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mimic-icd-visit

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nLeg pain\n \nMajor Surgical or Invasive Procedure:\nSkin Biopsy\n\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with history of\nhypertension who presents with leg pain.\n\nThe patient is interviewed with the assistance of a ___\ntranslator. The patient reports that she began to develop\nbilateral leg pain ___ weeks ago. She develop sored that began \nto\nweep fluid. The fluid was purulent and foul swelling. She \nreports\nthat she has a severe pain in her legs, and also a cramping in\nthe calves. She denies fevers or chills. Denies trauma to the\nleg. She saw her PCP for this issue, and was given a cream to\napply that did not help. She has been using Tylenol without much\nrelief of her pain. She has been able to ambulate, but is has\nbeen more difficult due to pain.\n\nIn the ED, vitals: 97.7 103 146/68 18 100% RA \nExam notable for significant bilateral lower extremity edema and\nchronic skin changes, with erythema and warmth most notable in\nthe left leg. Erosion along left medial ankle. Wounds/legs are\nmalodorous.\nLabs notable for: WBC 6.6, Hb 10.8\nImaging: Plain films negative for fracture; LENIs negative for\nDVT\nPatient given:\n___ 01:18 PO Acetaminophen 1000 mg \n___ 02:13 IV Piperacillin-Tazobactam 4.5 g\n___ 03:53 IV Vancomycin 1500 mg \n___ 03:53 IVF NS 1000 mL\n\nOn arrival to the floor, she reports that her leg pain is a ___\ndecreased from a ___. She implores us to help with her legs.\n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n\n \nPast Medical History:\n- Hypertension\n \nSocial History:\n___\nFamily History:\n Reviewed and found to be not relevant to this\nillness/reason for hospitalization.\n \nPhysical Exam:\nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. \nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: Ulcer of left medial ankle with purulent and malodorous\ndrainage; edema and chronic brawny skin changes of left calf;\nright calf with thick crusting/scaling with appearance of \nhealthy\nskin beneath with peau d'orange, hyperpigmentation, and\nnodules/plaques \nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: Pleasant, appropriate affect\n\nDischarge Exam: \nGen - not in distress. A&Ox3\nRS: CTAB\n___: S1S2 normal, no murmurs\nAbd: No tenderness, BS normal. \nExtremities: \n RLE: Extensive hyperkeratotic plaques from calf to foot \nwith\nulceration over L medial ankle with purulent drainage. Tender to\npalpation over calf\n LLE: Ulcer with purulent discharge over left medial\nmalleolus and some hyperkeratotic plaques over foot. Very tender\nto touch over calf. \n BLE: Pulses palpable\n \nPertinent Results:\nLabs:\n___ 10:40PM BLOOD WBC: 6.6 RBC: 4.03 Hgb: 10.8* Hct: 33.6*\nMCV: 83 MCH: 26.8 MCHC: 32.1 RDW: 16.1* RDWSD: 49.1* Plt Ct: 374 \n\n___ 10:40PM BLOOD Glucose: 100 UreaN: 7 Creat: 0.8 Na: 142\nK: 4.7 Cl: 101 HCO3: 26 AnGap: 15 \n___ 10:41PM BLOOD Lactate: 1.8 \n\nMicro:\n- Blood cultures negative\n\nImaging:\n- Bilateral ankle/tib/fib: Mild degenerative changes without\nevidence of acute fracture or dislocation. \n\n- LENIs: No evidence of deep venous thrombosis in the right or\nleft lower extremity veins to the level of the popliteal fossa.\nSuboptimal imaging of the vessels in the calves limits their \nevaluation.\n\n___ 3:39 pm SWAB Source: left medial ankle ulcer. \n\n **FINAL REPORT ___\n\n WOUND CULTURE (Final ___: \n PROTEUS MIRABILIS. SPARSE GROWTH. \n STAPH AUREUS COAG +. QUANTITATION NOT AVAILABLE. \n MIXED BACTERIAL FLORA. \n This culture contains mixed bacterial types (>=3) so an\n abbreviated workup is performed. Any growth of \nP.aeruginosa,\n S.aureus and beta hemolytic streptococci will be \nreported. IF\n THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT \nin this\n culture. \n Work-up of organism(s) listed discontinued (except \nscreened\n organisms) due to the presence of mixed bacterial flora \ndetected\n after further incubation. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n PROTEUS MIRABILIS\n | STAPH AUREUS COAG +\n | | \nAMPICILLIN------------ <=2 S\nAMPICILLIN/SULBACTAM-- <=2 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S\nCLINDAMYCIN----------- <=0.25 S\nERYTHROMYCIN---------- <=0.25 S\nGENTAMICIN------------ <=1 S <=0.5 S\nMEROPENEM-------------<=0.25 S\nOXACILLIN------------- 0.5 S\nPIPERACILLIN/TAZO----- <=4 S\nTETRACYCLINE---------- <=1 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S <=0.5 S\n \nBrief Hospital Course:\nMs. ___ is a ___ woman with history of hypertension \nwho presents with leg pain found to have retention \nhyperkeratosis complicated by superimposed cellulitis. \n\n# Skin and soft tissue infection - likely Retention \nhyperkeratosis based on prelim skin biopsy findings\n# L medial malleolus ulcer with infection - superimposed \ncellulitis\n# Leg pain\nPatient presented with several weeks of leg pain and skin \nchanges. On left leg there is a purulent and malodorous ulcer. \nOn both legs, there are brawny skin changes with overlying \ncrusting. Plain films of legs without clear bony changes. LENIs \nnegative for DVT. B/l pulses well-palpable. Venous stasis ulcer \nis a possibility. ESR 39. Ultimately treated for cellulitis and \nstarted on topical treatments for retention hyperkeratosis by \ndermatology as below. Referral placed to dermatology for \noutpatient follow up on discharge. She will continue to require \ndaily dressing changes on discharge. Home ___ was arranged for \nthis though patient continues to be reluctant about home ___ \nvisits stating she will go to nearby clinic for her daily \ndressing changes instead. \n- Wound care recs: \nRLE: \"urea cream or amlactin, then vaseline then wrapped in \nkerlix gauze from toes to knees\"\nLLE: \"mupirocin ointment then wrapped in kerlix gauze from toes \nto mid calf\"\n-Change dressings daily\n-F/U blood and wound cultures - negative blood cultures, wound \ncultures positive for MSSA and proteus with sensitivities as \nlisted. De-scalated antibiotics to Doxy and Keflex with plan to \ncomplete ___ day course on discharge. \n- Tylenol for pain, Tramadol for breakthrough\n\nCHRONIC/STABLE PROBLEMS:\n# Hypertension: Not currently on any medications\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. This patient is not taking any preadmission medications\n\n \nDischarge Medications:\n1. Cephalexin 500 mg PO Q6H \nRX *cephalexin [Keflex] 500 mg 1 capsule(s) by mouth four times \na day Disp #*20 Capsule Refills:*0 \n2. Doxycycline Hyclate 100 mg PO Q12H \nRX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day \nDisp #*10 Capsule Refills:*0 \n3. Mupirocin Ointment 2% 1 Appl TP DAILY \nRX *mupirocin 2 % 1 APP DAILY Refills:*1 \n4. TraMADol 25 mg PO Q6H:PRN Pain - Severe \n5. Ureacin-20 (urea) 20 % topical DAILY \nRX *urea [Ureacin-20] 20 % 1 APP Daily Refills:*1 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nRetention Hyperkeratosis\nSuperimposed Cellulitis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nClean biopsy site with soap, water, then pad dry every day for 2 \nweeks. Cover with a thin layer of vaseline and perform dressing \nchange every day for 2 weeks.\n- RIGHT lower extremity: urea cream or amlactin, then Vaseline \nthen wrapped in kerlix gauze from toes to knees\n- for the LEFT lower extremity: mupirocin ointment then wrapped \nin kerlix gauze from toes to mid calf\n- Both of these dressings to be changed daily\n\nContinue with antibiotics for another 5 days. \n\n \nFollowup Instructions:\n___\n" ]

[ "L03116", "L97329", "L570", "I10" ]

[ "L03116: Cellulitis of left lower limb", "L97329: Non-pressure chronic ulcer of left ankle with unspecified severity", "L570: Actinic keratosis", "I10: Essential (primary) hypertension" ]

