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mimic-icd-visit

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nlisinopril\n \nAttending: ___.\n \nChief Complaint:\nAltered Mental Status, Urinary Tract Infection, ___\n \nMajor Surgical or Invasive Procedure:\n- Intubation ___ \n- R femoral CVL ___\n- R brachial PICC ___\n- Fem line removed ___\n- Extubation ___\n \nHistory of Present Illness:\n___ with history of atrial fibrillation on Coumadin, CKD, CAD, \nHTN, CHF, who presents with altered mental status. \n\n___ was admitted to the ___ MICU after transfer from \n___. ___ previously had been living at home \nindependently with wife, recently discharged from ___ \nfollowing prolonged hospital course at ___ for UTI and Inferior \nSTEMI, c/b worsening hypotension, encephalopathy, and brief PEA \nfor which ___ was resuscitated. Following this ___ was intubated \nand had cardiogenic shock which gradually recovered. \nPost-extubation course was complicated by aspiration pneumonia \nand sepsis; gradually improved over several weeks and was \ndischarged to ___. Had short readmission in late ___ \nwith tachycardia, with optimization of his cardiac medications, \nand was discharged back to ___. ___ was released from \n___ about 1 week prior to day of admission.\n\n___ presented to ___ with altered mental status, and was \nfound to have a urinary tract infection and acute on chronic \nsubdural hematoma. ___ was transferred to ___ for neurosurgical \nevaluation. No history of fall, cough, diarrhea, vomiting per \nfamily. ___ was unable to provide further history secondary \nto altered mental status.\n\nIn the ED, initial vitals: 96.6 50 87/52 16 97% Nasal \nCannula \nExam was notable for a minimally responsive ___. Pt was \nintubated for airway protection and placed on fentanyl and \nmidazolam gtts. ___ underwent CT scan which showed a 5mm \nacute/subacute on chronic subdural hematoma. \nNeurosurgery was consulted and recommended giving 2u FFP, q1h \nneuro checks, and repeat CT head. Overall, they felt this was \nunlikely to be the cause of his depressed mental status. \n\nOn arrival to the MICU, pt's SBPs ___ systolics. Given 1L LR, \nstarted on peripheral levophed. Pt was given 2 units FFP as a \nright femoral CVL was placed. \n \nPast Medical History:\n- CAD with prior inferior MI\n- Ischemic cardiomyopathy\n- Severe Mitral Regurgitation\n- Chronic kidney disease\n- AFib on Coumadin\n- Hypothyroidism\n- Gout\n- Carotid stenosis\n- HTN\n- Pulmonary HTN\n- Celiac disease \n \nSocial History:\n___\nFamily History:\nNot relevant to current admission\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVitals: T: 98.9 BP: 70/35 P: 54 R: 16 O2: 100% on CMV 500x16, \n0.5, 5 \nGENERAL: intubated, sedated, responds to pain\nHEENT: Sclera anicteric, dry MM, oropharynx clear\nNECK: supple, bilateral CEA scars \nLUNGS: CTAB with mechanical breath sounds\nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops.\nCHEST: Pacer over left chest no erythema \nABD: PEG tube present without surrounding erythema. soft, \nnon-tender, non-distended, bowel sounds present\nGEN: Foley in place\nEXT: cool, trace edema of ankles/feet bilaterally\nSKIN: no jaundice, no rash\nNEURO: Pupils constricted but reactive, +corneals, +moves all \nextremities to pain.\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n================================================================\nDISCHARGE PHYSICAL EXAM: Exam per Dr. ___ on ___ at 0030.\nNo VS\nGeneral: Unresponsive. Cold, Cool. Did not wake to painful \nstimuli.\nHEENT: fixed and dilated pupil.\nCV: No HR or pulse.\nResp: No respirations.\nExt: Cold. \n\n \nPertinent Results:\nADMISSION LABS:\n___ 12:17AM WBC-16.3* RBC-3.90* HGB-9.9* HCT-34.7* MCV-89 \nMCH-25.4* MCHC-28.5* RDW-18.4* RDWSD-59.5*\n___ 12:17AM PLT COUNT-309\n___ 12:17AM ___ PTT-41.0* ___\n___ 12:17AM LIPASE-17\n___ 12:17AM ALT(SGPT)-19 AST(SGOT)-61* ALK PHOS-97 TOT \nBILI-1.6*\n___ 12:17AM GLUCOSE-81 UREA N-32* CREAT-1.4* SODIUM-142 \nPOTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-28 ANION GAP-15\n___ 12:32AM LACTATE-2.1*\n\n=\n=\n=\n=\n================================================================\nPERTINENT LABS\n___ 05:40AM BLOOD ALT-16 AST-23 AlkPhos-106 TotBili-0.7\n___ 02:33AM BLOOD cTropnT-0.37*\n___ 07:09AM BLOOD CK-MB-5 cTropnT-0.42*\n___ 05:40AM BLOOD Vanco-10.5\n___ 03:16AM BLOOD Lactate-1.7\n=\n=\n=\n=\n=\n================================================================\nMICROBIOLOGY\nC.diff: POSITIVE \n\n___ 10:30 am URINE Source: Catheter. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. \n NITROFURANTOIN sensitivity testing performed by ___ \n___. \n Sensitivity testing performed by Sensititre. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ENTEROCOCCUS SP.\n | \nAMPICILLIN------------ <=2 S\nNITROFURANTOIN-------- S\nTETRACYCLINE---------- =>16 R\nVANCOMYCIN------------ 2 S\n\n___ 5:06 pm SPUTUM Source: Endotracheal. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n ___ PMNs and <10 epithelial cells/100X field. \n NO MICROORGANISMS SEEN. \n\n RESPIRATORY CULTURE (Final ___: \n Commensal Respiratory Flora Absent. \n YEAST. SPARSE GROWTH. \n\n=\n=\n=\n=\n=\n================================================================\nIMAGING\nCT HEAD ___:\n1. 5 mm acute/subacute on chronic subdural hematoma. Outside \nimages are not available for comparison. \n2. Background atrophy and probable chronic small vessel disease. \n\n3. Paranasal sinus disease as described above. \n\nCT HEAD ___. Stable right frontal acute on chronic subdural hematoma \nmeasuring up to 5 mm, with no definite midline shift identified.\n2. No new hemorrhage is identified.\n3. Paranasal sinus disease as described, unchanged.\n\nCXR ___. ET tube terminates 5.2 cm above the carina.\n2. Probable left retrocardiac pneumonia, with a presumed left \npleural effusion.\n3. Mild pulmonary vascular congestion.\n\nECHO ___\nThe left atrium is mildly dilated. The right atrium is \nmoderately dilated. No atrial septal defect is seen by 2D or \ncolor Doppler. There is mild symmetric left ventricular \nhypertrophy with normal cavity size. There is mild to moderate \nregional left ventricular systolic dysfunction with akinesis of \nthe inferior and inferolateral walls. The remaining segments \ncontract normally (LVEF = 32 %). [Intrinsic left ventricular \nsystolic function is likely more depressed given the severity of \nmitral regurgitation.] The estimated cardiac index is normal \n(>=2.5L/min/m2). No masses or thrombi are seen in the left \nventricle. The right ventricular cavity is mildly dilated with \nnormal free wall contractility. [Intrinsic right ventricular \nsystolic function is likely more depressed given the severity of \ntricuspid regurgitation.] The diameters of aorta at the sinus, \nascending and arch levels are normal. The aortic valve leaflets \n(3) are mildly thickened but aortic stenosis is not present. No \naortic regurgitation is seen. The mitral valve leaflets are \nmildly thickened. There is no mitral valve prolapse. Severe (4+) \nmitral regurgitation is seen. Moderate [2+] tricuspid \nregurgitation is seen. There is severe pulmonary artery systolic \nhypertension. There is no pericardial effusion. \n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with \nregional systolic dysfunction most c/w CAD (PDA distribution). \nSevere mitral regurgitation. Severe pulmonary artery systolic \nhypertension. Moderate tricuspoid regurgitation. \n\nRenal U/S ___\nNo definite hydronephrosis or stones identified.\nSmall amount of ascites and bilateral small pleural effusions.\nMild edematous gallbladder wall thickening and ghravel/sludge \nmeasuring up to 5 mm, without definite gallbladder distention. \nGiven the ascites and pleural effusions, this is most likely \nrelated to third spacing.\n \nCXR ___\nIn comparison to previous radiograph from 1 day earlier, cardiac \nsilhouette\nhas slightly decreased in size and is accompanied by improvement \nin the extent\nof pulmonary edema and decrease in right pleural effusion. \nResidual\nconsolidation is most marked in the right lower lobe and may \nreflect\nasymmetrical edema or coexisting pneumonia. No other relevant \nchange.\n\nCT Head ___. No significant interval change in the size of the known right \nsubdural\nacute on chronic hematoma. No evidence of new hemorrhage and no \nsignificant\nmass effect.\n2. Moderate background involutional changes.\n3. Persistent left paranasal sinus disease.\n4. Bilateral partial or complete opacification of the mastoid \nair cells is\nnonspecific, likely related to prolonged dependent positioning.\n\nECHO ___ \nThe left atrial volume index is severely increased. There is \nmild symmetric left ventricular hypertrophy. The left \nventricular cavity is mildly dilated. Overall left ventricular \nsystolic function is moderately-severely depressed (LVEF= 30%). \nDoppler parameters are indeterminate for left ventricular \ndiastolic function. The right ventricular free wall is \nhypertrophied. The right ventricular cavity is mildly dilated \nwith normal free wall contractility. The aortic valve leaflets \n(3) are mildly thickened but aortic stenosis is not present. No \naortic regurgitation is seen. The mitral valve leaflets are \nstructurally normal. There is no mitral valve prolapse. The \nmitral regurgitation vena contracta is >=0.7cm. Severe (4+) \nmitral regurgitation is seen. There is moderate pulmonary artery \nsystolic hypertension. There is no pericardial effusion. \n\nCompared with the prior study (images reviewed) of ___, \nthere is less tricuspid regurgitation and pulmonary artery \nsystolic pressure is lower (possibly underestimated as RA \npressure could not be assessed). Left ventricular cavity \nsize/systolic function and degree of functional mitral \nregurgitation are similar. \n\nCT HEAD ___. No significant interval change in the size of the known \nright subdural acute on chronic hematoma. No evidence of new \nhemorrhage and no significant mass effect. \n2. Moderate background involutional changes. \n3. Persistent left paranasal sinus disease. \n4. Bilateral partial or complete opacification of the mastoid \nair cells is nonspecific, likely related to prolonged dependent \npositioning. \nCOMMENTS ON ATTENDING REVIEW: \nThe right subdural collection appears slightly smaller than on \n___. It remains mixed intensity without evidence for \nnew hemorrhage. \n\nEEG ___\nThis is an abnormal portable routine study as it shows the \npresence of symmetric background slowing and disorganization \ntogether with frequent suppressive bursts, consistent with a \nmoderate-severe diffuse encephalopathy that is etiologically \nnonspecific. There are no epileptiform discharges or \nelectrographic seizures. \n\nCXR ___\nThe endotracheal tube tip is 4 cm above the carina. The PICC \nline on the right is unchanged. The pacemaker and leads are \nstable. There is stable patchy atelectasis in both lung bases. \nThere are no new areas of consolidation.. \n\n=\n=\n=\n=\n=\n=\n=\n================================================================\nDISCHARGE LABS (no labs for last 3 days prior to discharge)\n___ 02:10AM BLOOD WBC-11.4* RBC-3.51* Hgb-8.9* Hct-31.2* \nMCV-89 MCH-25.4* MCHC-28.5* RDW-18.9* RDWSD-61.4* Plt ___\n___ 02:10AM BLOOD Plt ___\n___ 02:10AM BLOOD Glucose-120* UreaN-38* Creat-1.1 Na-148* \nK-4.7 Cl-104 HCO3-37* AnGap-12\n___ 02:10AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.6\n___ 02:10AM BLOOD ___ PTT-35.6 ___\n___ 01:58AM BLOOD Glucose-112* UreaN-37* Creat-1.0 Na-146* \nK-4.3 Cl-101 HCO3-38* AnGap-___ with history of atrial fibrillation on Coumadin, CKD, CAD \n(hx STEMI ___, sCHF (___), severe MR/TR, who presents \nwith altered mental status, initially admitted to MICU for \nseptic shock, enterococcus UTI, pneumonia, SDH, and cdiff \ncolitis, transferred to the medicine for comfort care, who \npassed on ___ at 0030.\n\n#Goals of Care: Due to severe critical illness, a family meeting \nwas held when ___ was in the intensive care unit. The aim \nwas to make him as comfortable as possible. ___ was DNR/DNI, \nand transferred to the floor for comfort measure care. All of \nhis medications were discontinued. A second family meeting was \nheld with palliative care service and nearly all immediate \nfamily members on ___. The goal was to discontinue tube feed, \nstop all medications, and transfer ___ to a facility closer \nto home for comfort care. ___ pain was well-controlled and \npassed away on ___ at 0030. \n\n#SEPTIC SHOCK: ___ was initially admitted with fever, \nleukocytosis, and altered mental status, found to be severely \nhypotensive to ___, admitted to the MICU. ___ was started on \nlevophed for hemodynamic support, and intubated. The source was \nconcerning for enterococcus UTI and pneumonia. ___ was started on \nvanc/cefepime and narrowed to vanc/ceftriaxone to complete a 7 \nday course. Unasyn was also added to complete 7 day course of \nUTI. ___ blood cultures were negative. ___ was \nhemodynamically stable afterward, and levophed was turned off. \n___ was transferred to the floor for comfort care.\n\n#ACUTE RESPIRATORY FAILURE: ___ was intubated on ___ for \nairway protection. CXR concerning for PNA and pulmonary edema. \n___ was treated with antibiotics as above and aggressively \ndiuresed with IV furosemide and furosemide gtt with improvement \nof respiratory status. Per discussion with family on ___, \ndecision was made to medically optimize for extubation with the \nplan for no reintubation. ___ was extubated on ___, his \nrespiratory status stabilized. ___ was transferred to the \nfloor for comfort care.\n\n#SUBDURAL HEMATOMA: ___ presented with AMS, CT head revealed \nright frontal 5 mm acute/subacute on chronic subdural hematoma. \nNeurosurgery was consulted and denied need for surgical \nintervention. Supratherapeutic INR of 4.1 on admission was \nreversed with FFP and antiplatelet and anticoagulation was held. \n___ was initiated on keppra BID for a total of 7 days. ___ \nwas closely monitored with serial CTs. Subdural hematoma \nremained stable and, per neurosurgery, ASA was re-initated on \n___ and coumadin on ___ with plan for repeat CT head 2 weeks \nafter re-initiation of anticoagulation. However, all medications \nwere discontinued upon transitioning to comfort care. \n\n# Acute on chronic systolic CHF: TTE revealed EF of ___, \nsevere MR ___ was aggressively diuresed as above. \nRepeat TTE once ___ was euvolemic did not demonstrate \nimprovement in severe MR. \n\n#Atrial fibrillation: CHADS2=3. Home warfarin held due to SDH. \nMetoprolol held initially due to hypotension, resumed at 25 q6h \nonce off of pressors. Home digoxin continued but decreased to \nevery other day given fluctuating renal function and \nsubsequently discontinued. All medications were stopped upon \ntransitioning to comfort care. \n\n___ on CKD: Cr of 1.4 on admission, likely secondary to ATN in \nthe setting of shock. ___ Cr improved to 1.0 upon transfer \nto the floor. \n \n#BPH: We initially continued home Tamsulosin 0.4 mg PO QHS, and \nstopped it upon comfort care. \n\n#Hypothryoidism: We initially continued Levothyroxine Sodium 88 \nmcg PO DAILY,and stopped it upon comfort care. \n\n#CAD: ___ has a history of STEMI in ___, we continued \nAspirin 81 mg PO DAILY, fractionated metoprolol as above, and \nstopped it upon comfort care. \n\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n================================================================\nTransitional Issues\n# Communication: HCP: \n___ ___ \n___\n___ ___\n# Code: DNR/DNI \n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Levothyroxine Sodium 88 mcg PO DAILY \n2. Omeprazole 20 mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Digoxin 0.125 mg PO DAILY \n5. Tamsulosin 0.4 mg PO QHS \n6. Multivitamins 1 TAB PO DAILY \n7. Furosemide 20 mg PO DAILY \n8. Docusate Sodium Dose is Unknown PO Frequency is Unknown \n9. Polyethylene Glycol Dose is Unknown PO Frequency is Unknown \n10. Metoprolol Tartrate 62.5 mg PO BID \n11. Warfarin 2 mg PO DAILY16 \n\n \nDischarge Medications:\n1. Glycopyrrolate 0.2 mg IV Q8H:PRN secretions \n2. LORazepam 0.5-2 mg IV Q4H:PRN agitation \n3. Morphine Sulfate 0.5-10 mg/hr IV DRIP TITRATE TO Comfort\nAllow bolus: No \n4. Morphine Sulfate ___ mg IV Q4H:PRN comfort \n\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nPrimary Diagnoses:\n1. Septic shock\n2. Enterococcus UTI\n3. Pneumonia\n4. Acute toxic metabolic encephalopathy\n5. Cdiff infection\n6. SDH\n\nSecondary Diagnoses:\n1. Afib\n2. Hypothyroidism\n3. BPH\n4. GERD\n\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Lethargic and not arousable.\nActivity Status: Bedbound.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure to care for you at ___ \n___. You initially presented to the hospital for \nfever, low blood pressure and confusion. Your blood pressure was \nlow and you were hospitalized in the intensive care unit and \nneeded IV fluids as well as medications to sustain your blood \npressure. You initially had breathing difficulty and needed to \nbe intubated for breathing support. We found that you had a \npneumonia and urinary tract infection and gave you antibiotics. \nWe also found that you had an infection in your intestines, and \nstarted you on another antibiotic for treatment. A family \nmeeting was held in the intensive care unit regarding goals of \ncare with overall aim to make you as comfortable as possible. \nThe breathing tube was removed and you were transferred to the \nfloor for further care. While on the floor, we stopped most of \nyour medications and started medications that made you \ncomfortable.\n\nIt was a pleasure to care for you at ___.\n\nWarmest regards,\nYour ___ Care Team\n\nA CT scan of your head showed a small bleed but it was stable. \n \nFollowup Instructions:\n___\n" ]

[ "A419", "R6521", "I6201", "J189", "I5023", "I472", "K900", "N179", "E870", "I509", "I6203", "E873", "A047", "N390", "Z66", "I272", "I129", "N189", "I4891", "Z7901", "E039", "I252", "M109", "I081", "N139", "Z515", "K219", "N400", "I255", "I2510", "Z6822" ]

[ "A419: Sepsis, unspecified organism", "R6521: Severe sepsis with septic shock", "I6201: Nontraumatic acute subdural hemorrhage", "J189: Pneumonia, unspecified organism", "I5023: Acute on chronic systolic (congestive) heart failure", "I472: Ventricular tachycardia", "K900: Celiac disease", "N179: Acute kidney failure, unspecified", "E870: Hyperosmolality and hypernatremia", "I509: Heart failure, unspecified", "I6203: Nontraumatic chronic subdural hemorrhage", "E873: Alkalosis", "A047: Enterocolitis due to Clostridium difficile", "N390: Urinary tract infection, site not specified", "Z66: Do not resuscitate", "I272: Other secondary pulmonary hypertension", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "I4891: Unspecified atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "E039: Hypothyroidism, unspecified", "I252: Old myocardial infarction", "M109: Gout, unspecified", "I081: Rheumatic disorders of both mitral and tricuspid valves", "N139: Obstructive and reflux uropathy, unspecified", "Z515: Encounter for palliative care", "K219: Gastro-esophageal reflux disease without esophagitis", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "I255: Ischemic cardiomyopathy", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z6822: Body mass index [BMI] 22.0-22.9, adult" ]

[ "N179", "N390", "Z66", "I129", "N189", "I4891", "Z7901", "E039", "I252", "M109", "Z515", "K219", "N400", "I2510" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nMorbid Obesity\n \nMajor Surgical or Invasive Procedure:\n___\nPROCEDURE: Laparoscopic Roux-en-Y gastric bypass\n\n \nHistory of Present Illness:\n___ is a ___ female referred for the evaluation \nof gastric restrictive surgery in the treatment and management \nof morbid obesity by her primary care provider ___ \n___ in ___, \n___. ___ was seen and evaluated in our ___ \n___ clinic on ___ and ___ and deemed \nappropriate for surgical intervention.\n \nPast Medical History:\nHer medical history includes:\n\n1) hepatic steatosis by ultrasound study\n2) infertility\n3) pre-diabetes (has normal hemoglobin A1c of 5.6%)\n4) vitamin D deficiency\n\nHer surgical history is noted for:\n\n1) D&C in ___\n2) abdominoplasty in ___\n \nSocial History:\n___\nFamily History:\nHer family history is noted for both parents living father with \ndiabetes and she has a sister with cancer. \n\n \nPhysical Exam:\nVital Signs: T: 99.2 BP: 127/79 P: 91 RR: 18 O2: 93 % on room \nair \n\nGEN: The patient was resting comfortably in bed and in no acute \ndistress. \nCV: Regular rate and rythmn. No murmurs. \nRESP: Clear to auscultation b/l\nGI: Her abdomen is soft, mildly tender, non distended. Incisions \nwith clean dry and intact steri-strips. Drain site is \nnon-erythematous with no drainage. \nExt: No peripheral edema noted. Palpable ___ pulses b/l. \n \nPertinent Results:\n___ 05:52AM BLOOD Hct-37.2\n___ 01:27PM BLOOD Hct-41.1\n\n___ UGI:\nIMPRESSION: No evidence of gastrojejunal anastomotic leak or \nobstruction. \n\n \nBrief Hospital Course:\nPt was evaluated by anaesthesia and taken to the operating room \nfor laparoscopic Roux-en-Y gastric bypass. There were no adverse \nevents in the operating room; please see the operative note for \ndetails. Pt was extubated, taken to the PACU until stable, then \ntransferred to ___ 9 for observation. \n\nNeuro: The patient was alert and oriented throughout \nhospitalization; pain was initially managed with a PCA and then \ntransitioned to oral oxycodone once tolerating a stage 2 diet. \nCV: The patient remained stable from a cardiovascular \nstandpoint; vital signs were routinely monitored.\nPulmonary: Good pulmonary toilet, early ambulation and incentive \nspirometry were encouraged throughout hospitalization. Pt was \nweaned from O2 to room air. She was found to have an O2 \nsaturation of 88% after ambulation on ___. She was \nasymptomaitic with no chest pain, shortness of breath or ay \nother signs of DVT/PE. She was kept one more day as a \nprecaution. On ___ she was 93% O2 saturated. \nGI/GU/FEN: The patient was initially kept NPO with a \n___ tube in place for decompression. On POD1, the NGT \nwas removed and an upper GI study was negative for a leak, \ntherefore, the diet was advanced sequentially to a Bariatric \nStage 3 diet, which was well tolerated. Patient's intake and \noutput were closely monitored. JP output remained \nserosanguinous throughout admission; the drain was removed prior \nto discharge.\nID: The patient's fever curves were closely watched for signs of \ninfection, of which there were none.\nHEME: The patient's blood counts were closely watched for signs \nof bleeding, of which there were none.\nProphylaxis: The patient received subcutaneous heparin and ___ \ndyne boots were used during this stay and was encouraged to get \nup and ambulate as early as possible.\n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating a stage 3 \ndiet, ambulating, voiding without assistance, and pain was well \ncontrolled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Cetirizine 10 mg PO DAILY \n2. Multivitamins 1 TAB PO DAILY \n3. HydrOXYzine 25 mg PO QHS:PRN itching \n\n \nDischarge Medications:\n1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain \n2. OxycoDONE Liquid ___ mg PO Q4H:PRN pain \nRX *oxycodone 5 mg ___ tablets by mouth every four (4) hours \nDisp #*35 Tablet Refills:*0\n3. Ranitidine (Liquid) 150 mg PO BID \nRX *ranitidine HCl 15 mg/mL 10 ml by mouth twice a day \nRefills:*0\n4. Ursodiol 300 mg PO BID \nRX *ursodiol 300 mg 1 capsule(s) by mouth twice a day Disp #*360 \nCapsule Refills:*0\n5. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation \nRX *docusate sodium 50 mg/5 mL 10 ml by mouth twice a day \nRefills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nMorbid Obesity\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDischarge Instructions: Please call your surgeon or return to \nthe emergency department if you develop a fever greater than \n101.5, chest pain, shortness of breath, severe abdominal pain, \npain unrelieved by your pain medication, severe nausea or \nvomiting, severe abdominal bloating, inability to eat or drink, \nfoul smelling or colorful drainage from your incisions, redness \nor swelling around your incisions, or any other symptoms which \nare concerning to you.\n\nDiet: Stay on Stage III diet until your follow up appointment. \nDo not self advance diet, do not drink out of a straw or chew \ngum.\n\nMedication Instructions:\nResume your home medications, CRUSH ALL PILLS.\nYou will be starting some new medications:\n1. You are being discharged on medications to treat the pain \nfrom your operation. These medications will make you drowsy and \nimpair your ability to drive a motor vehicle or operate \nmachinery safely. You MUST refrain from such activities while \ntaking these medications.\n2. You should begin taking a chewable complete multivitamin with \nminerals. No gummy vitamins.\n3. You will be taking Zantac liquid ___ mg twice daily for one \nmonth. This medicine prevents gastric reflux.\n4. You will be taking Actigall 300 mg twice daily for 6 months. \nThis medicine prevents you from having problems with your \ngallbladder.\n5. You should take a stool softener, Colace, twice daily for \nconstipation as needed, or until you resume a normal bowel \npattern.\n6. You must not use NSAIDS (non-steroidal anti-inflammatory \ndrugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and \nNaproxen. These agents will cause bleeding and ulcers in your \ndigestive system.\n\nActivity:\nNo heavy lifting of items ___ pounds for 6 weeks. You may \nresume moderate\nexercise at your discretion, no abdominal exercises.\n\nWound Care:\nYou may shower, no tub baths or swimming. \nIf there is clear drainage from your incisions, cover with \nclean, dry gauze. \nYour steri-strips will fall off on their own. Please remove any \nremaining strips ___ days after surgery.\nPlease call the doctor if you have increased pain, swelling, \nredness, or drainage from the incision sites\n\n \nFollowup Instructions:\n___\n" ]

