar affective disorder, was admitted for noncompliance to the outpatient treatment and increased mood lability.,CHIEF COMPLIANT: , "I'm here because I'm different." The patient exhibits poor insight into illness and need for treatment.,HISTORY OF PRESENT ILLNESS: , The patient has a history of bipolar affective disorder and poor outpatient compliance. According to mental health professionals, he had not been compliant with medications or outpatient followup, and over the past several weeks, the patient had become increasingly labile. The patient had expressed grandiose delusions that he is Martin Luther King, and was found recently at a local church agitated throwing a pew and a lectern and required Tasering by police. On admission interview, the patient remains euphoric with poor insight.,PAST PSYCHIATRIC HISTORY: , History of bipolar affective disorder. The patient has been treated with Depakote and Seroquel, but has had no recent treatment or followup. Dates of previous hospitalizations are not known.,PAST MEDICAL HISTORY: , None known.,CURRENT MEDICATIONS: , None.,FAMILY SOCIAL HISTORY: , Unemployed. The patient resides independently. The patient denies recent substance abuse, although tox screen was positive for benzodiazepines.,LEGAL HISTORY: , Need to increase database.,FAMILY PSYCHIATRIC HISTORY: , Need to increase database.,MENTAL STATUS EXAMINATION: ,Attitude: Suspicious, but cooperative.,Appearance: Shows appropriate hygiene and grooming.,Psychomotor Behavior: Within normal limits. No agitation or retardation. No EPS or TDS noted.,Affect: Labile.,Mood: Euphoric.,Speech: Pressured.,Thoughts: Disorganized.,Thought Content: Remarkable for grandiose delusions as noted. The patient denies auditory hallucinations.,Psychosis: Grandiose delusions as noted above.,Suicidal/Homicidal Ideation: The patient denies on admission.,Cognitive Assessment: Grossly intact. The patient is oriented x 3.,Judgment: Poor shown by noncompliance to the outpatient treatment.,Assets: Include stable physical status.,Limitations: Include recurrent psychosis.,FORMULATION: , The patient with a history of bipolar affective disorder, was admitted for increasing mood lability and noncompliance to the outpatient treatment.,INITIAL IMPRESSION:,AXIS I: BAD, manic with psychosis.,AXIS II: None.,AXIS III: None known.,AXIS IV: Severe.,AXIS V: 10.,ESTIMATED LENGTH OF STAY: , 12 days.,PLAN: , The patient will be restarted on Depakote for mood lability and Seroquel for psychosis and his response will be monitored closely. The patient will be evaluated for more structural outpatient followup following stabilization.

Psychiatric consultation for alcohol withdrawal and dependance.

Psychiatry / Psychology

Psych Consult - Alcohol Withdrawal

REASON FOR CONSULT:, Evaluation of alcohol withdrawal and dependance as well as evaluation of anxiety.,HISTORY OF PRESENT ILLNESS: , This is a 50-year-old male who was transferred from Sugar Land ER to ABCD Hospital for admission to the MICU for acute alcohol withdrawal. The patient had been on a drinking binge for the past 12 days prior to admission and had not been eating. He reported that he called 911 secondary to noticing bilious vomiting and dry heave. The patient has been drinking for the past 25 years and has noted it to be a problem for at least the past 3 years. He has been away from work secondary to alcohol cravings and drinking. He has also experienced marital and family conflict as a result of his drinking habit. On average, the patient drinks 5 to 8 glasses or cups of vodka or rum per day, and on the weekend, he tends to drink more heavily. He reports a history of withdrawal symptoms, but denied history of withdrawal seizures. His longest period of sobriety was one year, and this was due to the assistance of attending AA meetings. The patient reports problems with severe insomnia, more so late insomnia and low self esteem as a result of feeling guilty about what he has done to his family due to his drinking habit. He reports anxiety that is mostly related to concern about his wife's illness and fear of his wife leaving him secondary to his drinking habits. He denies depressive symptoms. He denies any psychotic symptoms or perceptual disturbances. There are no active symptoms of withdrawal at this time.,PAST PSYCHIATRIC HISTORY: , There are no previous psychiatric hospitalizations or evaluations. The patient denies any history of suicidal attempts. There is no history of inpatient rehabilitation programs. He has attended AA for periodic moments throughout the past few years. He has been treated with Antabuse before.,PAST MEDICAL HISTORY:, The patient has esophagitis, hypertension, and fatty liver (recently diagnosed).,MEDICATIONS: , His outpatient medications include Lotrel 30 mg p.o. q.a.m. and Restoril 30 mg p.o. q.h.s.,Inpatient medications are Vitamin supplements, potassium chloride, Lovenox 40 mg subcutaneously daily, Lactulose 30 mL q.8h., Nexium 40 mg IV daily, Ativan 1 mg IV p.r.n. q.6-8h.,ALLERGIES:, No known drug allergies.,FAMILY HISTORY: , Distant relatives with alcohol dependance. No other psychiatric illnesses in the family.,SOCIAL HISTORY:, The patient has been divorced twice. He has two daughters one from each marriage, ages 15 and 22. He works as a geologist at Petrogas. He has limited contact with his children. He reports that his children's mothers have turned them against him. He and his wife have experienced marital discord secondary to his alcohol use. His wife is concerned that he may loose his job because he has skipped work before without reporting to his boss. There are no other illicit drugs except alcohol that the patient reports.,PHYSICAL EXAMINATION:, VITAL SIGNS: Temperature 98, pulse 89, and respiratory rate 20, and blood pressure is 129/83.,MENTAL STATUS EXAMINATION:, This is a well-groomed male. He appears his stated age. He is lying comfortably in bed. There are no signs of emotional distress. He is pleasant and engaging. There are no psychomotor abnormalities. No signs of tremulousness. His speech is with normal rate, volume, and inflection. Mood is reportedly okay. Affect euthymic. Thought content, no suicidal or homicidal ideations. No delusions. Thought perception, there are no auditory or visual hallucinations. Thought process, Logical and goal directed. Insight and judgment are fair. The patient knows he needs to stop drinking and knows the hazardous effects that drinking will have on his body.,LABORATORY DATA:, CBC: WBC 5.77, H&H 14 and 39.4 respectively, and platelets 102,000. BMP: Sodium 140, potassium 3, chloride 104, bicarbonate 26, BUN 13, creatinine 0.9, glucose 117, calcium 9.5, magnesium 2.1, phosphorus 2.9, PT 13.4, and INR 1.0. LFTs: ALT 64, AST 69, direct bilirubin 0.5, total bilirubin 1.3, protein 5.8, and albumin 4.2. PFTs within normal limits.,IMAGING:, CAT scan of the abdomen and pelvis reveals esophagitis and fatty liver. No splenomegaly.,ASSESSMENT:, This is a 50-year-old male with longstanding history of alcohol dependence admitted secondary to alcohol withdrawal found to have derangement in liver function tests and a fatty liver. The patient currently has no signs of withdrawal. The patient's anxiety is likely secondary to situation surrounding his wife and their marital discord and the effect of chronic alcohol use. The patient had severe insomnia that is likely secondary to alcohol use. Currently, there are no signs of primary anxiety disorder in this patient.,DIAGNOSES:, Axis I: Alcohol dependence.,Axis II: Deferred.,Axis III: Fatty liver, esophagitis, and hypertension.,Axis IV: Marital discord, estranged from children.,Axis V: Global assessment of functioning equals 55.,RECOMMENDATIONS:,1. Continue to taper off p.r.n. Ativan and discontinue all Ativan prior to discharge, benzodiazepine use, also on the same receptor as alcohol and prolonged use can cause relapse in the patient. Discontinue outpatient Restoril. The patient has been informed of the hazards of using benzodiazepines along with alcohol.,2. Continue Alcoholics Anonymous meetings to maintain abstinence.,3. Recommend starting Campral 666 mg p.o. t.i.d. to reduce alcohol craving.,4. Supplement with multivitamin, thiamine, and folate upon discharge and before. Marital counseling strongly advised as well as individual therapy for patient once sobriety is reached. Referral has been given to the patient and his wife for the sets of counseling #713-263-0829.,5. Alcohol education and counseling provided during consultation.,6. Trazodone 50 mg p.o. q.h.s. for insomnia.,7. Follow up with PCP in 1 to 2 weeks.