[ "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nswollen ear, severe headache, fevers\n \nMajor Surgical or Invasive Procedure:\nintubation\n\n \nHistory of Present Illness:\n___ is a ___ yo M with a history of afib on anticoag,\ndiabetes, HTN who presented to ___ with severe headache,\nfever 102, shaking chills, and toxic appearance. ___ reports\ngradual onset headache that began 1 day ago, associated with\nright ear pain. Headache throbbing, dull, frontal. Subjective\nfevers, chills, nausea.\nConcern for mastoiditis vs meningitis, was started on Vanc,\nZosyn, Ceftriaxone. CT head negative for acute pathology. and\ntransferred to our ___ remained A&Ox3. \n\n___ in Afib with RVR, stable BPs; given diltiazem with\nappropriate response by time of transfer to ICU. ENT consulted\nwhile in ___ and thought to be auriculitis, were less concerned\nfor meningitis and unable to do LP as ___ on anticoag.\n___ continued on zosyn. \n\nIn the ___, \n\nInitial Vitals: T: 99.2 HR: 120 BP; 126/90 RR: 18 SpO2: 94% 4L\nNC \n\nExam: no menigismus, neck stiffness\n erythematous and indurated R ear \n\nLabs: WBC 12.5 (82% neutrophils)\n Lactate: 2.0 \n\nImaging: \n\nConsults: ENT \n\nInterventions: Diltiazem, Zosyn\n\nVS Prior to Transfer: T: 98.7 HR: 115-131 BP: 170/87 RR: 20 92%\n2L NC \n\n \nPast Medical History:\nA fib on anticoagulation\nDiabetes \nHypertension\nesophageal cancer ___ CRT in remission \nHeart failure with reduced ejection fraction\nT2DM\n \nSocial History:\n___\nFamily History:\nMarried. Lives with his wife.\n \nPhysical Exam:\nADMISSION EXAM: \n================\nVS: T: 98.5 BP:131/81 HR:93 afib RR: 16 \nGEN: pleasant, no apparent distress\nHEENT: right ear is erythematous indurated and edematous, behind\nthe right ear is markedly tender and swollen, the right TM is\nerythematous, the canal is erythematous \nNECK: wide full \nCV: irregular rhythm \nRESP: CTAB\nGI: abd soft, non tender to palpation\nMSK: \nSKIN: \nNEURO: no gross deficits \nPSYCH: appropriate affect\n\nDISCHARGE EXAM\n===============\n24 HR Data (last updated ___ @ 1308)\n Temp: 97.7 (Tm 98.4), BP: 123/77 (116-134/59-93), HR: 79 \n(68-103), RR: 18 (___), O2 sat: 98% (92-98), O2 delivery: Ra, \nWt: 231.8 lb/105.14 kg \n\nGeneral: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNeck: Supple, JVP not elevated, no LAD \nLungs: Scant crackles in lower lung bilaterally\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops \nAbdomen: Soft, non-tender, non-distended, bowel sounds present,\nno rebound tenderness or guarding, no organomegaly \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema \nNeuro: AAOx3. Some difficulty with months-of-year-backwards. \n \nPertinent Results:\nADMISSON LABS\n==============\n___ 05:22AM BLOOD WBC-12.1* RBC-5.20 Hgb-15.1 Hct-46.6 \nMCV-90 MCH-29.0 MCHC-32.4 RDW-14.8 RDWSD-48.9* Plt ___\n___ 05:22AM BLOOD Neuts-78.6* Lymphs-13.9* Monos-6.6 \nEos-0.1* Baso-0.4 Im ___ AbsNeut-9.48* AbsLymp-1.67 \nAbsMono-0.79 AbsEos-0.01* AbsBaso-0.05\n___ 05:22AM BLOOD ___ PTT-47.2* ___\n___ 05:22AM BLOOD Glucose-101* UreaN-16 Creat-1.1 Na-142 \nK-4.1 Cl-105 HCO3-22 AnGap-15\n___ 05:22AM BLOOD ALT-29 AST-25 LD(LDH)-209 AlkPhos-63 \nTotBili-0.6\n___ 05:22AM BLOOD Albumin-3.8 Calcium-8.5 Phos-3.5 Mg-1.8\n___ 02:15AM BLOOD ___ pO2-83* pCO2-37 pH-7.43 \ncalTCO2-25 Base XS-0 Comment-GREEN TOP\n___ 02:15AM BLOOD Lactate-1.5\n\nDISCHARGE LABS:\n===============\n___ 08:18AM BLOOD WBC-9.9 RBC-4.63 Hgb-13.2* Hct-42.2 \nMCV-91 MCH-28.5 MCHC-31.3* RDW-14.5 RDWSD-48.5* Plt ___\n___ 08:18AM BLOOD Glucose-248* UreaN-18 Creat-1.0 Na-138 \nK-4.8 Cl-98 HCO3-24 AnGap-16\n___ 08:17AM URINE Color-Yellow Appear-Hazy* Sp ___\n___ 08:17AM URINE Blood-SM* Nitrite-NEG Protein-300* \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-SM*\n___ 08:17AM URINE RBC-47* WBC-43* Bacteri-FEW* Yeast-NONE \nEpi-<1\n\nMICRO\n======\nNo significant micro data from admission\n\nIMAGING\n=======\nCXR ___\nIMPRESSION: \n \nRetrocardiac opacities may reflect atelectasis and/or \nconsolidation. \n \nProminence of the hila bilaterally may reflect enlarged \npulmonary arteries. \nAttention on follow-up imaging is recommended. \n\nCT Neck ___\nIMPRESSION: \n \n \n1. Venous contrast pooling and dental amalgam streak artifact \nand ___ body \nhabitus limits study. \n2. Edema and stranding inferior to the right external auditory \ncanal involving \nthe right parotid gland and right-sided platysma with slight \nprominence of the \nright tonsillar tissue relative to the left and suggestion of \nlymphadenopathy \nas described. Findings concerning for cellulitis and/or \nparotitis. \n3. Asymmetric edema of right or occult compatible with provided \nhistory of \nAuriculitis. \n4. Within limits of study, no definite evidence of focal \nperipherally \nenhancing fluid collections. \n5. Limited imaging lungs demonstrate biapical septal thickening \nand patchy \nopacities. If concern for pulmonary edema or \ninfectious/inflammatory \netiologies, consider correlation with dedicated chest imaging. \n6. Paranasal sinus disease, as described. \n7. Multilevel cervical spondylosis with at least mild to \nmoderate vertebral \ncanal narrowing C5-6. \n \nCT Chest ___\nIMPRESSION: \n \n \n1. Interlobular septal thickening and ground-glass \nopacification, \npredominantly within the mid to upper bilateral lungs, in an \natypical \ndistribution for pulmonary edema, although this cannot be \nexcluded. \nDifferential includes atypical multifocal infection, organizing \npneumonia, \nhypersensitivity pneumonitis. \n2. Nodular opacities measuring up to 1.3 cm are likely \ninfectious or \ninflammatory with similar differential as mentioned above, \nalthough separate \nprocess cannot be excluded. \n3. Trace bilateral pleural effusions. \n4. Mediastinal lymphadenopathy is likely reactive. \n5. Main pulmonary arterial dilatation suggests pulmonary \nhypertension. \n \nCXR ___\nIMPRESSION: \n \nRight-sided PICC line terminates at the level of the cavoatrial \njunction. No \nevidence of pneumothorax. \n \nRe-demonstrated are diffuse ill-defined bilateral opacities. \n \nDense left basilar atelectasis and small left pleural effusion. \n\nTTE ___\nIMPRESSION: Suboptimal image quality. Mild symmetric left \nventricular hypertrophy with normal\ncavity size and mild-moderate global biventricular hypokinesis. \nMild aortic regurgitation. Mildly\ndilated thoracic aorta. Mild pulmonary artery systolic \nhypertension.\n\nCLINICAL IMPLICATIONS: The ___ LVEF is less than 40%; a \nthreshold for which they may benefit\nfrom a beta blocker and an ACE inhibitor (or ___ and a \nmineralocorticoid receptor antagonist. The ___\nhas a mildly dilated ascending aorta. Based on ___ ACCF/AHA \nThoracic Aortic Guidelines, if not previously\nknown or a change, a follow-up echocardiogram is suggested in ___ \nyear; if previously known and stable, a\nfollow-up echocardiogram is suggested in ___ years.\n\nCXR ___\nIMPRESSION: \n \nInterval increase of ill-defined opacities at the bilateral \nlungs in the \nabsence of mediastinal venous engorgement suggests differential \ndiagnoses \nwhich include ARDS, pulmonary hemorrhage, drug reaction to \nantibiotics or \ninfection. \n\nCXR ___\nIMPRESSION: \n \nLungs are well expanded with moderate pulmonary edema. \nCardiomediastinal \nsilhouette is stable. Right-sided PICC line projects to the \nSVC. The ET tube \nand NG tube are unchanged. Left pleural effusions unchanged. \nNo \npneumothorax. \n\nCXR ___\nIMPRESSION: \n \nPulmonary edema has improved. Right-sided PICC line is \nunchanged. The ET, NG \ntube are also unchanged. Cardiomediastinal silhouette is \nstable. Bilateral \neffusions right greater than left are also stable. No \npneumothorax. \n\nCXR ___\nIMPRESSION: \n \nIn comparison with the study of ___, the monitoring and \nsupport devices are \nunchanged and in standard position. Cardiomediastinal \nsilhouette is stable. \nThere is little change in the degree of pulmonary vascular \ncongestion. The \nbilateral pleural effusions, right greater than left, appear \nslightly less \nprominent, though this could merely reflect a more upright \nposition of the \n___. \n\nCXR ___\nIMPRESSION: \n \nComparison to ___. Stable monitoring and support \ndevices. Moderate \ncardiomegaly persists. Small right pleural effusion, minimal \nleft pleural \neffusion. Bilateral areas of basilar atelectasis are unchanged. \n No pulmonary \nedema \n\nCXR ___\nIMPRESSION: \n \nComparison to ___. The ___ is now extubated, the \nfeeding tube is \nremoved. The right PICC line stays in correct position. \nIncreased lung \nvolumes likely reflect improved ventilation. The current \nradiograph shows \nmild cardiomegaly but no evidence of pneumonia, pulmonary edema \nor \npneumothorax. \n\n \nBrief Hospital Course:\nOutpatient Providers: ___ for Admission\n==============================\nMr. ___ is a ___ yo M with a history of afib on dabigitran, \ndiabetes (A1c unknown, on oral antihyperglycemic meds at home), \nand HTN who presented to ___ with a severe headache and \nright ear pain/swelling x 1 day, fever, and chills with concern \nfor auriculitis. ENT was consulted. CT head was negative for \nacute pathology. He was started on Vanc, Zosyn, and