[ "E6601", "K7689", "Z6841", "Z713", "N978", "R7309", "E559" ]

[ "E6601: Morbid (severe) obesity due to excess calories", "K7689: Other specified diseases of liver", "Z6841: Body mass index [BMI]40.0-44.9, adult", "Z713: Dietary counseling and surveillance", "N978: Female infertility of other origin", "R7309: Other abnormal glucose", "E559: Vitamin D deficiency, unspecified" ]

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[ " \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:\nfevers, fatigue \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with HIV (CD4 665, viral load undetected), CKD IV (due to\ntenofovir toxicity, no longer on HD), p/w 1 week of fatigue,\nsubjective fevers, chills, and cough productive of greenish\nsputum. Symptoms began with fatigue. Several days later \ndeveloped\nthe fevers and cough. Feeling progressively worse for past ___\ndays. No dyspnea, chest pain, or hemoptysis. No sick contacts or\ntravel. No recent infections or antibiotic exposures. He \nendorses\ndecreased appetite and UOP. Had a couple episodes of \npost-tussive\nemesis but no nausea, diarrhea, or abdominal pain. No headache,\nneck stiffness, rhinorrhea, sore throat, dysuria, rashes.\n\nIn the ED, patient was afebrile, tachy to 120s, BP stable, SpO2\nnormal on RA. \n\nExam was only notable for RLQ tenderness. \n\nLabs were notable for leukocytosis, Cr 6.0 (unknown recent\nbaseline), normal lactate. FluA PCR was positive. Blood and \nurine\ncultures were sent. CXR revealed patchy opacities concerning for\npneumonia. CT A/P showed multifocal pneumonia at lung bases but\nno intra-abdominal pathology. \n\nPatient was given 2.5L LR, vanc/cefepime for multifocal PNA, and\nadmitted for further management.\n\nOn the floor, patient feels slightly better with fluids and\nantibiotics.\n\n \nPast Medical History:\n HIV \n CKD Stage IV, previously on HD via AVF, had recovery of renal\nfunction\n Smoker - tobacco and marijuana\n Vertigo - thought to be due to inner ear infection\n \nSocial History:\n___\nFamily History:\nMother with dementia. Father healthy and takes care of her. 2\nbrothers and 2 sisters, all healthy. Paternal grandmother with\nkidney cancer (was a smoker). Does not known other grandparents'\nhistory.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVS: reviewed, afebrile, tachycardia, BP and SpO2 normal\nGeneral: Thin older man, appears fatigued but not ill.\nHEENT: No icterus or injection. +Nasal congestion. OP moist and\nclear.\nCV: Mild tachycardia, regular, no murmurs or rubs.\nResp: Normal work of breathing. Diffuse coarse breath sounds. No\nwheezes, egophony, or dullness to percussion.\nAbd: Soft, mild RLQ tenderness, no rebound or guarding, NABS.\nExtr: Warm, no c/c/e.\nNeuro: Alert, oriented, attentive. CN intact. Normal strength \nand\ncoordination. No meningismus.\n\nDISCHARGE PHYSICAL EXAM: \nVS: 97.5 PO 115 / 66 (110-120s/60-70s) L Sitting 92 (80-90s) 18\n96 Ra Ambulated patient on ___ and no dyspnea with exertion, O2\nsats >95% \nI/O 1050/905\nGENERAL: NAD \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM\nNECK: nontender supple neck, no JVD \nHEART: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNGS: Expiratory wheezes diffusely and fine crackles in bases\n(L>R), no increased work of breathing \nABDOMEN: nondistended, +BS, tender in RLQ, no rebound/guarding.\nEcchymosis over suprapubic region \nEXTREMITIES: no cyanosis, clubbing or edema, moving all 4\nextremities with purpose \nNEURO: CN II-XII intact \nSKIN: warm and well perfused, no excoriations or lesions, no\nrashes \n \nPertinent Results:\n==============\nADMISSION LABS\n==============\n___:32PM BLOOD WBC-16.5* RBC-3.18* Hgb-11.3* Hct-31.8* \nMCV-100*# MCH-35.5* MCHC-35.5 RDW-13.1 RDWSD-47.8* Plt ___\n___ 02:32PM BLOOD Glucose-114* UreaN-74* Creat-6.0*# Na-136 \nK-3.6 Cl-98 HCO3-13* AnGap-25*\n\n==============\nPERTINENT LABS\n==============\n___ 02:32PM BLOOD VitB12-981*\n___ 02:42PM BLOOD Lactate-1.8\n___ 10:15AM BLOOD WBC-18.5* RBC-2.82* Hgb-9.9* Hct-27.8* \nMCV-99* MCH-35.1* MCHC-35.6 RDW-13.3 RDWSD-48.6* Plt ___\n\n============\nMICROBIOLOGY\n============\n___ 2:33 pm BLOOD CULTURE: NGTD \n___ 7:15 pm URINE\n URINE CULTURE (Final ___: < 10,000 CFU/mL.\n___ 4:13 Legionella Urinary Antigen (Final ___: \n NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. \n___ 6:46 am MRSA SCREEN NEGATIVE \n\n=======\nIMAGING\n=======\n___ CXR\nFindings concerning for multifocal pneumonia. \n\n___ CT A/P \n1. No acute abnormality identified to account for the patient's \nright lower quadrant pain. Appendix not definitively \nvisualized, but no secondary signs to suggest acute \nappendicitis. \n2. Multifocal pneumonia or aspiration within the lung bases. \n3. Diverticulosis without diverticulitis. \n\n___ Appendix ultrasound\nNo evidence of appendicitis or any other abnormalities in the \nright lower \nquadrant. \n\n==============\nDISCHARGE LABS\n==============\n___ 06:22AM BLOOD WBC-14.6* RBC-2.77* Hgb-9.6* Hct-27.8* \nMCV-100* MCH-34.7* MCHC-34.5 RDW-13.7 RDWSD-50.4* Plt ___\n___ 06:22AM BLOOD Glucose-93 UreaN-43* Creat-3.8* Na-144 \nK-3.1* Cl-110* HCO3-15* AnGap-19*\n\n \nBrief Hospital Course:\nMr. ___ is a ___ with HIV (CD4 665, viral load \nundetectable), CKD IV ___ to tenofovir toxicity, previously on \nHD), who presented with 1 week history of fevers, fatigue, and \nproductive cough, found to have influenza, pneumonia, and acute \nkidney injury. \n\n#Influenza A\n#Multifocal pneumonia: Presents with one week history of \nworsening dyspnea, fatigue, and productive cough, worsened over \nthe few days prior to presentation. He was found to have \ninfluenza A with leukocytosis to 16. CXR demonstrated multifocal \npneumonia. Low suspicion for PJP given well controlled HIV. \nGiven presence of symptoms > 1 week, he was not a candidate for \nTamiflu. He was started on ceftriaxone, azithromycin and \ntransitioned to cefpodoxime/azithromycin (___) on \ndischarge. QTc on day of discharge 450 He was discharged with \nalbuterol PRN and cough suppressants \n\n#Acute kidney injury on chronic kidney disease: Most recent Cr \nof 3.15 in ___. Previously on HD after acute renal failure \nfor tenofovir toxicity, has RUE AV fistula. UNa with significant \nNa avidity. Suspect large component is pre-renal from poor PO \nintake, improving with re-hydration. Continued to make urine. \nMedications were dose adjusted for CrCl. He was resumed on home \nsodium bicarbonate. He is scheduled to follow up with nephrology \non discharge. Cr of 3.8 on discharge, plan for repeat chem panel \nwith PCP ___ 3 days \n\n#Right sided abdominal pain: \nCT A/P in ED reassuring against acute abnormality. Pain may be \nmusculoskeletal Interestingly, has suprapubic ecchymosis of \nunclear etiology, no trauma. No hydro or\nevidence of nephrolithiasis on imaging, no appendicitis on \nabdominal ultrasound. Abdominal pain improved without \nintervention during hospitalization \n\n#HIV on ART (last CD4 665 with undetectable viral load): Dose \nadjusted emtricitabine, tivacay, kaletra. He should discuss with \nPCP about further dose adjustments as Cr improves. \n\n#Weight loss: reports 13 lb weight loss over the past week in \nsetting of poor appetite. Nutrition consulted and patient \nstarted on nepro TID. Consider outpatient workup if no \nimprovement after acute illness \n\n#Anemia: macrocytic, appears near baseline. No evidence of acute \nbleed. B12 wnl. Would ensure age appropriate cancer screening \n(has never had colonoscopy) \n\nTRANSITIONAL ISSUES\n===================\n- MEDICATION CHANGES\n[ ] ANTIBIOTIC REGIMEN: cefpodoxime (___) + azithromycin \n(___) \n[ ] CHANGED: Emtricitabine reduced to 200 mg q96h due to ___\n[ ] NEW: benzonate, sodium bicarbonate, albuterol inhaler PRN \n- Patient should have repeat chem 7 at PCP appointment on ___ \nto ensure resolution ___ \n- Emtricitabine will need to be dose adjusted as kidney function \nimproves\n- Please ensure age appropriate cancer screening given weight \nloss and anemia as above \n- Patient scheduled to follow up with nephrology as an \noutpatient \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Tussin CF (pseudoephedrine-DM-guaifenesin) ___ mg/5 mL \noral QID:PRN \n2. TraZODone 25 mg PO QHS:PRN insomnia \n3. Dolutegravir 50 mg PO DAILY \n4. Lopinavir-Ritonavir 2 TAB PO DAILY \n5. Emtricitabine 200 mg PO Q24H \n6. Vitamin D ___ UNIT PO 1X/WEEK (MO) \n7. Meclizine 12.5 mg PO Q8H:PRN vertigo \n8. Acetaminophen Dose is Unknown PO Q6H:PRN Pain - Mild \n\n \nDischarge Medications:\n1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob \nRX *albuterol sulfate [Proventil HFA] 90 mcg ___ puff IH q4h PRN \nDisp #*1 Inhaler Refills:*0 \n2. Azithromycin 250 mg PO DAILY Duration: 4 Doses \nlast day ___ \nRX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*2 \nTablet Refills:*0 \n3. Benzonatate 100 mg PO TID \nRX *benzonatate 100 mg 1 capsule(s) by mouth TID PRN Disp #*30 \nCapsule Refills:*0 \n4. Cefpodoxime Proxetil 400 mg PO Q24H \nstart ___, last day ___ \nRX *cefpodoxime 200 mg 2 tablet(s) by mouth daily Disp #*8 \nTablet Refills:*0 \n5. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough \nRX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 5 ml by mouth \nq6h prn Refills:*0 \n6. Multivitamins W/minerals 1 TAB PO DAILY \n7. Sodium Bicarbonate 650 mg PO TID \nRX *sodium bicarbonate 650 mg 1 tablet(s) by mouth three times a \nday Disp #*90 Tablet Refills:*0 \n8. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever \n9. Emtricitabine 200 mg PO Q96H \n10. Dolutegravir 50 mg PO DAILY \n11. Lopinavir-Ritonavir 2 TAB PO DAILY \n12. Meclizine 12.5 mg PO Q8H:PRN vertigo \n13. TraZODone 25 mg PO QHS:PRN insomnia \n14. Vitamin D ___ UNIT PO 1X/WEEK (MO) \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nInfluenza\nCommunity Acquired Pneumonia\nAcute renal failure \nChronic kidney disease\nHIV \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\nIt was a pleasure caring for you at ___. You were admitted to \nthe hospital for fevers and fatigue. You were found to have the \nflu and a pneumonia, for which you were treated with \nantibiotics. Your labs also showed acute kidney failure \nsecondary to severe dehydration. You received fluids and your \nkidney function improved. \n\nIt is very important that you continue the medications below. \nPlease also follow up with your primary care physician and \nkidney doctor as below.\n\nWishing you well,\n\nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "J09X1", "N184", "N179", "E872", "Z681", "T375X5S", "Z21", "E860", "Z720", "F1290", "R1031", "R634", "D539" ]

[ "J09X1: Influenza due to identified novel influenza A virus with pneumonia", "N184: Chronic kidney disease, stage 4 (severe)", "N179: Acute kidney failure, unspecified", "E872: Acidosis", "Z681: Body mass index [BMI] 19.9 or less, adult", "T375X5S: Adverse effect of antiviral drugs, sequela", "Z21: Asymptomatic human immunodeficiency virus [HIV] infection status", "E860: Dehydration", "Z720: Tobacco use", "F1290: Cannabis use, unspecified, uncomplicated", "R1031: Right lower quadrant pain", "R634: Abnormal weight loss", "D539: Nutritional anemia, unspecified" ]

[ "N179", "E872" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \natorvastatin / lisinopril / amlodipine\n \nAttending: ___\n \nChief Complaint:\nAFib w/ RVR\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nHISTORY OF PRESENTING ILLNESS: Ms. ___ is a ___ y/o female\nwith past medical history of AFib treated with sotalol and\nanticoagulated on rivaroxaban, OSA and hypertension who presents\nfor concerns of AFib with RVR. \n\nShe reports that on the night of ___ she awoke with a\nsensation of chest heaviness/discomfort but it passed in a short\nperiod of time so she went back to sleep. On the morning of\n___ she felt short of breath and her heart felt \"erratic.\"\nShe also reports \"just not feeling herself.\" She reports a\nfeeling of \"fogginess\" and malaise, which she has difficulty\ndescribing. She took her blood pressure at home and the reading\nkept fluctuating. She went to an urgent care clinic and had an\nECG that showed AFib with RVR, rate of 129. From Urgent care she\nwas sent by ambulance to the ED for further evaluation. \n\nShe endorses chest discomfort during the day, which is not\nexertional or positional. She has not had urinary symptoms,\ndenies dysuria, urgency or foul smelling urine. \n\nShe reports that she was hospitalized one year ago for AFib with\nRVR and then in ___ in ___ where she was treated for a UTI\nand caridoverted. Since her initial diagnosis of AFib last year,\nshe reports exercise intolerance and shortness of breath after\nwalking just a several blocks, which is new for her. \n \nPast Medical History:\nPAST MEDICAL HISTORY: \n=====================\n1. CARDIAC RISK FACTORS \n- Hypertension \n2. CARDIAC HISTORY \n- CABG: None \n- PERCUTANEOUS CORONARY INTERVENTIONS: None \n- PACING/ICD: None \n3. OTHER PAST MEDICAL HISTORY \nVenous insufficiency\nObstructive sleep apnea\nObesity\nSplenectomy\n\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or\nsudden cardiac death. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION: \n===============================\nVITALS: 97.5PO 128/77 73 16 95 RA \nGENERAL: Well-developed, well-nourished. NAD. Mood, affect\nappropriate.\nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no\npallor or cyanosis of the oral mucosa. No xanthelasma. \nNECK: No appreciable JVD or LAD. \nCARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. No \nthrills,\nlifts. \nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp\nwere unlabored, no accessory muscle use. No crackles, wheezes or\nrhonchi. \nABDOMEN: Obese abdomen. Soft, NTND. No HSM or tenderness. \nEXTREMITIES: No c/c/e. No femoral bruits. \nSKIN: Right lower extremity, wound from skin biopsy with \nsutures.\nNo erythema, tenderness or warmth. \nPULSES: Distal pulses palpable and symmetric \n\n===============================\nDISCHARGE PHYSICAL EXAMINATION: \n===============================\nVITALS: 97.7PO 117/76 63 20 96 RA \nGENERAL: Well-developed, well-nourished. NAD. Mood, affect\nappropriate.\nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no\npallor or cyanosis of the oral mucosa. No xanthelasma. \nNECK: No appreciable JVD or LAD. \nCARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. No \nthrills,\nlifts. \nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp\nwere unlabored, no accessory muscle use. No crackles, wheezes or\nrhonchi. \nABDOMEN: Obese abdomen. Soft, NTND. No HSM or tenderness. \nEXTREMITIES: No c/c/e. No femoral bruits. \nSKIN: Right lower extremity, wound from skin biopsy with \nsutures.\nNo erythema, tenderness or warmth. \nPULSES: Distal pulses palpable and symmetric \n\n \nPertinent Results:\n==================\nLABS ON ADMISSION:\n==================\n___ 06:45PM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 06:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 \nLEUK-NEG\n___ 08:42PM cTropnT-<0.01\n___ 08:42PM TSH-2.2\n___ 02:25PM GLUCOSE-109* UREA N-20 CREAT-0.8 SODIUM-142 \nPOTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-27 ANION GAP-13\n___ 02:25PM estGFR-Using this\n___ 02:25PM cTropnT-<0.01\n___ 02:25PM proBNP-2665*\n___ 02:25PM WBC-8.1 RBC-4.56 HGB-14.0 HCT-43.0 MCV-94 \nMCH-30.7 MCHC-32.6 RDW-12.7 RDWSD-43.8\n___ 02:25PM NEUTS-52.9 ___ MONOS-6.9 EOS-1.1 \nBASOS-0.7 IM ___ AbsNeut-4.26 AbsLymp-3.08 AbsMono-0.56 \nAbsEos-0.09 AbsBaso-0.06\n___ 02:25PM PLT COUNT-384\n___ 02:25PM ___ PTT-35.5 ___\n___ 01:35PM URINE HOURS-RANDOM\n___ 01:35PM URINE UHOLD-HOLD\n___ 01:35PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 01:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-SM*\n___ 01:35PM URINE RBC-<1 WBC-8* BACTERIA-NONE YEAST-NONE \nEPI-2\n___ 01:35PM URINE MUCOUS-RARE*\n\n==================\nLABS ON DISCHARGE:\n==================\n\n___ 07:10AM BLOOD WBC-8.3 RBC-4.50 Hgb-13.6 Hct-42.5 MCV-94 \nMCH-30.2 MCHC-32.0 RDW-12.8 RDWSD-44.3 Plt ___\n___ 07:10AM BLOOD Glucose-101* UreaN-26* Creat-0.8 Na-142 \nK-4.7 Cl-102 HCO3-28 AnGap-12\n___ 07:10AM BLOOD Calcium-9.6 Phos-4.3 Mg-2.2\n___ 08:42PM BLOOD TSH-2.2\n \nBrief Hospital Course:\nMs. ___ is a ___ y/o female with past medical history of AFib \ntreated with sotalol and anticoagulated on rivaroxaban, OSA and \nhypertension who presents with AFib with RVR, now spontaneously \nback to NSR.\n\n-CORONARIES: unknown\n-PUMP: EF >65%\n-RHYTHM: AFib on admission, currently sinus\n\n#AFib with RVR: This is the patient's ___ hospitalization for \nAFib w/ RVR. Prior triggers were UTI post-cholecystectomy and \nUTI alone. During last admission in ___ required DC \ncardioversion. She has had one failure on sotalol 80 mg BID, \nthis admission being the second. She presented to urgent care \nwith HR in the 120s, feeling chest pain and some numbness in the \nleft hand. On admission her Troponin was negaitve x2 with proBNP \nelevated. Patient received dilt 10mg x 1 and 30mg x2 in the ED \nin addition to Metoprolol 5 IV x2 and Metoprolol 10 IV. She then \nspontaneously converted to sinus rhythm. Patient denies anything \nout of the ordinary in the last week prior to chest discomfort. \nTrigger is unknown. CXR is clear and UA unimpressive. Patient's \ncardiologist Dr. ___ was contacted who recommended formal \nconsultation with EP, who saw here and recommended continuation \nof her current medications and outpatient follow-up with EP for \npossible ablation. She was recommended to stay on her current \ndose of sotolol and remain on xarelto. On the floor she was \ncontinued on her home sotalol and xarelto. \n\n#Concern for UTI: Patient UA not impressive for UTI especially\nconsidering patient's age and lack of symptoms. She has had UTIs\nin the past and UTI was thought to be the trigger for last \nepisode of AFib with RVR episode. Received one dose of cipro in \nthe ED but abx were not continued on the floor. \n\nCHRONIC ISSUES: \n#Chronic lower extremity edema: Likely venous insufficiency. No\npitting edema on exam. She was continued on her home Lasix 40 mg \ndaily.\n\n#Obstructive Sleep apnea: continued on CPAP. Would recommend f/u \nin outpatient sleep clinic for adjustment of her CPAP device. \n\n#Osteoarthritis. Pain treated with Tylenol ___ mg q8 PRN\n\n===================\nTRANSITIONAL ISSUES\n===================\n-No medication changes\n-Consider follow-up in the sleep clinic for possible adjustment \nof her CPAP device as this may be contributing to trigger atrial \nfibrillation\n-F/u final results of urine culture. Patient remained \nsymptomatic on discharge. \n-Ensure follow up with Dr. ___ in ___ clinic for \nconsideration of alternative anti-arrhythmic vs. AF ablation. \nShe was advised to stay on xarelto by EP.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Losartan Potassium 25 mg PO DAILY \n2. Sotalol 80 mg PO BID \n3. Rivaroxaban 20 mg PO DAILY \n4. Furosemide 40 mg PO DAILY \n5. Tylenol Arthritis Pain (acetaminophen) 1300 mg PO DAILY \n\n \nDischarge Medications:\n1. Furosemide 40 mg PO DAILY \n2. Losartan Potassium 25 mg PO DAILY \n3. Rivaroxaban 20 mg PO DAILY \n4. Sotalol 80 mg PO BID \n5. Tylenol Arthritis Pain (acetaminophen) 1300 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\nAtrial Fibrillation with Rapid Ventricular Rate\n\nSecondary:\nChronic lower extremity edema\nObstructive Sleep Apnea\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___\n\n___ was a pleasure taking care of you at the ___ \n___!\n\nWHY WAS I IN THE HOSPITAL?\n==========================\nYou were in the hospital because you were in AFib with a high \nheart rate. \n\nWHAT HAPPENED IN THE HOSPITAL?\n==============================\nYou were given medication to control your heart rate and you \nwere briefly treated with antibiotics for a urinary tract \ninfection. \n\nWHAT SHOULD I DO WHEN I GO HOME?\n================================\nYou should continue to take all of your medications as directed \nby your doctors and ___ should follow up with your primary \ndoctor and your cardiologist. Additionally, you should also make \nan appointment to see Dr. ___ who \nspecializes in heart rhythms. \n\nThank you for allowing us to be involved in your care, we wish \nyou all the best! \n\nYour ___ Healthcare Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I480", "I10", "G4733", "Z7901", "I872", "E669", "Z6839" ]

[ "I480: Paroxysmal atrial fibrillation", "I10: Essential (primary) hypertension", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z7901: Long term (current) use of anticoagulants", "I872: Venous insufficiency (chronic) (peripheral)", "E669: Obesity, unspecified", "Z6839: Body mass index [BMI] 39.0-39.9, adult" ]