The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.

Psychiatry / Psychology

Psych Consult - Assaultive Behavior

IDENTIFYING DATA: ,The patient is a 40-year-old white male. He is married, on medical leave from his job as a tree cutter, and lives with his wife and five children.,CHIEF COMPLAINT AND REACTION TO HOSPITALIZATION: ,The patient is admitted on a 72-hour involuntary treatment for dangerousness to others after repeated assaultive behaviors at Hospital Emergency Room, the morning prior to admission.,HISTORY OF PRESENT ILLNESS: ,The patient was very sleepy this morning, only minimally cooperative with interview. Additional information taken from the emergency room records that accompanied him from Hospital yesterday as well as from his wife, who I contacted by telephone. The patient was apparently at his stable baseline when discharged from the Hospital on 01/21/10, status post back surgery following a work-related injury. The patient returned to Emergency Room on the evening prior to admission complaining of severe back pain. His ER course is notable for yelling, spitting, and striking multiple staff members. The patient was originally to be admitted for pain control, but when he threatened to leave, he was referred to MHPs, who subsequently detained him for 72 hours for dangerousness to others. On interview, the patient reports only hazy memories of these incidences and states this behavior was secondary to his pain and his medications. He was contrite about the violence. When his wife was contacted by telephone, she agreed with this assessment and reports that he has a history of domestic violence usually in the setting of alcohol and illicit substance intoxication, but denies any events in the last 3 years.,His wife reports that after discharge from the hospital, on 01/21/10, he was prescribed Percocet, Soma, hydroxyzine, and Valium. He essentially exhausted his approximately 10 days' supply of these agents on the morning of 01/23/10, and as above believes that this was responsible for his presentation yesterday. She reports that she has been in contact with him since his arrival in our facility and reports that he is "back to normal." She denies feeling that he currently represents a threat to her or her five children. She was unaware of his mental health history, but denies that he has received care for any condition since they were married three years ago.,PAST PSYCHIATRIC HISTORY: , The patient has a history of Involuntary Treatment Act of 72 hours in our facility in 2004 or 2005 for assaultive behaviors; however, these records are not currently available for review. The patient denies any outpatient mental health treatment before or since this hospitalization. He describes his mental health diagnosis of bipolar affective disorder; however, he denies a history of dramatic mood swings in the absence of illicit substances or alcohol intoxication.,PAST MEDICAL HISTORY:, Notable for status post back surgery, discharged from Hospital on 01/21/10.,MEDICATIONS:, From discharge from Hospital on 01/21/10, include Percocet, Valium, Soma, and Vistaril, doses and frequency are not currently known. His wife reports that he was discharged with approximately 10 days' supply of these agents.,SOCIAL AND DEVELOPMENTAL HISTORY: ,The patient is employed as a tree cutter, currently on medical leave for the last 2 months following a back injury. He lives with his wife and children. He has a history of domestic violence, but not recently. Other details of occupational, educational history not currently known.,SUBSTANCE AND ALCOHOL HISTORY:, Records indicate a previous history of methamphetamine and alcohol abuse/dependence. The wife states that he has not consumed either since 12/07. Of note, urine tox screen at Hospital was positive for marijuana.,LEGAL HISTORY: ,The patient has been charged with domestic violence in the past, but his wife denies any repeat instances since in the last 3 years. It is not known whether the patient is currently on probation.,GENETIC PSYCHIATRIC HISTORY: , Unknown.,MENTAL STATUS EXAMINATION:,Attitude: The patient is only minimally cooperative with interview secondary to being sleepy, and after repeated attempts to ask questions, he rolled over and went to bed.,Appearance: He is unkempt and there are multiple visible tattoos on his biceps.,Psychomotor: There is no obvious psychomotor agitation or retardation. There are no obvious extrapyramidal symptoms of tardive dyskinesia.,Affect: His affect is notably restricted probably due to the fact that he is sleepy.,Mood: Describes his mood as "okay.",Speech: Speech is normal rate, volume, and tone.,Thought Processes: His thought processes appear to be linear.,Thought Content: His thought content is notable for his expressions of contrition about violence at Hospital last night. He denies suicidal or homicidal ideation.,Cognitive Assessment: Cognitively, he is alert and oriented to person, place, and date but not situation. Attributes this to not really remembering the events at Hospital that resulted in this hospitalization.,Judgment and Insight: His insight and judgment are both appear to be improving.,Assets: Include his supportive wife and the fact he has been able to remain alcohol and methamphetamine sobriety for the last 3 years.,Limitations: Include his back injury and possible need for improvement of health treatment engagement.,FORMULATION: ,This is a 40-year-old white male, who was admitted for an acute agitation in the setting of misuse of prescribed opiates, Soma, hydroxyzine, and Valium. He appears much improved from his condition at Hospital last night and I suspect that his behavior is most likely attributed to delirium and this since resolved. He reports historical diagnosis of bipolar affective disorder, however, the details of this diagnosis are not currently available for review.,DIAGNOSES:,AXIS I: Delirium, resolved (recent mental status changes likely secondary to misuse of prescribed opiates, Soma, Valium, and hydroxyzine.) Rule out bipolar affective disorder.,AXIS II: Deferred.,AXIS III: Chronic pain status post back surgery.,AXIS IV: Appears to be moderate. He is currently on medical leave from his job.,AXIS V: Global Assessment of Functioning is currently 50 (his GAF was 20 approximately 24 hours ago).,ESTIMATED LENGTH OF STAY:, Three days.,PLAN:, I will hold psychiatric medications for now given the patient's fairly rapid improvement as he cleared from the condition, I suspect is likely due to misuse of prescribed medications. The patient will be placed on CIWA protocol given that one of the medications he overused was Valium. Of note, he does not currently appear to be withdrawing and I anticipate that his CIWA will be discontinued prior to discharge. I would like to increase the database regarding the details of his historical diagnosis of bipolar affective disorder before pursuing referrals for outpatient mental health care. The internal medicine service will evaluate for treatment for any underlying medical problems specifically to provide recommendations regarding pain management.

The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.