Ceftriaxone, \nand transferred to ___ ___. He was initially admitted to the \ngeneral medicine floor but was then transferred to the ICU in \nthe setting of hypoxemic respiratory failure. Respiratory \nfailure felt to be mixed picture in the setting of multifocal \npneumonia and fluid overload. He was treated with cefepime for a \n___nd diuresed to euvolemia with Lasix. He was \nintubated for four days, and after extubation, transferred to a \nmedicine floor. Post-extubation course complicated by agitation \nand ICU delirium. This improved with BID Seroquel which was \nweaned off once transferred back to medicine floor. Though \n___ was alert and oriented most of the time, at discharge he \nwas still intermittently confused which was felt to be \ncombination of ICU delirium resolving and possible UTI. Hospital \ncourse also complicated by rapid ventricular rates in the \nsetting of his known atrial fibrillation and his home rate \ncontrol medications were uptitrated. At discharge ___ \ncomplained of dysuria and a UA revealed pyuria/bactiuria \nconcerning for cystitis. He was afebrile and otherwise \nhemodynamically stable at this time and was felt safe to be \ndischarged to rehab on an oral course of nitrofurantoin for 5 \ndays. \n\nTRANSITIONAL ISSUES:\n====================\n[ ] ___ was prescribed Macrobid (nitrofurantoin) for a \nurinary tract infection. He will take this antibiotic twice a \nday for five days ending ___\n\n[ ] Will need a repeat urinalysis after completion of the \nantibiotic to ensure the resolution of microscopic hematuria \nseen on UA ___. F/u with urology if repeat UA positive for \nblood. \n\n[ ] ___ would likely benefit from weaning off diltiazem \ngiven heart failure with ejection fraction of 35%.\n\nAcute issues:\n=============\n#Hypoxemic respiratory failure. \n#Pulmonary Edema\n#Multifocal Pneumonia\n___ was transferred to the ICU in the setting of respiratory \nfailure requiring intubation. Hypoxia felt to be multifactorial \nin the setting of multifocal pneumonia and pulmonary edema \nrelated to acute on chronic HFrEF exacerbation. He received IV \nLasix and a 7 day course of cefepime. Successfully extubated \nafter several days. His hypoxia had resolved at the time of \ndischarge. \n\n#Acute on Chronic HFrEF: \nLV EF 35-40%. ___ has a history of Heart failure with \nreduced ejection fraction. Per cardiology records at ___, the \n___ EF was 31% as far back as ___. Acute exacerbation \nof heart failure and volume overload felt to play a role in \nrespiratory failure as above. Upon return to the medicine floor, \nthe ___ continued his outpatient Lasix schedule of 20mg \nQday. Captopril was started to add ACEi for guideline directed \nmedical therapy of HFrEF. Diltiazem was attempted to be weaned \noff during admission given increased mortality in heart failure \nhowever ___ HRs would not tolerate lowering of his dose \ndespite increased metoprolol dosing.\n\n#A fib w/ RVR: \nOn dabigatran, diltiazem, digoxin, and metoprolol at home. The \n___ experienced rapid ventricular rate that was terminated \nusing IV diltiazem. During his hospital course his heart rate \nfluctuated from the 100-150's. Per the patients wife, his heart \nrate is consistently over 100, even when on medications at home. \nHis dosing of diltiazem and metoprolol were uptitrated over the \ncourse of his hospitalization and at discharge HRs mostly \n___. Would benefit from weaning of dilt as outpatient if \nable given contraindication in HFrEF. \n\n#Delirium: \nPost-extubation ___ became acutely agitated and delirium. \nFelt to be ICU delirium. He was treated with melatonin and \nquetiapine with improvement in mental status. Despite return to \ncomplete orientation, at discharge ___ still intermittently \nconfused occasionally forgetting he is in the hospital or that \nhe is in fact in his own hospital room though able to complete \n___ backwards and recount hospitalization. \n\n___: \nDeveloped an acute kidney injury with Cr uptrending to 1.3 from \nbaseline 0.9 in the setting of IV diuresis for acute HFrEF \nexacerbation causing pulmonary edema. Further diuresis held with \ndevelopment ___ and renal function improved. that was \nresolved by the time of discharge. \n\n#Auriculitis: \nPresented with a swollen ear, fevers, and chills concerning for \nauriculitis. ENT was consulted. A CT scan did not reveal any \nacute pathology such as mastoiditis. He complete a course of \ncefepime 7 days on ___ for pneumonia as above which \nconcomitantly treated his auriculitis. Can follow-up with ENT as \noutpatient if new symptoms but no indication for routine f/u. \n\nCHRONIC/RESOLVED ISSUES \n======================= \n#Diabetes:\nProvided sliding scale scale insulin while hospitalized. The \nhome medications, metformin, glipizide, and empagliflozin, were \nwithheld then restarted at discharge. \n\n#HTN: \n-Home metoprolol and diltiazem were uptitrated as above. Started \ncaptopril while inpatient\n\n#Hyperlipidemia:\nContinued home atorvastatin 20mg daily\n\n#Abdominal pain:\n#heartburn\n-Continued home ppi, provided calcium carbonate prn\n\n#Constipation\n-Senna, bisacodyl, miralax\n\n___ was seen on day of discharge and examined. >30 minutes \nspent on discharge planning and care coordination on day of \ndischarge. \n \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Succinate XL 100 mg PO DAILY \n2. Gabapentin 100 mg PO BID \n3. Dabigatran Etexilate 150 mg PO BID \n4. GlipiZIDE 5 mg PO BID \n5. MetFORMIN (Glucophage) 500 mg PO 2 TABS IN AM, 1 TAB IN ___ \n6. Furosemide 20 mg PO DAILY \n7. Jardiance (empagliflozin) 10 mg oral DAILY \n8. Digoxin 0.125 mg PO DAILY \n9. Diltiazem Extended-Release 360 mg PO DAILY \n10. Atorvastatin 20 mg PO QPM \n11. Omeprazole 40 mg PO BID \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \n2. Bisacodyl ___AILY \n3. Calcium Carbonate 500 mg PO QID:PRN gerd \n4. Captopril 6.25 mg PO TID \n5. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN throat \nirritation \n6. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H urinary \ntracr infection Duration: 7 Days \n7. Polyethylene Glycol 17 g PO DAILY \n8. Ramelteon 8 mg PO QPM:PRN sleep \n9. Selenium Sulfide 5 mL TP Q12H:PRN seborrheic dermatitis on \nface and neck \n10. Senna 8.6 mg PO BID \nPlease hold for loose stools \n11. Sodium Chloride Nasal ___ SPRY NU TID:PRN dry mucous \nmembranes \n12. Diltiazem Extended-Release 240 mg PO DAILY \n13. Metoprolol Succinate XL 200 mg PO DAILY \n14. Omeprazole 40 mg PO DAILY \n15. Atorvastatin 20 mg PO QPM \n16. Dabigatran Etexilate 150 mg PO BID \n17. Digoxin 0.125 mg PO DAILY \n18. Furosemide 20 mg PO DAILY \n19. Gabapentin 100 mg PO BID \n20. GlipiZIDE 5 mg PO BID \n21. Jardiance (empagliflozin) 10 mg oral DAILY \n22. MetFORMIN (Glucophage) 500 mg PO 2 TABS IN AM, 1 TAB IN ___ \n\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nAtrial Fibrilation with Rapid Ventricular Rates\nAcute Hypoxemic Respiratory Failure\nMultifocal Pneumonia\nPulmonary Edema\nVolume OVerload\nAcute on Chronic Heart Failure with Reduced Ejection Fraction\nDelirium\nDeconditioning\nAcute Kidney Injury\nDiabetes\nAuriculitis\nHTN\nHLD\nGERD\nConstipation\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear ___\n\n___ was a privilege taking care of you at ___ \n___. \n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n===================================\n- You were admitted to the hospital for an infection of your ear \n(auriculitis). \n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n==========================================\n- You were treated with antibiotics for the infection in your \near\n\n- You needed to go to the intensive care unit because your heart \nwas beating too fast and your oxygen levels dropped\n\n- You were unable to breathe on your own due to an infection and \nfluid in your lungs. You were intubated so a machine could help \nyou breathe while you recovered from these things. Your \npneumonia was treated with antibiotics and the fluid in your \nlungs was treated with a medication called Lasix which helps you \npee out that extra fluid\n\n-The doses of the medications you are on for your blood pressure \nand heart rate were changed to help control your heart rate \nbetter\n\n- An infection developed in your bladder. You were given \nantibiotics to treat this when you go to rehab\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?\n============================================ \n- Please continue to take all your medications and follow up \nwith your doctors at your ___ appointments. \n\n-Please see your cardiologist for managing your Atrial \nFibrillation. Changes were made to the medications that you take \nat home for your heart.\n\n-Please take the antibiotic (Macrobid) to treat an infection in \nyour bladder. Follow up with your primary care doctor for ___ \nrepeat urine analysis to make sure the infection is cleared and \nthere is no more blood in your urine\n\nWe wish you all the best!\n\nSincerely, \nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "H6011", "J189", "A419", "J9601", "I5023", "E872", "F05", "N179", "E119", "I4891", "E785", "K5900", "G4733", "E669", "E8770", "I110", "K219", "N3090", "Z8501" ]