[ "I480", "I10", "G4733", "Z7901", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nacute appendicitis\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\n___ is a ___ year-old man with a history of GERD\nwho presented with abdominal pain. He reports vague abdominal\npain beginning 3 days ago with chills. Today, the pain increased\nin his right lower quadrant causing him to lay down and curl up.\nHe was subsequently evaluated by his school nurse who \nrecommended\nhe present to the ED. On exam, he notes the pain prevents him\nfrom bending over. He otherwise denies nausea, vomiting,\ndiarrhea, constipation, fevers, or further episodes of chills.\nHis appetite has decreased a small amount over the past few \ndays.\n\nIn the ED a CT scan was performed which demonstrated findings\nconcerning for acute uncomplicated appendicitis. His WBC was\nnotably 7.0. He notes he would prefer to trial antibiotics as he\nis an ___ and has his ___ recital this coming\nweekend. \n\nROS: A 10-point review of systems was negative except as noted \nin\nthe HPI. \n \nPast Medical History:\nPast Medical History: \nGERD\nRhinitis\n\nPast Surgical History: \nBenign cyst removal from neck in childhood \n \nSocial History:\n___\nFamily History:\nfather with CVA\n \nPhysical Exam:\nDischarge Physical Exam\nVS: 98.2 BP 139 / 82 HR 66 RR18 PO2 96 Ra \nGen: NAD, A&Ox3, pleasant, conversant\nCV: RRR\nPulm: Breathing comfortably on room air\nAbd: Tender to palpation in RLQ, no rebound or guarding \nExt: Warm, well-perfused \n \nPertinent Results:\nCT A/P ___\n\nIMPRESSION:\n \n1. While the appendiceal lumen is decompressed, the appendix is \nenlarged due\nto wall thickening with mild periappendiceal stranding \nconcerning for acute\nuncomplicated appendicitis.\n2. Hepatic steatosis.\n \nBrief Hospital Course:\n___ is a ___ year-old man with a history of GERD \nwho presented with abdominal pain and was found on imaging to \nhave acute uncomplicated appendicitis. Due to his upcoming \nperformance, he did not want to undergo surgery at this time as \nto prevent intubation and vocal swelling. Therefore, he opted \nfor medical management of his acute appendicitis with plan for \ninterval appendectomy. He was admitted to the surgical service \nfor further management. \n\nHe remained afebrile, his diet was initially sips, and advanced \nto clears and finally regular as tolerated. He was started on IV \nciprofloxacin and flagyl and transitioned to oral medication \nonce he was tolerating a diet. \n\nAt the time of discharge, he was afebrile and hemodynamically \nstable, tolerating a regular diet, his pain was well controlled \non oral pain medication, he was ambulating without assistance, \nvoiding adequately and spontaneously, and he was discharged home \nwith a course of oral antibiotics and appropriate outpatient \nfollow up. He verbalized understanding and agreement with the \nplan\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Omeprazole 20 mg PO DAILY \n2. Ranitidine Dose is Unknown PO DAILY \n3. Cetirizine 10 mg PO DAILY \n4. Fluticasone Propionate NASAL 1 SPRY NU BID \n5. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Ciprofloxacin HCl 500 mg PO BID \nRX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice \na day Disp #*26 Tablet Refills:*0 \n3. MetroNIDAZOLE 500 mg PO Q8H \nRX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every \neight (8) hours Disp #*39 Tablet Refills:*0 \n4. Ranitidine 150 mg PO DAILY \n5. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath \n6. Cetirizine 10 mg PO DAILY \n7. Fluticasone Propionate NASAL 1 SPRY NU BID \n8. Omeprazole 20 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nacute appendicitis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___, \nYou were admitted to ___ after \nyou were found to have acute appendicitis and you opted for \nmedical management with surgical management in the future. You \nwere treated initially with IV antibiotics, and your diet was \nslowly advanced to regular. You were transitioned to oral \nantibiotics once you were tolerating a regular diet. You are now \nready for discharge home. Please follow the following \ninstructions to aid in a speedy recovery\n\nPlease follow up in our outpatient surgery clinic at the below \nappointment to discuss an interval appendectomy. \n\nPlease complete your antibiotic course as prescribed.\n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nBest Wishes, \nYour ___ Surgery Team\n\n \nFollowup Instructions:\n___\n" ]

[ "K3580", "K8050", "K219", "J310" ]

[ "K3580: Unspecified acute appendicitis", "K8050: Calculus of bile duct without cholangitis or cholecystitis without obstruction", "K219: Gastro-esophageal reflux disease without esophagitis", "J310: Chronic rhinitis" ]

[ "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nErythromycin Base / codeine / ketoconazole\n \nAttending: ___.\n \nChief Complaint:\nFever \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ male with a past medical history notable for HIV on \nantiretroviral therapy (Last VL ___: 5,960 copies/ml CD4: \n108) and prophylactic Bactrim, recently admitted to Medicine \nservice in ___ presents four days of fever, chills, \ndrenching night sweats and cough. Pt states that Tmax at home of \n~102. Around this time, he complains of new onset headache, \nfrontal, +photophobia and asso nausea, no emesis, worsened with \nlying supine. States that headache can be \"paralyzing\" it is so \nsevere. Denies rash. As these symptoms began, he states that he \nstopped taking his ART therapy, thinking that they were \ncontributing to his nausea. Denies any chest pain, abdominal \npain, nausea, vomiting, dysuria, bowel changes. His cough is \nproductive of scant yellow sputum. His last CD4 count was 108 in \n___. \n\nIn the ED: Initial VS 97.2 65 107/66 20 98% RA \nPhysical examination in ED: Unremarkable\nLabs notable for: WBC 17.3, lytes WNL\nImaging: Right middle lobe linear opacity appears to have been \npresent on prior examinations, slightly more conspicuous, may \nreflect atelectasis or post inflammatory/infectious changes. An \nacute process is difficult to exclude.\nConsults called: non\nPt given IV Ketorolac 30 mg; 1000 mL; cloniDINE .2 mg Gabapentin \n800 mg x 2, Promethazine 25 mg \n\nOn the floor, pt endorses ___ headache with photophobia. \nStating that Toradol and gabapentin did not work for pain, \nrequesting home dose methadone. Pt endorses above history as \nabove. \n\n \nPast Medical History:\nHIV/AIDS on Norvir truvada, prezista, Bactrim\nAnal dysplasia, ? anorectal cancer\nChronic pain on methadone/gabapentin\nAnxiety on clonidine\nHep C\n? Bipolar vs depression\nRecurrent pneumonoccal pneumonia \n \nSocial History:\n___\nFamily History:\nCardiac disease in mother and father.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nGENERAL - pleasant, well-appearing gentleman, with mild head \ndiscomfort. Able to keep eyes open in lit room, speaking full \nsentences\nHEENT - normocephalic, atraumatic, no conjunctival pallor or \nscleral icterus, PERRLA, EOMI, OP clear\nNECK - supple, no LAD, no thyromegaly, JVP flat\nCARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs \nor gallops\nPULMONARY - clear to auscultation bilaterally, without wheezes \nor rhonchi\nABDOMEN - normal bowel sounds, soft, non-tender, non-distended, \nno organomegaly\nEXTREMITIES - warm, well-perfused, no cyanosis, clubbing or \nedema \nSKIN - without rash\nNEUROLOGIC - A&Ox3, CN II-XII fully tested and intact; strength \n___ throughout. Gait assessment deferred. Negative Kernig and \nBrudzinki\nPSYCHIATRIC - listen & responds to questions appropriately, \npleasant\n\nDISCHARGE PHYSICAL EXAM\n=======================\nVitals: T: 98.6/98.5 49-56 ___ 20 100% RA \nGeneral: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, PERRL, MMM, oropharynx clear, no \nthrush, no leukoplakia, dentures in place \nNeck: supple, full ROM, no LAD \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \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, no edema \nSkin: No evidence of rash \nNeuro: A&Ox3, CNIII-XII intact and symmetric, strength ___ in \nUE and ___ bilaterally\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 03:08PM BLOOD WBC-17.3*# RBC-4.47* Hgb-13.9 Hct-41.8 \nMCV-94 MCH-31.1 MCHC-33.3 RDW-12.7 RDWSD-43.3 Plt ___\n___ 03:08PM BLOOD Neuts-66.5 ___ Monos-6.4 Eos-0.1* \nBaso-0.3 Im ___ AbsNeut-11.51*# AbsLymp-4.39* AbsMono-1.11* \nAbsEos-0.02* AbsBaso-0.05\n___ 03:08PM BLOOD Glucose-80 UreaN-19 Creat-1.0 Na-137 \nK-3.7 Cl-97 HCO3-29 AnGap-15\n___ 03:13PM BLOOD Lactate-1.2\n\nDISCHARGE AND PERTINENT LABS\n============================\n___ 05:40AM BLOOD WBC-6.5 RBC-4.24* Hgb-13.0* Hct-39.8* \nMCV-94 MCH-30.7 MCHC-32.7 RDW-13.0 RDWSD-44.6 Plt ___\n___ 11:00AM BLOOD Neuts-55.3 ___ Monos-9.3 Eos-0.8* \nBaso-0.2 Im ___ AbsNeut-4.96# AbsLymp-2.91 AbsMono-0.83* \nAbsEos-0.07 AbsBaso-0.02\n___ 06:34AM BLOOD ___ PTT-28.7 ___\n___ 11:00AM BLOOD WBC-PND Lymph-PND Abs ___ CD3%-PND \nAbs CD3-PND CD4%-PND Abs CD4-PND CD8%-PND Abs CD8-PND \nCD4/CD8-PND\n___ 05:40AM BLOOD Glucose-87 UreaN-13 Creat-0.8 Na-139 \nK-5.0 Cl-101 HCO3-30 AnGap-13\n___ 06:34AM BLOOD ALT-15 AST-22 LD(LDH)-155 AlkPhos-50 \nTotBili-0.3\n___ 05:40AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.1\n\nMICROBIOLOGY\n============\n___ 3:07 pm BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n\n___ 6:15 pm URINE\n **FINAL REPORT ___\n URINE CULTURE (Final ___: NO GROWTH. \n\n___ 11:00 am SEROLOGY/BLOOD\n\n **FINAL REPORT ___\n\n CRYPTOCOCCAL ANTIGEN (Final ___: \n CRYPTOCOCCAL ANTIGEN NOT DETECTED. \n (Reference Range-Negative). \n Test performed by Lateral Flow Assay. \n A negative serum does not rule out localized or \ndisseminated\n cryptococcal infection. \n Appropriate specimens should be sent for culture. \n\n___ 6:15 am SEROLOGY/BLOOD\n\n **FINAL REPORT ___\n\n RPR w/check for Prozone (Final ___: \n NONREACTIVE. \n Reference Range: Non-Reactive. \n\nIMAGING\n=======\n\n___ CXR PA&L\nFINDINGS: \nPA and lateral chest radiograph obscuration of the right heart \nborder which on the lateral radiograph corresponds to a linear \nopacity. This appears to have been present on examination dated \n___, may be post infectious/inflammatory in etiology \nor atelectasis, slightly more conspicuous. Retrocardiac is \nslightly more conspicuous relative to prior study, may reflect a \nsmall hiatal hernia or confluence of shadows. There is no \npleural effusion or pneumothorax. Cardiomediastinal and hilar \ncontours are within normal limits. No evidence of pulmonary \nedema. \n \nIMPRESSION: \nRight middle lobe linear opacity appears to have been present on \nprior \nexaminations, slightly more conspicuous, may reflect atelectasis \nor post \ninflammatory/infectious changes. An acute process is difficult \nto exclude. \n\n___ CT Head w/o contrast\nFINDINGS: \nThere is no evidence of acute infarct,hemorrhage, edema, or mass \neffect. The ventricles and sulci are normal in size and \nconfiguration. \nThere is no evidence of fracture. The visualized portion of the \nparanasal \nsinuses, mastoid air cells, and middle ear cavities are clear. \nThe visualized portion of the orbits are unremarkable. \n \nIMPRESSION: \n1. No acute intracranial abnormality. \n2. Please note that MR is more sensitive in the detection of \nintracranial mass or infection. \n\n \nBrief Hospital Course:\n___ is a ___ with a h/o HIV/AIDS on antiretroviral \ntherapy (Last VL ___: 5,960 copies/ml CD4: 108) and \nprophylactic Bactrim who presented with four days of fever, \nchills, drenching night sweats, cough and new severe headaches, \nconcerning for meningitis.\n\n# Fever/chills/headaches: Symptoms concerning for meningitis \nalthough other viral illnesses a possibility. Unlikely bacterial \nmeningitis given duration of symptoms. Patient presented with \nleukocytosis, new onset fever to 102, headache, and cough in the \nsetting of immunosuppression due to HIV. Patient had recent \nadmission to ___ d/t viral syndrome and has a h/o of recurrent \npneumonia and PCP ___ given equivocal CXR and productive \ncough, PNA including PCP possible although LDH is normal. CT \nhead unremarkable, and without meningismus on exam. He continued \nto refuse an LP but was started on empiric treatment with \nvancomycin, ceftriaxone, ampicillin, and acyclovir (day ___ = \n___ until he left AMA on ___. After discussion with \ninfectious disease, he was written for PO acyclovir and \ncefpodoxime to complete a 10 day course (day 10 = ___. On \nthe day of AMA discharge, his fevers, chills, and sweats, and \nheadaches had resolved. He did complain of a productive cough \nwith scant bloody sputum. His blood cultures showed no growth to \ndate. A urine culture was negative and a serum cryptococcal \nantigen was negative. An RPR was negative, and CD4 count 146. \nPatient discharged AMA despite numerous conversations explaining \nthe risks of leaving, including seizure, permanent neurologic \ninjury, and death. He expressed understanding of these risks and \nwas deemed to have capacity. His PCP was notified by email of \nthese events.\n\n# HIV/AIDS: Has a history of struggling to take his medications \nas prescribed. Admitted to having occasionally taken ARVs while \nat ___ a month ago given negative stigma associated with \nthem. Was continued on home truvada, darunavir, ritonavir, \nBactrim ppx. CD4 count 146 as above. \n\n# Prolonged QTc: has a longstanding history with QTc 495. Was \ncontinued on home methadone given stability on this medication. \nOther QTc prolonging agents were avoided. \n\nTransitional issues:\n====================\n[] Patient discharged AMA despite numerous conversations \nexplaining the risks of leaving, including seizure, permanent \nneurologic injury, and death. He expressed understanding of \nthese risks and was deemed to have capacity. \n[]Patient discharged on PO acyclovir 800 mg TID, 400 mg q12h \ncefpodoxime (through ___\n[]Needs ID and PCP follow up within the next few days\n-Code: full\n-Contact: HCP: ___ ___ \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Acetaminophen 500 mg PO DAILY:PRN headache \n2. BusPIRone 15 mg PO BID \n3. CloniDINE 0.2 mg PO BID \n4. Darunavir 800 mg PO DAILY \n5. Emtricitabine-Tenofovir (___) 1 TAB PO DAILY \n6. Gabapentin 800 mg PO TID \n7. Ibuprofen 400 mg PO DAILY:PRN headache \n8. Lidocaine Jelly 2% 1 Appl TP TID:PRN rectal pain \n9. RiTONAvir 100 mg PO DAILY \n10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n11. Methadone 90 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 500 mg PO DAILY:PRN headache \n2. BusPIRone 15 mg PO BID \n3. CloniDINE 0.2 mg PO BID \n4. Darunavir 800 mg PO DAILY \n5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY \n6. Gabapentin 800 mg PO TID \n7. Methadone 90 mg PO DAILY \n8. RiTONAvir 100 mg PO DAILY \n9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n10. Ibuprofen 400 mg PO DAILY:PRN headache \n11. Lidocaine Jelly 2% 1 Appl TP TID:PRN rectal pain \n12. Acyclovir 800 mg PO Q8H Duration: 8 Days \nRX *acyclovir 800 mg 1 tablet(s) by mouth three times a day Disp \n#*24 Tablet Refills:*0\n13. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 8 Days \nRX *cefpodoxime 200 mg 2 tablet(s) by mouth every twelve (12) \nhours Disp #*32 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnoses:\n==================\nMeningitis\nHIV/AIDS\n\nSecondary diagnoses:\n====================\nHepatitis C\nAnxiety\nProlonged QTc\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 in the hospital because you were having fevers and \nheadaches. We believe that your symptoms are due to an infection \naround your brain called meningitis. We started treating you \nwith multiple strong antibiotics through an IV in your arm. \n\nYou wanted to leave the hospital because you felt better and \nthat you wanted to rest at home. We explained to you that \nleaving is very dangerous because you will be unable to receive \nthese strong IV antibiotics. We will give you antibiotics you \ncan take by mouth but these are unlikely to work because pill \nantibiotics do not work against brain infections. \n\nWe explained that if you leave the hospital, you would be \nleaving against medical advice. You would be at risk of \nworsening infection, seizure, permanent neurologic injury, and \ndeath. You said that you understood these risks.\n\nYou should return to the hospital if you experience worsening \nheadache, seizures, fevers, chills, night sweats, or other \nconcerning symptoms.\n\nIt was a pleasure participating in your care.\n\nSincerely,\n\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "G039", "B20", "F419", "I4581", "B1920", "F17210", "Z9114", "G629", "F329" ]

[ "G039: Meningitis, unspecified", "B20: Human immunodeficiency virus [HIV] disease", "F419: Anxiety disorder, unspecified", "I4581: Long QT syndrome", "B1920: Unspecified viral hepatitis C without hepatic coma", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z9114: Patient's other noncompliance with medication regimen", "G629: Polyneuropathy, unspecified", "F329: Major depressive disorder, single episode, unspecified" ]

[ "F419", "F17210", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins\n \nAttending: ___.\n \nChief Complaint:\nchest pain\n \nMajor Surgical or Invasive Procedure:\npatient had PICC line placed ___.\n\n \nHistory of Present Illness:\nMr. ___ is a ___ male with recent admission for \nurosepsis, STEMI with stent placement, and history of spina \nbifida, who presents after an episode of shortness of breath and \nchest tightness. \n\nPatient states that 2 days prior to admission he developed \nsudden-onset chest tightness and shortness of breath. Reports \nbreathing heavily to get a breath. Tightness located right in \nthe ___ his chest. Associated with a bit of a cough. Also \nvery nauseous, but that had been ongoing since before his heart \nattack. No fevers/chills. Given his recent heart attack, patient \npresented to the ED.\n\nAdditionally, patient reports some back pain while he was last \nin the hospital - states that sleeping in hospital beds bothered \nit. However, when he went home his back still bothered him. Pain \nlocated in lower right side. Used heat packs, and his pain is \nnow much improved. No saddle anesthesia, bowel incontinence \n(does straight cath at baseline), or difficulty ambulating. \n\nHe was evaluated at ___ where he had an elevated \nd-dimer, CTA was negative for PE, it revealed T9 and T10 \ndiscitis. He was therefore transferred to ___ for neurosurgery \neval. \n\nOn review of records, patient was hospitalized at ___ from \n___ after having a STEMI in the setting of \nurosepsis, and found to have complete heart block. He was in the \nCCU with a temporary pacer. However, he did not have any \nepisodes of heart block while at ___ and therefore was able to \nbe discharged. \n\nIn the ED:\n\nInitial vital signs were notable for: T 97.8, HR 63, BP 100/70, \nRR 16, 100% RA \n\nExam notable for: Neuro- A+O x3, CN2-12 intact, ___ strength and \nsensation to light touch in all ext, normal rectal tone, no \nsaddle anesthesia, normal coordination, speech and gait\n\nAn MRI to further assess for discitis was ordered, but was \ndeferred given patient's metal artificial bladder sphincter. \nDecision was therefore made to admit to medicine. \n\nPatient was given: ___ 22:10 PO Aspirin 243 mg ___ \n23:04 PO/NG Atorvastatin 80 mg ___ 23:04 PO/NG TiCAGRELOR \n90 mg \n\nVitals on transfer: HR 62, BP 94/64, RR 16, 97% RA \n\nUpon arrival to the floor, recounts history as above. No chest \npain, trouble breathing, or back pain. \n\nROS: Pertinent positives and negatives as noted in the HPI. All \nother systems were reviewed and are negative. \n \nPast Medical History:\n- coronary artery disease s/p STEMI s/p DES to RCA \n- Spina bifida \n- Chronic neurogenic bladder requiring self catheterization\n- History of Seizure Disorder\n\nSURGICAL HISTORY \n- VP Shunt placement\n- Testicular removal \n- Spinal surgery \n- Bilateral toe surgeries \n \nSocial History:\n___\nFamily History:\n- father - colon cancer\n- mother - brain cancer \n \nPhysical Exam:\nADMISSION\n=========\n\nVITALS: T 97.6, HR 68, BP 101/69, RR 18, 100% RA \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 with mild wheezing bilaterally. Breathing is\nnon-labored\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. No HSM\nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nEXT: wwp, no edema \nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, ___ strength in proximal and distal lower\nextremities, sensation to light touch intact \nPSYCH: pleasant, appropriate affect\n\nDISCHARGE\n=========\nvitals: ___: 1113 97.9, BP 106/66, HR 55, RR 18, O2 \nsaturation 99% on RA.\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 CTA. 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\nEXT: wwp, no edema , PICC present in right arm with dressing \nc/d/i.\nSKIN: right wrist blanching erythema with no significant warmth\nor signs of infection, no ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, ___ strength in proximal and distal lower\nextremities, sensation to light touch intact \nPSYCH: pleasant, appropriate affect\n \nPertinent Results:\nADMISSION/SIGNIFICANT LABS: \n==========================\n___ 11:45PM CK(CPK)-48\n___ 11:45PM CK(CPK)-48\n___ 11:45PM cTropnT-0.06*\n___ 11:45PM CK-MB-1\n\n___ 06:00PM CRP-63.6*\n___ 06:00PM WBC-10.0 RBC-2.95* HGB-8.8* HCT-28.3* MCV-96 \nMCH-29.8 MCHC-31.1* RDW-13.8 RDWSD-48.2*\n___ 06:00PM PLT COUNT-262\n___ 06:00PM NEUTS-72.0* LYMPHS-15.8* MONOS-8.7 EOS-2.2 \nBASOS-0.9 IM ___ AbsNeut-7.17* AbsLymp-1.58 AbsMono-0.87* \nAbsEos-0.22 AbsBaso-0.09*\n\nMICRO:\n===========\nblood cultures from ___ with NGTD\nurine cultures from ___ notable for PsA colonization\n\nIMAGING/OTHER STUDIES: \n======================\nCT T-spine: ___ \nIMPRESSION: \n1. No significant change in erosive changes of the inferior \nendplate of T9 and \nsuperior endplate of T10, with associated enhancing prevertebral \nsoft tissue \nswelling, concerning for discitis/osteomyelitis. No other \nthoracic levels \nconcerning for infection identified. \n2. Multiple prominent mediastinal nodes, which could be \nreactive. \n3. Other findings, as described above. \n \nBarium swallow study FRI ___ \nIMPRESSION: \nNormal primary esophageal peristalsis with intermittent tertiary \nwaves which \nspontaneously resolved. No evidence of diffuse esophageal spasm \nor achalasia. \nNo mass or stricture. \n\nLABS AT DISCHARGE: \n=================\n___ 05:18AM BLOOD WBC-10.0 RBC-3.32* Hgb-9.7* Hct-31.3* \nMCV-94 MCH-29.2 MCHC-31.0* RDW-14.4 RDWSD-48.7* Plt ___\n___ 05:18AM BLOOD Plt ___\n___ 05:18AM BLOOD Glucose-110* UreaN-8 Creat-0.8 Na-140 \nK-4.3 Cl-101 HCO3-25 AnGap-14\n___ 05:18AM BLOOD Calcium-9.4 Phos-4.5 Mg-2.1\n___ 03:56AM BLOOD CRP-50.5*\n \nBrief Hospital Course:\nMr. ___ is a ___ male with recent admission for \nurosepsis, STEMI with stent placement, and history of spina \nbifida presents after an episode of shortness of breath and \nchest tightness, found to have findings concerning for diskitis \non CTA. \n\nACUTE/ACTIVE PROBLEMS: \n\n# Presumed Diskitis/Osteomyelitis of T9-T10 \n# Back pain \nFindings of T9-T10 diskitis/osteomyelitis discovered \nincidentally on OSH CTA obtained to evaluate for PE due to \npatient's presentation of chest tightness and shortness (later \nfelt likely to be panic attacks). Thoracic spine changes were \nnot present on imaging obtained approximately four weeks prior \nwhen he was admitted for urosepsis and STEMI. On this prior \nadmission, he did have gram negative bacteremia, thus possible \nseeding of vertebrae. Case was discussed with ___ for possible \nsampling the suspected diskitis but was deferred due to patient \nbeing on DAPT with ASA and Brilinta. Repeat CT T-spine done on \n___ was again suggestive of T9 and T10 \ndiskits/osteomyelitis. Ultimately, decision was made to treat \nfor osteomyelitis/discitis and patient started on \nCFTX/Vancomycin on ___ with plan for ___ week course. Final \nduration to be determined in outpatient ___ clinic follow up. \nGiven patient's urine cultures with PsA colonization, ID is \nconsidering switching Rocephin to Cefepime if CRP does not show \nclear signs of improvement as outpatient. \n\n# Asymptomatic bacteruria: \nPatient without symptoms. Urine growing pan-sensitive \nPseudomonas which is covered by the aforementioned discitis \nregimen.\n\n# Dysphagia: \n# n/v # acid reflux \nSuspect cause of patient's symptoms are related to GERD with \nreflux given improvement on IV ppi. Entertaining the thought of \ninflammation from diskitis might be irritating the Vagus nerve \ngiven concomitant hiccups. However, patient reports usually \nhaving nausea preceding the hiccups and not vice versa, which \ncould indicate the former being the culprit of the latter. \nBarium swallow on ___ normal. Improved on ___ BID IV PPI, \nwhich was then discontinued due to risk of CDI. He was \ntransitioned back to his daily oral PPI. Dysphagia resolved and \nhe was tolerating a regular diet prior to discharge. \n\n#Intermittent Complete Heart Block: \n# Sinus Bradycardia: \nS/p temp pacing wire placement and removal given resolution on \nprior admission. Chart review shows patient being evaluated on \n___ by EP who suspected heart block was due to increased \nvagal tone. Patient was to follow up with Dr. ___ in clinic for \nEP and Dr. ___ with general cardiology in ___ following \nrecent discharge. Patient was supposed to be discharged on \nZiopatch which patient does not remember if he had it placed. \nThis should be discussed at his next Cardiology follow up \nappointment. \n\n#back pain: \nLikely due to MSK given symptoms are positional and reproducible \non exam. Unclear if actually related to discitis. \n\n# Troponemia \nTrop elevated to 0.05 -> 0.06 on admission with normal CKBM. No \nsymptoms of ACS. Suspect resolving troponin from STEMI a few \nweeks ago as this biomarker can take several weeks to clear. \n\n#Panic attacks: - uncertain if cause of this could be related to \nongoing infection and recent STEMI suggestive of acute stress \nresponse. panic attacks were the cause of patient's initial \npresentation to the hospital. - patient also reports symptoms \nthat are suggestive of globus. - psychiatry consulted, \nappreciate recs \n\nCHRONIC/STABLE PROBLEMS:\n\n#Acute Inferior STEMI s/p DES to RCA \n#Coronary Artery Disease/ Ischemic Cardiomyopathy \nIn the ICU at ___ during previous admission, the patient \nwas found to have an acute inferior STEMI w/CHB. He underwent \ncoronary angiography with DES x2 to the RCA. He was continued on \nDAPT consisting of ticagrelor and ASA 81. Also continued on \nmetop succ and atorvastatin 80mg. Patient will continue to \nfollow with Cardiology team as an outpatient. \n\n- Continue ASA 81mg PO QD - Continue Ticagrelor 90mg PO BID - \nContinue Atorvastatin 80mg PO QPM - continue metop XL 12.5mg \ndaily - ACEi to be added and BB further uptitrated as an \noutpatient - Telemetry monitoring \n\n#HFrEF ___ Ischemic Cardiomyopathy\nPatient without evidence of CHF exacerbation throughout stay. \nContinued on metoprolol succinate. ACEi deferred as on last \nadmission due to borderline low BPs. Patient did not require \nactive nor maintenance diuretics. \n \n# Urinary retention: \nPatient straight caths at home. Continued while inpatient \nwithout issue. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Metoprolol Succinate XL 12.5 mg PO DAILY \n4. TiCAGRELOR 90 mg PO BID \n5. Pantoprazole 40 mg PO Q24H \n6. Oxybutynin XL (*NF*) 5 mg Other DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Baclofen 5 mg PO TID PRN hiccups \nRX *baclofen 5 mg 1 tablet(s) by mouth three times a day Disp \n#*15 Tablet Refills:*0 \n3. CefTRIAXone 2 gm IV Q24H \nRX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 1 vial IV daily \nDisp #*37 Intravenous Bag Refills:*0 \n4. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat \n5. Docusate Sodium 100 mg PO BID \n6. Lidocaine 5% Patch 1 PTCH TD QAM \nRX *lidocaine [Aspercreme (lidocaine)] 4 % daily Disp #*5 Patch \nRefills:*0 \n7. Pantoprazole 40 mg PO Q24H acid reflux \nRX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*1 \n8. Sarna Lotion 1 Appl TP TID:PRN right wrist itching \n9. Vancomycin 1000 mg IV Q 12H \nRX *vancomycin 1 gram 1 vial IV twice a day Disp #*75 Vial \nRefills:*0 \n10. Aspirin 81 mg PO DAILY \n11. Atorvastatin 80 mg PO QPM \n12. Metoprolol Succinate XL 12.5 mg PO DAILY \n13. Oxybutynin XL (*NF*) 5 mg Other DAILY \n14. TiCAGRELOR 90 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n#diskitis/osteomyelitis\n#back pain\n#panic disorder\n#sinus Bradycardia\n#acid reflux\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\nIt was a priviliege to care for you at the ___ \n___. You were admitted for shortness of breath and \nwas found to have infection of your T9 and T10 vertebra and \ndiscs (also known as osteomyelitis and diskits, respectively). \nYou were started on IV antibiotics with vancomycin and \nCeftriaxone. You are to complete a total of 6 weeks of IV \nantibiotics and follow up with infectious disease clinic. ___ \nwill assist with setting up the antibiotics and collect labs as \nneeded to forward it to the infectious disease clinic. Please \nfollow up with the infectious disease clinic as mentioned in the \nfollow up section. \n\nFor the episodes of the panic attacks, I recommend that you \nfollow up with your primary care for need of treatment.\n\nPlease see Dr. ___ with cardiology in ___ for \nestablishing cardiology outpatient care. \n\nPlease continue to take all medications as prescribed and follow \nup with all appointments as detailed below. \n\nWe wish you the best! \n\nSincerely,\nYour ___ team\n\n \nFollowup Instructions:\n___\n" ]