Psychiatry / Psychology

Neuropsychological Evaluation - 4

REASON FOR REFERRAL:, The patient is a 58-year-old African-American right-handed female with 16 years of education who was referred for a neuropsychological evaluation by Dr. X. She is presenting for a second opinion following a recent neuropsychological evaluation that was ordered by her former place of employment that suggested that she was in the "early stages of a likely dementia" and was thereafter terminated from her position as a psychiatric nurse. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning. Note that this evaluation was undertaken as a clinical exam and intended for the purposes of aiding with treatment planning. The patient was fully informed about the nature of this evaluation and intended use of the results.,RELEVANT BACKGROUND INFORMATION: ,Historical information was obtained from a review of available medical records and clinical interview with the patient. A summary of pertinent information is presented below. Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM:, The patient reported that she had worked as a nurse supervisor for Hospital Center for four years. She was dismissed from this position in September 2009, although she said that she is still under active status technically, but is not able to work. She continues to receive some compensation through FMLA hours. She said that she was told that she had three options, to resign, to apply for disability retirement, and she had 90 days to complete the process of disability retirement after which her employers would file for charges in order for her to be dismissed from State Services. She said that these 90 days are up around the end of November. She said the reason for her dismissal was performance complaints. She said that they began "as soon as she arrived and that these were initially related to problems with her taking too much sick time off secondary to diabetes and fibromyalgia management and at one point she needed to obtain a doctor's note for any days off. She said that her paperwork was often late and that she received discipline for not disciplining her staff frequently enough for tardiness or missed workdays. She described it as a very chaotic and hectic work environment in which she was often putting in extra time. She said that since September 2008 she only took two sick days and was never late to work, but that she continued to receive a lot of negative feedback.,In July of this year, she reportedly received a letter from personnel indicating that she was being referred to a state medical doctor because she was unable to perform her job duties and due to excessive sick time. Following a brief evaluation with this doctor whose records we do not have, she was sent to a neuropsychologist, Dr. Y, Ph.D. He completed a Comprehensive Independent Medical Evaluation on 08/14/2009. She said that on 08/27/2009, she returned to see the original doctor who told her that based on that evaluation she was not able to work anymore. Please note that we do not have copies of any of her work-related correspondence. The patient never received a copy of the neuropsychological evaluation because she was told that it was "too derogatory." A copy of that evaluation was provided directly to this examiner for the purpose of this evaluation. To summarize, the results indicated "diagnostically, The patient presents cognitive deficits involving visual working memory, executive functioning, and motor functioning along with low average intellectual functioning that is significantly below her memory functioning and below expectation based on her occupational and academic history. This suggests that her intellectual functioning has declined." It concluded that "results overall suggest early stages of a likely dementia or possibly the effects of diabetes, although her deficits are greater than expected for diabetes-related executive functioning problems and peripheral neuropathy… The patient' deficits within the current test battery suggest that she would not be able to safely and effectively perform the duties of a nurse supervisor without help handling documentary demands and some supervision of her visual processing. The prognosis for improvement is not good, although she might try stimulant medication if compatible with her other. Following her dismissal, The patient presented to her primary physician, Henry Fein, M.D., who referred her to Dr. X for a second opinion regarding her cognitive deficits. His neurological examination on 09/23/2009 was unremarkable. The patient scored 20/30 on the Mini-Mental Status Exam missing one out of three words on recall, but was able to do so with prompting. A repeat neurocognitive testing was suggested in order to assess for subtle deficits in memory and concentration that were not appreciated on this gross cognitive measure.,IMAGING STUDIES: , MRI of the brain on 09/14/2009 was unremarkable with no evidence of acute intracranial abnormality or abnormal enhancing lesions. Note that the MRI was done with and without gadolinium contrast.,CURRENT FUNCTIONING: ,The patient reported that she had experienced some difficulty completing paperwork on time due primarily to the chaoticness of the work environment and the excessive amount of responsibility that was placed upon her. When asked about changes in cognitive functioning, she denied noticing any decline in problem solving, language, or nonverbal skills. She also denied any problems with attention and concentration or forgetfulness or memory problems. She continues to independently perform all activities of daily living. She is in charge of the household finances, has had no problems paying bills on time, has had no difficulties with driving or accidents, denied any missed appointments and said that no one has provided feedback to her that they have noticed any changes in her cognitive functioning. She reported that if her children had noticed anything they definitely would have brought it to her attention. She said that she does not currently have a lawyer and does not intend to return to her previous physician. She said she has not yet proceeded with the application for disability retirement because she was told that her doctors would have to fill out that paperwork, but they have not claimed that she is disabled and so she is waiting for the doctors at her former workplace to initiate the application. Other current symptoms include excessive fatigue. She reported that she was diagnosed with chronic fatigue syndrome in 1991, but generally symptoms are under better control now, but she still has difficulty secondary to fibromyalgia. She also reported having fallen approximately five times within the past year. She said that this typically occurs when she is climbing up steps and is usually related to her right foot "like dragging." Dr. X's physical examination revealed no appreciable focal peripheral deficits on motor or sensory testing and notes that perhaps these falls are associated with some stiffness and pain of her right hip and knee, which are chronic symptoms from her fibromyalgia and osteoarthritis. She said that she occasionally bumps into objects, but denied noticing it happening one on any particular part of her body. Muscle pain secondary to fibromyalgia reportedly occurs in her neck and shoulders down both arms and in her left hip.,OTHER MEDICAL HISTORY: , The patient reported that her birth and development were normal. She denied any significant medical conditions during childhood. As mentioned, she now has a history of fibromyalgia. She also experiences some restriction in the range of motion with her right arm. MRI of the C-spine 04/02/2009 showed a hemangioma versus degenerative changes at C7 vertebral body and bulging annulus with small central disc protrusion at C6-C7. MRI of the right shoulder on 06/04/2009 showed small partial tear of the distal infraspinatus tendon and prominent tendinopathy of the distal supraspinatus tendon. As mentioned, she was diagnosed with chronic fatigue syndrome in 1991. She thought that this may actually represent early symptoms of fibromyalgia and said that symptoms are currently under control. She also has diabetes, high blood pressure, osteoarthritis, tension headaches, GERD, carpal tunnel disease, cholecystectomy in 1976, and ectopic pregnancy in 1974. Her previous neuropsychological evaluation referred to an outpatient left neck cystectomy in 2007. She has some difficulty falling asleep, but currently typically obtains approximately seven to eight hours of sleep per night. She did report some sleep disruption secondary to unusual dreams and thought that she talked to herself and could sometimes hear herself talking in her sleep.,CURRENT MEDICATIONS:, NovoLog, insulin pump, metformin, metoprolol, amlodipine, Topamax, Lortab, tramadol, amitriptyline, calcium plus vitamin D, fluoxetine, pantoprazole, Naprosyn, fluticasone propionate, and vitamin C.,SUBSTANCE USE: , The patient reported that she rarely drinks alcohol and she denied smoking or using illicit drugs. She drinks two to four cups of coffee per day.,SOCIAL HISTORY: ,The patient was born and raised in North Carolina. She was the sixth of nine siblings. Her father was a chef. He completed third grade and died at 60 due to complications of diabetes. Her mother is 93 years old. Her last job was as a janitor. She completed fourth grade. She reported that she has no cognitive problems at this time. Family medical history is significant for diabetes, heart disease, hypertension, thyroid problems, sarcoidosis, and possible multiple sclerosis and depression. The patient completed a Bachelor of Science in Nursing through State University in 1979. She denied any history of problems in school such as learning disabilities, attentional problems, difficulty learning to read, failed grades, special help in school or behavioral problems. She was married for two years. Her ex-husband died in 1980 from acute pancreatitis secondary to alcohol abuse. She has two children ages 43 and 30. Her son whose age is 30 lives nearby and is in consistent contact with her and she is also in frequent contact and has a close relationship with her daughter who lives in New York. In school, the patient reported obtaining primarily A's and B's. She said that her strongest subject was math while her worst was spelling, although she reported that her grades were still quite good in spelling. The patient worked for Hospital Center for four years. Prior to that, she worked for an outpatient mental health center for 2-1/2 years. She was reportedly either terminated or laid off and was unsure of the reason for that. Prior to that, she worked for Walter P. Carter Center reportedly for 21 years. She has also worked as an OB nurse in the past. She reported that other than the two instances reported above, she had never been terminated or fired from a job. In her spare time, the patient enjoys reading, participating in women's groups doing puzzles, playing computer games.,PSYCHIATRIC HISTORY: , The patient reported that she sought psychotherapy on and off between 1991 and 1997 secondary to her chronic fatigue. She was also taking Prozac during that time. She then began taking Prozac again when she started working at secondary to stress with the work situation. She reported a chronic history of mild sadness or depression, which was relatively stable. When asked about her current psychological experience, she said that she was somewhat sad, but not dwelling on things. She denied any history of suicidal ideation or homicidal ideation.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test

Psychiatric Consultation of patient with anxiety.