[ "H6011: Cellulitis of right external ear", "J189: Pneumonia, unspecified organism", "A419: Sepsis, unspecified organism", "J9601: Acute respiratory failure with hypoxia", "I5023: Acute on chronic systolic (congestive) heart failure", "E872: Acidosis", "F05: Delirium due to known physiological condition", "N179: Acute kidney failure, unspecified", "E119: Type 2 diabetes mellitus without complications", "I4891: Unspecified atrial fibrillation", "E785: Hyperlipidemia, unspecified", "K5900: Constipation, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E669: Obesity, unspecified", "E8770: Fluid overload, unspecified", "I110: Hypertensive heart disease with heart failure", "K219: Gastro-esophageal reflux disease without esophagitis", "N3090: Cystitis, unspecified without hematuria", "Z8501: Personal history of malignant neoplasm of esophagus" ]

[ "J9601", "E872", "N179", "E119", "I4891", "E785", "K5900", "G4733", "E669", "I110", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nshellfish derived\n \nAttending: ___\n \nChief Complaint:\nRight-sided weakness\n \nMajor Surgical or Invasive Procedure:\nLumbar puncture\n \nHistory of Present Illness:\nMr. ___ is a ___ man with a past medical history of\nthyroid cancer status post resection followed by ___,\nhyperlipidemia who presents with 10 days of discrete episodes of\nheadache, lightheadedness, and focal neurologic deficits. \nHistory is obtained by wife at the bedside as patient not able \nto\nparticipate.\n\nOn ___, wife notes that patient had sudden \nonset\n\"massive headache\" with associated lightheadedness and tunnel\nvision. He also experienced numbness in his right arm. There\nwas no vertigo. It is unclear how long this episode lasted but\npatient went to bed and slept for approximately 15 hours. On\nawakening the following day, patient felt back to baseline. He\ncalled his primary care physician and went in for evaluation \nthat\nday. His PCP performed ___ \"lightheadedness workup\" and found no\nneurologic deficits. He felt his symptoms were most likely\nsecondary to migraine headache.\n\nTwo days later, on ___, patient sent wife \"incoherent\"\ntext message via phone. She called him afterward and he had\ndifficulty getting the words out when speaking with her. The\nwife took patient to ___ where he had a\nnoncontrast ___ CT which was unremarkable. He would that he \nwas\ndiagnosed with migraine and sent home. The whole episode lasted\napproximately 1 hour.\n\nPatient and his wife followed up with a neurologist through\n___ the following day and he had an MRI brain\nwithout contrast/MRA ___ and neck as an outpatient. Imaging \nwas\nunremarkable. There are no notes to review from this encounter,\nbut the wife reports the neurologist agreed the etiology of his\nsymptoms was most likely migraine.\n\nThe following day, patient complained of headache which felt \nlike\na headband putting pressure on his whole ___, right worse than\nleft side. The wife began to document his symptoms and she\nnotes: \n12 ___ lightheadedness and vision issues\n12:15 ___ went to bed and slept until 2 ___ \n2:05 ___ woke up with a raging headache behind eyes and\nphotophobia. \nShe documents an exaggerated startle, jumping every time she\nwalks by her opens a soda can. He went to sleep shortly\nafterward and awoke 4 hours later.\n6:15 ___ awoke with continued lightheadedness and headache\n9 ___ out of bed, feeling better\nHe slept until 8:30 AM.\n\nHe was asymptomatic the following day.\n\nToday at 7 ___ he experienced sudden onset right hand numbness\nwhich traveled to his right arm and leg. He also had twitching\nof his right face and clenched his right eye in pain. He also\nhad difficulty speaking, getting any words out. EMS was called\nand he was brought to ___ where code stroke was called. \nNoncontrast ___ CT was negative for bleed or other intracranial\nabnormality. Shortly after arrival to the ED his symptoms\nresolved and TPA was deferred. He began to complain of a\nheadache at this time. \n\nHe was transferred to ___ for further management. Neurology\nwas consulted for question of seizures versus atypical migraine.\n\nUnable to complete review of systems, though positive neurologic\nreview of systems are noted as above. Specifically, patient's\nwife denies a history of headache or migraines. She denies any\nrecent fever or chills. \n\n \nPast Medical History:\nThyroid cancer status post resection. No chemo or radiation. \nDiagnosed in ___, managed at ___. On maintenance \nlevothyroxine.\nHyperlipidemia\n \nSocial History:\n___\nFamily History:\nNo family history of stroke, seizure, or migraine.\n \nPhysical Exam:\n==============\nADMISSION EXAM\n==============\nVitals: Tm: 102.5 P: 40-70 r: 16 BP: 136/90 SaO2: 99% on room \nair\nBlood glucose 89 \nGeneral: Agitated, thrashing in bed, pulling off telemetry \nleads,\nand trying to get out of bed, holding ___ periodically and\nmoaning\nHEENT: NC/AT, positive photophobia, no scleral icterus noted,\nMMM, no lesions noted in oropharynx, incessant yawning\nNeck: Supple, No nuchal rigidity\nPulmonary: Normal work of breathing\nCardiac: Bradycardic, regular rhythm, warm, well-perfused\nAbdomen: soft, non-distended\nExtremities: No ___ edema. He repeatedly lifts his left arm \nabove\nhis ___ and then yawns and almost stereotyped fashion multiple\ntimes throughout the examination. \nSkin: no rashes or lesions noted.\n\nNeurologic:\n\n-Mental Status: Agitated, moving back and forth in bed, appears\nuncomfortable, grimacing and moaning. Will attend to examiner\nbriefly when shouting his name but then turns away and\nrepositions himself. Does not track. When asked his name, he\nreplies \"okay.\" He perseverates on \"I am sorry.\" He attempts \nto\nanswer the question, but there is never a straight response. At\ntimes, he repeats \"what?\" over and over. He then appears to get\nagitated and says \"leave me alone.\" Other spontaneous speech\nincludes \"oh God.\" It is difficult to say if he follows any\ncommands. His speech does not sound dysarthric. He is unable \nto\nparticipate in any further language testing. \n\n-Cranial Nerves:\nHe is severely photophobic so pupil examination is limited. \nOverall pupils appear symmetric and reactive. He moves eyes in\nboth horizontal directions. He has bilateral blink to threat. \nUnable to visualize fundi bilaterally. No facial droop, facial\nmusculature symmetric. Palate elevates symmetrically. Tongue\nprotrudes in midline.\n\n-Motor: Normal bulk, tone throughout. No adventitious movements,\nsuch as tremor, noted. Arms and legs are antigravity and appear\nstrong, though formal confrontational testing is not possible.\n \n-Sensory: He withdraws to noxious stimuli in all 4 extremities. \n\n-DTRs:\n Bi Tri ___ Pat Ach\nL 2 2 2 2 2\nR 2 2 2 2 2\nPlantar response was flexor bilaterally.\n\n-Coordination: Grabs for his IV with his left hand and pulls off\ntelemetry leads with his right hand. \n\n-Gait: Able to bring himself to a standing position unassisted. \n\nDISCHARGE EXAM:\nNonfocal\n \nPertinent Results:\n====\nLABS\n====\n- CBC\n___ 10:00PM BLOOD WBC-6.7 RBC-4.63 Hgb-14.0 Hct-42.4 MCV-92 \nMCH-30.2 MCHC-33.0 RDW-12.6 RDWSD-42.2 Plt ___\n___ 10:00PM BLOOD Neuts-57.0 ___ Monos-8.8 Eos-2.1 \nBaso-0.3 Im ___ AbsNeut-3.83 AbsLymp-2.13 AbsMono-0.59 \nAbsEos-0.14 AbsBaso-0.02\n___ 05:59AM BLOOD WBC-7.8 RBC-4.43* Hgb-13.3* Hct-40.4 \nMCV-91 MCH-30.0 MCHC-32.9 RDW-12.4 RDWSD-41.8 Plt ___\n___ 05:25AM BLOOD WBC-4.8 RBC-4.46* Hgb-13.6* Hct-41.8 \nMCV-94 MCH-30.5 MCHC-32.5 RDW-12.7 RDWSD-43.9 Plt ___\n___ 05:25AM BLOOD Neuts-53.2 ___ Monos-10.9 Eos-2.7 \nBaso-0.4 Im ___ AbsNeut-2.52 AbsLymp-1.55 AbsMono-0.52 \nAbsEos-0.13 AbsBaso-0.02\n\n- Coag\n___ 10:23PM BLOOD ___ PTT-27.2 ___\n___ 05:59AM BLOOD ___ PTT-26.5 ___\n\n- CMP\n___ 10:00PM BLOOD Glucose-98 UreaN-19 Creat-1.2 Na-140 \nK-3.7 Cl-100 HCO3-28 AnGap-16\n___ 10:00PM BLOOD ALT-15 AST-16 CK(CPK)-56 AlkPhos-25* \nTotBili-0.2\n___ 05:59AM BLOOD Glucose-126* UreaN-17 Creat-1.1 Na-139 \nK-3.9 Cl-103 HCO3-22 AnGap-18\n___ 05:25AM BLOOD ALT-13 AST-17 AlkPhos-22* TotBili-0.3\n___ 05:25AM BLOOD Glucose-125* UreaN-9 Creat-1.0 Na-141 \nK-4.2 Cl-103 HCO3-29 AnGap-13\n\n___ 10:00PM BLOOD Albumin-4.3 Calcium-9.1 Phos-3.8 Mg-2.0\n___ 05:59AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.8\n___ 05:25AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.1\n\n- Other\n___ 10:00PM BLOOD cTropnT-<0.01\n___ 05:59AM BLOOD TSH-0.37\n___ 10:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 10:14PM BLOOD Lactate-1.0\n\n- Urine\n___ 02:47AM URINE Blood-TR Nitrite-NEG Protein-TR \nGlucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG\n___ 02:47AM URINE Color-Straw Appear-Clear Sp ___\n___ 02:47AM URINE RBC-3* WBC-1 Bacteri-NONE Yeast-NONE \nEpi-0\n___ 02:47AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG \ncocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG\n\n- CSF\n___ 12:43AM CEREBROSPINAL FLUID (CSF) WBC-270 RBC-0 Polys-0 \n___ ___ 12:43AM CEREBROSPINAL FLUID (CSF) WBC-244 RBC-0 Polys-0 \n___ Monos-4 Other-2\n___ 12:43AM CEREBROSPINAL FLUID (CSF) TotProt-211* \nGlucose-63\n___ 01:00PM CEREBROSPINAL FLUID (CSF) WBC-230 RBC-1* \nPolys-0 ___ Monos-3 Other-3\n___ 09:42AM CEREBROSPINAL FLUID (CSF) TotProt-212* \nGlucose-58 LD(LDH)-23\n___ 09:42AM CEREBROSPINAL FLUID (CSF) HIV1 VL-NOT DETECT\n- Micro\n___ CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID \nCULTURE-PRELIMINARY \n GRAM STAIN (Final ___:\n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count.. \n FLUID CULTURE (Preliminary): \n___ CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID \nCULTURE-PRELIMINARY \n GRAM STAIN (Final ___:\n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count. \n FLUID CULTURE (Preliminary): \n___ CSF VDRL, VZV, CMV, EBB, Autoimmune Encephalopathy \nPanel, Paraneoplastic Panel, Enterovirus pending\n___ Blood (LYME) Lyme IgG-PENDING; Lyme \nIgM-PENDING \n___ BLOOD CULTURE Blood Culture, Routine-PENDING \n\n___ BLOOD CULTURE Blood Culture, Routine-PENDING \n\n___ URINE URINE CULTURE-PENDING \n___ 12:43AM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS \nPCR-negative\n___ 05:10AM BLOOD WBC-5.6 RBC-4.46* Hgb-13.4* Hct-41.5 \nMCV-93 MCH-30.0 MCHC-32.3 RDW-12.7 RDWSD-43.0 Plt ___\n___ 05:10AM BLOOD ___ PTT-25.8 ___\n___ 05:10AM BLOOD Glucose-94 UreaN-11 Creat-1.0 Na-140 \nK-3.8 Cl-100 HCO3-26 AnGap-18\n___ 05:25AM BLOOD ALT-13 AST-17 AlkPhos-22* TotBili-0.3\n___ 05:10AM BLOOD Calcium-8.8 Phos-4.7* Mg-2.0\n___ 05:59AM BLOOD TSH-0.37\n___ 05:10AM BLOOD HIV Ab-Negative\n\n=========\nPATHOLOGY\n=========\n___ CSF Cytology-negative for malignant cells\n___- CSF Cytology pending\n\n=======\nIMAGING\n=======\n- ___ MR ___ CONTRAST\n1. Study is moderately degraded by motion. \n2. No evidence of venous sinus thrombosis. \n3. Within limits of study, no definite leptomeningeal \nenhancement identified. \n4. New nonspecific diffuse subarachnoid signal abnormality, as \ndescribed. \nWhile finding is compatible with meningitis, differential \nconsiderations \ninclude subarachnoid hemorrhage, leptomeningeal carcinomatosis, \nsequelae of hyperoxygenation therapy or artifact. If clinically \nindicated, noncontrast ___ CT may be obtained to evaluate for \npresence of new subarachnoid hemorrhage since ___ \nnoncontrast ___ CT prior exam. \n5. Paranasal sinus disease as described. \n\n- ___ EEG \nThis is an abnormal continuous ICU monitoring study because of \ncontinuous slowing on the left, maximal temporally, indicative \nof focal \ndysfunction. No pushbutton activations, epileptiform discharges, \nor seizures are recorded. Compared to the prior day's recording, \nthere are no significant changes. Of note, sinus bradycardia to \nthe ___ is seen during portions of the record. \n\n \nBrief Hospital Course:\nMr. ___ is a ___ year old man with history of thyroid cancer \n(s/p resection in ___ and hyperlipidemia who presented with a \nten day course of episodic headaches, lightheadedness and focal \nneurological deficits (extremity numbness, aphasia). He was \nfound to have CSF pleomorphic lymphocytosis, and nonspecific \ndiffuse subarachnoid signal abnormality on MRI. He was given a \nprovisional diagnosis of HaNDL syndrome, pending additional \ntests and CSF studies, and was discharged on Verapamil 120mg for \nprophylactic headache treatment. He will follow-up with \noutpatient neurologist.\n\n#Neuro\nOn presentation at ___, the patient was acutely agitated and \nconfused, with a low grade fever and sinus bradycardia. He had a \nsevere headache, multiple neurological deficits and exhibited \nstereotyped movements. ___ at outside hospital revealed no \nacute intracranial process. Patient was admitted to the ICU for \nEEG and neurological monitoring, out of concern for \nmeningoencephalitis vs seizure vs neoplastic process. LP \n(___) revealed elevated opening pressure, lymphocytic \npleiocytosis, elevated protein level, and no malignant cells. \nThe patient was initially maintained on droplet precautions, and \ntreated empirically for meningitis with ceftriaxone, vancomycin \nand acyclovir until HSV PCR was negative and CSF cultures showed \nno bacterial growth. His symptoms had largely resolved the \nmorning after admission and he was subsequently transferred to \nthe floor. His symptoms did not reoccur throughout the rest of \nhis hospital stay. EEG showed continuous slowing on the left, \nmaximal temporally, indicative of focal dysfunction, with no \nepileptiform discharges. MRI revealed new nonspecific diffuse \nsubarachnoid FLAIR hyperintensities, but no evidence of venous \nsinus thrombosis or definite leptomeningeal enhancement. An \nadditional ___ LP was obtained on ___ for further \nCSF studies, with results showing continued lymphocytic \npleocytosis w/ elevated protein level but improved from previous \ntap.\nAt the time of discharge, the patient most closely fit the \ncriteria for syndrome of transient Headache and Neurological \nDeficits with cerebrospinal fluid Lymphocytosis (HaNDL). \nHowever, HaNDL remains a provisional diagnosis until all pending \nresults are back and other etiologies are excluded. If HaNDL is \ndeemed to be the final diagnosis, it should be noted that it is \nusually a self-limiting disease and only prophylactic therapy \nfor associated headaches is recommended. The patient was thus \nstarted on verapamil 120mg for symptomatic improvement and \nheadache prophylaxis.\n\n#Cardiovascular\nCXR showed no acute cardiopulmonary process. The patient was \nmonitored on telemetry with no evidence of atrial fibrillation. \nAtorvastatin 40mg daily was continued per home regimen. \n\nTransition Issues:\n-Pt will need to continue taking Verapamil SR 120mg daily in the \nnear future as prophylactic therapy for migrainous headaches\n-Pt will need to follow up with Neurology as scheduled\n-Pt instructed to present to ED for evaluation if develops \nrecurrent neurologic deficits\n-Pt to be informed if abnormal CSF studies present\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Levothyroxine Sodium 150 mcg PO DAILY \n2. Atorvastatin 40 mg PO QPM \n3. ValACYclovir 2 g PO BID:PRN Cold sore \n\n \nDischarge Medications:\n1. Verapamil SR 120 mg PO Q24H \nRX *verapamil 120 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet \nRefills:*2 \n2. Atorvastatin 40 mg PO QPM \n3. Levothyroxine Sodium 150 mcg PO DAILY \n4. ValACYclovir 2 g PO BID:PRN Cold sore \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nMigraine w/ focal neurologic deficits and lymphocytic \npleocytosis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were hospitalized at ___ due to recurrent migraines \nassociated w/ focal neurologic deficits. You were initially in \nthe NeuroICU and later transferred to the general floor. You \nunderwent extensive laboratory workup indicative of inflammation \nin your cerebrospinal fluid. You were empirically treated with \nantibiotics and antiviral agents which were stopped when \nsubsequent cultures were negative. You underwent EEG which \nshowed no sign of seizure activity. Due to appearing clinically \nstable on exam and w/ no recurrent symptoms, you will be \ndischarged from the hospital.\n\nPlease continue taking Verapamil SR 120mg daily at this time. \nPlease continue your other home medications.\n\nPlease follow up with your PCP and ___ as listed below. If \nyou find yourself having acute focal neurologic deficits in the \nfuture, please go to your nearest ED for evaluation.\n\nIt was a pleasure taking care of you,\n\n___ Neurology Team \n \nFollowup Instructions:\n___\n" ]

[ "G43809", "R001", "R29818", "E785", "R509", "Z85850" ]

[ "G43809: Other migraine, not intractable, without status migrainosus", "R001: Bradycardia, unspecified", "R29818: Other symptoms and signs involving the nervous system", "E785: Hyperlipidemia, unspecified", "R509: Fever, unspecified", "Z85850: Personal history of malignant neoplasm of thyroid" ]

