allergies: iodine; iodine containing attending: addendum: see the following summary pertinent results: mr head w & w/o contrast; mr contrast gadolin reason: r/o stroke v/s infection contrast: magnevist medical condition: 51 year old man with maxillary tumor found down reason for this examination: r/o stroke v/s infection contraindications for iv contrast: none. indication: 51-year-old man with maxillary tumor, status post fall. technique: t1 and t2-weighted images of the brain, with and without the administration of intravenous contrast . comparison: comparison was made to the prior ct scan performed approximately 4 hours earlier on the same day. findings: note is made of hyperintense intensity in the sulci of the bilateral frontal and parietal areas, consistent with subarachnoid hemorrhage given the finding on prior ct scan. there are thin areas of subdural hematoma in bilateral frontal areas, great on the left. there is hyperintensity within the brain parenchyma in left parietal and bilateral frontal lobes, most likely representing hemorrhagic contusions given the history of trauma. no abnormal enhancement is seen in the brain. no area of slow diffusion is noted. the patient is status post left maxillary surgery. again, note is made of opacification of bilateral frontal and right maxillary sinuses as well as right nasal cavity, with t1 hyperintense material, persistent since prior studies, probably due to chronic mucous retention. impression: 1) bilateral subarachnoid hemorrhage within the sulci, as well as bilateral thin subdural hematoma, somewhat more prominent on the left. hyperintense signal in brain parenchyma in left parietal and bilateral frontal lobes on flair, most likely representing hemorrhagic contusions in this patient with trauma. 2) no area of slow diffusion. 3) left maxillary surgery, with opacified paranasal sinuses. radiology final report (revised) ct head w/o contrast 7:20 am ct head w/o contrast reason: s/p fall ?bleed medical condition: 51 year old man with h/o left maxillary tumor resection now s/p fall with head trauma and suspected seizure reason for this examination: ? bleed contraindications for iv contrast: none. indication: 51-year-old male with history of left maxillary tumor resection status post fall. comparison: . technique: non-contrast head ct. findings: study is limited secondary to excessive motion artifact. allowing for this factor, there is no acute intra- or extra-axial hemorrhage, mass effect, shift of normally midline structures or hydrocephalus. there is no new major vascular or territorial infarct. _____ symmetrically of the lateral and third ventricles are stable. note added at attending review: there is a small amount of subarachnoid blood in the interhemispheric cistern and in the left sylvian fissure. these findings are compatible with the history of trauma. there is an old right frontal infarction. in this distribution it is difficult to exclude a superimposed acute infarction. the sulci are partially effaced. this may be due to a small amount of subarachnoid blood creating isodense csf within the sulci, but the possibility of swelling due to global hypoperfusion should be considered. again seen are postoperative findings after resection of the left maxilla and orbital exenteration. radiology final report c-spine flex and ext only 2 views 2:25 pm c-spine flex and ext only 2 vi reason: please do flexion, extension and lateral neck film medical condition: 51 year old man fell out of bed in hospital. now with rue weakness. reason for this examination: please do flexion, extension and lateral neck film cervical spine indication: 51-year-old man fell out. comments: lateral radiographs of the cervical spine with flexion and extension demonstrated no evidence of fracture or dislocation or translation indicating instability. c1 through c7 cervical vertebrae are visualized. the patient has fusion of the c5-c7 cervical vertebrae with loss of normal lordosis. the prevertebral soft tissue appears within normal limits. there are multiple surgical staples overlying the neck lesion. impression: no evidence of fracture, dislocation or instability. name birthdate age sex pathology # , 51 male report to: dr. gross description by: dr. /dif specimen submitted: lt hand palate,lt maxillary teeth,lt fossa. procedure date tissue received report date diagnosed by dr. /cla previous biopsies: lt maxella l. orbital cavity, lt. pterygioma maxillary fossa & deep lt mid/inferior pterygomaxillary fossa. left sphenoid + orbital cavity contents,left orbital (and more) diagnosis: i. left hard palate, resection (a-c; f-l): recurrent adenoid cystic carcinoma, involving