Psychiatry / Psychology

Psych Consult - Anxiety

REASON FOR CONSULT:, Anxiety.,CHIEF COMPLAINT:, "I felt anxious yesterday.",HPI:, A 69-year-old white female with a history of metastatic breast cancer, depression, anxiety, recent UTI, and obstructive uropathy, admitted to the ABCD Hospital on February 6, 2007, for lightheadedness, weakness, and shortness of breath. The patient was consulted by Psychiatry for anxiety. I know this patient from a previous consult. During this recent admission, the patient has experienced anxiety and had a panic attack yesterday with "syncopal episodes." She was given Ativan 0.25 mg on a p.r.n. basis with relief after one to two hours. The patient was seen by Abc, MD, and Def, Ph.D. The laboratories were reviewed and were positive for UTI, and anemia is also present. The TSH level was within normal limits. She previously responded well to trazodone for depression, poor appetite, and decreased sleep and anxiety. A low dose of Klonopin was also helpful for sedation.,PAST MEDICAL HISTORY:, Metastatic breast cancer to bone. The patient also has a history of hypertension, hypothyroidism, recurrent UTI secondary to obstruction of left ureteropelvic junction, cholelithiasis, chronic renal insufficiency, Port-A-Cath placement, and hydronephrosis.,PAST PSYCHIATRIC HISTORY:, The patient has a history of depression and anxiety. She was taking Remeron 15 mg q.h.s., Ambien 5 mg q.h.s. on a p.r.n. basis, Ativan 0.25 mg every 6 hours on a p.r.n. basis, and Klonopin 0.25 mg at night while she was at home.,FAMILY HISTORY:, There is a family history of colorectal cancer, lung cancer, prostate cancer, cardiac disease, and Alzheimer disease in the family.,SOCIAL HISTORY:, The patient is married and lives at home with her husband. She has a history of smoking one pack per day for 18 years. The patient quit in 1967. According to the chart, the patient also drinks wine everyday for the last 50 years, usually one to two drinks per day.,MEDICATIONS:,1. Klonopin 0.25 mg p.o. every evening.,2. Fluconazole 200 mg p.o. daily.,3. Synthroid 125 mcg p.o. everyday.,4. Remeron 15 mg p.o. at bedtime.,5. Ceftriaxone IV 1 g in 1/2 NS every 24 hours.,P.R.N. MEDICATIONS:,1. Tylenol 650 mg p.o. every 4 hours.,2. Klonopin 0.5 mg p.o. every 8 hours.,3. Promethazine 12.5 mg every 4 hours.,4. Ambien 5 mg p.o. at bedtime.,ALLERGIES:,No known drug allergies,LABORATORY DATA:,These laboratories were done on February 6,2007, sodium 137, potassium 3.9, chloride 106, bicarbonate 21, BUN 35, creatinine 1.5, glucose 90. White blood cell 5.31, hemoglobin 11.2, hematocrit 34.7, platelet count 152000. TSH level 0.88. The urinalysis was positive for UTI.,MENTAL STATUS EXAMINATION:,GENERAL APPEARANCE: The patient is dressed in a hospital gown. She is lying in bed during the interview. She is well groomed with good hygiene.,MOTOR ACTIVITY: No psychomotor retardation or agitation noted. Good eye contact.,ATTITUDE: Pleasant and cooperative.,ATTENTION AND CONCENTRATION: Normal. The patient does not appear to be distracted during the interview.,MOOD: Okay.,AFFECT: Mood congruent normal affect.,THOUGHT PROCESS: Logical and goal directed.,THOUGHT CONTENT: No delusions noted.,PERCEPTION: Did not assess.,MEMORY: Not tested.,SENSORIUM: Alert.,JUDGMENT: Good.,INSIGHT: Good.,IMPRESSION:,1. AXIS I: Possibly major depression or generalized anxiety disorder.,2. AXIS II: Deferred.,3. AXIS III: Breast cancer with metastasis, hydronephrosis secondary to chronic uteropelvic junction obstruction status post stent placement, hypothyroidism.,4. AXIS IV: Interpersonal stressors.

The patient was referred due to a recent admission for pseudoseizures.