[ "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nBactrim / codeine / doxycycline / metronidazole\n \nAttending: ___.\n \nChief Complaint:\nacute onset dyspnea\n \nMajor Surgical or Invasive Procedure:\nNone \n\n \nHistory of Present Illness:\n___ y/o F with history of CAD, CHF, and COPD presenting with SOB. \nPatient reports 1 month of gradually worsening SOB in the \nsetting of stopping her HCTZ. However, her breathing became much \nworse in last 3 days, and she ultimately went to the ___. She had a mild non-productive cough but denied fevers, \nchills, paroxysmal nocturnal dyspnea, orthopnea, and weight \ngain. Patient also has had bilateral ___ edema that has been \nworsening in the last ___ days. At the OSH, she was hypoxic in \nthe ___ and CXR showed concern for CHF. She was given 40mg of \nLasix and started on a nitro gtt. She became briefly hypotensive \nand was started on levophed via peripheral IV. She was placed on \nBiPAP for transport. Upon arrival to the Cardiology floor, she \nwas hemodynamically stable and was satting comfortably on room \nair. She put out about 1L of urine after receiving Lasix and \ndenied CP and SOB.\n \nPast Medical History:\n3 vessel CAD (cath at ___ in ___\nHTN\nCOPD\nDepression/anxiety\n \nSocial History:\n___\nFamily History:\nnoncontributory\n \nPhysical Exam:\nADMISSION\n=========\nPHYSICAL EXAMINATION: \nVS: T AF, BP 151-156/45-74, HR 64-91, RR 18, O2 sat ___ RA\nWeight: 58.7 kg\nGENERAL: NAD \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera\nCARDIAC: RRR, S1/S2, systolic murmur heard loudest at LLSB and \napex, JVP ~ 11 \nLUNG: bibasilar crackles, no wheezing \nABDOMEN: nondistended, +BS, nontender in all quadrants, no \nrebound/guarding, no hepatosplenomegaly \nEXTREMITIES: WWP, trace ___ edema, +DP b/l\nNEURO: CN II-XII grossly intact \nSKIN: warm and well perfused, no excoriations or lesions, no \nrashes \n\nDISCHARGE\n==========\nVS: T Afebrile, BP 103-117/36-43, P 57-80, RR 18, O2sat 98-100% \non RA\nWeight: 52.3 kg (58.7 on admission)\nI/O: since midnight ___\n24 hours: 1136/850\nGENERAL: NAD \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera\nCARDIAC: RRR, S1/S2, systolic murmur heard loudest at LLSB and \napex, JVP not elevated \nLUNG: No audible crackles, no wheezing \nABDOMEN: nondistended, nontender in all quadrants\nEXTREMITIES: no ___ edema\nNEURO: CN II-XII grossly intact \n \nPertinent Results:\nADMISSION LABS:\n=====================\n___ 09:00PM BLOOD WBC-13.2* RBC-4.27 Hgb-12.7 Hct-39.0 \nMCV-91 MCH-29.7 MCHC-32.6 RDW-13.8 RDWSD-46.5* Plt ___\n___ 09:00PM BLOOD Neuts-90.4* Lymphs-7.1* Monos-1.6* \nEos-0.0* Baso-0.1 Im ___ AbsNeut-11.89* AbsLymp-0.94* \nAbsMono-0.21 AbsEos-0.00* AbsBaso-0.01\n___ 10:29PM BLOOD ___ PTT-29.3 ___\n___ 10:29PM BLOOD Glucose-128* UreaN-17 Creat-0.6 Na-136 \nK-3.6 Cl-99 HCO3-26 AnGap-15\n___ 10:29PM BLOOD ___\n___ 10:29PM BLOOD cTropnT-0.15*\n___ 09:09PM BLOOD ___ pO2-177* pCO2-34* pH-7.46* \ncalTCO2-25 Base XS-1 Intubat-NOT INTUBA\n___ 09:09PM BLOOD Lactate-1.4\n___ 09:09PM BLOOD O2 Sat-96\n___ 09:00PM URINE Color-Yellow Appear-Clear Sp ___\n___ 09:00PM URINE Blood-NEG Nitrite-NEG Protein-30 \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG\n___ 09:00PM URINE RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE \nEpi-<1\n___ 09:00PM URINE Mucous-RARE\n\nOTHER RELEVANT LABS:\n========================\n___ 05:34AM BLOOD WBC-11.8* RBC-3.97 Hgb-11.7 Hct-35.3 \nMCV-89 MCH-29.5 MCHC-33.1 RDW-13.7 RDWSD-44.9 Plt ___\n___ 07:00AM BLOOD WBC-6.0 RBC-3.73* Hgb-11.1* Hct-33.8* \nMCV-91 MCH-29.8 MCHC-32.8 RDW-14.2 RDWSD-47.0* Plt ___\n___ 09:20PM BLOOD PTT-40.7*\n___ 03:23AM BLOOD PTT-52.8*\n___ 03:49AM BLOOD PTT-70.9*\n___ 08:05AM BLOOD ___ PTT-75.6* ___\n___ 03:05PM BLOOD Glucose-129* UreaN-24* Creat-0.8 Na-135 \nK-3.8 Cl-95* HCO3-29 AnGap-15\n___ 07:00AM BLOOD Glucose-71 UreaN-24* Creat-0.7 Na-137 \nK-4.3 Cl-99 HCO3-29 AnGap-13\n___ 07:00AM BLOOD Glucose-80 UreaN-15 Creat-0.7 Na-138 \nK-4.1 Cl-102 HCO3-27 AnGap-13\n___ 07:00AM BLOOD ALT-31 AST-32 LD(LDH)-187 CK(CPK)-22* \nAlkPhos-91 TotBili-0.7\n___ 07:00AM BLOOD ALT-30 AST-34 LD(LDH)-174 AlkPhos-88 \nTotBili-0.7\n___ 02:01AM BLOOD CK-MB-13* cTropnT-0.13*\n___ 07:00AM BLOOD CK-MB-3 cTropnT-0.18*\n___ 09:05PM BLOOD CK-MB-2 cTropnT-0.18*\n___ 07:00AM BLOOD %HbA1c-5.5 eAG-111\nURINE CULTURE (Final ___: NO GROWTH\nStaph aureus Screen (Final ___: NO STAPHYLOCOCCUS AUREUS \nISOLATED.\n\nDISCHARGE LABS:\n====================\n___ 08:05AM BLOOD WBC-4.7 RBC-4.10 Hgb-11.8 Hct-37.6 MCV-92 \nMCH-28.8 MCHC-31.4* RDW-13.9 RDWSD-46.9* Plt ___\n___ 03:29PM BLOOD PTT-66.8*\n___ 08:05AM BLOOD Glucose-92 UreaN-14 Creat-0.7 Na-138 \nK-4.6 Cl-104 HCO3-25 AnGap-14\n___ 08:05AM BLOOD Calcium-9.2 Phos-4.6* Mg-2.3\n\nTTE ___:\nThe left atrium is moderately dilated. Left ventricular wall \nthickness, cavity size and regional/global systolic function are \nnormal (LVEF >55%). Doppler parameters are indeterminate for \nleft ventricular diastolic function. Right ventricular chamber \nsize and free wall motion are normal. The aortic valve leaflets \nare mildly thickened (?#). There is no aortic valve stenosis. \nModerate (2+) aortic regurgitation is seen. The mitral valve \nleaflets are mildly thickened. There is no mitral valve \nprolapse. Mild to moderate (___) mitral regurgitation is seen. \nThe pulmonary artery systolic pressure could not be determined. \nThere is no pericardial effusion. \n\nIMPRESSION: Normal biventricular cavity sizes with preserved \nglobal and regional biventricular systolic function. Moderate \naortic regurgitation. Mild to moderate mitral regurgitation. \n\nCXR (___): IMPRESSION: Heart size is normal. Mediastinum \nis normal. Lungs are hyperinflated but overall clear. Minimal \ninterstitial opacities are unchanged since the prior study. Mild \nincrease in overall interstitial opacities might represent \nslight volume overload, similar to ___ that had \nshown an interval resolution on ___ and in can be \nseen again on today's radiograph. \n\nCT Chest w/o contrast (___): \nRECOMMENDATION(S):\n1. ___ recommendations for follow up of pulmonary \nnodules: \nSolid nodules >4 - 6 mm: Low risk: Follow-up at 12 months and if \nno change, no further imaging needed. High risk: Follow-up at \n___ months and if no change, again at ___ months. The \n___ pulmonary nodule recommendations are intended \nas guidelines for follow-up and management of newly incidentally \ndetected pulmonary nodules smaller than 8 mm, in patients ___ \nyears of age or ___. Low risk patients have minimal or absent \nhistory of smoking or other known risk factors for primary lung \nneoplasm. High risk patients have a history of smoking or other \nknown risk factors for primary lung neoplasm. \n2. Echocardiography, if pop already performed elsewhere, for \nfurther \nevaluation of aortic valvular calcifications. \n3. Diagnostic mammography and axillary ultrasound is recommended \nif \nmammography has not been obtained recently. \n \nBrief Hospital Course:\nMs. ___ is a ___ F with 3 vessel CAD (had a cath at \n___ in ___ that indicated need for \nCABG), HTN and COPD who presented with new acute CHF and \nelevated troponins c/f possible type 2 NSTEMI. She was \nhemodynamically stable at ___ after having briefly been on NRB \nand pressors at ___. She was initially started on \na heparin drip on ___, diuresed for acute HFpEF, and had her BP \nmedications optimized. Her Plavix was dc'd on ___ to prepare \nfor possible CABG later that week. She had a preop workup done, \nincluding CXR, CT chest, and ECHO. However, she was deemed to \nnot be a surgical candidate and was managed medically. \n\n# Multivessel coronary artery disease- Patient had known 3 \nvessel disease on recent cath recommending CABG Cardiac Surgery \nwas consulted to perform CABG this admission. In preparation for \nCABG, Plavix was dc'd ___. Cardiac surgery completed a preop \nworkup including CXR, CT chest w/o contrast, and ECHO. Patient \nwas deemed not a surgical candidate during this admission and \nmanaged medically with metoprolol tartate 12.5 mg BID, ISMN \nshort acting 20 mg BID, ASA 81 mg daily, pravastatin 20 mg qPM, \nand lisinopril 20 mg BID. Heparin drip was discontinued and \nPlavix was restarted on ___. \n\n#Acute diastolic heart failure- New dx of acute heart failure \nduring this admission. pBNP on admission was ___. Elevated \ntroponin was thought to be secondary to demand from CHF given \nknown severe CAD. She was started on a heparin drip ___ that \nwas discontinued on ___ when patient was deemed not a surgical \ncandidate. Patient appeared volume overloaded on admission and \nwas given 40 mg IV Lasix x2. However, she did not require \nfurther diuresis during this admission. TTE was obtained ___ \nthat showed LVEF of >55%. To optimize her afterload reduction, \nhome lisinopril was increased to 20 daily, isosorbide MN was \nincreased to 20 BID, and her HCTZ was dc'd. She was continued on \nher home metoprolol tartrate 12.5 mg BID.\n\n#Oral thrush- Patient had oral thrush during this admission and \nwas started on nystatin for a 2 week course (___). \n \n#COPD: Patient was continued on her Advair and given Fluticasone \nPropionate NASAL 2 SPRY NU DAILY and Fluticasone-Salmeterol \nDiskus (100/50) 1 INH IH BID. \n\n#HTN: Patient was treated with ISMN, lisinopril, and metoprolol \nas above.\n \n#Depression/anxiety: Patient was continued on home Ativan and \nDuloxetine. \n\nTRANSITIONAL ISSUES:\n=========================\n-Discharge weight: 115 lbs\n-Medications added: Aspirin 81, Nystatin Oral Solution (for \nthrush), Pravastatin 20 mg qpm \n-Medications changed: Isosorbide increased to 20 mg BID, \nLisinopril 20 mg daily \n-Medications stopped: Blood pressures stable on above regimen, \nHydrochlorothiazide 12.5 mg daily held, please resume as needed \n-Patient initially presented with shortness of breath, and was \ngiven IV Lasix 40x2. She did not need further diuresis and thus \nis not being discharged with PO Lasix. If symptoms re-develop, \nplease consider low dose oral diuretic. \n-Patient was given a 1 month supply of all her medications \nthrough the ___ Pharmacy at ___. Two home medications that \ncould not be filled were: Duloxetine (may need prior \nauthorization) and Methylphenidate. Please follow up. \n-On non-contrast CT chest, numerous pulmonary nodules measuring \nup to 6 mm for which follow-up chest CT is recommended in ___ \nmonths. \n-On non-contrast CT chest there was borderline left axillary \nlymph node, which may be reactive. Correlation with axillary \nultrasound and mammography is recommended, if not already \nperformed elsewhere. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 10 mg PO DAILY \n2. Hydrochlorothiazide 12.5 mg PO DAILY \n3. Metoprolol Tartrate 12.5 mg PO BID \n4. DULoxetine 60 mg PO DAILY \n5. MethylPHENIDATE (Ritalin) 10 mg PO QID \n6. LORazepam 1 mg PO Q8H:PRN anxiety \n7. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB \n8. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID \n9. Isosorbide Mononitrate (Extended Release) 15 mg PO BID \n10. Mirtazapine 15 mg PO QHS \n11. Clopidogrel 75 mg PO DAILY \n12. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n2. Nicotine Patch 14 mg TD DAILY \nRX *nicotine 14 mg/24 hour once daily Disp #*15 Patch \nRefills:*0 \n3. Nystatin Oral Suspension 5 mL PO QID \nRX *nystatin 100,000 unit/mL 5 mL by mouth four times a day \nRefills:*0 \n4. Pravastatin 20 mg PO QPM \nRX *pravastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0 \n5. Isosorbide Mononitrate 20 mg PO BID \nRX *isosorbide mononitrate 20 mg 1 tablet(s) by mouth twice a \nday Disp #*60 Tablet Refills:*0 \n6. Lisinopril 20 mg PO DAILY \nRX *lisinopril 20 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n7. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB \nRX *albuterol sulfate [ProAir HFA] 90 mcg 1 inhalation every six \n(6) hours Disp #*1 Inhaler Refills:*0 \n8. Clopidogrel 75 mg PO DAILY \nRX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n9. DULoxetine 60 mg PO DAILY \nRX *duloxetine 60 mg 1 capsule(s) by mouth once a day Disp #*30 \nCapsule Refills:*0 \n10. Fluticasone Propionate NASAL 2 SPRY NU DAILY \nRX *fluticasone 50 mcg/actuation 2 sprays once a day Disp #*1 \nSpray Refills:*0 \n11. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID \nRX *fluticasone-salmeterol [Advair Diskus] 100 mcg-50 mcg/dose 1 \ninhalation twice a day Disp #*1 Disk Refills:*3 \n12. LORazepam 1 mg PO Q8H:PRN anxiety \nRX *lorazepam 1 mg 1 tablet by mouth every eight (8) hours Disp \n#*20 Tablet Refills:*0 \n13. MethylPHENIDATE (Ritalin) 10 mg PO QID \nRX *methylphenidate 10 mg 1 capsule(s) by mouth four times a day \nDisp #*120 Capsule Refills:*0 \n14. Metoprolol Tartrate 12.5 mg PO BID \nRX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth \ntwice a day Disp #*30 Tablet Refills:*0 \n15. Mirtazapine 15 mg PO QHS \nRX *mirtazapine 15 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0 \n16. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication \nwas held. Do not restart Hydrochlorothiazide until your doctor \nsays it is okay to do so\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis:\n-Multivessel coronary artery disease\n-Acute diastolic heart failure\n\nSecondary diagnosis:\n-Chronic obstructive pulmonary disease\n-Hypertension\n-Oral thrush\n-Depression\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nYou were admitted to ___ on ___ for shortness of breath. \nWe gave you some medications to help your heart. We also talked \nto the heart surgeons. However, surgery was unable to be \nperformed so we continued to manage your heart with medications \nthat you should continue taking when you go home. \n\nPlease follow up with your PCP and cardiologist. It was a \npleasure taking care of you.\n\nSymptoms to look out for:\n-Shortness of Breath: you were given IV medications to get fluid \nout of your lungs, but did not need this medication in the last \nfew days of your hospitalization. Please weigh yourself \neveryday. If you feel short of breath or your weight goes up by \n3 lbs in a week, let Dr. ___ know as you may need a water \npill (diuretic).\n\n-Chest Pain: Please come to your nearest emergency room if you \nhave any chest pain. Symptoms of pain from your heart can also \nbe arm, shoulder and jaw pain, so if you are worried, please do \nnot hesitate to seek out care.\n\nSincerely, \nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "I214", "B370", "Z006", "J449", "F17210", "I10", "F329", "F419", "I2510" ]