[ "M4624", "I2119", "I5020", "M4644", "R8271", "R1310", "K219", "F410", "Z955", "R001", "I255", "R339", "N319", "M549", "Z9689", "I2510", "Q059", "G40909", "Z982", "F17210" ]

[ "M4624: Osteomyelitis of vertebra, thoracic region", "I2119: ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall", "I5020: Unspecified systolic (congestive) heart failure", "M4644: Discitis, unspecified, thoracic region", "R8271: Bacteriuria", "R1310: Dysphagia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "F410: Panic disorder [episodic paroxysmal anxiety]", "Z955: Presence of coronary angioplasty implant and graft", "R001: Bradycardia, unspecified", "I255: Ischemic cardiomyopathy", "R339: Retention of urine, unspecified", "N319: Neuromuscular dysfunction of bladder, unspecified", "M549: Dorsalgia, unspecified", "Z9689: Presence of other specified functional implants", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Q059: Spina bifida, unspecified", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "Z982: Presence of cerebrospinal fluid drainage device", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]

[ "K219", "Z955", "I2510", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Prednisone\n \nAttending: ___\n \nChief Complaint:\nChest pain, neck pain\n \nMajor Surgical or Invasive Procedure:\nCoronary angiogram ___\n\n \nHistory of Present Illness:\nMr. ___ is a ___ y/o male with a history of HLD, DM, cervical\nradiculopathy and recent root canal (right sided) who presents\nwith 1 week of right sided jaw pain and reflux pain.\n\nHe endorses one week of jaw pain radiating to the neck, ear,\nright shoulder, arm, and sometimes reflux pain. He initially\nthought these symptoms were due to dental issues, and thus had a\nroot canal yesterday. However, this did not improve his \nsymptoms.\n\nHe reports the symptoms are sometimes worse with exertion, such\nas walking up the stairs, and sometimes associated with\ndiaphoresis. Per ED report, he has been on clindamycin for the\npast ___ days without improvement.\n\nOf note, he has been seen in urgent care and our ED many times\nfor jaw pain, including most recently in ___ and\n___. In the ___ evaluation, he presented with \n5\ndays of jaw pain and chest pressure. It was noted then that he\nhas had extensive workup for these neck/jaw symptoms and has\ntrialed gabapentin. It was felt the pain was neuropathic in\nnature. He is seen in neurology clinic for injections for\ncervical radiculopathy.\n \nIn the ED, initial vitals were T 96.5, HR 64, BP 162/70, RR 16,\nO2 100% RA. Exam notable for well appearing root canal site\nwithout pus or drainage. Tender to palpation on right cheek. EKG\nshowed SR with rate of 63 bpm and no acute ST-T wave changes.\nLabs showed trop negative x1, MB 3, wbc 9.1, hgb 15.2, cr 1.2,\nchemistries otherwise normal. UA was unremarkable. CXR showed no\nacute intrathoracic process. The patient's symptoms were thought\nto be multifactorial from underlying tooth disease, cervical\nradiculopathy, trigeminal neuralgia, or heart disease. Given the\npatient's cardiovascular risk factors including diabetes, prior\nsmoking hx, HLD, and family hx of CAD, cardiology was consulted\nand recommended admission for observation and possible pMIBI. He\nwas given aspirin 325 x1. \n\nUpon transfer to medicine, VS were HR 60 BP 136/80 RR 18 99% RA \nThe patient states that he has had jaw pain off and on for at\nleast ___ years. The pain is burning in nature, on either the R or\nL side of his jaw (never both sides at once), ___ in intensity\nat the worst. The pain is continuous at ___ for several days,\nthen subsides partially to ___, but never completely \ndisappears.\nHe has had multiple previous visits and CT, MRI scans in the\npast. His neurologist is Dr ___ here at ___. States he has\nno history of heart disease.\n\nPatient states that he tried gabapentin in the past, but it made\nhim too sleepy. He states he also tried Lyrica before, which he\nthinks may have helped a little bit, but he can't remember why \nhe\nstopped it. Per neurology notes, he has known multilevel\ndegenerative changes which are most severe C4-5 and C5-6\nresulting in moderate canal narrowing and cervical \nradiculopathy.\nHe was prescribed trileptal in the past. \n\nThe current episode of pain started about a week ago. He went to\nsee his PCP on ___ and was prescribed clindamycin because \nhis\n\"lymph node appeared slightly enlarged.\" He thought his pain may\nbe tooth pain so went to his dentist on the day before admission\nand had a root canal (upper jaw, R side). However, the procedure\ndid not alleviate the pain. Tylenol and ibuprofen do not help. \nHe\nstates the pain is sometimes worse with jaw opening or head\nturning. It is so bad he has trouble sleeping. He stopped taking\nthe clindamycin today.\n \nPast Medical History:\nDM, diet controlled - ___ HgA1c 6.1% \nLeft chest cyst removal \nOverweight \nOnychomycosis, hands and feet \n\n \nSocial History:\n___\nFamily History:\nMother and father died of Lung cancer in their ___ \n(non-smokers), brother died at ___ of MI, sister has ___ \n\ndisease \n\n \nPhysical Exam:\nADMISSION EXAM\n=========================\nVITALS: ___ 1632 BP: 138/79 R Sitting HR: 57 O2 sat: 100%\nO2 delivery: Ra \nGENERAL: Well-developed, well-nourished elderly man sitting up \nin\nbed, NAD. Flat affect. \nHEENT: NCAT. Sclera anicteric. EOMI. Slight tenderness over\nmaxillary portion of R jaw where root canal was done. \nNECK: No lymphadenopathy appreciated. No JVD.\nCARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. \nLUNGS: Resp were unlabored, no accessory muscle use. No \ncrackles,\nwheezes or rhonchi. \nABDOMEN: Soft, NTND. \nEXTREMITIES: No c/c/e. \nSKIN: No rahes \nNEURO: CN II-XII grossly intact, symmetric strength bilaterally. \n\n\nDISCHARGE EXAM\n=======================\nVITALS: 24 HR Data (last updated ___ @ 656)\n Temp: 98.5 (Tm 98.8), BP: 131/76 (123-155/64-85), HR: 57\n(52-61), RR: 15 (___), O2 sat: 96% (95-98), Wt: 211.86 lb/96.1\nkg \nHEENT: NC/AT, EOMI, sclera anicteric, MMM \nNECK: No JVD\nCARDIAC: RRR, normal S1, S2, No murmurs/rubs/gallops. \nLUNGS: CTAB, no wheezes, crackles, or rhonchi, unlabored\nrespirations \nABDOMEN: Soft, NTND, +BS \nEXTREMITIES: No c/c/e\nSKIN: No rashes \nNEURO: A/Ox3, moving all four extremities with purpose \n \nPertinent Results:\nADMISSION LABS\n===========================\n___ 09:40AM BLOOD WBC-9.1 RBC-4.87 Hgb-15.2 Hct-45.1 MCV-93 \nMCH-31.2 MCHC-33.7 RDW-12.6 RDWSD-43.0 Plt ___\n___ 07:30AM BLOOD ___ PTT-35.1 ___\n___ 09:40AM BLOOD Glucose-226* UreaN-13 Creat-1.2 Na-139 \nK-4.5 Cl-103 HCO3-26 AnGap-10\n___ 09:40AM BLOOD CK-MB-3\n___ 09:40AM BLOOD cTropnT-<0.01\n___ 03:57AM BLOOD CK-MB-2 cTropnT-<0.01\n\nRELEVANT STUDIES\n==========================\n___ CXR PA/LATERAL:\nNo acute intrathoracic process.. Innumerable calcified \ngranulomas are stable.\n\n___ MRI C-SPINE W/O CONTRAST:\n1. Mild global spinal canal narrowing from C3 through C6 due to \nslightly short pedicles and superimposed multilevel cervical \ndegenerative disease, are again demonstrated. \n2. Severe spinal canal stenosis at C4-C5 and C5-C6, progressed \nsince ___. No evidence for spinal cord signal abnormalities. \n3. Advanced multilevel neural foraminal narrowing has not \nsignificantly \nchanged since ___. \n\n___ CORONARY ANGIOGRAPHY:\n1. Mild global spinal canal narrowing from C3 through C6 due to \nslightly short pedicles and superimposed multilevel cervical \ndegenerative disease, are again demonstrated. \n2. Severe spinal canal stenosis at C4-C5 and C5-C6, progressed \nsince ___. No evidence for spinal cord signal abnormalities. \n3. Advanced multilevel neural foraminal narrowing has not \nsignificantly \nchanged since ___. \n\nMICROBIOLOGY\n========================\n___ 9:23 am URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH. \n\nDISCHARGE LABS\n========================\n___ 06:20AM BLOOD WBC-8.2 RBC-4.95 Hgb-15.4 Hct-45.6 MCV-92 \nMCH-31.1 MCHC-33.8 RDW-12.4 RDWSD-41.9 Plt ___\n___ 06:20AM BLOOD Glucose-141* UreaN-15 Creat-1.1 Na-139 \nK-4.3 Cl-102 HCO3-23 AnGap-14\n \nBrief Hospital Course:\nMr. ___ is a ___ y/o male with a history of HLD, DM, cervical \nradiculopathy, trigeminal neuralgia and recent root canal (right \nsided) who presents with 1 week of right sided jaw pain and R \narm numbness, ultimately attributed to cervical radiculopathy vs \ntrigeminal neuralgia.\n\n#R jaw pain\n#R arm numbness\n#Trigeminal neuralgia\n#Cervical radiculopathy\nPatient had multiple similar previous episodes for which he \npresented to the ED/urgent care. Cardiac workup negative during \nthese visits. Trop<0.01 x2, MB 3 then 2, EKG unremarkable. \nChem-10 reassuring as well. His history of jaw pain is chronic \nbut given the new right arm numbness, the decision was made to \nrule out ischemia contributing to his symptoms. He therefore \nunderwent pMIBI which was positive for probable mild inferior \nwall defect (in the presence of soft tissue attenuation at the \nlevel of exercise achieved). Given this, he underwent cardiac \ncatheterization on ___ which showed no coronary artery \ndisease, making ischemia less likely. Dental etiologies for the \npain were considered given recent root canal; however, infection \nor abscess felt to be less likely due to clear oropharynx, no \nleukocytosis, no fevers, and no e/o cellulitis, lymphadenopathy, \nor erythema in the area of pain. Ultimately, his jaw/neck pain \nand R arm numbness was attributed to his known trigeminal \nneuralgia and cervical radiculopathy with cervical stenosis. He \nfollows with neurology for this as an outpatient but was lost to \nfollow up. He had repeat MRI c-spine this admission to monitor \nfor progression of previously seen findings in comparison to \nlast C-spine MRI in ___. He was initiated on pregabalin and \nwill follow up with neurology as an outpatient for further \nmanagement.\n\n#Constipation: patient continued on bowel regimen while admitted\n\n#NIDDM: held home glyburide; initiated on sliding scale insulin \nwhile admitted.\n\n#Hyperlipidemia: continued home atorvastatin\n\n#CAD primary prevention: pt initially received asa 325 x1 in the \nED given concern for possible ACS contributing to his symptoms \nas above. He was then transitioned to asa 81 and will remain on \nthis for CAD primary prevention given HLD and DM. As above, he \ndid not have significant CAD on coronary cath this admission.\n\nTRANSITIONAL ISSUES:\n- As above, patient's jaw pain and R shoulder numbness \nattributed to his cervical radiculopathy and trigeminal \nneuralgia. MRI c-spine shows severe cervical stenosis and \nradiculopathy. Please consider uptitration of pregabalin as an \noutpatient and consider surgical intervention if warranted. EMG \nmay also be considered; notably without weakness on exam during \nadmission.\n- Noted glucosuria and elevated FSG this admission; consider \ntitration of glyburide as an outpatient if A1c elevated\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. GlyBURIDE 5 mg PO QAM \n2. Atorvastatin 10 mg PO QPM \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n2. Pregabalin 50 mg PO TID neuropathic pain \nRX *pregabalin [Lyrica] 50 mg 1 capsule(s) by mouth three times \na day Disp #*90 Capsule Refills:*0 \n3. Atorvastatin 10 mg PO QPM \n4. GlyBURIDE 5 mg PO QAM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nJaw Pain\nCervical radiculopathy\n\nSecondary:\nType II diabetes mellitus\nConstipation\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nActivity Status: Ambulatory - Independent.\nLevel of Consciousness: Alert and interactive.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nWhy were you admitted to the hospital?\n- You were admitted due to jaw/ear pain as well as R arm \nnumbness.\n\nWhat happened while you were admitted to the hospital?\n- You had a stress test that showed that your heart was not \ncontributing to your arm numbness. However, given an abnormality \non the stress test, you underwent a cardiac catheterization. \nThis showed that you do not have any blockages in your heart.\n\nWhat should you do when you leave the hospital?\n- You should continue to take medications as prescribed. We have \nstarted you on Lyrica, which is a medication to treat your jaw \npain.\n- You should follow up with the appointments we have arranged \nbelow.\n\nIt was a pleasure taking care of you at ___.\n\nSincerely,\nYour ___ care team\n \nFollowup Instructions:\n___\n" ]

[ "M5412", "G500", "E119", "K5900", "E785", "M4802", "Z7984", "Z87891", "R6884", "D472", "R9439" ]

[ "M5412: Radiculopathy, cervical region", "G500: Trigeminal neuralgia", "E119: Type 2 diabetes mellitus without complications", "K5900: Constipation, unspecified", "E785: Hyperlipidemia, unspecified", "M4802: Spinal stenosis, cervical region", "Z7984: Long term (current) use of oral hypoglycemic drugs", "Z87891: Personal history of nicotine dependence", "R6884: Jaw pain", "D472: Monoclonal gammopathy", "R9439: Abnormal result of other cardiovascular function study" ]

[ "E119", "K5900", "E785", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAbdominal Pain\n \nMajor Surgical or Invasive Procedure:\n___: laparoscopic cholecystectomy\n\n \nHistory of Present Illness:\n___ with 24 hours of epigastric pain and cholithiasis on US. Ms. \n___ is a healthy ___ year old woman who initially had an \nepisode of epigastric pain and emesis one week ago that resolved \nwithin one day. Yesterday she again developed epigastric pain \nthat has persisted now 24 hours and is associated with nausea.\nShe hasn't eaten since yesterday morning at which time her \nsymptoms worsened. She has been having diarrhea, last BM \nyesterday. She has had no subjective fevers. \n \nPast Medical History:\nPast Medical History:\nNone\n\nPast Surgical History:\nHysterectomy, breast augmentation\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nAdmission Physical Exam:\nVitals: 98.8 72 166/100 16 97RA\nGEN: A&O, NAD\nCV: RRR, No M/G/R\nPULM: Clear to auscultation b/l, No W/R/R\nABD: Soft, nondistended. Tender in the epigastrium and RUQ\nwithout rebound or guarding. \nExt: No ___ edema, ___ warm and well perfused\n\nDischarge Physical exam:\nVitals: 98.4 PO 155 / 92 85 16 92 Ra \nGEN: A&O, NAD\nCV: RRR, No M/G/R\nPULM: Clear to auscultation b/l, No W/R/R\nABD: Soft, nondistended. Tender incisionally as expected. gauze \ncovered with tegaderm CDI. \nExt: No ___ edema, ___ warm and well perfused. no edema. \n \nPertinent Results:\n___ 09:37AM BLOOD WBC-8.5 RBC-4.05 Hgb-12.6 Hct-37.6 MCV-93 \nMCH-31.1 MCHC-33.5 RDW-11.7 RDWSD-39.7 Plt ___\n___ 05:44AM BLOOD WBC-7.9 RBC-4.72 Hgb-14.5 Hct-43.1 MCV-91 \nMCH-30.7 MCHC-33.6 RDW-11.5 RDWSD-38.9 Plt ___\n___ 09:37AM BLOOD Glucose-140* UreaN-8 Creat-0.6 Na-138 \nK-4.1 Cl-101 HCO3-25 AnGap-12\n___ 05:44AM BLOOD Glucose-140* UreaN-9 Creat-0.7 Na-139 \nK-4.1 Cl-101 HCO3-22 AnGap-16\n___ 05:44AM BLOOD ALT-29 AST-22 AlkPhos-95 TotBili-0.5\n___ 09:37AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.7\n\nIMAGING:\nCholelithiasis and sludge without signs of acute cholecystitis. \nNormal bile ducts. \n\n \nBrief Hospital Course:\nThe patient was admitted to the General Surgical Service on \n___ for evaluation and treatment of abdominal pain. \nAdmission abdominal ultra-sound revealed cholelithiasis and \nsludge without signs of acute cholecystitis and normal bile \nducts. The patient underwent laparoscopic cholecystectomy, which \nwent well without complication. Please see operative report for \ndetails. After a brief, uneventful stay in the PACU, the patient \narrived on the floor tolerating clears , on IV fluids, and oral \noxycodone and Tylenol for pain control. The patient was \nhemodynamically stable.\n\nPain was well controlled. Diet was progressively advanced as \ntolerated to a regular diet with good tolerability. The patient \nvoided without problem. During this hospitalization, the patient \nambulated early and frequently, was adherent with respiratory \ntoilet and incentive spirometry, and actively participated in \nthe plan of care. The patient received subcutaneous heparin and \nvenodyne boots were used during this stay.\n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating a regular \ndiet, ambulating, voiding without assistance, and pain was well \ncontrolled. The patient was discharged home without services. \nThe patient received discharge teaching and follow-up \ninstructions with understanding verbalized and agreement with \nthe discharge plan.\n \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Zolpidem Tartrate 5 mg PO QHS insomnia \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \nRecommend taking around the clock x ___ days then as needed. \n2. Docusate Sodium 100 mg PO BID \nHold for loose stools \n3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nTake lowest effective dose. \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*15 Tablet Refills:*0 \n4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third \nLine \n5. Senna 8.6 mg PO BID:PRN Constipation - First Line \n6. HELD- Zolpidem Tartrate 5 mg PO QHS insomnia This \nmedication was held. Do not restart Zolpidem Tartrate until you \nare no longer taking narcotics/oxycodone. \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nacute cholecystitis with cystic duct obstruction \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 the Acute Care Surgery Service on ___ \nwith abdominal pain and found to have an infection and stones in \nyour gallbladder. You underwent laparoscopic surgery and had \nyour gallbladder removed. You are now doing better, tolerating a \nregular diet, and ready to be discharged to home to continue \nyour recovery. Please note the following discharge instructions:\n\nPlease note the following discharge instructions:\n\nPlease follow up in the Acute Care Surgery clinic at the \nappointment listed below.\n \nACTIVITY:\n \no Do not drive until you have stopped taking pain medicine and \nfeel you could respond in an emergency.\no You may climb stairs. \no You may go outside, but avoid traveling long distances until \nyou see your surgeon at your next visit.\no Don't lift more than ___ lbs for 4 weeks. (This is about \nthe weight of a briefcase or a bag of groceries.) This applies \nto lifting children, but they may sit on your lap.\no You may start some light exercise when you feel comfortable.\no You will need to stay out of bathtubs or swimming pools for a \ntime while your incision is healing. Ask your doctor when you \ncan resume tub baths or swimming.\n \nHOW YOU MAY FEEL: \no You may feel weak or \"washed out\" for a couple of weeks. You \nmight want to nap often. Simple tasks may exhaust you.\no You may have a sore throat because of a tube that was in your \nthroat during surgery.\no You might have trouble concentrating or difficulty sleeping. \nYou might feel somewhat depressed.\no You could have a poor appetite for a while. Food may seem \nunappealing.\no All of these feelings and reactions are normal and should go \naway in a short time. If they do not, tell your surgeon.\n \nYOUR INCISION:\no Tomorrow you may shower and remove the gauzes over your \nincisions. Under these dressing you have small plastic bandages \ncalled steri-strips. Do not remove steri-strips for 2 weeks. \n(These are the thin paper strips that might be on your \nincision.) But if they fall off before that that's okay).\no Your incisions may be slightly red around the stitches. This \nis normal.\no You may gently wash away dried material around your incision.\no Avoid direct sun exposure to the incision area.\no Do not use any ointments on the incision unless you were told \notherwise.\no You may see a small amount of clear or light red fluid \nstaining your dressing or clothes. If the staining is severe, \nplease call your surgeon.\no You may shower. As noted above, ask your doctor when you may \nresume tub baths or swimming.\n \nYOUR BOWELS:\no Constipation is a common side effect of narcotic pain \nmedications. If needed, you may take a stool softener (such as \nColace, one capsule) or gentle laxative (such as milk of \nmagnesia, 1 tbs) twice a day. You can get both of these \nmedicines without a prescription.\no If you go 48 hours without a bowel movement, or have pain \nmoving the bowels, call your surgeon. \n \nPAIN MANAGEMENT:\no It is normal to feel some discomfort/pain following abdominal \nsurgery. This pain is often described as \"soreness\". \no Your pain should get better day by day. If you find the pain \nis getting worse instead of better, please contact your surgeon.\no You will receive a prescription for pain medicine to take by \nmouth. It is important to take this medicine as directed. o Do \nnot take it more frequently than prescribed. Do not take more \nmedicine at one time than prescribed.\no Your pain medicine will work better if you take it before your \npain gets too severe.\no Talk with your surgeon about how long you will need to take \nprescription pain medicine. Please don't take any other pain \nmedicine, including non-prescription pain medicine, unless your \nsurgeon has said its okay.\no If you are experiencing no pain, it is okay to skip a dose of \npain medicine.\no Remember to use your \"cough pillow\" for splinting when you \ncough or when you are doing your deep breathing exercises.\nIf you experience any of the following, please contact your \nsurgeon:\n- sharp pain or any severe pain that lasts several hours\n- pain that is getting worse over time\n- pain accompanied by fever of more than 101\n- a drastic change in nature or quality of your pain\n \nMEDICATIONS:\nTake all the medicines you were on before the operation just as \nyou did before, unless you have been told differently.\nIf you have any questions about what medicine to take or not to \ntake, please call your surgeon.\n\n \nFollowup Instructions:\n___\n" ]