Psychiatry / Psychology

Pseudoseizures

REASON FOR REFERRAL: , The patient was referred to me by Dr. X of the Hospitalist Service at Children's Hospital due to a recent admission for pseudoseizures. This was a 90-minute initial intake completed on 10/19/2007 with the patient's mother. I have reviewed with her the boundaries of confidentiality and the treatment consent form, and she stated that she had understood these concepts.,PRESENTING PROBLEM: , It is reported that the patient was recently hospitalized and has been hospitalized in 2 occasions for pseudoseizure activity. These were confirmed by video EEG and consist of trembling, shaking, and things of that nature. She does have a history of focal seizures and perhaps simple seizures, which were diagnosed when she was 5 years old, but the seizure activity that was documented during the hospital stay is of a significant different quality. I had met with them in the hospital and introduced myself and gathered some basic background information, but this is a supplement to that information, which is contained within this chart. It was reported to me that she has been under considerable stress. First of all, it should be noted that the patient is developmentally delayed. Although she is 17 years old, she operates at about a fourth grade level. Mother reported that The patient becomes stressed because she thinks that everyone is against her, that she cannot do anything unless someone is there, that she needs a lot of direction, that she gets confused easily, that she thinks that people become angry at her, that she misinterprets what people are saying and thinks that they are upset. It is reported, the patient feels that her mother yells at her, and that is mad at her often. It was reported that in addition she recently has had change in her visitation with her father, that she within the last 6 months, has started seeing her father every other weekend after he had been discharged from prison. She reported that what is stress for her is that sometimes he does not always show up for visits or is late and that upsets her a lot and that she is upset when she has to leave him, also additional stressor is at school. She reports that she has no friends that she feels unwanted and picked on. She gets confused easily at school, worries about things, and believes that the teachers become angry with her. In regards to her mood, mother reported that she is usually happy, unless things do not go her way, and then, she becomes upset and says that nobody cares about her. She sits in the couch, she become angry, does not speak. Mother sends her to her room, and she calms down, takes a couple of deep breaths, and that passes. It is reported that the patient has "always been this way" and that is not a change in her behavior. Mother did think that she did seem a little more depressed, that she seems more lonely. Over the last few months, she has seemed a little bit more down because she does not have any friends and that she is bored. Mother reported that she frequently complains of being bored, but has always been this way. No sleep disturbance was noted. No changes in weight. No suicidal ideation. No deficits in energy were noted. Mother did report that she does tend to worry, but her worries tend to be because she gets confused, does not understand what she needs to do, and is quite rigid, but mother did not feel that the worry was actually affecting her functioning on a daily basis.,DEVELOPMENTAL HISTORY:, The patient was the 5 pound 12 ounce product of an unplanned pregnancy and normal spontaneous vaginal delivery. She was delivered at 36 weeks' gestation. Mother reported that she received prenatal care. Difficulties during the pregnancy were denied. The use of drugs, alcohol, tobacco during the pregnancy were denied. No eating or sleeping difficulties during the perinatal period were reported. Temperament was described as easy. The patient is described as a cuddly baby. In terms of serious injuries, they were denied. Serious illnesses: She has been diagnosed since age 5 with seizures. Mother was not able to tell me the exact kind of seizures, but it would appear from I could gather that they are focal seizures and possibly simple-to-complex partial seizures. The patient does not have a history of allergy or toileting problems. She is currently taking Trileptal 450 mg b.i.d., and she is currently taking Depakote, although she is going to be weaned off the Depakote by her neurologist. She is taking Prevacid and ibuprofen. The neurologist that she sees is Dr. Y here at Children's Hospital.,FAMILY BACKGROUND:, In terms of family background, the patient lives with her mother age 38 and her mother's partner, who is age 40, and with her 16-year-old sister who does not have any developmental delays. Mother had been married to the patient's father, but they were together as a couple beginning 1990, married in 1997, separated in 2002, and divorced in 2003; he lives in the ABC area and visits them every other Saturday, but there are no overnight visits. The paternal grandparents are both living here in California, but are separated. They are 3 paternal uncles and 2 paternal aunts. In terms of the maternal family, maternal grandmother and grandfather are deceased. Maternal grandfather deceased in 1991 due to cancer. Maternal grandmother deceased in 2001 due to cancer. There are 5 maternal aunts and 2 maternal uncles, all who live in California. She reported that the patient is particularly close to her maternal aunt, whose name is Carmen. Mother's partner had been married previously; he has 2 children from that relationship, a 23-year-old, and a 20-year-old female, who really are not part of the patient's daily life. In terms of other family background, it was reported that the mother's partner gets frustrated with The patient, does not completely understand the degree of her delay and how that may affect her ability to do things as well as her interpretation of things. The sister was described as having some resentment towards her older sister, that she feels like she was just to watch out for her, care for her, and that sister has always wanted to follow her around and do the things that she does. The biological father allegedly was in jail for a year due to drug possession. Mother reported that he had a problem with methamphetamine. In addition, she reported there is an accusation that he had molested their niece; however, she stated that there was a trial, and he was found to be not guilty of that. She stated there was no evidence that he had ever molested the patient or her sister. There had been quite a bit of chaos in the family when the mother and father were together. There was a lot of arguing. There were a lot of moves, there was domestic violence both from father to mother and mother to father consisting mostly of pushing and shoving by mother's report. The patient did observe this. After the separation, it was reported that there were continued difficulties that the father took the patient and her sister from school without mother's knowledge and had filed to get custody of them and actually ended up having custody of them for a month, and told the patient and her sister that the mother had abandoned them. Mother reported that they went to court, and there was a court order giving the mother custody back after the father went to jail. Mother stated that was approximately 5 years ago. In terms of current, mother reports that she currently works 2 jobs from 8 to 5 on Monday and Friday and from 6 to 10 on Monday, Wednesday's, and Friday's, but she does have the weekends off. The patient was reported also to have a job through her school on several weeknights.,Mother reported that she graduated from high school, had a year of college. She was an average student, had learning difficulties in reading. No psychological or drug or alcohol history was reported by mother. In terms of the biological father, mother stated that he graduated from high school, had a couple of years of college, was a good student, no learning problems or psychological problems for him were reported. Mother reported that he had a history of methamphetamine use.,Other psychiatric history in the family was denied.,SOCIAL HISTORY: , She reported that the patient feels like she does not have any friends, that she is lonely and bored, really does not do much for fun. Her fun consists primarily of doing crafts with mother, sewing, painting, drawing, beadwork, and things like that. It was reported that she really feels that she is bored and does not have much to do.,ACADEMIC BACKGROUND: ,The patient is in the 11th grade at High School. She has 2 regular education classes, mother could not tell me what they were, but the rest of her classes are special education. Mother could not tell me what her IQ was, although she noticed she works at about a 4th or 5th grade level. Mother reported that the terminology most often used with the patient was developmental delay. Her counselor's name is Mr. XYZ, but she reported that overall she is a good student, but she does have sometimes some difficulties at school, becoming upset or angry regarding the little things that she does not seem to understand. It is reported that the patient feels that she has no friends at school that she is lonely, and that is she does not really care for school. She reported that the patient is involved in a work program through the school where she works at Pet Extreme on Mondays and Wednesdays from 3 to 8 p.m. where she stocks shelves. It is reported that she does not like to go to school because she feels like nobody likes her. She is not involved in any kind of clubs or groups at school. Mother reported that she is also not receiving CVRC services.,PREVIOUS COUNSELING: , Mother reported that she has been in counseling before, but mother could not give me any information about that, who did the counseling, or what it was about. She does receive evidently some peer counseling at school because she gets upset and needs help in calming down.,DIAGNOSTIC SUMMARY AND IMPRESSION:, It appears that the patient best qualifies for a diagnosis of conversion disorder, and information from Neurology suggests that the "seizure episodes" are not true seizures, but appear to be pseudoseizures. The patient is experiencing quite bit of stress with a lot of changes in her life, also difficulty in functioning likely due to her developmental delay makes it difficult for her to understand.,PLAN:, My plan is to meet with the patient in approximately 1 to 2 weeks to complete a clinical interview with her, and then to begin teaching coping skills as well as explore ways for reducing her stress.,DSM IV DIAGNOSES: ,AXIS I: Conversion disorder (300.11).,AXIS II: Diagnoses deferred.,AXIS III: Seizure disorder.,AXIS IV: Problems with primary support group, peer problems, and educational problems.,AXIS V: Global assessment of functioning equals 60.

psychiatry / psychology, conversion disorder, global assessment of functioning, primary support group, peer problems, developmental delays, seizures, developmentally, axis, pseudoseizures,

The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness.

Psychiatry / Psychology

Neuropsychological Evaluation - 5

PROBLEMS AND ISSUES:,1. Headaches, nausea, and dizziness, consistent with a diagnosis of vestibular migraine, recommend amitriptyline for prophylactic treatment and Motrin for abortive treatment.,2. Some degree of peripheral neuropathy, consistent with diabetic neuropathy, encouraged her to watch her diet and exercise daily.,HISTORY OF PRESENT ILLNESS: , The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness. I obtained and documented a full history and physical examination. I reviewed the new patient questionnaire, which she completed prior to her arrival today. I also reviewed the results of tests, which she had brought with her.,Briefly, she is a 60-year-old woman initially from Ukraine, who had headaches since age 25. She recalls that in 1996 when her husband died her headaches became more frequent. They were pulsating. She was given papaverine, which was successful in reducing the severity of her symptoms. After six months of taking papaverine, she no longer had any headaches. In 2004, her headaches returned. She also noted that she had "zig-zag lines" in her vision. Sometimes she would not see things in her peripheral visions. She had photophobia and dizziness, which was mostly lightheadedness. On one occasion she almost had a syncope. Again she has started taking Russian medications, which did help her. The dizziness and headaches have become more frequent and now occur on average once to twice per week. They last two hours since she takes papaverine, which stops the symptoms within 30 minutes.,PAST MEDICAL HISTORY: ,Her past medical history is significant for injury to her left shoulder, gastroesophageal reflux disorder, diabetes, anxiety, and osteoporosis.,MEDICATIONS:, Her medications include hydrochlorothiazide, lisinopril, glipizide, metformin, vitamin D, Centrum multivitamin tablets, Actos, lorazepam as needed, Vytorin, and Celexa.,ALLERGIES: , She has no known drug allergies.,FAMILY HISTORY: ,There is family history of migraine and diabetes in her siblings.,SOCIAL HISTORY: , She drinks alcohol occasionally.,REVIEW OF SYSTEMS: , Her review of systems was significant for headaches, pain in her left shoulder, sleeping problems and gastroesophageal reflex symptoms. Remainder of her full 14-point review of system was unremarkable.,PHYSICAL EXAMINATION:, On examination, the patient was pleasant. She was able to speak English fairly well. Her blood pressure was 130/84. Heart rate was 80. Respiratory rate was 16. Her weight was 188 pounds. Her pain score was 0/10. Her general exam was completely unremarkable. Her neurological examination showed subtle weakness in her left arm due to discomfort and pain. She had reduced vibration sensation in her left ankle and to some degree in her right foot. There was no ataxia. She was able to walk normally. Reflexes were 2+ throughout.,She had had a CT scan with constant, which per Dr. X's was unremarkable. She reports that she had a brain MRI two years ago which was also unremarkable.,IMPRESSION AND PLAN:, The patient is a delightful 60-year-old chemist from Ukraine who has had episodes of headaches with nausea, photophobia, and dizziness since her 20s. She has had some immigration problems in recent months and has experienced increased frequency of her migraine symptoms. Her diagnosis is consistent with vestibular migraine. I do not see evidence of multiple sclerosis, Ménière's disease, or benign paroxysmal positional vertigo.,I talked to her in detail about the importance of following a migraine diet. I gave her instructions including a list of foods times, which worsen migraine. I reviewed this information for more than half the clinic visit. I would like to start her on amitriptyline at a dose of 10 mg at time. She will take Motrin at a dose of 800 mg as needed for her severe headaches.,She will make a diary of her migraine symptoms so that we can find any triggering food items, which worsen her symptoms. I encouraged her to walk daily in order to improve her fitness, which helps to reduce migraine symptoms.