[ "I214: Non-ST elevation (NSTEMI) myocardial infarction", "B370: Candidal stomatitis", "Z006: Encounter for examination for normal comparison and control in clinical research program", "J449: Chronic obstructive pulmonary disease, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris" ]

[ "J449", "F17210", "I10", "F329", "F419", "I2510" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / Flagyl / Keflex / lactated \nringers / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)\n \nAttending: ___.\n \nChief Complaint:\nHeadache, Left arm weakness\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n Mr. ___ is a ___ year-old right-handed man with\na history of myoclonic and abdominal seizures, undifferentiated\nmitochondrial disorder, migraines, and radiculoneuropathy, \nrecent\nprolonged hospitalization in ___ for perforated\ndiverticulitis s/p ___ repair and stomal retraction, now \ns/p\nreversal of colostomy who presents for evaluation of an 11 day\nhistory of progressively severe headache and left arm weakness. \nHistory provided by the patient.\n\nPatient reports he was in his usual state of health until 11 \ndays\nprior to presentation. At that time, he began developing \ngradual\nonset of a headache. The headache was different than his\nbaseline headaches, which are discussed below. This pain was\ndifferent and that it was described as pain \"deep inside\"his\nhead, located over the occipital region with radiation towards\nthe left neck. He notes that it was somewhat similar to the\nheadache he experienced after having a post epidural headache\nduring his recent hospitalization in ___. However, it is\ndifferent from even that headache in that it is not as severe \nand\nis associated with left arm weakness. When the headache started\n11 days ago, he did not make much of the headache as it was \nquite\nmild in severity. He was able to go about his usual activities. \n\n___ days after the headache started, he tried taking his home\nZomig nasal spray, which typically aborts his migraines, and it\ndid not help. He also tried taking over-the-counter Tylenol,\nAleve, and Advil without relief. Over the last 11 days, the \npain\ngradually became more severe and more debilitating. The pain\nbegan to spread throughout his head, not just occipital but\nspread into the right temporal area, and then the left temporal\narea. The headache eventually became so severe, that it did \nwake\nhim up from sleep multiple times (he is explicit about this). \nHeadache is not worsened with Valsalva. It is not positional. \nIt is associated with mild phonophobia and nausea. He denies\nassociated visual symptoms, denies any associated\nnumbness/tingling, denies vomiting, denies\nlightheadedness/dizziness. It is not the worst headache of his\nlife.\n\nAlso, at some point throughout this time, his left arm began to\nfeel weak. He cannot pinpoint when exactly this started. He\nnoticed that the left arm did not have quite the same strength\nand was slower to move than the right. Nonetheless, he was able\nto do all the things with this arm that he wanted to do,\nincluding opening and closing hands, and opening and closing\ndoors. He had never had associated weakness with his headaches\nbefore.\n\nRegarding his baseline headaches, he has what he describes as\nmigraines. These are characterized by throbbing pain located\nbetween his eyes, associate with intense photophobia. These are\nrelieved by lying in a dark room and taking his sumatriptan \nnasal\nspray. He has no preceding aura. He has mild nausea without\nvomiting associated with it. He has never had associated\nweakness or sensory symptoms with a headache. Headaches\ntypically last for 6 hours and occur once a month.\n\nGiven his ongoing, refractory headache, he was planned to see \nhis\noutpatient neurologist Dr. ___ 2 days ago, however the\nappointment was canceled due to the ___ parade. As a \nresult,\ndue to ongoing symptoms that have led to his inability to\nfunction and sleep properly, he came to the emergency room today\nfor further evaluation.\n\nOf note, prior to onset of the symptoms above, patient denies \nany\nrecent changes in his routine. He denies any recent new or\nmissed medications. His blood pressure have been running high\nrecently, and his nephrologist have plan to start losartan,\nhowever patient was reluctant to do so due to difficulty\ntolerating losartan in the past. No recent illness. No\nfevers/chills, no recent upper respiratory symptoms. No recent\ntrauma. No recent neck manipulations. He has gone to the \nbarber\nshop where his hair was washed on the open end sink 5 weeks ago.\n\nPatient recently had a prolonged hospitalization in ___,\nafter presenting with perforated diverticulitis, status post\nrepair and stoma retraction, subsequently status post reversal \nof\ncolostomy on ___. He required epidural placement for the\noperation at T11/T12. Neurology was consulted postoperatively\ndue to intermittent severe headache status post procedure. This\nheadache was notably postural, worse with sitting or elevation\nand improved with lying flat. He was felt to be likely due to\npost epidural headache, less likely due to migraine. He \nimproved\nwith aggressive hydration and symptomatic treatment. For \nworkup,\nhe underwent MRI of the cervical spine which showed moderate to\nsevere degenerative disease without cord enhancement. He did \nnot\nrequire placement of an epidural blood patch. There also was a\nsignificant component of cervicalgia.\n\nRegarding the remainder of his neurologic history:\n- Per Dr. ___ consult note in ___: \"Mr.\n___ has a history of abdominal seizures, first diagnosed \nin\n___. While abroad for work in ___, he described eating tainted\nfish that made him feel nauseous. On his trip back\nto ___, he had fits of vomiting followed by severe fatigue.\nHis vomiting continued whenever he ate, and he lost 55 lb in 3\nmonths. Around this time, he experienced myoclonic seizures with\nfull-body jerks as well, with occasional waves of pain that felt\nlike lanceting electrical shocks down the anterior aspects of \nhis\nthighs. He began seeing Dr. ___ at ___ for his seizures in\n___, and reports that his seizures have been well-controlled on\nLamictal 400mg/500mg and Onfi 20mg qhs with recent lamictal \nlevel\nin ___ being therapeutic. He reports that he has not had a\nseizure in several years. Dr. ___ notes that Mr.\n___ previously has had temporal seizures where he feels a\nsense of familiarity/ unfamiliarity. These episodes usually last\na minute and are followed by fatigue.\"\n- He has an undifferentiated Mitochondrial encephalomyopathy, \nfor\nwhich he also follows w/ Dr. ___. Per OMR, in ___, Mr. ___ developed myoclonic jerks and lost 55 pounds in 3.5\nmonths. He had additional symptoms including elevated lactic\nacid, global fatigue, exercise-induced myalgias, small fiber\npolyneuropathy, pain, and intermittent hypoxia with REM\nhypoventilation. He was on a feeding tube for ___ years and was\ndiagnosed with abdominal epilepsy. \n-At baseline, on neurologic exam he has \"significant decreased\nrapid coordinated function, specifically,rapid finger movements,\nforearm alterations, hand tapping and also some cerebellar signs\nwith dysdiadochokinesis where he has difficulty doing\nfinger-nose-finger testing\" per Dr. ___. \n \n\n \nPast Medical History:\n- recent hospitalization for diverticulitis as above\n- Mitochondrial encephalomyopathy\n- Migraines\n-Benign prostatic hypertrophy\n-OSA: Mild; Failed CPAP ___ inability to tolerate mask.\n-Radicular leg pain: s/p epidural injections \n-Positive PPD\n-Ulceration in the terminal ileum ___\n- Diverticulosis of the sigmoid colon & descending colon \n___\n- Anal fistula repair\n-Right knee partial medial menisectomy\n-Transurethral prostate resection ___ adenocarcinoma ___\n \nSocial History:\n___\nFamily History:\n- Mother had dementia and died at ___ ___ stroke.\n- Father had DM and died at ___ ___ \"old age\". \n- Oldest brother has colon and prostate cancer. \n- Another brother has ankylosing spondylitis. \n \nPhysical Exam:\n==============\nADMISSION EXAM\n==============\n\nPhysical Exam:\nVitals: T 98.5F, HR 94, BP 153/90, RR 18, O2 97% RA\n\nGeneral: Awake, cooperative, NAD.\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx\nNeck: no palpable muscle tension in neck. Supple, No nuchal\nrigidity\nPulmonary: Normal work of breathing\nCardiac: RRR, warm, well-perfused\nAbdomen: soft, non-distended\nExtremities: No ___ edema.\nSkin: no rashes or lesions noted.\n \nNeurologic:\n-Mental Status: Alert, oriented x 3. Able to relate history\nwithout difficulty. Attentive, able to name ___ backward without\ndifficulty. Language is fluent with intact repetition and\ncomprehension. Normal prosody. There were no paraphasic errors.\nPt was able to name both high and low frequency objects. Able \nto\nread without difficulty. Speech was not dysarthric. Able to\nfollow both midline and appendicular commands.There was no\nevidence of apraxia or neglect.\n\n-Cranial Nerves:\nII, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without\nnystagmus. Normal saccades. VFF to confrontation. Fundoscopic\nexam performed, revealed no papilledema, exudates, or\nhemorrhages.\nV: Facial sensation intact to light touch.\nVII: No facial droop, facial musculature symmetric.\nVIII: Hearing intact to finger-rub bilaterally.\nIX, X: Palate elevates symmetrically.\nXI: ___ strength in trapezii bilaterally.\nXII: Tongue protrudes in midline with good excursions. Strength\nfull with tongue-in-cheek testing.\n\n-Motor: Normal bulk, tone throughout. No pronator drift\nbilaterally. No adventitious movements, such as tremor, noted. \nNo\nasterixis noted.\n+ Orbiting around L hand\n Delt Bic Tri WrE FE IP Quad Ham TA ___ ___ \nL 4+* 5 4+* 5 4+* 5 5 5 5 5 5\nR 5 5 5 5 5 5 5 5 5 5 5 \n4+/5 in bilateral ADM \n*there is a give way weakness component, but even when asked to\ngive 2 seconds of best effort it is easily breakable. \n\n-Sensory: No deficits to light touch, pinprick, proprioception\nthroughout. No extinction to DSS. Romberg with sway but not\npositive. \n \n-DTRs:\n Bi Tri ___ Pat Ach\nL ___ 1 0\nR ___ 1 0\nPlantar response was flexor on right, extensor on left.\n\n-Coordination: No intention tremor. reduced speed and amplitude \nof rapid alternating movements of hands, though not overtly \nataxic. No clear overshoot on cerebellar mirroring. No dysmetria \non HKS bilaterally. \n\n-Gait: Good initiation. Gait is hesistant and somewhat wide \nbase, sways back and forth but not to either direction. No \ntruncal ataxia. Falls back in bed when asked to do tandem walk. \nCan take a few steps without assistance, but is unsteady. Unable \nto do Unteberger due to unsteadiness. \n\n==============\nDISCHARGE EXAM\n==============\nUnchanged except as noted below: \n\n-Motor: Normal bulk, tone throughout. No pronator drift\nbilaterally.\n Delt Bic Tri WrE FE IP Quad Ham TA ___ ___ \nL 5 5 5 5 5 5 5 5 5 5 5\nR 5 5 5 5 5 5 5 5 5 5 5 \n* Give-way weakness on every muscle tested on left side. All \nwere full strength on momentary best effort. \n\n-Sensory: Proprioception intact to fine movements of bilateral \nindex fingers and great toes. No deficits to light touch \nthroughout. \n\n-Coordination: FNF intact bilaterally. \n\n-Gait: Ambulating independently with normal gait, stride, base. \n \nPertinent Results:\n====\nLABS\n====\n___ 04:30AM BLOOD WBC-11.1* RBC-4.75 Hgb-15.5 Hct-46.2 \nMCV-97 MCH-32.6* MCHC-33.5 RDW-12.9 RDWSD-46.5* Plt ___\n___ 04:30AM BLOOD Neuts-44.2 ___ Monos-6.7 Eos-3.9 \nBaso-0.5 Im ___ AbsNeut-4.90 AbsLymp-4.91* AbsMono-0.74 \nAbsEos-0.43 AbsBaso-0.06\n___ 04:30AM BLOOD Glucose-83 UreaN-18 Creat-1.0 Na-145 \nK-4.7 Cl-105 HCO3-26 AnGap-14\n___ 10:50AM BLOOD ALT-16 AST-14 CK(CPK)-70 AlkPhos-75 \nTotBili-0.3\n___ 04:30AM BLOOD Calcium-9.4 Phos-4.2 Mg-1.9\n___ 10:50AM BLOOD Triglyc-275* HDL-35* CHOL/HD-6.1 \nLDLcalc-123\n___ 10:50AM BLOOD %HbA1c-5.4 eAG-108\n___ 10:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n\n=======\nIMAGING\n=======\n- ___ MRI & MRA Brain WITHOUT Contrast, MRA Neck WITH \nContrast\n1. No significant intracranial abnormality. No evidence of acute \ninfarction, hemorrhage or mass. \n2. Patent intracranial and cervical vasculature without evidence \nof \ndissection, stenosis, occlusion or aneurysm formation. \n \n\n \nBrief Hospital Course:\nMr. ___ is a ___ year-old right-handed man with a history \nof myoclonic and abdominal seizures, undifferentiated \nmitochondrial disorder, migraines, and radiculoneuropathy, \nrecent prolonged hospitalization in ___ for perforated \ndiverticulitis s/p ___ repair and stomal retraction, now \ns/p reversal of colostomy who presents for evaluation of an 11 \nday history of progressively severe headache and left arm \nweakness. Given his history and constellation of symptoms, he \nwas admitted for neuroimaging to evaluate for central process. \nMRI was negative for stroke or other CNS lesion. Exam was \nnotable for give-way weakness on left side with normal \nproprioception and sensation. His headache improved moderately \nwith a migraine cocktail. He endorsed significant \nmusculoskeletal discomfort and was seen by ___. He will be \ndischarged home with a cervical soft collar and will follow-up \nwith Dr. ___ week. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Clobazam 20 mg PO QHS \n2. ZOLMitriptan 5 mg nasal ASDIR \n3. TraZODone ___ mg PO QHS:PRN insomnia \n4. LamoTRIgine 400 mg PO BID mitochondrial seizure disorder \n\n \nDischarge Medications:\n1. Clobazam 20 mg PO QHS \n2. LamoTRIgine 400 mg PO BID mitochondrial seizure disorder \n3. TraZODone ___ mg PO QHS:PRN insomnia \n4. ZOLMitriptan 5 mg nasal ASDIR \n5.Outpatient Physical Therapy\nCervical musculoskeletal pain \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nHeadache\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMr. ___, \n\nYou were admitted to the neurology service for symptoms of left \narm weakness which was concerning for stroke. Your brain MRI was \nnormal and did not show any stroke or other abnormalities. On \nexamination, you did not have physiologic weakness. We \nrecommended a cervical soft-collar for your neck pain which was \nexacerbating your headache. You were seen by physical therapy \nwho recommended outpatient ___. \n\nPlease follow-up with Dr. ___ as already scheduled. \n\nBest, \nYour ___ Neurology Team\n\n \nFollowup Instructions:\n___\n" ]