[ "K8013" ]

[ "K8013: Calculus of gallbladder with acute and chronic cholecystitis with obstruction" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\ncough, shortness of breath, pleuritic chest pain\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ G2P1 @ ___ presents to ED with ___ days of pleuritic \nchest pain, cough, and SOB. She reports similar symptoms one \nmonth ago where she presented to ___ and was discharged after a \nnormal EKG. Per the patient, she had labs or imaging done at \nthat time. She describes her chest pain as present upon \ninspiration\nand expiration and diffuse across her chest, epigastrum and \nback. She denies radiation to her arms. She has had a productive \ncough since yesterday. She denies fevers but reports chills. She \ndenies sick contacts. She reports N/V/D ___ yesterday as well as \nmild headache, but no abdominal pain. She reports bilateral calf \npain L>R. She denies VB, LOF, ctx. +FM\n\n \nPast Medical History:\nPNC:\n- EDC ___ by 6 week US discordant with LMP\n- labs: B pos\n- Records unavailable at this time, per patient no issues in \nthis\npregnancy except N/V in early pregnancy\n\nOBHx: ___\n- G1: cesarean for arrest of dilation following IOL at 40wks\n(unclear indication) in ___ (___)\n- G2: current\n\nGynHx:\n- menarche age ___ q monthly -> irregular q ___ days x ___ days\n- denies dysmenorrhea, menorrhagia\n- denies hx of abnl bleeding\n- reports initial abnl Pap (unknown cytology) ___ with plan \nto\nrpt prior to delivery\n- hx of ovarian cyst resolved on OCPs\n- denies hx of STIs or fibroids\n\nPMHx: fatty liver, obesity, hidradenitis suppurativa\nPSHx: c-section, lsc cholecystectomy for gallbladder polyp, eye\nsurgery\n\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nAdmission physical exam:\nVS T 97.6 HR 118 BP 117/63 RR 20 99% RA \n rpt T 98.0 HR 110 BP 105/67 RR 20 100% RA \nGen: NAD, sounds congested, coughing at times\nChest: TTP of upper chest and upper back\nCV: RRR, tachycardic\nPulm: CTAB, no wheeze\nAbd: soft, gravid, NT\nBack: No CVAT\nExt: no edema, NT ___, no erythema or palpable cords of b/l ___\n\nDischarge physical exam:\nAVSS\nGen: NAD\nCV: RRR\nP: slightly diminished breath sounds throughout, no rhonchi or \nwheezing\nAbd: soft, gravid, nontender\nExt: WWP\n \nPertinent Results:\n___ 02:34PM OTHER BODY FLUID FluAPCR-NEGATIVE \nFluBPCR-NEGATIVE\n___ 03:00AM GLUCOSE-93 UREA N-7 CREAT-0.5 SODIUM-135 \nPOTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-20* ANION GAP-17\n___ 03:00AM estGFR-Using this\n___ 03:00AM proBNP-<5\n___ 03:00AM D-DIMER-3149*\n___ 03:00AM WBC-8.2 RBC-4.40 HGB-12.8 HCT-37.9 MCV-86 \nMCH-29.1 MCHC-33.8 RDW-13.9 RDWSD-43.7\n___ 03:00AM NEUTS-83.5* LYMPHS-8.4* MONOS-6.0 EOS-0.6* \nBASOS-0.2 IM ___ AbsNeut-6.84* AbsLymp-0.69* AbsMono-0.49 \nAbsEos-0.05 AbsBaso-0.02\n___ 03:00AM PLT COUNT-___ G2P1 @ 21w0d by 6 wk US presenting to the Emergency \nDepartment with pleuritic chest pain, SOB, and tachycardia with \nimaging concerning for pneumonia. The patient initially \npresented to the ED and underwent a thorough workup including a \nchest xray that demonstrated hazy opacification in the RLL, \nconcerning for pneumonia. She had bilateral LENIs which showed \nno evidence ___ DVT. Her lab work was reassuring, with a \nnormal WBC count. Given the findings on chest xray, she was \nadmitted to the antepartum service and she was treated for \npresumed community acquired PNA with IV azithromycin and \nceftriaxone. She was also given a dose of Tamiflu while waiting \nfor the rapid influenza culture to return, which was ultimately \nnegative and the Tamiflu was discontinued. She received a \nnebulizer treatment with improvement in her SOB and chest \ntightness. She remained afebrile overnight and on HD2 had a \nrepeat normal WBC. She felt significantly improved and requested \ndischarge home. Given clinical improvement, the patient was sent \nfor a formal ultrasound to confirm reassuring fetal status and \nwas subsequently discharged home with a plan for a 5 day (total) \ncourse of PO azithromycin and outpatient follow up next week. \nStrict return precautions were reviewed with the patient at \nlength with an interpreter present. She expressed clear \nunderstanding and agreement.\n\n \nMedications on Admission:\nPNV\n \nDischarge Medications:\n1. Azithromycin 250 mg PO Q24H Duration: 4 Days \nRX *azithromycin 250 mg 1 tablet(s) by mouth DAILY Disp #*3 \nTablet Refills:*0 \n2. Prenatal Vitamins 1 TAB PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\ncommunity acquired pneumonia\npregnancy at 21weeks 1 day GA\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted to the hospital for treatment of pneumonia. \nYour clinical status has improved on IV antibiotics and you are \nnow stable to be discharged home with antibiotics to take by \nmouth. Please continue to take the antibiotic as prescribed, one \npill per day for three more days. \n \nFollowup Instructions:\n___\n" ]

[ "O99512", "Z3A21" ]

[ "O99512: Diseases of the respiratory system complicating pregnancy, second trimester", "Z3A21: 21 weeks gestation of pregnancy" ]

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[ " \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROLOGY\n \nAllergies: \nmetoprolol\n \nAttending: ___.\n \nChief Complaint:\nTransfer from OSH with Right MCA stroke\n \nMajor Surgical or Invasive Procedure:\nThrombectomy ___\nPEG ___\n\n \nHistory of Present Illness:\nNeurology at bedside after Code Stroke activation within: 1 mins\nTime/Date the patient was last known well: 1230\n\nI was present during the CT scanning and reviewed the images \nwithin 20 minutes of their completion.\n\n___ Stroke Scale Score: 14\n\nt-PA administered: \n[x] Yes - Time given: 1353\n[] No - Reason t-PA was not given or considered: __\n\nThrombectomy performed: \n[x] Yes \n[] No - Reason not performed or considered: __\n\nNIHSS Performed within 6 hours of presentation at: 1445 \n___ Total: 14\n1a. Level of Consciousness: 0\n1b. LOC Question: 0\n1c. LOC Commands: 0 \n2. Best gaze: 2\n3. Visual fields: 2\n4. Facial palsy: 2\n5a. Motor arm, left: 2\n5b. Motor arm, right: 0\n6a. Motor leg, left: 1\n6b. Motor leg, right: 0\n7. Limb Ataxia: 0\n8. Sensory: 2\n9. Language: 0\n10. Dysarthria: 1\n11. Extinction and Neglect: 2\n \nREASON FOR CONSULTATION: right mca syndrome\n \nHPI: \nEU Critical ___ is a ___ year old left \nhanded woman with unknown past medical history who presents as a \ntransfer from ___ for right MCA syndrome.\n\nHistory is limited, but reportedly, she was teaching a class and \nsuddenly developed weakness on the left side. Last known well \nwas ___. She was initially seen at ___, where telestroke was \ncalled. Initial NIHSS was 14, and a noncontrast head CT was \nunremarkable. tPA was started at ___. A CTA showed a right M2 \nsignal cutoff, and she was subsequently transferred via \nmedflight for\nintervention. She was also reportedly hypertensive, and received \nbolus doses of labetalol en route.\n\nHer school, ___, was contacted \nmultiple times, but was unable to be reached, as it was past \n3PM.\n\n \nPast Medical History:\nHypertension\nHyperlipidemia\n \nSocial History:\n___\nFamily History:\nUnknown\n\n \nPhysical Exam:\nON ADMISSION\n============\n___: Awake, cooperative, NAD.\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in \noropharynx.\nNeck: Supple, no carotid bruits appreciated. No nuchal rigidity.\nPulmonary: Normal work of breathing.\nCardiac: RRR, warm, well-perfused.\nAbdomen: Soft, non-distended.\nExtremities: No ___ edema.\nSkin: Multiple flesh colored papules throughout the body\n \nNeurologic: (limited, as heading to thrombectomy)\n-Mental Status: alert, speech appears fluent, can follow axial \nand appendicular commands. Dense neglect of the left side when \ncounting number of people in the room, and to DSS\n\n-Cranial Nerves:\nPupils are equally reactive. Forced right gaze deviation, but \nable to cross midline spontaneously. No blink to threat on left. \nProminent facial droop.\n\n-Sensorimotor: right arm and leg are full. left arm is able to \nbriefly lift antigravity but falls, left leg mild drift but able \nto sustain AG effort. Dense anesthesia on the left side, but \nwithdraws arm and leg within plane of bed, no grimace.\n\nON DISCHARGE:\n=============\n24 HR Data (last updated ___ @ 655)\n Temp: 98.2 (Tm 98.6), BP: 123/69 (121-160/57-84), HR: 69\n(60-71), RR: 18 (___), O2 sat: 94% (94-98), O2 delivery: RA \n\nExam:\n___: Comfortable and in no distress, lying in bed with eyes\nopen \nHead: No irritation/exudate from eyes, nose, throat, black \nmolars\nand multiple missing teeth\nCardio: Regular rate and rhythm, warm, no peripheral edema \nLungs: Unlabored breathing, decreased sounds ___ bases \nAbdomen: Soft, non tender, non distended; foam binder in place \nSkin: smooth raised nodules throughout\n\nNeurologic examination:\nMental status: \nAwake, alert. Tracks and regards examiner, pays more attention \nto\nright side of room. Gives thumbs up and shows two fingers with\nright hand, wiggles feet\nto command. Nods yes or no to simple direct questions, has\ndifficulty with more complex questions.\n\nCranial nerves: \nPERRL. Eyes conjugate midline. Mild right gaze preference \nthough\ncrosses the midline to the left. Left facial droop. Shoulders\nsit symmetric. Does not consistently blink to threat on left \n\nMotor: \nRUE: moves purposefully antigravity\nLUE: spontaneously flexes at the elbow in the plane of the bed,\ndose not hold antigravity, lets fall to bed\nRLE: moves purposefully, antigravity\nLLE: spontaneously shakes foot, withdraws antigravity to tickle \n \nPertinent Results:\nLABS:\n=====\n___ 10:40PM GLUCOSE-93 UREA N-14 CREAT-0.7 SODIUM-142 \nPOTASSIUM-4.5 CHLORIDE-108 TOTAL CO2-21* ANION GAP-13\n___ 10:40PM CK(CPK)-67\n___ 10:40PM CK-MB-1 cTropnT-<0.01\n___ 10:40PM CALCIUM-9.5 PHOSPHATE-4.2 MAGNESIUM-3.8*\n___ 10:40PM WBC-11.4* RBC-3.90 HGB-13.1 HCT-39.6 MCV-102* \nMCH-33.6* MCHC-33.1 RDW-13.2 RDWSD-49.3*\n___ 10:40PM PLT COUNT-196\n___ 10:40PM ___ PTT-26.7 ___\n___ 04:49PM GLUCOSE-91 UREA N-16 CREAT-0.8 SODIUM-139 \nPOTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-17* ANION GAP-14\n___ 04:49PM estGFR-Using this\n___ 04:49PM ALT(SGPT)-18 AST(SGOT)-15 LD(LDH)-207 \nCK(CPK)-41 ALK PHOS-79 TOT BILI-0.9\n___ 04:49PM CK-MB-<1 cTropnT-<0.01\n___ 04:49PM ALBUMIN-4.0 CALCIUM-9.2 PHOSPHATE-3.8 \nMAGNESIUM-1.6 CHOLEST-220*\n___ 04:49PM %HbA1c-5.8 eAG-120\n___ 04:49PM TRIGLYCER-62 HDL CHOL-43 CHOL/HDL-5.1 \nLDL(CALC)-165*\n___ 04:49PM TSH-2.9\n___ 04:49PM CRP-0.5\n___ 04:49PM ___ PTT-22.0* ___\n\nDISCHARGE AND OTHER SIGNIFICANT LABS:\n\n___ 10:31AM BLOOD WBC-10.0 RBC-3.32* Hgb-11.4 Hct-35.0 \nMCV-105* MCH-34.3* MCHC-32.6 RDW-14.3 RDWSD-55.1* Plt ___\n___ 10:31AM BLOOD ___ PTT-32.0 ___\n___ 10:31AM BLOOD Glucose-136* UreaN-23* Creat-0.9 Na-140 \nK-4.3 Cl-101 HCO3-25 AnGap-14\n___ 05:15AM BLOOD ALT-21 AST-19 LD(LDH)-232\n___ 10:31AM BLOOD Phos-3.6 Mg-1.8\n___ 04:49PM BLOOD Triglyc-62 HDL-43 CHOL/HD-5.1 \nLDLcalc-165*\n___ 07:40AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG\n___ 04:00AM BLOOD Digoxin-0.7\n___ 07:40AM BLOOD HCV Ab-NEG\n\nIMAGING:\n========\nCT PERFUSION ___\n1. Study is degraded by motion. \n2. Mismatched perfusion defect in the right MCA territory \nconcerning for \nevolving acute ischemic stroke. \n3. Perfusion data as follows: CBF<30% volume: 11 mL, T-max > \n6.0s volume: 55 mL, Mismatch volume: 44 mL. \n4. Within limits of study, no definite evidence of acute \nintracranial \nhemorrhage. Please note MRI of the brain is more sensitive for \nthe detection of acute infarct. \n\nMRI Head ___:\n1. Study is mildly degraded by motion. \n2. Redemonstration of known right MCA distribution acute to \nsubacute infarct, without definite evidence of hemorrhagic \ntransformation, as described. \n3. Left temporal punctate probable artifact as described, with \ndifferential consideration of small subacute infarct less \nlikely. \n \nTTE ___:\nIMPRESSION: Left atrial dilation. No structural cardiac source \nof embolism (e.g.patent foramen ovale/atrial septal defect, \nintracardiac thrombus, or vegetation) seen. Normal biventricular \ncavity sizes and regional/global biventricular systolic \nfunction. No valvular pathology or pathologic flow\nidentified. Normal estimated pulmonary artery systolic pressure. \n\n\nCT brain ___: \n1. Acute infarct left MCA territory with cortical \nmicrohemorrhage. No \nparenchymal hematoma. \n2. Evolving large subacute infarct in the right MCA territory, \nsimilar. \n\nMRI ___ IMPRESSION: \n1. Acute infarct left MCA territory with cortical \nmicrohemorrhage. No \nparenchymal hematoma. \n2. Evolving large subacute infarct in the right MCA territory, \nsimilar. \n\nTTE ___:\nIMPRESSION: No spontaneous echo contrast or thrombus in the left \n atrium/left atrial appendage/right atrium/right atrial \nappendage. No structural cardiac source of embolism (e.g.patent \nforamen ovale/atrial septal defect, intracardiac thrombus, or \nvegetation) seen. Normal biventricular systolic function. Simple \natheroma in the descending aorta and simple atheroma in the \naortic arch.\n\nCT head ___:\n1. Bilateral large MCA territory subacute infarct with \nhemorrhagic foci \ncentrally in the left MCA infarct distribution, in the setting \nof known \nhemorrhagic transformation. \n2. No new areas of infarction. \n\nCT head ___:\n1. Redemonstration of evolving bilateral MCA territory infarcts \nwith similar associated edema and stable appearance of \nhemorrhagic transformation in the left MCA territory infarct. \nNo evidence of new hemorrhage or other infarction. \n2. Mild paranasal sinus disease. \n3. Stable 6 mm subcutaneous hyperdensity along the right \nfrontoparietal scalp is nonspecific but may represent a \nsebaceous cyst \n\nAbdominal U/S ___:\n1. Small amount of sludge within the gallbladder. \n2. Mild ectasia of the abdominal aorta, up to 2.0 cm. \n\nCT HEAD ___ IMPRESSION: \n1. Continued evolution of bilateral MCA distribution \ninfarctions. \n2. Decreased degree of cortical linear microhemorrhage in the \nright MCA \ndistribution as compared to ___. \n3. No evidence of new intracranial hemorrhage. \n \nBrief Hospital Course:\nPATIENT SUMMARY:\n================\nMs. ___ is a ___ year old left handed woman with history of \nHTN, HLD p/w right MCA syndrome s/p tPA and thrombectomy. \nCourse complicated by new onset atrial flutter with RVR as well \nas new left MCA infarct, now s/p PEG.\n\n# Right and left MCA stroke\nShe presented with left sided weakness and was found to have a \nright M2 cutoff at ___ with an NIHSS of \n14. She received tPA and was transferred to ___ (still with \n___ 14) and underwent mechanical thrombectomy with TICI 2B \n___. Exam post procedure was notable for left field cut, left \nfacial droop, left arm weakness and leg hand plegia. Due to size \nof infarct and risk for hemorrhagic transformation, plan was to \nwait ___ days before starting anticoagulation. On hospital day \n5, she became non-verbal with roving eye movements and repeat \nMRI showed left superior division MCA stroke. Etiology of her \nstroke is likely cardioembolic, given her un-anticoagulated \natrial flutter (CHADSVASC 5). Other stroke risk factors include \nprediabetes (HgA1C 5.8), hypertension, and hyperlipidemia (LDL \n165). She was started on a heparin gtt for anticoagulation due \nto continued atrial flutter and later bridged to apixaban for \nanticoagulation in the setting of aflutter. A PEG was placed on \n___ to help meet nutritional needs.\n\n#PEDs, original concern for seizure\nOn hospital day 5 the patient was unresponsive and received \nAtivan and loaded with keppra. EEG was placed and there were no \nongoing seizure, but there were right temporal PEDs. She did \nhave two electrographical seizures on hospital day 6. She was \nloaded with fosphenytoin and started on maintenance keppra which \nwas subsequently discontinued as there was no indication to \ntreat PEDs and due to a rash (see below). No further concern for \nseizure throughout hospitalization.\n\n#Atrial flutter with RVR\nUnclear if this is new onset or not. Of note, her pharmacy fill \nhistory does show prior prescriptions for Metoprolol and \nApixaban, but she does not recall this (last filled ___. \nShe was trialed on both diltiazem PO and metoprolol IV and PO \nand frequently required diltiazem gtt to maintain a HR <130. \nMetoprolol was discontinued per family wishes as they noted \nsneezing around 30 minutes after she took metoprolol and after \nmultiple discussions, family felt it was detrimental to her \nhealth. She was started on a heparin gtt for continued atrial \nflutter with RVR and second stroke occurring during \nhospitalization. Cardiology EP was consulted and patient was \nloaded with digoxin followed by maintenance dose. PO diltiazem \nwas increased to 90 mg q6h. On this regimen, HR still \nconsistently in 150s (blood pressure stable) and an esmolol gtt \nwas started. Given hemodynamic stability otherwise, TEE with \ncardioversion was deferred. She was started on labetolol for \nboth BP and HR control and was improved. She was eventually \nweaned to diltiazem 60mg q6h due to bradycardia and lack of RVR.\n\n#HLD\nDiscontinued atorvastatin due to rising LFTS on ___. LDL: 165 \n\n#Transaminitis\nUnclear if due to Keppra drug reaction or atorvastatin. Both \nmedications were held with improvement of transaminitis. \nAbdominal ultrasound was unrevealing. And LFTs improved.\n\n#FEN \nPEG with TF-Jevity 1.2 bolus (480mL AM and lunch; 360mL dinner); \n50 cc FWF before and after boluses; 480mL \n\n#Dentition\nBlack upper molars, guards mouth, poor PO intake and nodded head \nyes that mouth is painful. Dentistry came to evaluate pt ___ \nbut she did not cooperate with exam. Panorex ordered, cannot \ncomplete as pt cannot sit unassisted. Patient has not had any \nfurther pain with ongoing oral care.\n\n#E. Coli UTI\nCompleted a 7 day course of ceftriaxone.\n\n#Anxiety/ Agitation\n#Depression\nCurrently displaying increased restlessness, likely a reaction \nto her prolonged sedentary state. Has been out of restraints \nsince ___. Responds well to trazodone as needed at bedtime. \nDue to prolonged hospital stay she exhibited some anhedonia \nwhich was initially treated with fluoxetine but was then \nswitched to mirtazapine to also help with sleep.\n\n#Exanthemous drug reaction\n___ patient developed erythematous rash to left wrist, upper \narm, and back/buttocks. There were no vesicles of bullae. \nThought to be secondary to Keppra. Dermatology was consulted and \nbelieved rash to be consistent with an exanthematous drug \nreaction, most likely due to Keppra. LFTs were elevated (normal \non admission), there was slight eosinophilia but no abnormal \nlymphocytes, so overall picture not consistent with DRESS. \nKeppra was discontinued and triamcinolone cream was started. \nRash resolved over the next few days. \n\nTRANSITIONAL ISSUES:\n====================\n[]Neurology Follow up\n- consider restarting statin\n- Apixaban 5 mg BID \n[] Cardiology Follow up\n- Atrial flutter with difficult to control rate\n[]Dentition \n\n====================\n\nAHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic \nAttack \n1. Dysphagia screening before any PO intake? (x) Yes, confirmed \ndone - () Not confirmed () No. If no, reason why: \n2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not \n(I.e. bleeding risk, hemorrhage, etc.) \n3. Antithrombotic therapy administered by end of hospital day 2? \n(x) Yes - () No. If not, why not? (I.e. bleeding risk, \nhemorrhage, etc.)\n4. LDL documented? (x) Yes (LDL = 165 ) - () No \n5. Intensive statin therapy administered? (simvastatin 80mg, \nsimvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, \nrosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL \n>70, reason not given: \n [ ] Statin medication allergy \n [ ] Other reasons documented by physician/advanced practice \nnurse/physician ___ (physician/APN/PA) or pharmacist \n [ ] LDL-c less than 70 mg/dL \n6. Smoking cessation counseling given? () Yes - (x) No [reason \n(x) non-smoker - () unable to participate] \n7. Stroke education (personal modifiable risk factors, how to \nactivate EMS for stroke, stroke warning signs and symptoms, \nprescribed medications, need for followup) given in written \nform? (x) Yes - () No \n8. Assessment for rehabilitation or rehab services considered? \n(x) Yes - () No. If no, why not? (I.e. patient at baseline \nfunctional status)\n9. Discharged on statin therapy? (x) Yes - () No [if LDL >70, \nreason not given: \n [ ] Statin medication allergy \n [ ] Other reasons documented by physician/advanced practice \nnurse/physician ___ (physician/APN/PA) or pharmacist \n [ ] LDL-c less than 70 mg/dL \n10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) \nAntiplatelet - () Anticoagulation] - () No \n11. Discharged on oral anticoagulation for patients with atrial \nfibrillation/flutter? (x) Yes - () No - If no, why not (I.e. \nbleeding risk, etc.) () N/A \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 80 mg PO QPM \n2. Apixaban 5 mg PO BID \n3. Metoprolol Succinate XL 25 mg PO DAILY \n\n \nDischarge Medications:\n1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation \n2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID \n3. Digoxin 0.125 mg PO DAILY \n4. Diltiazem 60 mg PO Q8H \n5. Docusate Sodium 100 mg PO BID \n6. Labetalol 100 mg PO Q6H hold for SBP < 100, HR<50 \n7. Miconazole Powder 2% 1 Appl TP PRN to reddened ___ area \n8. Mirtazapine 15 mg PO QHS \n9. Multivitamins W/minerals 15 mL PO DAILY \n10. Nystatin Cream 1 Appl TP BID \n11. Polyethylene Glycol 17 g PO DAILY \n12. Ramelteon 8 mg PO QHS \n13. Senna 8.6 mg PO BID:PRN Constipation \n14. Simethicone 40 mg PO TID:PRN gas \n15. TraZODone 25 mg PO QHS:PRN insomnia \n16. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP TID:PRN \nrash \n17. Apixaban 5 mg PO BID \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nLeft and right MCA infarcts \nAtrial fibrillation/Atrial flutter \n\n \nDischarge Condition:\nLevel of Consciousness: Alert and interactive.\nMental Status: Confused - always\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nYou were hospitalized due to symptoms of left sided weakness \nresulting from an ACUTE ISCHEMIC STROKE, a condition where a \nblood vessel providing oxygen and nutrients to the brain is \nblocked by a clot. While in the hospital, you suddenly became \nnon-verbal with roving eye movements and repeat imaging showed a \nnew stroke on the opposite side of your brain as the stroke \nwhich brought you in. The brain is the part of your body that \ncontrols and directs all the other parts of your body, so damage \nto the brain from being deprived of its blood supply can result \nin a variety of symptoms. Your strokes most likely occurred due \nto your abnormal heart rhythm, known as atrial flutter, for \nwhich Cardiology was involved in your care.\n\nStroke can have many different causes, so we assessed you for \nmedical conditions that might raise your risk of having stroke. \nIn order to prevent future strokes, we plan to modify those risk \nfactors. Your risk factors are: \n1. Atrial flutter (abnormal heart rhythm)\n2. High blood pressure\n3. High cholesterol\n\nWe are changing your medications as follows: \n1) Start Apixaban (for stroke prevention with your abnormal \nheart rhythm)\n2) Start Digoxin (for stroke prevention with your abnormal heart \nrhythm)\n3) Start Diltiazem (for stroke prevention with your abnormal \nheart rhythm)\n4) Start labetalol (for your abnormal heart rhythm and high \nblood pressure)\n5) Mirtazapine(to help with motor recovery and depression)\n6) Ramelteon and trazodone(to help with sleep as needed)\n\nPlease follow up with Neurology and Cardiology as listed below. \n \nIf you experience any of the symptoms below, please seek \nemergency medical attention by calling Emergency Medical \nServices (dialing 911). In particular, since stroke can recur, \nplease pay attention to the sudden onset and persistence of \nthese symptoms: \n - Sudden partial or complete loss of vision \n - Sudden loss of the ability to speak words from your mouth \n - Sudden loss of the ability to understand others speaking to \nyou \n - Sudden weakness of one side of the body \n - Sudden drooping of one side of the face \n - Sudden loss of sensation of one side of the body \n\nSincerely, \nYour ___ Neurology Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I63411", "I619", "J690", "I4892", "N390", "I63412", "R29714", "I10", "E785", "Z9282", "Q8500", "I4891", "R7303", "B9620", "F419", "F329", "L271", "T426X5A", "I959", "R569", "R4701" ]