psychiatry / psychology, nausea, dizziness, migraine, peripheral neuropathy, diabetic neuropathy, neuropathy, positional vertigo, photophobia and dizziness, neurology consultation, tunnel vision, vestibular migraine, migraine symptoms, headaches, photophobia, ataxia,

Patient was referred for a neuropsychological evaluation after a recent hospitalization for possible transient ischemic aphasia. Two years ago, a similar prolonged confusional spell was reported as well. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.

Psychiatry / Psychology

Neuropsychological Evaluation - 3

REASON FOR REFERRAL:, The patient is a 76-year-old Caucasian gentleman who works full-time as a tax attorney. He was referred for a neuropsychological evaluation by Dr. X after a recent hospitalization for possible transient ischemic aphasia. Two years ago, a similar prolonged confusional spell was reported as well. A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION: , Historical information was obtained from a review of available medical records and clinical interview with the patient. A summary of pertinent information is presented below. Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM: , The patient was brought to the Hospital Emergency Department on 09/30/09 after experiencing an episode of confusion for which he has no recall the previous day. He has no recollection of the event. The following information is obtained from his medical record. On 09/29/09, he reportedly went to a five-hour meeting and stated several times "I do not feel well" and looked "glazed." He does not remember anything from midmorning until the middle of the night and when his wife came home, she found him in bed at 6 p.m., which is reportedly unusual. She thought he was warm and had chills. He later returned to his baseline. He was seen by Dr. X in the hospital on 09/30/09 and reported to him at that time that he felt that he had returned entirely to baseline. His neurological exam at that time was unremarkable aside from missing one of three items on recall for the Mini-Mental Status Examination. Due to mild memory complaints from himself and his wife, he was referred for more extensive neuropsychological testing. Note that reportedly when his wife found him in bed, he was shaking and feeling nauseated, somewhat clammy and kept saying that he could not remember anything and he was repeating himself, asking the same questions in an agitated way, so she brought him to the emergency room. The patient had an episode two years ago of transient loss of memory during which he was staring blankly while sitting at his desk at work and the episode lasted approximately two hours. He was hospitalized at Hospital at that time as well and evaluation included negative EEG, MRI showing mild atrophy, and a neurological consultation, which did not result in a specific diagnosis, but during this episode he was also reportedly nauseous. He was also reportedly amnestic for this episode.,In 2004, he had a sense of a funny feeling in his neck and electrodes in his head and had an MRI at that time which showed some small vessel changes.,During this interview, the patient reported that other than a coworker noticing a few careless errors in his completion of some documents and his wife reporting some mild memory changes that he had not noticed any significant decline. He thought that his memory abilities were similar to those of his peers of his same age. When I asked about this episode, he said he had no recall of it at all and that he "felt fine the whole time." He appeared to be somewhat questioning of the validity of reports that he was amnestic and confused at that time. So, The patient reported some age related "memory lapses" such as going into a room and forgetting why, sometimes putting something down and forgetting where he had put it. However, he reported that these were entirely within normal expectations and he denied any type of impairment in his ability to continue to work full-time as a tax attorney other than his wife and one coworker, he had not received any feedback from his children or friends of any problems. He denied any missed appointments, any difficulty scheduling and maintaining appointments. He does not have to recheck information for errors. He is able to complete tasks in the same amount of time as he always has. He reported that he has not made additional errors in tasks that he completed. He said he does write everything down, but has always done things that way. He reported that he works in a position that requires a high level of attentiveness and knowledge and that will become obvious very quickly if he was having difficulties or making mistakes. He did report some age related changes in attention as well, although very mild and he thought these were normal and not more than he would expect for his age. He remains completely independent in his ADLs. He denied any difficulty with driving or maintaining any activities that he had always participated in. He is also able to handle their finances. He did report significant stress recently particularly in relation to his work environment.,PAST MEDICAL HISTORY:, Includes coronary artery disease, status post CABG in 1991, radical prostate cancer, status post radical prostatectomy, nephrectomy for the same cancer, hypertension, lumbar surgery done twice previously, lumbar stenosis many years ago in the 1960s and 1970s, now followed by Dr. Y with another lumbar surgery scheduled to be done shortly after this evaluation, and hyperlipidemia. Note that due to back pain, he had been taking Percocet daily prior to his hospitalization.,CURRENT MEDICATIONS: , Celebrex 200 mg, levothyroxine 0.025 mg, Vytorin 10/40 mg, lisinopril 10 mg, Coreg 10 mg, glucosamine with chondroitin, prostate 2.2, aspirin 81 mg, and laxative stimulant or stool softener. Note that medical records say that he was supposed to be taking Lipitor 40 mg, but it is not clear if he was doing so and also there was no specific reason found for why he was taking the levothyroxine.,OTHER MEDICAL HISTORY: , Surgical history is significant for hernia repair in 2007 as well. The patient reported drinking an occasional glass of wine approximately two days of the week. He quit smoking cigarettes 25 to 30 years ago and he was diagnosed with cancer. He denied any illicit drug use. Please add that his prostatectomy was done in 1993 and nephrectomy in 1983 for carcinoma. He also had right carpal tunnel surgery in 2005 and has cholelithiasis. Upon discharge from the hospital, the patient's sleep deprived EEG was recommended.,MRI completed on 09/30/09 showed "mild cerebral and cerebellar atrophy with no significant interval change from a prior study dated June 15, 2007. No evidence of acute intracranial processes identified. CT scan was also unremarkable showing only mild cerebral and cerebellar atrophy. EEG was negative. Deferential diagnosis was transient global amnesia versus possible seizure disorder. Note that he also reportedly has some hearing changes, but has not followed up with an evaluation for hearing aid.,FAMILY MEDICAL HISTORY:, Reportedly significant for TIAs in his mother, although the patient did not report this during our evaluation and so that she had no memory problems or dementia when she passed away of old age at the age of 85. In addition, his father had a history of heart disease and passed away at the age of 75. He has one sister with diabetes and thought his mom might have had diabetes as well.,SOCIAL HISTORY:, The patient obtained a law degree from the University of Baltimore. He did not complete his undergraduate degree from the University of Maryland because he was able to transfer his credits in order to attend law school at that time. He reported that he did not obtain very good grades until he reached law school, at which point he graduated in the top 10 of his class and had no problem passing the Bar. He thought that effort and motivation were important to his success in his school and he had not felt very motivated previously. He reported that he repeated math classes "every year of school" and attended summer school every year due to that. He has worked as a tax attorney for the past 48 years and reported having a thriving practice with clients all across the country. He served also in the U.S. Coast Guard between 1951 and 1953. He has been married for the past 36 years to his wife, Linda, who is a homemaker. They have four children and he reported having good relationship with them. He described being very active. He goes for dancing four to five times a week, swims daily, plays golf regularly and spends significant amounts of time socializing with friends.,PSYCHIATRIC HISTORY: , The patient denied any history of psychological or psychiatric treatment. He reported that some stressors occasionally contribute to mildly low mood at this time, but that these are transient.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test

A neuropsychological evaluation to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.