soft tissue; bone with reactive changes, necrosis and acute and chronic inflammation; special stains for bacteria will be sent as an addendum. ii. left maxillary teeth (d): teeth fragments. iii. soft tissue and bone, left pterygomaxillary fossa, resection (e,m): recurrent adenoid cystic carcinoma, small foci; fibroadipose tissue and skeletal muscle with reactive changes. brief hospital course: on the eve of the patient's potential discharge, in the middle of the night, he got up out of bed, fell and hit his head. he was found by nurses, who noticed that his eyes were rolling. they also noted shaking movements in his extremities and he had lost urine. his sbp has been in the 90-100's. no fever. we intubated him in preparation for a ct-scan to rule out a hemorrhage given the fall given a very poor airway given the history of the adenoca with subsequent surgeries. neurology and neurosurgery were consulted; both recommended starting seizure prophalaxis and an mri scan. patient was loaded with dilantin (later he was switched to keppra as a home med). ct showed a sah, and the mri showed l parietal contusion, evidence of subarchnoid blood seen on ct, as well as a small subdural hemorrhage bifrontally. neurology attempted lp x2 without success, was planning for third try when he self-extubated. patient was moved to the icu for 3 days for closer monitoring and placed in a c-collar for ?fx. repeat ct scans of the head were stable without evidence of hemmorhage progression. trauma and ortho surgery were consulted for possible ctl-spine fractures from the fall. after dedicated films and clinical exam, it was decided that no fractures ensued, and c-collar was dc'd and patient was again allowed to have full body movement. in addition, do to the patient's poor nutritional status, the patient agreed to have a peg placed for gtube feedings to supplement his poor po intake. patient then remained in house for 2 more days to get his tube feeds to goal and monitor tolerance. chronic pain was also consulted to help manage his home pain regimen, especially when a final diagnosis of metastatic cancer came back on path. he was stbilized on a good pain regimen in house and was tolerating tf when he was dc'd on pod10. patient was to f/u next week with dr as well as have a fitting for his prosthesis on monday and a later f/u with neurology and possibly chronic pain. discharge medications: 1. lansoprazole 30 mg susp,delayed release for recon sig: thirty (30) ml po daily (daily): via ng. disp:*500 ml* refills:*0* 2. oxycodone-acetaminophen 5-325 mg/5 ml solution sig: 5-10 mls po q4-6h (every 4 to 6 hours) as needed for pain. disp:*500 ml(s)* refills:*0* 3. levetiracetam 500 mg tablet sig: three (3) tablet po bid (2 times a day). disp:*180 tablet(s)* refills:*2* 4. nortriptyline 25 mg capsule sig: one (1) capsule po hs (at bedtime). disp:*30 capsule(s)* refills:*0* 5. fentanyl 50 mcg/hr patch 72hr sig: three (3) patch 72hr transdermal q72h (every 72 hours) for 2 doses: 3 patches (150mg) for 2 doses, then 2 patches (100mg) for 2 doses, then 1 patch. disp:*20 patch 72hr(s)* refills:*0* 6. tube feeding 1. promote with fiber tube feeds @ 90cc/hr for 24hrs. 2. pump - kangaroo 224 7. protonix 20 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. disp:*30 tablet, delayed release (e.c.)(s)* refills:*2* discharge disposition: home with service facility: discharge diagnosis: left maxillary osteoradionecrosis discharge condition: good discharge instructions: continue applying dressing to left face as before, changing once daily. continue applying benzeyl peroxide to g-tube site for one week and a daily gauze to the external bumper. please take new meds as directed please call your surgeon if you have any of the following: -fever >101 -difficulty breathing, speaking or swallowing -worsening abdominal pain, nausea, vomiting -persistent diarrhea or constipation followup instructions: please follow up with dr. in 1 week. call to schedule an appointment. you have an appointment with dr. on monday morning at 9:30am to have your prosthesis refitted. please follow up with (neurology) on at 3 pm want to f/u with the chronic pain clinic (at md Procedure: Spinal tap Incision of lung Enteral infusion of concentrated nutritional substances Percutaneous [endoscopic] gastrostomy [PEG] Partial ostectomy of other facial bone Local excision or destruction of lesion or tissue of bony palate Diagnoses: Unspecified protein-calorie malnutrition Other convulsions Unspecified fall Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness Malignant neoplasm of connective and other soft tissue of head, face, and neck Malignant neoplasm of hard palate