[ "I63411: Cerebral infarction due to embolism of right middle cerebral artery", "I619: Nontraumatic intracerebral hemorrhage, unspecified", "J690: Pneumonitis due to inhalation of food and vomit", "I4892: Unspecified atrial flutter", "N390: Urinary tract infection, site not specified", "I63412: Cerebral infarction due to embolism of left middle cerebral artery", "R29714: NIHSS score 14", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z9282: Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility", "Q8500: Neurofibromatosis, unspecified", "I4891: Unspecified atrial fibrillation", "R7303: Prediabetes", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "L271: Localized skin eruption due to drugs and medicaments taken internally", "T426X5A: Adverse effect of other antiepileptic and sedative-hypnotic drugs, initial encounter", "I959: Hypotension, unspecified", "R569: Unspecified convulsions", "R4701: Aphasia" ]

[ "N390", "I10", "E785", "I4891", "F419", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nDilaudid / morphine\n \nAttending: ___\n \nChief Complaint:\ndyspnea/cough\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ ___ man with history of \nHTN, DM, CAD, asthma/COPD, and BPH who presented to the ED on \n___ with dyspnea and cough. He notes 5 days of gradually \nworsening shortness of breath, associated with a cough \nproductive of white sputum. He also has a mild sore throat. He \ndenies any chest pain, fever, leg swelling/pain, or abdominal \npain. He has been admitted to ___ last ___ for \nsimilar symptoms and was found to have pneumonia and COPD/asthma \nexacerbation improved with steroids and antibiotics. ROS \nsignificant for some sore throat, and some constipation.\n \nPast Medical History:\n Past Medical History: \n - HTN \n - Stable Angina \n - DM II \n - GERD \n - DJD/Knee pain \n - Asthma \n - H/O RBBB \n - COPD \n - Hearing loss \n - Tinnitus \n - Coronary Artery Disease: abnml ETT ___ ___ \n - Glasses for Vision: Follows with Eye Specialist \n - Left Fascicular Block \n - Prostatitis \n - Elevated BMI \n - BPH \n Past Surgical History: \n - TKR bilateral\n \nSocial History:\n___\nFamily History:\n No history of coronary artery disease \n daughter killed ___ in crash in ___: strong religious \n \n faith married: ___ years 13 children, 50 grandchildren \n \nPhysical Exam:\nADMISSION EXAM\n=============\nPhysical Exam: \n Vitals: T 98.2 BP 144/78 HR 64 R 18 ___ \n GEN: lethargic, opens eyes to voice \n ___: regular without murmurs \n RESP: No increased WOB, no wheezing, rhonchi or crackles \n ABD: NTND no HSM \n EXT: warm, without edema \n Neuro: Opens eyes to voice \n\nDISCHARGE EXAM\n==============\nVitals: 97.4 166 / 66 ___\nGeneral: AOx2 (person, ___ Appears stated age, ___ \nspeaking \nHEENT: AT/NC, Appears stated age. PERRLA, EOMI \nNeck: No thyromegally. \nLymph: No LND\nCV: RRR , no murmurs\nLungs: clear to auscultation bilaterally, no wheezes. \nAbdomen: Soft, nt, nd, +BS\nExt: No ___, warm\nNeuro: AOx2, CNII-XII grossly intact\nSkin: warm, well perfused. Multiple Seborrheic keratosis on \nskin, increased pigmentation on arms. \n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 02:50PM BLOOD WBC-3.7* RBC-4.76 Hgb-11.8* Hct-40.4 \nMCV-85 MCH-24.8* MCHC-29.2* RDW-15.9* RDWSD-49.5* Plt ___\n___ 02:50PM BLOOD ___ PTT-27.4 ___\n___ 02:50PM BLOOD Glucose-85 UreaN-11 Creat-0.9 Na-141 \nK-5.0 Cl-101 HCO3-30 AnGap-15\n___ 02:50PM BLOOD Calcium-8.8 Phos-3.4 Mg-2.2\n___ 02:56PM BLOOD ___ pO2-24* pCO2-75* pH-7.30* \ncalTCO2-38* Base XS-6\n___ 04:00PM URINE Color-Yellow Appear-Hazy Sp ___\n___ 04:00PM URINE Blood-NEG Nitrite-NEG Protein-30 \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG\n___ 04:00PM URINE RBC-1 WBC-0 Bacteri-FEW Yeast-NONE Epi-0\n___ 04:00PM URINE Mucous-RARE\n.\n\nNOTABLE LABS/MICRO: \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___ 02:56PM BLOOD ___ pO2-24* pCO2-75* pH-7.30* \ncalTCO2-38* Base XS-6\n___ 03:24PM BLOOD ___ pO2-43* pCO2-69* pH-7.28* \ncalTCO2-34* Base XS-2\n\nBLOOD CULTURES ___: PENDING\n\nDISCHARGE LABS:\n==============\n___ 07:50AM BLOOD WBC-5.5 RBC-4.39* Hgb-10.9* Hct-36.8* \nMCV-84 MCH-24.8* MCHC-29.6* RDW-16.0* RDWSD-49.1* Plt ___\n___ 07:50AM BLOOD Glucose-80 UreaN-23* Creat-1.1 Na-141 \nK-3.9 Cl-102 HCO3-32 AnGap-11\n___ 08:40AM BLOOD ___ pO2-46* pCO2-57* pH-7.37 \ncalTCO2-34* Base XS-___ year old ___ speaking gentleman with a history of HTN, \nDM, CAD, asthma/COPD, and BPH presenting with dyspnea and cough \nfor ___ days. On admission, the patient was found to have course \nbreath sounds and was hypoxic requiring 2L NC. CXR did not show \npneumonia He was treated with Duonebs, Prednisone, and \nAzithromycin. His symptoms improved with this management; \nhowever patient became confused while on prednisone (AOx1-2, per \nHCP, becomes confused while taking steroids). Due to his marked \nimprovement in 24 hours, prednisone was discontinued after 2 \ndoses. His confusion improved after stopping prednisone. At the \ntime of discharge he was breathing comfortably on room air. His \nambulatory O2 was 91% on room air. On discharge he was AOx2 \n(could not state the date) but per grandson, this is his home \nbaseline.\n.\n#DYSPNEA/COUGH \n#COPD EXASERBATION: Patient p/w 5 days of worsening dyspnea and \ncough productive of white sputum, without fevers. Chest imaging \nand labs were not concerning for acute bacterial \ninfection/pneumonia. PE unlikely given low D-dimer. VBG \n(___) on admission was concerning for acute respiratory \nacidosis with metabolic compensation, likely from COPD \nexacerbation. Patient received Azithromycin in ED as well as IV \nsteroids, duonebs. Patient's symptoms improved since admission, \npatient was saturating 94-95% on RA on Tele, ___ on RA while \nambulatory. Prednisone was discontinued after 2 doses (40 mg \nPO) due to seteroid-induced AMS (patient's family reported \nhistory of this in past) and because his clinical symptoms were \ngreatly improved. He was continued on Azithromycin (5 day total \ncourse) to be be competed as outpatient. His VBG prior to \ndischarge was 7.37/57/46/34, improved from admission. He was \ndischarged with ___ services at home for nebulizer/medication \nhelp. \n.\n#AMS/Delirium: Patient was AOx1-2 on admission, however past \nrecords and collateral information does not indicate any history \nof dementia in past. Daughter and other family members reported \nhistory of patient being confused while taking prednisone in the \npast; prednisone was thus discontinued after two doses \nespecially iso improved respiratory status. On discharge \npatient was AOx2, however per grandson, this is the patient's \nbaseline and occasionally gets confused at home as well. \n.\nCHRONIC\n--------\n #CAD: \n - Continued home Simvastatin and Atenolol, not having chest \npain \n #HYPOTHYROIDISM: \n - Continued home Levothyroxine 75 mcg PO qD \n #GERD: \n - Continued home Omeprazole 20 mg PO QDaily \n #DIABETES MELLITUS: \n - Held home Metformin in hospital and placed on Insulin \nsliding scale. \n#HYPERTENSION: \n - Continued home Atenolol as above \n #KNEE PAIN \n - Continued home Naproxen \n #BPH with LUTS: \n - Continued home Tamsulosin \n.\nTRANSITIONAL ISSUES:\n[] Patient discharged on Azithromycin. Last day: ___\n[] follow up mental status as outpatient\n# CODE STATUS: Full (confirmed)\n# CONTACT/HCP: ___ (Daughter) ___ \n.\n\nGreater than 30 minutes spent coordinating this discharge. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN \ncough/wheeze/chest congestion/short of breath mdi with dose \ncounter \n2. Atenolol 50 mg PO DAILY \n3. Levothyroxine Sodium 75 mcg PO DAILY \n4. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n5. Montelukast 10 mg PO DAILY \n6. Omeprazole 20 mg PO DAILY \n7. Simvastatin 20 mg PO DAILY \n8. Tamsulosin 0.4 mg PO DAILY \n9. albuterol sulfate 2.5 mg /3 mL (0.083 %) INHALATION QID \n10. Iron Polysaccharides Complex ___ mg PO QPM \n11. Naproxen 500 mg PO BID:PRN pain \n12. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n13. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n14. Ferrous Sulfate 325 mg PO DAILY \n\n \nDischarge Medications:\n1. Azithromycin 250 mg PO Q24H Duration: 4 Doses \nRX *azithromycin 250 mg 1 tablet(s) by mouth Daily Disp #*3 \nTablet Refills:*0 \n2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n3. albuterol sulfate 2.5 mg /3 mL (0.083 %) INHALATION QID \nRX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 inhalation Oral \nfour times a day Disp #*20 Vial Refills:*0 \n4. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN \ncough/wheeze/chest congestion/short of breath mdi with dose \ncounter \n5. Atenolol 50 mg PO DAILY \n6. Ferrous Sulfate 325 mg PO DAILY \n7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n8. Iron Polysaccharides Complex ___ mg PO QPM \n9. Levothyroxine Sodium 75 mcg PO DAILY \n10. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n11. Montelukast 10 mg PO DAILY \n12. Naproxen 500 mg PO BID:PRN pain \n13. Omeprazole 20 mg PO DAILY \n14. Simvastatin 20 mg PO DAILY \n15. Tamsulosin 0.4 mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY: \nChronic Obstructive Pulmonary Disorder \nAsthma \n\nSECONDARY\nCoronary Artery Disease\nHypertension\nDiabetes Mellitus\nHypothyroidism \nGastroesophageal Reflux Disease\nBenign Prostatic Hypertrophy \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 admitted to the hospital for cough and shortness of \nbreath. Your chest imaging was normal. You were found to have a \nCOPD exacerbation. We treated you with steroids and antibiotics \nand your symptoms improved. Please finish your course of \nantibiotics at home as instructed. Please follow up with your \nprimary care doctor in the next one week. \n\nSincerely, \nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "J441", "E872", "E119", "I10", "J45909", "I2510", "E039", "K219", "N400", "M25569", "Z7984", "R410", "T380X5A", "Y92230", "Z96653" ]

[ "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "E872: Acidosis", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "J45909: Unspecified asthma, uncomplicated", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E039: Hypothyroidism, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "M25569: Pain in unspecified knee", "Z7984: Long term (current) use of oral hypoglycemic drugs", "R410: Disorientation, unspecified", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "Z96653: Presence of artificial knee joint, bilateral" ]

[ "E872", "E119", "I10", "J45909", "I2510", "E039", "K219", "N400", "Y92230" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / Verapamil / Percocet / Lupron \n/ Chloral Hydrate Analogues / Restoril / Percodan / \nCiprofloxacin / Clinoril / Flagyl / Advair Diskus / Abilify / \nLexapro / Zyprexa / Seroquel / Codeine / Aspirin / Ibuprofen / \nSucralfate / Depakote / Topamax / Risperdal / Lisinopril / \nTramadol / Provigil / Nuvigil / Focalin / Lithium / Lyrica / \nmodafinil / morphine / prochlorperazine / Xopenex / pravastatin \n/ Tegaderm Transparent Dressing / pramipexole\n \nAttending: ___.\n \nChief Complaint:\nabdominal/pelvic pain\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\nMs. ___ is a ___ female with history of MS,\nHTN, PTSD, and chronic pain disorder who presents with acute\nworsening of chronic abdominal/pelvic pain, complicated by \nreport\nof fevers and significant nausea.\n\n Upon arrival to the ED, patient was afebrile and mildly\nhypertensive, heart rates in the ___ with oxygen saturation 97%\non room air. Labs were notable for absence of leukocytosis, mild\nthrombocytopenia, alk phos 112, bicarbonate 21, and potassium \n5.3\n(whole blood cultures. A transvaginal ultrasound performed in \nthe\nemergency department showed unremarkable examination of the\nuterus, no free pelvic fluid or adnexal masses.\n\n Of note, patient saw her PCP 14 ___. At that time she was\ncomplaining of ongoing pelvic/bladder pain. Also full body pain.\nUnclear if this was related to her underlying multiple \nsclerosis.\nShe has been taking hydromorphone for pain relief. She also\nreported fevers, temperature to 101.7. Stools seemed to be more\nloose. She also noted some flushing of her skin. Amlodipine was\nincreased to 10 mg. No infectious workup was sent. Urine\nporphyria test was submitted (Porphobilinogen Screen NEGATIVE).\nPatient was initiated on fluoxetine 20 mg, no additional \nopioids.\n\n Patient then had a normal physical exam with OB/GYN the same\nday. No clear gynecologic etiology. Neuropathic pain was\nconsidered. Imaging was not pursued.\n\n Of note, patient has an ED plan (high utilizer ___ plan) as\nfollows:\n -Avoid opiates\n -Minimize CT scans\n -Involve outpatient providers (Drs. ___\nand ___ (her General Internist, Neurologist and\nGastroenterologist respectively) and ___, RN, her ___\n___ ___ in ___\n -Additional recommendations listed below: Pt has complex PTSD.\nCoping recommendations for team during hospital/ED stay:\n-Consistent messaging -Clear expectation setting -Provide\nopportunities for pt to feel part of team/in control when\npossible -Validate her emotional experience/ help her feel heard\n- Please see OMR note by Ms. ___ dated ___ for \nadditional\nguidance re individuals to contact if necessary.\n\n Patient was administered IVF and haloperidol in the ED.\nSubsequently patient was still unable to tolerate PO and thus\ndecision was made to admit to medicine.\n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n\n \nPast Medical History:\nDSM 5 DIAGNOSES:\nBorderline personality disorder\nPTSD\nSomatic symptom disorder, anxiety disorder\nUnspecified mood disorder (some notes label her as MDD, others \nappear to attribute her melancholic affect to her other \nconditions)\n\nMEDICAL HISTORY\nSecondary progressive MS- very questionable diagnosis, has \nlesions on MRI but no convincing clinical symptoms\nQuestion of a cognitive disorder, although evaluation is heavily \nconfounded by her other issues.\nAsthma\nIron deficiency\nB12 deficiency\nMigraines\nIBS\nUpper GI bleed\n \nSocial History:\n___\nFamily History:\ngrandfather with ___. \nUncle with ___ cancer\nFather w/ polio, lung mass, died of PsA infectious\nmother with superficial skin cancer\nmother with a chronic hematological malignancy \"version that \ndoesn't kill you,\" either leukemia or lymphoma\nlittle sister with breast cancer and bile duct cancer\n \nPhysical Exam:\nVital Signs:\n24 HR Data (last updated ___ @ 820)Temp: 98.5 (Tm 99.0), \nBP: 135/78 (135-152/77-98), HR: 57\n(57-94), RR: 18 (___), O2 sat: 97%, O2 delivery: Ra \n\nGen: Woman lying in bed, reporting whole body pain, weakness.\nEyes: Anicteric, PERLL.\nENT: Clear oropharynx, MMM, no cervical LAD.\nHeart: RRR, normal S1 S2, no r/m/g, no JVD.\nLungs: Breathing comfortably on RA, CTAB.\nAbd: Normoactive BS, soft, nondistended, tender to palpation in\nlower quadrants and suprapubic area, tenderness seems\nanticipatory and exaggerated, no rebound or guarding \nappreciated.\nExt: Palpable distal pulses, no pedal edema.\nSkin: No obvious rashes or scars.\nNeuro: A&Ox3, moving all extremities, upper and lower reflexes \nsymmetric and normal, difficult to assess strength due to \nparticipation but observed moving normally in bed, and walked \nwith ___ and nursing but would slide her feet and act like her \nknees were buckling.\nPsych: Labile emotions, at times angry and confrontational, and \nother times apologetic and almost charming.\n\n \nPertinent Results:\nLabs:\nMost recent labs:\n___ 05:46AM BLOOD WBC: 5.8 RBC: 4.51 Hgb: 12.7 Hct: 38.8\nMCV: 86 MCH: 28.2 MCHC: 32.7 RDW: 12.6 RDWSD: 39.___ \n___ 05:46AM BLOOD ___: 10.4 ___: 1.0 \n___ 05:46AM BLOOD Glucose: 104* UreaN: 13 Creat: 0.7 Na: \n137\nK: 4.2 Cl: 101 HCO3: 24 AnGap: 12 \n___ 05:46AM BLOOD Mg: 2.0 \n\nMicro: \n\nUrine culture ___\nMIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN\n AND/OR GENITAL CONTAMINATION. \n\nUA: \n___: Urine pH (Hem): 6.5\n___: Urine Glucose (Hem): NEG\n___: Urine Protein (Hem): NEG\n___: Urine Bilirubin (Hem): NEG\n___: Urobilinogen: NEG\n___: Urine Ketone (Hem): NEG\n___: Urine Blood (Hem): NEG\n___: Urine Nitrite (Hem): NEG\n___: Urine Leuks (Hem): LG*\n\nUCx: ___: Urine Culture: pending\n\nImaging & Studies:\n\n___ Transvaginal US\nFINDINGS: \nThe uterus is anteverted and measures 4.4 x 1.7 x 3.7 cm. The\nendometrium is homogeneous and measures 1 mm.\nPatient is status post bilateral salpingo-oophorectomy. No\nadnexal masses. \nThere is no free pelvic fluid.\nIMPRESSION: \nUnremarkable ultrasound examination of the uterus. No free\npelvic fluid. No adnexal masses.\n\n___ CT A/P with contrast at ___ \nFINDINGS: LOWER CHEST: Visualized lung fields are within normal\nlimits. There is no evidence of pleural or pericardial \neffusion. Moderate to large sized hiatal hernia is again\nvisualized. \n\nABDOMEN: \n\nHEPATOBILIARY: The liver demonstrates homogenous attenuation\nthroughout. There is no evidence of focal lesions. There \nis mild central intra and extrahepatic biliary ductal \ndilatation,\nwithin normal limits post cholecystectomy. The \ngallbladder is surgically resected. \n\nPANCREAS: The pancreas has normal attenuation throughout, \nwithout\nevidence of focal lesions or pancreatic ductal \ndilatation. There is no peripancreatic stranding. \n\nSPLEEN: The spleen shows normal size and attenuation throughout,\nwithout evidence of focal lesions. \n\nADRENALS: The right and left adrenal glands are normal in size\nand shape. \n\nURINARY: The kidneys are of normal and symmetric size with \nnormal\nnephrogram. There is no hydronephrosis. Millimetric \nright renal hypodensities are unchanged likely reflecting simple\ncysts. There is no perinephric abnormality. \n\nGASTROINTESTINAL: The stomach is unremarkable. Small bowel loops\ndemonstrate normal caliber, wall thickness, and \nenhancement throughout. The colon and rectum are within normal\nlimits. The appendix is normal. \n\nPELVIS: The urinary bladder is relatively decompressed. There is\nno free fluid in the pelvis. \n\nREPRODUCTIVE ORGANS: The uterus is not visualized. \n\nLYMPH NODES: There is no retroperitoneal or mesenteric\nlymphadenopathy. There is no pelvic or inguinal lymphadenopathy. \n\n\nVASCULAR: There is no abdominal aortic aneurysm. No significant\natherosclerotic disease is noted. \n\nBONES: There is no evidence of worrisome osseous lesions or \nacute\nfracture. Degenerative changes are again seen in the \nlower lumbar spine as well as minimal anterolisthesis of L4 on\nL5. Grade 1 retrolisthesis of L1 on L 2 is also noted. \n\nSOFT TISSUES: The abdominal and pelvic wall is within normal\nlimits. \n\nIMPRESSION: \n1. No acute abdominopelvic abnormality. \n2. Unchanged moderate to large hiatal hernia.\n\n \nBrief Hospital Course:\nMs. ___ is a ___ woman with PMH of MS ___ \nquestionable), complex PTSD, chronic pain disorder, and \napparently borderline personality disorder recently taken off \nopiates who presents with acute worsening of chronic \nabdominal/pelvic pain and nausea and subsequently weakness. \n\nACUTE/ACTIVE PROBLEMS:\n\n# Acute on Chronic Pain\nShe has had extensive testing in the past, recently saw gyn who\ndidn't suspect endometriosis (which would be very unusual in her\nage group). Labs were unremarkable. Ucx neg. No urinary \nsymptoms.\nNo s/sx of infection in general. Having BMs. TVUS unremarkable.\nCT abd/pelvis in ___ was unremarkable. Her description \nof\nthe pain and our exams were inconsistent and not pointing to a\nparticular physiologic mechanism/diagnosis. We do not treat\nchronic pain, even in exacerbation, with narcotics. Without a\nclear diagnosis in mind to evaluate for in a very stable patient\nwe did not favor blindly ordering more imaging and testing and\npotentially generate false positives and/or exposure her to\nradiation and other potential harms. Similarly we did not favor\nempiric antibiotics in a patient without a shred of evidence of\ninfection and exposing her to potential adverse effects. We saw \nno\nevidence for symptomatic multiple sclerosis or autonomic\ndysfunction and no indication for steroids. Based on our\ninteraction with the patient and review of her prior\ndocumentation and discussion with her outpatient neurologist, \nprimary ___ doctor, ___, we suspected a largely\nfunctional component to her concerns. Her outpatient providers \nagreed.\nShe consistently pursued Dilaudid for \"deep muscle pain\" and \nsteroids \nfor \"MS flare.\" This patient is not having an \"MS flare.\" Her \nneurologist\nwas very clear about this.\nPLAN:\n-AVOID narcotics, steroids, other therapies/diagnostics without \nindication\n-draw boundaries, avoid manipulation\n-continue gabapentin 300mg BID\n-continue acetaminophen 1g q6\n-continue duloxetine 60mg daily\n-continue naproxen 500mg BID prn pain\n-taper of oxcarbazepine: 300 mg daily x 7 days, stop ___\n-continue rest of home medications\n\n# Nausea\nReported nausea throughout the hospitalization. Was given prn \nondansetron. Reported vomiting although doesn't seem to have \nbeen observed by any staff. Ate meals, at least ___ daily. No \nweight loss during the hospitalization.\nPLAN:\n- continue prn ondansetron \n\n# Weakness\n# Possible MS\n___ and observation most consistent with functional weakness. \nAlthough patient is convinced otherwise, this patient is not \nhaving an multiple sclerosis flare. In fact she has no \nconsistent signs/symptoms to point to new non-functional \nneurologic deficit. Discussed patient with her long-time \noutpatient neurologist who recommended AGAINST neurology consult \nor further diagnostic work-up for neurologic deficits. Physical \ntherapy assessed her and recommended ___ rehab for \nphysical therapy, which she agreed to. \nPLAN:\n- ___ rehab for physical therapy\n\n# Constipation\nPLAN:\n- continue bowel regimen, titrate as needed\n\nCHRONIC/STABLE PROBLEMS:\n#HTN - continued home amlodipine\n#Asthma - continue home Spiriva, prn albuterol\n#GERD - continue home Nexium \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line \n2. OXcarbazepine 300 mg PO TID \n3. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line \n\n4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third \nLine \n5. amLODIPine 10 mg PO DAILY \n6. Vitamin D 1000 UNIT PO DAILY \n7. Cyanocobalamin 1000 mcg PO DAILY \n8. DULoxetine 20 mg PO DAILY \n9. esomeprazole magnesium 40 mg oral BID \n10. Tiotropium Bromide 1 CAP IH DAILY \n11. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H \n2. Gabapentin 300 mg PO BID \n3. Lidocaine 5% Patch 1 PTCH TD QPM \n4. Multivitamins W/minerals 1 TAB PO DAILY \n5. Naproxen 500 mg PO Q12H:PRN pain \n6. Ramelteon 8 mg PO QHS:PRN insomnia \n7. Senna 8.6 mg PO BID \n8. Docusate Sodium 200 mg PO BID \n9. DULoxetine 60 mg PO DAILY \n10. OXcarbazepine 300 mg PO DAILY \nTake for 1 week and stop. Last day ___. \n11. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing \n12. amLODIPine 10 mg PO DAILY \n13. Cyanocobalamin 1000 mcg PO DAILY \n14. esomeprazole magnesium 40 mg oral BID \n15. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line \n16. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third \nLine \n17. Tiotropium Bromide 1 CAP IH DAILY \n18. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended ___\n \nFacility:\n___\n \nDischarge Diagnosis:\nPain\nNausea\nWeakness\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the hospital with pain, nausea, and then \nlater endorsed weakness. \n\nYou also had a recent CT and transvaginal ultrasound that showed \nnothing concerning. Your labs were within normal. \n\nFor the pain we provided acetaminophen, gabapentin, duloxetine, \nlidocaine patch, and naproxen. We began tapering you off of \noxcarbazepine. \n\nFor your nausea we provided nausea medications and continued a \nproton-pump inhibitor. \n\nFor your weakness we examined you closely and had you evaluated \nby physical therapy and recommended rehab, which you agreed to.\n\nWe discussed your symptoms with your outpatient doctors \n___, neurologist, and primary ___ doctor) and they \nagreed with the assessment and plan. \n\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "R52", "R110", "R531", "G35", "K5900", "I10", "J45909", "K219" ]