Psychiatry / Psychology

Neuropsychological Evaluation - 2

REASON FOR REFERRAL: ,The patient was referred for a neuropsychological evaluation by Dr. X. A comprehensive evaluation was requested to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.,BRIEF SUMMARY & IMPRESSIONS:,RELEVANT HISTORY:,Historical information was obtained from a review of available medical records and an interview with ,the patient.,The patient presented to Dr. X on August 05, 2008 as she had been recently hospitalized for prolonged episodes of syncope. She was referred to Dr. X for diagnostic differentiation for possible seizures or other causes of syncope. The patient reports an extensive neurological history. Her mother used alcohol during her pregnancy with the patient. In spite of exposure to alcohol in utero, the patient reported that she achieved "honors in school" and "looked smart." She reported that she began to experience migraines at 11 years of age. At 15 years of age, she reported that she was thought to have hydrocephalus. She reported that she will frequently "bang her head against the wall" to relieve the pain. The patient gave birth to her daughter at 17 years of age. At 18 years of age, she received a spinal tap as a procedure to determine the cause of her severe headaches. She reported, in 1995 to 1996 she experienced a severe head injury, as she was struck by a car as a pedestrian and "thrown two and a half city blocks." The patient reported that she could recall before being hit, but could not recall the activities of that same day or the following day. She reported that she had difficulty walking following this head injury, but received rehabilitation for approximately one month. Her migraines became more severe following the head injury. In 1998, she reportedly was experiencing episodes of syncope where she would experience a headache with photophobia, phonophobia, and flashing lights. Following the syncope episode, she would experience some confusion. These episodes reportedly were related to her donating plasma.,The patient also reported that her ex-husband stated that she frequently jerked and would shake in her sleep. She reported that upon awakening, she would feel off balanced and somewhat confused. These episodes diminished from 2002 to June 2008. When making dinner, she suddenly dropped and hit the back of her head on refrigerator. She reported that she was unconscious for five to six minutes. A second episode occurred on July 20th when she lost consciousness for may be a full day. She was admitted to Sinai Hospital and assessed by a neurologist. Her EEG and head CT were considered to be completely normal. She did not report any typical episodes during the time of her 36-hour EEG. She reported that her last episode of syncope occurred prior to her being hospitalized. She stated that she had an aura of her ears ringing, vision being darker and "tunnel vision" (vision goes smaller to a pinpoint), and she was "spazzing out" on the floor. During these episodes, she reports that she cannot talk and has difficulty understanding.,The patient also reports that she has experienced some insomnia since she was 6 years old. She reported that she was a heavy drinker until about 1998 or 1999 and that she would drink a gallon daily of Jack Daniel. She stopped the use of alcohol and that time she experienced a suicide attempt. In 2002, she was diagnosed with bipolar disorder and was started on medication. At the time of the neuropsychological evaluation, she had stopped taking her medicine as she felt that she was now in remission and could manage her symptoms herself. The patient's medical history is also significant for postpartum depression.,The patient reported that she has been experiencing difficulty with cognitive abilities of attention/concentration, spelling, tangential and slow thinking, poor sequencing memory for events, and variable verbal memory. She reported that she sometimes has difficulty understanding what people say, specifically she has difficulty understanding jokes. She finds that she often has difficulty with expressing her thoughts, as she is very tangential. She experiences episodes of not recalling what she was speaking of or remembering what activities she was trying to perform. She reported that she had a photographic memory for directions. She said that she experienced a great deal of emotional lability, but in general her personality has become more subdued. At the present time, her daughter has now moved on to college. The patient is living with her biological mother. Although she is going through divorce, she reported that it was not really stressful. She reported that she spends her day driving other people around and trying to be helpful to them.,At the time of the neuropsychological evaluation, the patient's medication included Ativan, Imitrex, Levoxyl, vitamin B12, albuterol metered dose inhaler as needed, and Zofran as needed. (It should be noted that The patient by the time of the feedback on September 19, 2008 had resumed taking her Trileptal for bipolar disorder.). The patient's familial medical history is significant for alcohol abuse, diabetes, hypertension, and high cholesterol.,TESTS ADMINISTERED:,Clinical Interview,Cognistat,Mattis Dementia Rating Scale,Wechsler Adult Intelligence Scale - III (WAIS-III),Wechsler Abbreviated Scale of Intelligence (WASI),Selected Subtests from the Delis Kaplan Executive Function System (DKEFS), Trail Making Test, Verbal Fluency (Letter Fluency & Category Fluency), Design Fluency, Color-Word Interference Test, Tower,Wisconsin Card Sorting Test (WCST),Stroop Test,Color Trails,Trails A & B,Test of Variables of Attention,Multilingual Aphasia Examination II, Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test-2 (BNT-2),Animal Naming Test,The Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI),The Beery-Buktenica Developmental Test of Motor Coordination,The Beery-Buktenica Developmental Test of Visual Perception,Judgment Line Orientation,Grooved Pegboard,Purdue Pegboard,Finger Tapping Test,Rey Complex Figure,Wechsler Memory Scale -III (WMS-III),California Verbal Learning Test

Mental status changes after a fall. She sustained a concussion with postconcussive symptoms and syndrome that has resolved.

Psychiatry / Psychology

Mental Status Changes - Consult

CHIEF COMPLAINT: , Mental status changes after a fall.,HISTORY: , Ms. ABC is a 76-year-old female with Alzheimer's, apparently is normally very talkative, active, independent, but with advanced Alzheimer's. Apparently, she tripped backwards hitting her head on a wheelchair and, had although no loss consciousness, had altered mental status changes. She was very confused, incomprehensible speech, and was not responding appropriately. She was transported here stable, with no significant changes. She ultimately upon arrival here was unchanged in that she was not responding appropriately. She would have garbled speech, somewhat inappropriate at times, and unable to follow commands. No other history was able to be obtained. All pertinent history is documented within the records. Physical examination also documented in the records, essentially as above.,PHYSICAL EXAMINATION: , HEENT: Without any obvious signs of trauma. Pupils are equal and reactive. Extraocular movements are difficult to assess with her eyes closed, but she will open to voice. TMs, canals are normal without any signs of hemotympanum. Nasal mucosa and oropharynx are normal.,NECK: Nontender, full range of motion, was not examined initially, a collar was placed.,HEART: Regular.,LUNGS: Clear.,CHEST/BACK/ABDOMEN: Without trauma.,SKIN: With multiple excoriations from scratching and itching.,NEUROLOGIC: Otherwise she has good sensation, withdrawals to pain. When lifting the arm, she will hold them up and draw, let them down slowly. With movement of the legs, she did straighten them back out slowly. DTRs were intact and equal bilaterally. Otherwise, the remainder of the examination was unable to be done because of patient's non-cooperation and mental status change.,LABORATORY DATA: , CT scan of the head was negative as was cervical spine. She has a history of being on Coumadin. Her INR is 1.92, CBC was with a white count of 3.8, 50% neutrophils, 8% bands. CMP did note a potassium, which was elevated at 5.9, troponin was normal, mag is 2.5, valproic acid level 24.3.,ASSESSMENT AND PLAN: , Ms. ABC is a 76-year-old female with multiple medical problems who has sustained a head injury with mental status changes that on repeat examination now at approximately 1930 hours, has completely resolved. It is likely she sustained a concussion with postconcussive symptoms and syndrome that has resolved. At this time, she has some other abnormalities in her lab work and I recommend she be admitted for observation and further investigation. I have discussed this with her son, he agrees. Otherwise, she has improved significantly. The patient was discussed with XYZ, who will admit the patient for further evaluation and treatment.

psychiatry / psychology, alzheimer's, no loss consciousness, mental status,

Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.