[ "R51", "R531", "Z23", "G40802", "E8840", "G43909", "M5410", "G4733", "Z8546", "Z87891" ]

[ "R51: Headache", "R531: Weakness", "Z23: Encounter for immunization", "G40802: Other epilepsy, not intractable, without status epilepticus", "E8840: Mitochondrial metabolism disorder, unspecified", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "M5410: Radiculopathy, site unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z8546: Personal history of malignant neoplasm of prostate", "Z87891: Personal history of nicotine dependence" ]

[ "G4733", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nChest Pain\n\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ yo woman originally from ___ with PMHx pos\nfor hypertension, asthma, OSA (has APAP, doesn't use), obesity,\nGERD, depression, presenting with sx concerning for \npericarditis.\nShe recently had a laparascopic cholecystectomy on ___. She is\nnoted to have tolerated the procedure well, and only has mild\nresidual tenderness surrounding the central incision site. \n\nShe reports acute onset of chest pain in the morning 2 days ago,\nwith gradual progression to ___ severity when presenting to \nthe\nED. Pain was located in the midsternal region and radiated up\ntowards clavicles. Pain worse with inspiration and lying flat,\nand improves with leaning forwards. Also has mild-mod dysp, no\npain while swallowing. She denies fevers, chills, nausea,\nvomiting, abdominal pain, diarrhea, or dysuria. She endorses\ncough sx, feeling light-headed recently, nocturia over months,\nand bilateral knee arthritis. Her grandchildren have recently\nbeen sick with GI illness. \n\nIn the ED, initial VS: Tmax in ED 101.4 HR 99 107 128/80 16 \n100%\nRA \nExam notable for: rub on cardiac auscultation, surgical site\nfrom whole c/d/I. Cardiology and Surgery were consulted. \n\nWhile in ED Pt given: \nAcetaminophen 1000 mg \nMorphine Sulfate 4 mg \nOndansetron 4 mg \nIbuprofen 600 mg \nColchicine .6 mg \namLODIPine 10 mg \nFLUoxetine 40 mg \nIVF NS \nColchicine .6 mg \n\nOn the floor, pt endorses improvement in chest pain symptoms s/p\nbeginning treatment. She denies feeling faint. Denies fever,\nchills, abdominal pain, nausea, vomiting, diarrhea, dysuria.\nComplete ROS obtained and is otherwise negative. \n\n \nPast Medical History:\nPAST MEDICAL HISTORY: \n-obesity \n-seasonal allergies \n-gastroesophageal reflux disease\n-fibroid uterus \n-hypertension \n-anxiety \n-depression \n-asthma\n-obstructive sleep anemia\n-Fe deficiency anemia\n\nPast Surgical History: \n-tubal ligation \n-breast lumpectomy \n-s/p fibroid embolization \n-s/p laparascopic cholecystectomy\n \nSocial History:\n___\nFamily History:\nMother with DM and breast CA, living in ___\nFather, deceased ___, patient does not know much about her \nbiological father.\nHas 6 sisters, 3 brothers. Only one sister in the ___ with \nher, living in ___. Has one sister with fibroids, who \nlives in ___.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n============================== \nWeight 135.81 kg\nVITALS: Temp 99.3 PO BP 110 / 79 HR 98 RR 18 SAT 94 RA \nGENERAL: AOx3, NAD, obese. \nHEENT: Normocephalic, atraumatic. Pupils equal, round, and\nreactive bilaterally, extraocular muscles intact. Sclera\nanicteric and without injection. Moist mucous membranes, good\ndentition. Oropharynx is clear. \nNECK: Thyroid is normal in size and texture, no nodules. No\ncervical lymphadenopathy. \nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nrubs/gallops. No JVD. +friction rub. \nLUNGS: Clear to auscultation bilaterally w/appropriate breath\nsounds appreciated in all fields. No wheezes, rhonchi or rales.\nNo increased work of breathing. \nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. No organomegaly. \nEXTREMITIES: No clubbing, cyanosis, or edema, no sign of\natrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally. \nSKIN: Abdominal incision sites x3 c/d/I with mild tenderness. \nNEUROLOGIC: CN2-12 intact. ___ strength througout. Normal\nsensation.\n\nDISCHARGE PHYSICAL EXAM: \n==============================\nVITALS: 98.7PO, 124/87, 92, 30, 95% Ra \nGENERAL: AOx3, NAD, obese. \nHEENT: PERRL, EOMI, sclera anicteric, MMM.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No \nrubs/gallops. No JVD. +friction rub. \nLUNGS: decreased breath sounds throughout but otherwise clear to \nauscultation bilaterally. \nABDOMEN: Normal bowels sounds, non distended, non-tender to\npalpation in all four quadrants. No organomegaly. \nEXTREMITIES: No clubbing, cyanosis, or edema.\nSKIN: hypopigmented patches consistent with vitiligo on the \nface, Abdominal incision sites x3 c/d/I. \nNEUROLOGIC: CN2-12 grossly intact, no focal deficits.\n\n \nPertinent Results:\nADMISSION LABS:\n======================= \n___ 09:57PM BLOOD WBC-18.2* RBC-4.34 Hgb-11.3 Hct-33.7* \nMCV-78* MCH-26.0 MCHC-33.5 RDW-14.4 RDWSD-40.5 Plt ___\n___ 09:57PM BLOOD Neuts-75.2* Lymphs-8.9* Monos-14.9* \nEos-0.1* Baso-0.1 Im ___ AbsNeut-13.68* AbsLymp-1.62 \nAbsMono-2.71* AbsEos-0.01* AbsBaso-0.01\n___ 09:57PM BLOOD Hypochr-1+* Anisocy-NORMAL Poiklo-2+* \nMacrocy-NORMAL Microcy-1+* Polychr-NORMAL Target-2+*\n___ 11:48PM BLOOD ___ PTT-25.5 ___\n___ 09:57PM BLOOD Glucose-120* UreaN-12 Creat-0.9 Na-139 \nK-3.7 Cl-95* HCO3-28 AnGap-16\n___ 09:57PM BLOOD ALT-20 AST-28 AlkPhos-53 TotBili-1.3\n___ 09:57PM BLOOD Lipase-13\n___ 09:57PM BLOOD cTropnT-0.04*\n___ 09:57PM BLOOD Albumin-3.6\n___ 09:57PM BLOOD CRP-258.6*\n___ 10:45PM BLOOD Lactate-1.1\n___ 06:30AM URINE Color-Yellow Appear-Clear Sp ___\n___ 06:30AM URINE Blood-NEG Nitrite-NEG Protein-30* \nGlucose-NEG Ketone-NEG Bilirub-SM* Urobiln-8* pH-6.5 Leuks-MOD*\n___ 06:30AM URINE RBC-1 WBC-5 Bacteri-FEW* Yeast-NONE Epi-1\n\nPERTINENT LABS:\n=======================\n___ 09:57PM BLOOD CRP-258.6*\n___ 09:57PM BLOOD cTropnT-0.04*\n___ 06:10AM BLOOD cTropnT-0.04*\n___ 02:37PM BLOOD cTropnT-0.03*\n\nMICROBIOLOGY:\n=======================\n__________________________________________________________\n___ 10:32 pm Rapid Respiratory Viral Screen & Culture\n Source: Nasopharyngeal swab. \n\n Respiratory Viral Culture (Pending): \n\n Respiratory Viral Antigen Screen (Pending): \n__________________________________________________________\n___ 10:15 pm URINE\n\n URINE CULTURE (Pending): \n__________________________________________________________\n___ 12:15 am BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n__________________________________________________________\n___ 5:18 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n__________________________________________________________\n___ 10:45 pm BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n__________________________________________________________\n___ 3:55 am URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n\nIMAGING:\n=======================\n___: CXR: Bilateral low lung volumes. Mild bilateral\npulmonary vascular congestion. Left retrocardiac opacity likely\nrepresents atelectasis. Probable bilateral small pleural\neffusions. No pneumothorax. The cardiac and mediastinal\nsilhouettes are unchanged. \n \n___ Echo: \nThe left atrial volume index is normal. The estimated right \natrial pressure is ___ mmHg. Mild symmetric left ventricular \nhypertrophy with normal cavity size, and regional/global \nsystolic function (biplane LVEF = 68 %). The estimated cardiac \nindex is normal (>=2.5L/min/m2). Right ventricular chamber size \nand free wall motion are normal. The diameters of aorta at the \nsinus, ascending and arch levels are normal. The aortic valve \nleaflets (3) appear structurally normal with good leaflet \nexcursion and no aortic stenosis or aortic regurgitation. The \nmitral valve appears structurally normal with trivial mitral \nregurgitation. There is mild pulmonary artery systolic \nhypertension. There is a very small circumferential pericardial \neffusion. \n\nIMPRESSION: Suboptimal image quality. Mild symmetric left \nventricular hypertrophy with preserved regional and global \nbiventricular systolic function. Very small inferolateral \npericardial effusion. Mild pulmonary artery systolic \nhypertension. \n\nDISCHARGE LABS:\n=======================\n___ 05:40AM BLOOD WBC-7.6 RBC-3.46* Hgb-9.0* Hct-27.2* \nMCV-79* MCH-26.0 MCHC-33.1 RDW-14.5 RDWSD-41.4 Plt ___\n___ 05:40AM BLOOD Glucose-79 UreaN-15 Creat-0.8 Na-142 \nK-3.7 Cl-102 HCO3-29 AnGap-11\n___ 05:40AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.1\nOTHER BODY FLUID VIRAL, MOLECULAR FluAPCR FluBPCR \n___ 13:30 NEGATIVE NEGATIVE \nSource: Nasopharyngeal swab \n___ 22:32 NEGATIVE NEGATIVE \nSource: Nasopharyngeal swab \n___ 23:35 NEGATIVE NEGATIVE \n\n \nBrief Hospital Course:\n___ year old ___ woman with history of hypertension, \nobstructive sleep apnea, GERD, and recent laparascopic \ncholecystectomy (___) who presented with acute onset chest \npain consistent with pericarditis. She was discharged on \nibuprofen and colchicine for 3 months, per cardiology. \n\nACUTE ISSUES: \n======================= \n# Pericarditis: \nPt presented with acute onset chest pain with history, exam and \nEKG consistent pericarditis, likely secondary to viral illness \ngiven cough and fever. Flu negative x3, CXR without evidence of \npneumonia, UA without evidence of infection. Troponin peaked at \n0.04. TTE ___ showed minimal inferolateral effusion, with no \nsignificant valvular abnormalities or focal wall motion \nabnormalities and ejection fraction 68%. She remained \nhemodynamically stable and was discharged on ibuprofen and \nColchicine for 3 month course for likely viral pericarditis. \n\n#Microcytic Anemia\nLikely secondary to iron deficiency, given she has history of \nthis and only intermittently takes her iron supplementation due \nto constipation. \n\n#Recent cholecystectomy: Cholecystectomy on ___ done \nlaparoscopically with well healing wounds. LFTs unremarkable. \nShe was seen by surgery while in house without concern for \ninfection. \n\nCHRONIC ISSUES:\n=======================\n# Obstructive Sleep Apnea: Pt has APAP at home however does not \nuse it due to comfort issues. \n\n# Depression: Continued home Fluoxetine. \n\n# HTN: Continued home Amlodipine. \n\n# GERD: Continued home Zantac 150 mg BID. \n\n# Seasonal Allergies: Continued home Loratadine and fluticasone \nnasal spray. \n\nTRANSITIONAL ISSUES:\n======================\nDischarge hemoglobin/hematocrit: 9.0 / 27.2\n\n[] Patient was discharged on colchicine with plan for three \nmonth course [Day 1: ___ and ibuprofen as needed. \n[] Patient needs PCP follow up in ___ weeks.\n[] Please obtain follow up EKG in ___ weeks. \n[] Please monitor anemia and encourage adherence to ion \nsupplementation. \n[] Please follow up on pending lab studies: Respiratory viral \nculture, Respiratory viral antigen screening, urine culture, \nblood cultures. \n\n#CODE: Full Code, presumed. \n#CONTACT:\n Next of Kin: ___ \n Relationship: BROTHER \n Phone: ___ \n\n[x]>30 minutes spent on discharge planning and care coordination\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 10 mg PO DAILY \n2. FLUoxetine 40 mg PO DAILY \n3. Loratadine 10 mg PO DAILY \n4. Ranitidine 150 mg PO BID \n5. Ferrous Sulfate 325 mg PO DAILY \n6. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n7. Ibuprofen 800 mg PO Q8H:PRN AS DIR \n8. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild \n9. Docusate Sodium 100 mg PO BID:PRN constipation \n10. Senna 8.6 mg PO BID:PRN constipation \n\n \nDischarge Medications:\n1. Colchicine 0.6 mg PO BID Duration: 3 Months \nRX *colchicine 0.6 mg 1 tablet(s) by mouth twice a day Disp \n#*172 Tablet Refills:*0 \n2. Ibuprofen 600 mg PO Q8H \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every eight (8) hours \nDisp #*30 Tablet Refills:*0 \n3. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild \n4. amLODIPine 10 mg PO DAILY \n5. Docusate Sodium 100 mg PO BID:PRN constipation \n6. Ferrous Sulfate 325 mg PO DAILY \n7. FLUoxetine 40 mg PO DAILY \n8. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n9. Loratadine 10 mg PO DAILY \n10. Ranitidine 150 mg PO BID \n11. Senna 8.6 mg PO BID:PRN constipation \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnoses:\nPericarditis\n\nSecondary Diagnoses:\nMicrocytic Anemia\nObstructive Sleep Apnea\nSeasonal Allergies\nDepression\nHypertension\nGERD\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nWHY WAS I ADMITTED?\nYou were admitted to the hospital because you had chest pain.\n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n-You were diagnosed with a condition called pericarditis, which \nis caused by inflammation of the lining around your heart.\n- You had an echo (an ultrasound of your heart) which showed \nyour heart is pumping normally and your heart valves are normal. \n\n- The cardiologists (heart specialists) evaluated you and \nrecommended medicines called ibuprofen and colchicine to treat \nyour pericarditis. \n- The surgeons saw you. They felt you were recovering well from \nyour gallbladder surgery earlier this week.\n\nWHAT SHOULD I DO WHEN I GO HOME?\n-Continue to take all home medications as prescribed. \n-Follow up with your primary care doctor within ___ weeks. \n-Please return to the emergency room if you develop worsening \nchest pain, or any other symptoms of concern. \n\nIt was a pleasure caring for you, and we wish you all the best.\n\nSincerely,\nYour ___ team\n\n \nFollowup Instructions:\n___\n" ]

[ "I301", "Z6843", "B9789", "D509", "J302", "G4733", "F329", "I10", "K219", "E669", "F419", "L988" ]

[ "I301: Infective pericarditis", "Z6843: Body mass index [BMI] 50.0-59.9, adult", "B9789: Other viral agents as the cause of diseases classified elsewhere", "D509: Iron deficiency anemia, unspecified", "J302: Other seasonal allergic rhinitis", "G4733: Obstructive sleep apnea (adult) (pediatric)", "F329: Major depressive disorder, single episode, unspecified", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "E669: Obesity, unspecified", "F419: Anxiety disorder, unspecified", "L988: Other specified disorders of the skin and subcutaneous tissue" ]

[ "D509", "G4733", "F329", "I10", "K219", "E669", "F419" ]

[]

[" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Dat(...TRUNCATED)

[ "Q282", "J441", "E1165", "F17210", "I10", "E785", "K219", "Z7984", "Z86718", "Z86711" ]

["Q282: Arteriovenous malformation of cerebral vessels","J441: Chronic obstructive pulmonary disease(...TRUNCATED)

[ "E1165", "F17210", "I10", "E785", "K219", "Z86718" ]

[]

[" \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___(...TRUNCATED)

["A419","J189","J9621","I5032","I2720","M0510","J8489","I480","D638","Z66","Z9981","E8339","D509","G(...TRUNCATED)

["A419: Sepsis, unspecified organism","J189: Pneumonia, unspecified organism","J9621: Acute and chro(...TRUNCATED)

[ "I5032", "I480", "Z66", "D509", "G8929", "F329" ]

[]

[" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Da(...TRUNCATED)

["I110","I5021","N179","R64","I4892","Z681","E785","K219","E039","I482","Z7901","Z87891","I2720","J4(...TRUNCATED)

["I110: Hypertensive heart disease with heart failure","I5021: Acute systolic (congestive) heart fai(...TRUNCATED)

[ "I110", "N179", "E785", "K219", "E039", "Z7901", "Z87891" ]

[]

[" \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date:(...TRUNCATED)

["E1143","E1121","I69354","F1120","I2510","I252","Z85118","Z7902","D509","E1140","E11319","H548","Z7(...TRUNCATED)

["E1143: Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy","E1121: Type 2 diabetes (...TRUNCATED)

[ "I2510", "I252", "Z7902", "D509", "Z794" ]

[]