[ "R52: Pain, unspecified", "R110: Nausea", "R531: Weakness", "G35: Multiple sclerosis", "K5900: Constipation, unspecified", "I10: Essential (primary) hypertension", "J45909: Unspecified asthma, uncomplicated", "K219: Gastro-esophageal reflux disease without esophagitis" ]

[ "K5900", "I10", "J45909", "K219" ]

[]

[ " \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:\neye pain/swelling\n \nMajor Surgical or Invasive Procedure:\n___ line\nvitrectomy (___)\n\n \nHistory of Present Illness:\n___ w/ Hx of diabetes (A1C 8.5, not taking metformin 6 months \nago), hyperlipidemia ___ 294), s/p psychiatric dissociative \ndisorder, h/o suicidal ideation in past (given Effexor but no \nlonger taking, presenting with L eye pain /swelling x 1 week. \nStarted with \"head cold\" lots of congestion which resolved last \nweek after 3 days and then new onset L eye pain immediately \nafterwards. Tylenol has helped, looking to the far right is \nworst eye position and makes pain unbearable. She had a recent \nED admission on ___ when she presented with these sx and \ndiagnosed with acute anterior uveitis OS with 4+ cells and \nvitreous spillover with poor fundus view, first episode. She was \nstarted on hourly prednisolone eyedrops and cyclopentolate tid. \nAt the time, she had a protuberant L-eye at the time and \nnegative CT orbits. She has been taking eye drops (and swears \ncompliance) but now has worsening pain and visual changes in her \nL-eye to the point she could not tolerated and arrived. She \ndenies contact use, fevers, chills, nausea, vomiting or other \ninfectious symptoms. She denies other complaints. Thorough ROS \nnegative for chest pain, SOB, headache, hearing changes, \ndiarrhea/constipation/nausea/vomiting/joint pain/muscle ache. \nVision out of L eye is minimal and cannot count fingers past 2 \nmeters.\n\nIn the ED, initial VS were 98.5 63 109/63 18 99% RA. Initially \nhad ___ pain now at ___ controlled with IV morphine 4mg in ED \n+ oxycodone 5mg. She did not bring corrective lenses, her visual \nacutity ___ measured b/l, subjectively worse vision on R but \ncan count fingers, make out motion in 4 quadrants of vision. \nWas given NS bolus (Na 131), WBC elevated at 13.2 (up from ~10 \non ___. Glucose at 286 (not compliant with metformin) CRP \nelevated at 89.6. Given Zosyn. Recent CT showed no e/o orbital \ncellulitis. BCx x 2 of her eye drops and pain control as well as \nhyponatremia and diabetes management. \n\n \nPast Medical History:\n1. Major depressive disorder. \n2. Posttraumatic stress disorder. \n3. Dissociative reactions, NOS. \n4. Hyperlipidemia. \n5. Hearing loss. \n6. Fibromyalgia. \n7. Lower back pain, followed by pain clinic \n8. GERD. \n \nSocial History:\n___\nFamily History:\nNone contributory.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nVS - 98.8, 130/46, 61, 18, 100/r.a.\nGENERAL: NAD \nHEENT: mild proptosis of L eye, EOMI in tact and full, although \npain elicited on extreme R gaze, injected and swollen \nconjunctiva, notable chemosis, PERLLA, difficulty keeping eyelid \nopen\nR eye without injection or proptosis\nNECK: nontender supple neck, no LAD, no JVD \nCARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably \nwithout use of accessory muscles \nABDOMEN: obese, nondistended, +BS, nontender in all quadrants, \nno rebound/guarding, no hepatosplenomegaly \nEXTREMITIES: no cyanosis, clubbing or edema, moving all 4 \nextremities with purpose \nPULSES: 2+ DP pulses bilaterally \nNEURO: CN II-XII intact \nSKIN: warm and well perfused, no excoriations or lesions, no \nrashes \n\nDISCHARGE PHYSICAL EXAM\n=======================\nVS - 97.6, 144/77, 62, 20, 99% r.a.\nGeneral: well appearing, NAD, pt is hard of hearing\nHEENT: MMM, EOMI, L eye and surrounding soft tissue visibly \nswollen but improved with regards to chemosis/vision, CF at \n2feet on vision \nNeck: no JVD, no LAD \nCV: rrr, no m/r/g \nLungs: CTAB, breathing comfortably \nAbdomen: soft, nontender, nondistended, no HSM appreciated \nGU: deferred \nExt: warm and well perfused, pulses, no edema \nNeuro: grossly normal \n \nPertinent Results:\nPERTINENT LABS\n==================\n\n___ 02:02AM WBC-13.2* RBC-4.54 HGB-13.2 HCT-40.2 MCV-89 \nMCH-29.1 MCHC-32.8 RDW-12.9 RDWSD-41.8\n___ 02:02AM NEUTS-68.9 ___ MONOS-6.8 EOS-1.1 \nBASOS-0.4 IM ___ AbsNeut-9.08* AbsLymp-2.93 AbsMono-0.89* \nAbsEos-0.14 AbsBaso-0.05\n___ 02:11AM GLUCOSE-321* LACTATE-2.2* NA+-129* CL--96\n___ 06:25AM CRP-89.6*\n___ 06:25AM TSH-2.4\n___ 06:25AM ALBUMIN-3.0* CALCIUM-9.1\n___ 06:25AM GLUCOSE-286* UREA N-10 CREAT-0.6 SODIUM-131* \nPOTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-21* ANION GAP-19\n\nMICROBIOLOGY\n==================\n TOXOPLASMA IgG ANTIBODY (Final ___: \n NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA. \n 0.0 IU/ML. \n Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml. \n\n TOXOPLASMA IgM ANTIBODY (Final ___: \n NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA. \n INTERPRETATION: NO ANTIBODY DETECTED. \n RAPID PLASMA REAGIN TEST (Final ___: \n NONREACTIVE. \n\n___ 2:05 am BLOOD CULTURE\n\nBlood Culture, Routine (Final ___: NO GROWTH\n\n___ 7:10 pm EYE Source: Vitreous fluid. \n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n RESPIRATORY CULTURE (Final ___: NO GROWTH. \n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. \n POTASSIUM HYDROXIDE PREPARATION (Final ___: \n SPECIMEN NOT PROCESSED DUE TO: QUANTITY NOT SUFFICIENT. \n TEST CANCELLED, PATIENT CREDITED. \n\n___ 7:10 pm EYE Source: Vitreous fluid. ANTERIOR \nCHAMBER. \n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n RESPIRATORY CULTURE (Final ___: NO GROWTH. \n ANAEROBIC CULTURE (Preliminary): NO GROWTH. \n\n___ 6:30 pm FLUID,OTHER UNDILUTED VITREOUS FLUID- LEFT \nEYE. \n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n FLUID CULTURE (Final ___: NO GROWTH. \n ANAEROBIC CULTURE (Preliminary): NO GROWTH. \n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. \n \n \n___ 5:30 pm BLOOD CULTURE x 6\n Blood Culture, Routine (Pending)\n\nTEE ___:\nThe left atrium is dilated. No spontaneous echo contrast or \nthrombus is seen in the body of the left atrium/left atrial \nappendage or the body of the right atrium/right atrial \nappendage. The right atrium is dilated. Right atrial appendage \nejection velocity is good (>20 cm/s). No atrial septal defect is \nseen by 2D or color Doppler. Overall left ventricular systolic \nfunction is normal (LVEF>55%). Right ventricular chamber size \nand free wall motion are normal. There are simple atheroma in \nthe aortic arch. There are simple atheroma in the descending \nthoracic aorta. The aortic valve leaflets (3) are mildly \nthickened. There is a round, minimally mobile moderate-sized \nvegetation on the left ventricular outflow tract surface of the \nnoncoronary leaflet of the aortic valve, measuring 1.1 x 0.7 cm \nwith a 0.5 cm filamentous highly and independently mobile strand \nattached to the inferior surface. Mild to moderate (___) aortic \nregurgitation is seen. The aortic regurgitation jet is \neccentric, directed toward the anterior mitral leaflet and may \nbe underestimated. The mitral valve leaflets are mildly \nthickened. There is no mitral valve prolapse. No mass or \nvegetation is seen on the mitral valve. Mild to moderate (___) \nmitral regurgitation is seen. The pulmonary artery systolic \npressure could not be determined. No vegetation/mass is seen on \nthe pulmonic valve. There is no pericardial effusion. \n\n IMPRESSION: Moderate sized vegetation on the aortic valve with \nat least mild-to-moderate eccentric aortic regurgitation. Normal \nleft ventricular systolic function. Mild-to-moderate mitral \nregurgitation.\n\n \nBrief Hospital Course:\n___ yo female patient with h/o DM, hyperlipidemia, with new onset \nsevere left eye pain concerning for pan-endophthalmitis, ___ \nepisode in the setting of recent sinus infection vs occult \nbacteremia given chills ___. CT negative for cellulitis \nfindings on ___. Exam notable for injected/proprotic eye but \nEOMI intact and no double vision, although minimal vision in L \neye (CF ___. Now with new hypopion (ophtho exam: 4+ cells in AC \nwith new 1 mm hypopion, no KPs/no Synechiae/no ___ nodules, \ndense vitritis with no fundus view) admitted for management of \neye drops qhour and pain control. \n\n#eye swelling, endopthalmitis, culture negative native valve \nendocarditis: Initial concern was for infectious vs \nnon-infectious uveitis vs pan-endophthalmitis vs (periorbital vs \norbital) cellulitis. No double vision, EOMI in tact, and CT on \n___ negative but still need to r/o cellulitis. FHx negative for \nautoimmune and systemic ROS unrevealing of pulm/renal concerns \nfor sarcoidosis or vasculitis. However, non-infectious uveitis \netiologies can be from HLA-B27 and Behcet disease which manifest \nwith hypopion although dense vitritis on ophtho exam would be \nagainst an HLA-B27 associated uveitis. Infectious etiologies \nsuch as toxoplasmosis was considered in the setting of poor \nresponse to topical steroids although pt appears to have pain \ncontrol now with Tylenol. Low likelihood of mucor despite \ndiabetes given mild sinusitis which self-resolved, no nasal \nsymptoms. Intravitreal tap and vitrectomy fluid cultures were \nsterile, a universal PCR was sent from the vitreal cultures. RPR \nwas negative. CXR and CT was negative was sarcoid. A TEE was \ndone which showed some aortic vegetation with mild aortic \ninsufficiency. This was deemed to be a possible source from \ninfectious disease team. Pt had 8 sets of pending blood cultures \nat time of discharge and on vancomycin 1.5g q8h /ceftriaxone 2g \nqd at time of discharge. Pt was consented for a PICC and was \ndischarged on a PICC to continue antibiotics at rehab until \nfollow-up with ID and ophthalmology. \n\n#pain: Pt with ___ on current ED admission, now ___ on po \nTylenol, pred forte gtt and oxycodone ___ mg q6h:prn. Pt notes \nthat oxycodone helps and without pain control, pain can be \nsevere.\n\n#DM: Pt with longstanding h/o DM. Not compliant with metformin x \n6 months - thought she would be ok. ED glucose elevated at 286. \nPt was on insulin sliding scale while admitted.\n\nTRANSITIONAL ISSUES\n====================\n- Pt is to continue Vancomycin 1500 mg IV Q 12H and CefTRIAXone \n2 gm IV Q 24H, Start Date: ___ Projected End Date: ___ \n- per ID please monitor WEEKLY CBC with differential, BUN, Cr, \nVancomycin trough, ESR, CRP AST, ALT, TB, ALK PHOS. \n- ALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC - \nFAX: ___. These will be followed by ___ Infectious \nDisease Dept \n- Many of pt's labs are pending at time of discharge, including \n8 blood cultures and universal PCR for bacteria and viral \nstudies.\n- Pt is to continue prednisone drops every horus while awake, \natropine drops twice a day, and vigamox drops four times a day.\n- Per ID, pt should follow-up in Cardiology clinic for her \naortic valve vegetation after she is discharged from rehab\n- Pt is to follow-up in ophthalmology clinic with Dr. ___ \n___ on ___\n- Given unclear source of infection, consider further outpatient \nwork-up, including colonoscopy and CT scan of abdomen/pelvis \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Vitamin D 1000 UNIT PO DAILY \n2. MetFORMIN (Glucophage) 500 mg PO BID \n\n \nDischarge Medications:\n1. CefTRIAXone 2 gm IV Q 24H \n2. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE Q2H eye \ninflammation \n3. Vigamox (moxifloxacin) 0.5 % ophthalmic QID \n4. MetFORMIN (Glucophage) 500 mg PO BID \n5. Atropine Sulfate Ophth 1% 1 DROP LEFT EYE BID \n6. Vitamin D 1000 UNIT PO DAILY \n7. Docusate Sodium 100 mg PO BID:PRN constipation \n8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN breakthrough \npain \nRX *oxycodone 5 mg 1 tablet(s) by mouth Q6H:PRN Disp #*10 Tablet \nRefills:*0\n9. Senna 8.6 mg PO BID:PRN constipation \n10. Vancomycin 1500 mg IV Q 12H \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY: \npanophthalamitis\naortic valve vegetation\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\nIt was a pleasure caring for you during your recent admission. \nYou were hospitalized for your eye infection. It remains unclear \nwhere this infection came from, but we also found you have \nevidence of this infection on one of your heart valves as well. \nThere are still some studies pending at the time of your \ndischarge which may help us clarify the source, but oftentimes a \nsource is never found. While this is unsatisfying, the good news \nis that we have been treating you with the correct antibiotics \nsince your admission, and your infection is improving. For your \neye infection, the fluid inside the eye was removed and found to \nbe sterile. You were given IV antibiotics and several eye drops \nto keep in the inflammation under control. You were given a \nspecial IV to continue your antibiotics. You will continue your \nantibiotics until you follow-up with the infectious disease, \neye, and primary care doctors.\n\nIf you have worsening eye symptoms, fevers, chills, or other new \nsymptoms please return to the hospital for immediate evaluation. \nIt was a pleasure taking care of you!\n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "H44012", "I330", "E222", "H15002", "Z66", "E1165", "Z9114", "F329", "E785", "K219" ]

[ "H44012: Panophthalmitis (acute), left eye", "I330: Acute and subacute infective endocarditis", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "H15002: Unspecified scleritis, left eye", "Z66: Do not resuscitate", "E1165: Type 2 diabetes mellitus with hyperglycemia", "Z9114: Patient's other noncompliance with medication regimen", "F329: Major depressive disorder, single episode, unspecified", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis" ]

[ "Z66", "E1165", "F329", "E785", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ___\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nmelena, chest pain\n \nMajor Surgical or Invasive Procedure:\n___: EGD\n___: Colonoscopy \n\n \nHistory of Present Illness:\nMs. ___ is a ___ w hx of paroxysmal atrial fibrillation on \nCoumadin, CAD, diabetes, GERD, who initially presented to \n___ after having had a roughly 30 minute episode of chest \npain this afternoon while seated. \n\nThe patient states that she had some associated nausea but no \ndyspnea or diaphoresis and her symptoms resolved with a single \nnitroglycerin. \n\nShortly thereafter, she reported having a bowel movement which \nwas bloody. \n\nShe subsequently presented to the ED at ___ patient \nwaschest pain free however she was noted to be in afib with RVR \nwith rates in the 110-120's. She converted spontaneously out of \nRVR without intervention.\nLabs were notable for Trop T of .06, hgb 9.3, hct 27.8, INR3.5\n\nCardiology was consulted who recommended trending troponin and \nEKG. Full dose aspirin was not given in the setting of GI bleed. \nShe did received 80mg protonix and Vit K for reversal of INR in \nsetting of GI bleed.\n\nShe was thus transferred to ___ for further workup and MGMT of \nGi bleed and chest pain.\n\nIn regards to her history of CAD, per review of Atrius records, \nmost recent cardiology note is from ___: \nPer reivew of the note, the patient underwent cardiac \ncatheterization in ___ which revealed \"very severe diffuse \nCAD\". Medical treatment was recommended. \n\nIn addition, the patient unfortunately suffered an embolic \nstroke in ___ which is resulted in a left hemiparasis \nand a left-sided visual defect.\n\nUpon arrival at ___ ED, \n\nThe patient was chest pain free. She denied fevers/chills, SOB, \ncough. She did however report increased swelling of left leg and \nhas no mobility of left leg s/p stroke. She was tachycardia to \nthe 120's initially, however her tachycardia spontaneously \nresolved.\n\n \nExam notable for: \nWell-appearing and sitting in bed in no acute distress.\nNormal heart and lung sounds.\nab soft and nondistended and nontender to palpation.\nleft leg noticeably more swollen than right leg\nNo CVA tenderness\n\nECG: irregular rhythm concerning, widened QRS, mild ST \ndepressions in V3, V4. \n \nLabs showed: \nCr 1.3, WBC 5.2 H/H 7.6/23.6, Plt 98, Lactate 1.4\nguaic pos for melanotic stool\n\nImaging showed: \nCXR ___:\n1. Cardiomegaly. Mild cephalization.\nNo definite CHF pleural effusion or pneumonia.\n\nConsults:\nGI for managment of GI bleed:\nrecs as follows:\n -IV access x 2\n - IV PPI BID\n - type and cross\n - repeat INR this morning\n - transfuse for symptomatic anemia, active bleeding, etc. If \nactive chest pain or uptrending troponins would be reasonable to \nuse higher transfusion threshold than 7 (eg: 10).\n - trend troponin until stable/downtrending\n - please ensure adequately resuscitated, CP and EKG changes \nresolved so can safely sedate for EGD \n \nPatient received: \n1L NS\nIU PRBC\n\nTransfer VS were: \n\nT 97.8 HR86 BP100/47 RR14 O2 100% RA \n\nOn arrival to the floor, patient confirms above history. Denies \nchest pain.\n\nREVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as \nper HPI \n\n \nPast Medical History:\n-hypertension\n-hyperlipidemia\n-GERD\n-atrial fibrillation\n-seizures\n-insulin-dependent diabetes\n-DVT\n-CHF\n-CVA\n-myocardial infarct\n-chronic kidney disease\n \nSocial History:\n___\nFamily History:\nReviewed and deemed not relevant to current admission\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\nVS: ___ 0614 Temp: 97.5 PO BP: 123/46 R Lying HR: 54 RR: \n18 O2 sat: 100% O2 delivery: RA \nGENERAL: AAoX3 \nHEENT: moving neck in rhythmic motion to right (baseline per \nfamily) \nNECK: supple, no LAD \nCV: RRR, S1/S2, no murmurs, \nPULM: CTAB, no wheezes, \nGI: abdomen soft, nondistended, nontender \nEXTREMITIES: trace to 1+ edema\n\nDISCHARGE PHYSICAL EXAM\n___ 1148 Temp: 97.9 PO BP: 155/71 R Lying HR: 73 RR: 16 O2 \nsat: 96% O2 delivery: RA FSBG: 195 \nGeneral: Sitting up in bed, no acute distress, moves head in \nrhythmic manner while speaking. \nHEENT: Sclera anicteric, MMM\nLungs: Coarse breath sounds and mild crackles diffusely in \nbilateral\nlungs. No wheezes or rhonchi\nCV: irregularly irregular rhythm, no murmurs, rubs, or gallops\nAbdomen: soft non distended, non-tender to palpation, no rebound\nor guarding, non-tender, no suprapubic tenderness \nExt: Warm, well perfused, 2+ pulses. Swelling of left lower\nextremity up to above the knee with trace edema, trace ___ ain\nright lower extremity. L upper extremity with 1+ edema, chronic\nskin discoloration. R arm skin discoloration from wrist to\nforearm. \nNeuro: Face grossly symmetric, but notable rhythmic movements\nwhile awake. No vision in right eye s/p retinal detachment. left \nhemi neglect and left hemiparesis and hemiplegia. \n\n \nPertinent Results:\nADMISSION LABS\n___ 12:45AM BLOOD WBC-5.2 RBC-2.35* Hgb-7.6* Hct-23.6* \nMCV-100* MCH-32.3* MCHC-32.2 RDW-14.4 RDWSD-52.2* Plt Ct-98*\n___ 12:45AM BLOOD ___ PTT-39.0* ___\n___ 12:45AM BLOOD Glucose-133* UreaN-43* Creat-1.3* Na-138 \nK-4.6 Cl-106 HCO3-21* AnGap-11\n___ 09:20AM BLOOD Ret Aut-2.6* Abs Ret-0.07\n___ 12:45AM BLOOD ALT-24 AST-25 AlkPhos-189* TotBili-0.4\n___ 12:45AM BLOOD cTropnT-0.04*\n___ 09:20AM BLOOD CK-MB-3 cTropnT-0.04*\n___ 09:20AM BLOOD VitB12-803 Folate-10\n___ 12:45AM BLOOD Albumin-3.5\n___ 02:45AM BLOOD Lactate-1.4\n\nRELEVANT IMAGING/STUDIES:\n=========================\n___: EGD. Normal esophagus, stomach, and duodenum. \n___: Colonoscopy - Clotted blood seen in whole colon. A \nsingle medium bleeding angioectasia was seen in the cecum. Argon \nplasma coagulator was successfully applied for hemostasis in the \ncecum. Normal mucosa was noted in the terminal ileum to > 20cm. \n\nDISCHARGE LABS:\n================\n___ 05:30AM BLOOD WBC-5.2 RBC-3.06* Hgb-9.7* Hct-30.4* \nMCV-99* MCH-31.7 MCHC-31.9* RDW-15.9* RDWSD-56.9* Plt ___\n___ 05:30AM BLOOD Plt ___\n___ 05:30AM BLOOD ___\n___ 05:30AM BLOOD Glucose-138* UreaN-14 Creat-1.0 Na-139 \nK-3.9 Cl-103 HCO3-25 AnGap-11\n___ 05:30AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.7\n \nBrief Hospital Course:\nPATIENT SUMMARY FOR ADMISSION\n=============================\n___ yo woman with history of paroxysmal afib (on warfarin), IDDM, \nCHF w/ EF of 40-45%, CAD s/p MI in ___ and cardiac cath, CVA in \n___ who initially presented to an outside hospital on ___ with \n30 minutes of chest pain and elevated troponins consistent with \nType II NSTEMI, afib w/RVR, as well as melena and BRBPR and was \ntransferred to ___ for work-up of GI bleed, now s/p a normal \nEGD ___. Colonoscopy ___ showed a bleeding AVM in the cecum \nthat treated with APC with good hemostasis. \n\nACTIVE/ACUTE ISSUES ADDRESSED: \n============================== \n# GI Bleed \n# Acute on Chronic Anemia, macrocytic\nPatient was admitted with chest pain and melena. Per patient's \nfamily, she has had some chronic anemia over the past several \nmonths. Patient received vitamin K at the OSH on ___ + 2u pRBCs \n(transfusion goal >8 given NSTEMI). GI was consulted in the ED \nand patient subsequently underwent an EGD ___ which did not \nreveal any source of bleeding. She prepped for a colonoscopy \n___ and underwent colonoscopy ___ that showed bleeding AVM in \nthe cecum that was treated with APC. Coumadin was held \nthroughout admission given active bleeding. \n\n# Acute on Chronic Anemia\nPatient initially had a macrocytic anemia (MCV 100) but Vitamin \nB12 and folate were both normal. Despite having acute blood loss \nanemia, patient's absolute retic count was low likely due to her \nchronic iron deficiency anemia. Continued home ferrous sulfate \n325 mg PO/NG BID. Received 2u pRBCs. \n\n#Paroxysmal afib with intermittent RVR\nPatient has a history of afib with an embolic stroke in ___. \nCHADS2Vasc is 9. Patient was noted to be in afib with RVR at \noutside hospital and on exam morning of admission was in afib \nwith intermittent RVR on tele. Her anticoagulation was held due \nto GI bleed and rate control was continued with metoprolol. \nFamily was very concerned about risk of stroke but understood \nthat we were balancing stroke risk with bleeding risk. Given \nelevated CHADS2Vasc she was bridged with lovenox for 5 days at \nthe time of discharge. \n\n# Type II NSTEMI\nPatient presented with substernal chest pain. Trop-T at outside \nhospital noted to be 0.06 which has been stable at 0.04 on \nrepeat labs since admission to ___ with EKG showing ST \ndepressions similar to previous reports from earlier in the \nyear. Patient does have a significant cardiac history and was \nnoted to have multivessel disease on prior cath. Her chest pain \nwas likely due to demand ischemia in the setting of a GI bleed \nand acute on chronic anemia. Patient was monitored on telemetry \nthroughout admission. \n\n#HFpEF EF 40-45%\nPatient with known history of HF. Unclear etiology. Last ECHO \nper ___ records shows EF 40-45%. Had previously been on \nTorsemide 20 daily but family has been holding for 2 week prior \nto admission. They stated that they give it when she has \nevidence of increased fluid (they weigh her frequently) and when \nher weight is >134lbs. Continued afterload management with \nlisinopril 10mg. Continue home metoprolol (fractionated). Her \ndischarge weight was 137lbs and the family will give torsemide \nat home pending her weight when she arrives home. \n\n# Thrombocytopenia\nLikely also due to GI bleed and subsequent sequestration of \nplatelets. Patient does have CKD with a current BUN of 43, \ntherefore uremic platelet dysfunction should also be considered \nwhich can often take place in the setting of acute bleeding. \n\n___ on CKD: Cr on admission was 1.2. On review ___ \nrecords, baseline Cr is ___. Cr was trended throughout \nadmission and was 0.8 at the time of discharge. \n\n#Goals of care\nThe team had a discussion with ___, the patient's husband \nwho identifies as her second HCP ___ healthcare proxy is \ndaughter, ___ who was not present during conversation). \nHer husband expressed that should her condition deteriorate, Ms. \n___ would not want chest compressions but would want to be \nintubated. In the event of that acute issues arise during a \nprocedure or sedation which are likely to resolve, the family \nwould like her code status to be reversed and they would like \nresuscitation efforts. \n\n#UTI, patient reported dysuria and UA with large leuks. Urine \nculture with mixed bacterial flora but treated with Macrobid for \n5 day duration (___)\n\n#Removal of eye stitch, family noted a blue stitch appear from \nright eye from previous eyelid surgery ___ years ago. Patient had \npreviously been reporting discomfort on that eye for several \nmonths. Ophthalmology was able to remove the stitch in-house and \nrecommended artificial tears and erythromycin for 2 weeks after \nstitch removal. \n\nCHRONIC ISSUES:\n=============== \n#Stroke:\nPatient presented with known left sided deficits. Stable from \nprior. We continued her home Keppra 500mg BD.\n\n#CAD: Patient with history of multivessel disese. Continued home \nASA 81mg, Atorvastatin 40. Home metop was fractionated given \nactive GI bleeding, but home dose resumed at the time of \ndischarge. \n\n#IDDM (BG this AM 113): Continued home glargine 6 units qAM and \nmaintained patient on insulin sliding scale.\n\n#Left leg swelling\nPer family, left leg has been swelling is chronic and related to \nher left hemiparesis. We monitored throughout admission\n\nTRANSITIONAL ISSUES\n===================\n[ ] Follow up CBC at next outpatient appointment to monitor \nthrombocytopenia and anemia. Discharge Hb 9.7, platelets 117. \n[ ] Patient discharged with lovenox for bridging to warfarin. \nPCP ___ manage anticoagulation onward (discussed with office \nRN). Discharge INR 1.5. Discharged with 2 day supply of lovenox \nwith refills per family request to limit costs (last time \npatient bridged with lovenox script was filled and patient did \nnot need all the doses, and copay was several hundred dollars). \n[ ] Discharge weight 137lbs, continue to monitor volume status \nand resume torsemide as needed. \n[ ] Continue macrobid for UTI through ___\n[ ] Continue artificial tears and erythromycin drops to the \nright eye for 2 weeks. \n\n#CODE: DNR/ok to intubate \n#CONTACT: Husband ___ ___ Daughter ___ \n___\n\nAttending Addendum: \nI have seen and examined the patient and agree with the note by \nthe medical resident. I spent > 30 min in discharge planning \nand coordination of care. \n- ___, ___ \n___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Warfarin 1 mg PO DAILY16 \n2. Torsemide 20 mg PO DAILY \n3. Metoprolol Succinate XL 25 mg PO BID \n4. Lisinopril 10 mg PO DAILY \n5. Pantoprazole 40 mg PO Q24H \n6. Atorvastatin 40 mg PO QPM \n7. Aspirin 81 mg PO DAILY \n8. LevETIRAcetam 500 mg PO BID \n9. Niacin 500 mg PO DAILY \n10. Vitamin D 1200 UNIT PO DAILY \n11. Calcium Carbonate 600 mg PO DAILY \n12. Ferrous Sulfate 325 mg PO BID \n13. Glargine 6 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin\n14. Epoetin ___ ___ UNIT IV MONTHLY \n15. Hydrocerin 1 Appl TP QHS to feet \n16. Acetaminophen 325 mg PO Q4H:PRN Pain - Mild \n\n \nDischarge Medications:\n1. Artificial Tears ___ DROP RIGHT EYE TID \nRX *dextran 70-hypromellose (PF) [Artificial Tears (PF)] 0.1 \n%-0.3 % ___ drops right eye as needed up to 8 times per day for \neye dryness Disp #*1 Bottle Refills:*0 \n2. Enoxaparin Sodium 60 mg SC BID Duration: 5 Days \nStart: ___, First Dose: Next Routine Administration Time \nRX *enoxaparin 60 mg/0.6 mL 60 mg subcutaneous twice a day Disp \n#*4 Syringe Refills:*2 \n3. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE QID Duration: \n2 Weeks \nRX *erythromycin 5 mg/gram (0.5 %) 1 drop right eye four times a \nweek Refills:*0 \n4. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 5 \nDays \nRX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1 \ncapsule(s) by mouth twice a day Disp #*5 Capsule Refills:*0 \n5. Glargine 6 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin \n6. Torsemide 20 mg PO PRN when weight >137lbs \n7. Acetaminophen 325 mg PO Q4H:PRN Pain - Mild \n8. Aspirin 81 mg PO DAILY \n9. Atorvastatin 40 mg PO QPM \n10. Calcium Carbonate 600 mg PO DAILY \n11. Epoetin ___ ___ UNIT IV MONTHLY \n12. Ferrous Sulfate 325 mg PO BID \n13. Hydrocerin 1 Appl TP QHS to feet \n14. LevETIRAcetam 500 mg PO BID \n15. Lisinopril 10 mg PO DAILY \n16. Metoprolol Succinate XL 25 mg PO BID \n17. Niacin 500 mg PO DAILY \n18. Pantoprazole 40 mg PO Q24H \n19. Vitamin D 1200 UNIT PO DAILY \n20. Warfarin 1 mg PO DAILY16 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n=================\nLower GI bleeding from AVM\nAcute blood loss anemia \nAtrial fibrillation with RVR\nType II NSTEMI\n\nSECONDARY DIAGNOSIS\n===================\nCVA with L hemiparesis and hemiplegia\nCKD\nChronic Diastolic Heart Failure\nInsulin Dependent Diabetes\nUncomplicated UTI \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nIt was a pleasure to care for you at the ___ \n___. \n\nWhy did you come to the hospital? \nYou came into the hospital because you were having chest pain \nand bleeding in your stool.\n\nWhat did you receive in the hospital? \n- While you were here we did an endoscopy to look for the site \nof the bleeding. On ___ we looked through your esophagus and \nstomach and we did not find a source of your bleeding. \n- You received two blood transfusions while you were in the \nhospital. \n- While you were here, we stopped your blood thinners to try to \nminimize your bleeding. - We monitored your heart rate to watch \nfor any episodes of atrial fibrillation. \n- On ___ you received a colonoscopy which showed an area of \nbleeding (arteriovenous malformation) that was treated and the \nbleeding stopped. \n- Once we felt sure that you were no longer bleeding we \nrestarted your normal blood thinner medication. Since your INR \nwas not at your goal before you left we started you on lovenox \n(another blood thinner) to use until your INR is at your goal. \n\nWhat should you do once you leave the hospital? \n- You should continue to take your medications as prescribed and \nfollow up with all the appointments listed below. \n- Continue taking the lovenox shots and check your INR every \nday. Call your primary care doctor to discuss you warfarin \ndosing. You should continue to take the lovenox for 5 days.\n- Complete the antibiotics for your urinary tract infection. \n- Be sure to use the eye drops as directed for the next 2 days. \n\n- Continue to weigh yourself at home and take torsemide if you \nweight is greater than 134 lbs (as you were doing before). \n\nWe wish you the best! \nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "K5521", "I21A1", "D62", "N179", "N390", "I130", "I5032", "I69354", "I480", "Z7901", "I2510", "K219", "E785", "Z86718", "I252", "D696", "Z87891", "R791", "Z89412", "Z66", "E1122", "N189", "Z794", "G40909", "I69398", "I69314", "H539" ]