Psychiatry / Psychology

Major Depressive Disorder - IME Consult

IDENTIFYING DATA: ,Mr. T is a 45-year-old white male.,CHIEF COMPLAINT: , Mr. T presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus. His confidence and self-esteem are significantly low. He stated he has excessive somnolence, his energy level is extremely low, motivation is low, and he has a lack for personal interests. He has had suicidal ideation, but this is currently in remission. Furthermore, he continues to have hopeless thoughts and crying spells. Mr. T stated these symptoms appeared approximately two months ago.,HISTORY OF PRESENT ILLNESS: , On March 25, 2003, Mr. T was fired from his job secondary, to an event at which he stated he was first being harassed by another employee." This other, employee had confronted Mr. T with a very aggressive, verbal style, where this employee had placed his face directly in front of Mr. T was spitting on him, and called him "bitch." Mr. T then retaliated, and went to hit the other employee. Due to this event, Mr. T was fired. It should be noted that Mr. T stated he had been harassed by this individual for over a year and had reported the harassment to his boss and was told to "deal with it.",There are no other apparent stressors in Mr. T's life at this time or in recent months. Mr. T stated that work was his entire life and he based his entire identity on his work ethic. It should be noted that Mr. T was a process engineer for Plum Industries for the past 14 years.,PAST PSYCHIATRIC HISTORY:, There is no evidence of any psychiatric hospitalizations or psychiatric interventions other than a recent visit to Mr. T's family physician, Dr. B at which point Mr. T was placed on Lexapro with an unknown dose at this time. Mr. T is currently seeing Dr. J for psychotherapy where he has been in treatment since April, 2003.,PAST PSYCHIATRIC REVIEW OF SYSTEMS:, Mr. T denied any history throughout his childhood, adolescence, and early adulthood for depressive, anxiety, or psychotic disorders. He denied any suicide attempts, or profound suicidal or homicidal ideation. Mr. T furthermore stated that his family psychiatric history is unremarkable.,SUBSTANCE ABUSE HISTORY:, Mr. T stated he used alcohol following his divorce in 1993, but has not used it for the last two years. No other substance abuse was noted.,LEGAL HISTORY: , Currently, charges are pending over the above described incident.,MEDICAL HISTORY: , Mr. T denied any hospitalizations, surgeries, or current medications use for any heart disease, lung disease, liver disease, kidney disease, gastrointestinal disease, neurological disease, closed head injury, endocrine disease, infectious, blood or muscles disease other than stating he has a hiatal hernia and hypercholesterolemia.,PERSONAL AND SOCIAL HISTORY: , Mr. T was born in Dwyne, Missouri, with no complications associated with his birth. Originally, he was raised by both parents, but they separated at an early age. When he was about seven years old, he was raised by his mother and stepfather. He did not sustain a relationship with his biological father from that time on. He stated his parents moved a lot, and because this many times he was picked on in his new environments, Mr. T stated he was, at times, a rebellious teenager, but he denied any significant inability to socialize, and denied any learning disabilities or the need for special education.,Mr. T stated his stepfather was somewhat verbally abusive, and that he committed suicide when Mr. T was 18 years old. He graduated from high school and began work at Dana Corporation for two to three years, after which he worked as an energy, auditor for a gas company. He then became a homemaker while his wife worked for Chrysler for approximately two years. Mr. T was married for eleven years, and divorced in 1993. He has a son who is currently 20 years old. After being a home maker, Mr. T worked for his mother in a restaurant, and moved on from there to work for Borg-Warner corporation for one to two years before beginning at Plum Industries, where he worked for 14 years and worked his way up to lead engineer.,Mental Status Exam: Mr. T presented with a hyper vigilant appearance, his eye contact was appropriate to the interview, and his motor behavior was tense. At times he showed some involuntary movements that would be more akin to a resting tremor. There was no psychomotor retardation, but there was some mild psychomotor excitement. His speech was clear, concise, but pressured. His attitude was overly negative and his mood was significant for moderate depression, anxiety, anhedonia and loneliness, and mild evidence of anger. There was no evidence of euphoria or diurnal mood variation. His affective expression was restricted range, but there was no evidence of lability. At times, his affective tone and facial expressions were inappropriate to the interview. There was no evidence of auditory, visual, olfactory, gustatory, tactile or visceral hallucinations. There was no evidence of illusions, depersonalizations, or derealizations. Mr. T presented with a sequential and goal directed stream of thought. There was no evidence of incoherence, irrelevance, evasiveness, circumstantiality, loose associations, or concrete thinking. There was no evidence of delusions; however, there was some ambivalence, guilt, and self-derogatory thoughts. There was evidence of concreteness for similarities and proverbs. His intelligence was average. His concentration was mildly impaired, and there was no evidence of distractibility. He was oriented to time, place, person and situation. There was no evidence of clouded consciousness or dissociation. His memory was intact for immediate, recent, and remote events.,He presented with poor appetite, easily fatigued, and decreased libidinal drive, as well as excessive somnolence. There was a moderate preoccupation with his physical health pertaining to his headaches. His judgment was poor for finances, family relations, social relations, employment, and, at this time, he had no future plans. Mr. T's insight is somewhat moderate as he is aware of his contribution to the problem. His motivation for getting well is good as he accepts offered treatment, complies with recommended treatment, and seeks effective treatments. He has a well-developed empathy for others and capacity for affection.,There was no evidence of entitlement, egocentricity, controllingness, intimidation, or manipulation. His credibility seemed good. There was no evidence for potential self-injury, suicide, or violence. The reliability and completeness of information was very good, and there were no barriers to communication. The information gathered was based on the patient's self-report and objective testing and observation. His attitude toward the examiner was neutral and his attitude toward the examination process was neutral. There was no evidence for indices of malingering as there was no marked discrepancy between claimed impairment and objective findings, and there was no lack of cooperation with the evaluation or poor compliance with treatment, and no evidence of antisocial personality disorder.,IMPRESSIONS: , Major Depressive Disorder, single episode,RECOMMENDATIONS AND PLAN: , I recommend Mr. T continue with psychopharmacologic care as well as psychotherapy. At this time, the excessive amount of psychiatric symptoms would impede Mr. T from seeking employment. Furthermore, it appears that the primary precipitating event had occurred on March 25, 2003, when Mr. T was fired from his job after being harassed for over a year. As Mr. T placed his entire identity and sense of survival on his work, this was a deafening blow to his psychological functioning. Furthermore, it only appears logical that this would precipitate a major depressive episode.

psychiatry / psychology, muscle tremor, headaches, excessive nervousness, poor concentration, independent medical evaluation, psychopharmacologic, poor ability to focus, major depressive disorder, tremor, depressive, psychiatric,