[ "K5521: Angiodysplasia of colon with hemorrhage", "I21A1: Myocardial infarction type 2", "D62: Acute posthemorrhagic anemia", "N179: Acute kidney failure, unspecified", "N390: Urinary tract infection, site not specified", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5032: Chronic diastolic (congestive) heart failure", "I69354: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side", "I480: Paroxysmal atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "I252: Old myocardial infarction", "D696: Thrombocytopenia, unspecified", "Z87891: Personal history of nicotine dependence", "R791: Abnormal coagulation profile", "Z89412: Acquired absence of left great toe", "Z66: Do not resuscitate", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N189: Chronic kidney disease, unspecified", "Z794: Long term (current) use of insulin", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "I69398: Other sequelae of cerebral infarction", "I69314: Frontal lobe and executive function deficit following cerebral infarction", "H539: Unspecified visual disturbance" ]

[ "D62", "N179", "N390", "I130", "I5032", "I480", "Z7901", "I2510", "K219", "E785", "Z86718", "I252", "D696", "Z87891", "Z66", "E1122", "N189", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nchlorhexidine\n \nAttending: ___\n \n___ Complaint:\nIleostomy reversal\n \nMajor Surgical or Invasive Procedure:\nIleostomy reversal by Dr. ___ on ___\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year-old man with rectal cancer clinical \nstage T2N1M0 (Stage IIIA), enrolled on the ___ trial, \nrandomized to the control arm, completed neoadjuvant \nchemoradiotherapy ___, underwent robotic resection\n(LAR) on ___, and is here to further discuss ileostomy \nreversal plans and initiating adjuvant therapy.\n\n \nPast Medical History:\nECTAL CANCER \nRectal cancer stage IIIA (T2N1M0)\n- ___ Presented to PCP with hematochezia ___ 4 weeks\n- ___ Colonoscopy revealed an ulcerated 3 cm mass in the \nproximal rectum. Biopsy showed adenocarcinoma\n- ___ MR pelvis showed a T2N1 rectal cancer. CT torso \nshowed no metastatic disease. \n- ___ Offer enrollment in ___ ___ Signed consent for PROSPECT ___ ___ Start chemoradiotherapy with ci5FU 225 mg/m2/day\nCONTACT DERMATITIS \nTINEA CORPORIS \nELEVATED PSA\n \nSocial History:\n___\nFamily History:\nNoncontributory\n \nPhysical Exam:\nDISCHARGE PHYSICAL EXAMINATION:\nVS: Temp 98.8 HR 63 BP 119/75 RR 18 O2 98RA\nGENERAL: Thin, well appearing man in no distress.\nNECK: Soft and supple. \nCARDIO: Regular rate and rhythm. No murmurs, rubs or gallops.\nLUNGS: Clear to auscultation bilaterally. \nABDOMEN: Soft, mildly distended, +BS in all four quadrants. \nDressing: c/d/I\nEXTR: No edema, cyanosis, or erythema.\n \nPertinent Results:\n___ 06:40PM SODIUM-138 POTASSIUM-4.4 CHLORIDE-102\n___ 06:40PM MAGNESIUM-1.9\n___ 06:40PM HCT-38.7*\n \nBrief Hospital Course:\n___ admitted after ileostomy reversal on ___ ___. Post-operatively he did well. His pain was well \ncontrolled with oral regimen. On post-operative day 4 he was \nable to tolerate a regular diet, had reliable bowel function, \nand frequent flatus. His abdominal exam was benign. He was \ntherefore discharged home with plan to follow up with Dr. \n___ in clinic in two weeks. \n \nMedications on Admission:\n1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \nRX *oxycodone [Oxaydo] 5 mg ___ tablet(s) by mouth every four \n(4) hours Disp #*50 Tablet Refills:*0\n2. Pravastatin 80 mg PO QPM \n3. Acetaminophen 650 mg PO Q6H:PRN headache \nRX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by \nmouth every six (6) hours Disp #*50 Tablet Refills:*0\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO TID \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*60 Capsule Refills:*0\n3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain \nRX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every six (6) \nhours Disp #*60 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nIleostomy reversal\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 hospital following ileostomy reversal \nprocedure. You are now ready to be discharged home. \n\nPlease follow these instructions to ensure good recovery.\n\nPlease monitor your bowel function closely. You may or may not \nhave had a bowel movement prior to your discharge which is \nacceptable, however it is important that you have a bowel \nmovement in the next ___ days. After anesthesia it is not \nuncommon for patient’s to have some decrease in bowel function \nbut your should not have prolonged constipation. Some loose \nstool and passing of small amounts of dark, old appearing blood \nare expected however, if you notice that you are passing bright \nred blood with bowel your please seek medical attention. If you \nare passing loose stool without improvement please call the \noffice or go to the emergency room if the symptoms are severe. \nIf you are taking narcotic pain medications there is a risk that \nyou will have some constipation. Please take an over the counter \nstool softener such as Colace, and if the symptoms does not \nimprove call the office. It is also not uncommon after an \nileostomy takedown to have frequent loose stools until you are \ntaking more regular food however this should improve. \n\nThe muscles of the sphincters have not been used in quite some \ntime and you may experience urgency or small amounts of \nincontinence however this should improve. If you do not show \nimprovement in these symptoms within ___ days please call the \noffice for advice. \n\nOccasionally, patients will need to take a medication to slow \ntheir bowel movements as their bodies adjust to the new normal \nwithout an ileostomy, you should consult with our office for \nadvice. If you have any of the following symptoms please call \nthe office for advice or go to the emergency room if severe: \nincreasing abdominal distension, increasing abdominal pain, \nnausea, vomiting, inability to tolerate food or liquids, \nprolonged loose stool, or constipation. \n \nYou have a small wound where the old ileostomy once was. This \nshould be covered with a dry sterile gauze dressing. The wound \nno longer requires packing with gauze packing strip. Please \nmonitor the incision for signs and symptoms of infection \nincluding: increasing redness at the incision, opening of the \nincision, increased pain at the incision line, draining of \nwhite/green/yellow/foul smelling drainage, or if you develop a \nfever. Please call the office if you develop these symptoms or \ngo to the emergency room if the symptoms are severe. You may \nshower, let the warm water run over the wound line and pat the \narea dry with a towel, do not rub. Please apply a new gauze \ndressing after showering. \n \nNo heavy lifting for at least 6 weeks after surgery unless \ninstructed otherwise by your surgical team. You may gradually \nincrease your activity as tolerated but clear heavy exercise \nwith your surgical team.\n \nYou will be prescribed a small amount of the pain medication \noxycodone. Please take this medication exactly as prescribed. \nYou may take Tylenol as recommended for pain. Please do not take \nmore than 3000mg of Tylenol daily. Do not drink alcohol while \ntaking narcotic pain medication or Tylenol. Please do not drive \na car while taking narcotic pain medication. \n \nThank you for allowing us to participate in your care! Our hope \nis that you will have a quick return to your life and usual \nactivities. \n\nGood luck! \n \nFollowup Instructions:\n___\n" ]

[ "Z432", "C20", "E785" ]

[ "Z432: Encounter for attention to ileostomy", "C20: Malignant neoplasm of rectum", "E785: Hyperlipidemia, unspecified" ]

[ "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCephalosporins\n \nAttending: ___.\n \nChief Complaint:\nabdominal pain, bloody diarrhea, n/v\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ y/o woman with hx. htn, hcl, chronic pain, breast cancer \n___ s/p lumpectomy/chemo/radiation), who developed abdominal \npain and nausea/vomiting and diarrhea 3 dd ago. This has been \nassociated with chills, lightheadedness, and the diarrhea became \nbloody yesterday. She denies new medications, sick contacts. \nShe was refered to the ED today from urgent care at primary MDs \npractice. \n\nIn the ED found to be hemodynamically stable. CTAP revealed \nlikely descending diverticulitis, felt to be uncomplicated. Pt. \nwas given morphine multiple times for pain, two litres of NS in \nbolus, and ciprofloxacin IV and admitted. Labs are largely \nunremarkable. \n\nOn arrival to the ward, and on my exam, VS are 98 99/60 57 18 \n ___ppears mildly uncomfortable, endorsing some LLQ pain only. \nDenies current f/c, LH. \n\nROS: abd pain. ___. All other systems reviewed and negative. \n\n\n \n \nPast Medical History:\nHTN\nHCL\nBreast Cancer ___ - currently has calcifications in breast(s) \nagain, under surveillance per her\nRestless Leg\nChronic pain mostly in feet\n\n \nSocial History:\n___\nFamily History:\nFather died of CAD\nMother has ___, has had GI bleeding in past\n\n \nPhysical Exam:\nDISCHARGE EXAM\nGEN: No acute distress, comfortable appearing\nHEENT: NCAT, anicteric sclera\nCV: Normal S1, S2, no murmurs\nRESP: Good air entry, no rales or wheezes\nABD: Normal bowel sounds, soft, non-tender, non-distended, no \nrebound/guarding; \nEXTR: No edema. Intact pulses.\nDERM: No rash.\nNEURO: Face symmetric, speech fluent, non-focal \nPSYCH: Calm, cooperative \n \nPertinent Results:\nADMISSION LABS\n___ 03:50PM ___ PTT-30.1 ___\n___ 03:50PM PLT COUNT-319\n___ 03:50PM NEUTS-65.6 ___ MONOS-6.3 EOS-0.6* \nBASOS-0.6 IM ___ AbsNeut-7.04* AbsLymp-2.86 AbsMono-0.67 \nAbsEos-0.06 AbsBaso-0.06\n___ 03:50PM WBC-10.7*# RBC-3.58* HGB-11.1* HCT-32.7* \nMCV-91 MCH-31.0 MCHC-33.9 RDW-13.6 RDWSD-45.9\n___ 03:50PM ALBUMIN-3.7\n___ 03:50PM ALT(SGPT)-13 AST(SGOT)-14 ALK PHOS-91 TOT \nBILI-0.5\n___ 03:50PM ALT(SGPT)-13 AST(SGOT)-14 ALK PHOS-91 TOT \nBILI-0.5\n___ 03:50PM estGFR-Using this\n___ 04:04PM LACTATE-1.1\n___ 04:04PM LACTATE-1.1\n___ 04:04PM COMMENTS-GREEN TOP\n___ 05:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-NEG\n___ 05:20PM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 05:20PM URINE UHOLD-HOLD\n___ 05:20PM URINE HOURS-RANDOM\n___ CT ABDOMEN\n1. Focal colonic wall thickening involving the splenic flexure \nand proximal descending colon could be due to diverticulitis \nversus focal colitis, with differential diagnosis including \ninfection, inflammatory, ischemic etiology. \n2. Combination of intrahepatic biliary ductal prominence, \npossibly secondary to cholecystectomy, and periportal edema. \n\n___ COLONOSCOPY:\nFINDINGS\nDiverticulae in left and right colon\n\nENDOSCOPIC DIAGNOSIS\nDiverticulosis, colonic.\n\nRECOMMENDATIONS\nHigh fiber diet\nRepeat colonoscopy in ___ years\n\nDISCHARGE LABS\n___ 06:20AM BLOOD WBC-6.7 RBC-3.62* Hgb-11.0* Hct-34.3 \nMCV-95 MCH-30.4 MCHC-32.1 RDW-13.7 RDWSD-47.5* Plt ___\n___ 06:20AM BLOOD Glucose-91 UreaN-6 Creat-0.7 Na-141 K-4.1 \nCl-106 HCO3-28 AnGap-___bdominal pain, bloody diarrhea\n# Diverticulitis\n# GI bleed\n# Anemia, mild, normocytic\n# Mild dehydration\nSymptoms are likely explained by diverticulosis with \ndiverticulitis. Ischemic, inflammatory, or infectious \netiologies also possible. Symptoms resolved upon arrival to the \nfloor and patient immediately tolerated a regular diet. \nElectrolytes and CBC consistently within nomral limits. Last \ncolonoscopy ___ revealed diverticulosis. Patient also \nreports intermittent constipation alternating with diarrhea and \npossible melena over ___ months, but she had no instances of \nloose or bloody bowel movements during this hospitalization. \nShe was treated with ciprofloxacin and metronidazole, which she \nwill continue for a total 10-day course.\n- Counseled the patient to undergo colonoscopy and possible EGD \nabout 6 weeks after resolution of acute episode to evaluate for \nmalignancy \n\nCHRONIC / STABLE ISSUES\n# HTN: Held ___ given low BPs, volume depletion, restarted upon \ndischarge\n# HLD, restless legs syndrome, overactive bladder, chronic lower \nextremity pain: Continue home medications\n# h/o Breast cancer: In remission\n\n[x]Pt is medically stable for discharge.\n[]Time spent coordinating discharge: > 30 minutes.\n \nMedications on Admission:\nondansetron HCl (ZOFRAN, AS HYDROCHLORIDE,) 2 mg/mL Solution \nAdminister 2 mL intravenously once for 1 dose \n gabapentin 300 mg capsule Take 1 capsule by mouth twice daily \n oxyCODONE-acetaminophen ___ mg tablet Take ___ tablets by \nmouth every 6 hours as needed for pain . No more than 6 tablets \nper day \n triamcinolone 0.1 % Cream BID up to 2 weeks, then decrease to \n3 times per week, repeat if needed \n oxybutynin 5 mg tablet extended release 24hr SR 24 Hr Take 1 \ntablet by mouth daily \n rOPINIRole 1 mg tablet 1 PO QHS \n losartan 50 mg Oral tablet Take 1 tablet by mouth daily \n omeprazole 20 mg Oral capsule,delayed ___ Take 1 \ncapsule by mouth twice daily take first capsule 30 minutes \nbefore first meal of day \n atorvastatin 80 mg Oral tablet Take 1 tablet by mouth daily \n diphenhydrAMINE (BENADRYL) 25 mg Oral capsule \n\n \nDischarge Medications:\n1. Atorvastatin 40 mg PO QPM \n2. Gabapentin 300 mg PO BID \n3. Omeprazole 20 mg PO DAILY \n4. Ropinirole 1 mg PO QHS \n5. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve \n(12) hours Disp #*14 Tablet Refills:*0\n6. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H \nRX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) \nhours Disp #*21 Tablet Refills:*0\n7. Aspirin 81 mg PO DAILY \n8. DiphenhydrAMINE 50 mg PO QHS:PRN see comment \n9. Losartan Potassium 50 mg PO DAILY \n10. oxybutynin chloride 5 mg oral DAILY \n11. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain \n12. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nDiverticulitis / diverticulosis\nColitis\nLower GI bleeding\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nYou were hospitalized for bloody diarrhea and were found to have \nlikely diverticulitis or colitis (inflamed areas of your colon). \n You were treated with antibiotics and IV fluids and your \nsymptoms resolved. \n\nPlease continue antibiotics as prescribed.\n\nPlease ensure that you have a colonoscopy and possibly an upper \nendoscopy, which can be arranged through your PCP and \ngastroenterologist - this should be performed in ___ months. \nThis is very important because cancer or inflammatory bowel \ndisease can also cause similar findings. \n \nFollowup Instructions:\n___\n" ]

[ "K5732", "N3281", "I10", "K529", "E860", "D649", "G2581", "G8929", "M79606", "E785", "Z853", "Z9221", "Z923" ]

[ "K5732: Diverticulitis of large intestine without perforation or abscess without bleeding", "N3281: Overactive bladder", "I10: Essential (primary) hypertension", "K529: Noninfective gastroenteritis and colitis, unspecified", "E860: Dehydration", "D649: Anemia, unspecified", "G2581: Restless legs syndrome", "G8929: Other chronic pain", "M79606: Pain in leg, unspecified", "E785: Hyperlipidemia, unspecified", "Z853: Personal history of malignant neoplasm of breast", "Z9221: Personal history of antineoplastic chemotherapy", "Z923: Personal history of irradiation" ]

[ "I10", "D649", "G8929", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nDemerol / Depakote\n \nAttending: ___.\n \nChief Complaint:\nunresponsive episode, transferred from ___\n\n \nMajor Surgical or Invasive Procedure:\nN/A\n \nHistory of Present Illness:\n___ with PMH of MELAS c/b epilepsy, prior CVA (___) c/b \ncortical\nblindness, hearing impairment, cognitive decline, who presented\nto the ED as a transfer from ___ after an episode of\nunresponsiveness.\n\nHistory was obtained from father at bedside as patient cannot\nprovide history. \n\nOver the past several months, patient has had a \"post urinary\nsensation\", of which he feels that he is still dripping after\nurination, even though he is not. Father states that the\nsensation would make him agitated, sit on the toilet for hours,\ntrying to get all the urine out. His father took him to see a\nurologist, but the sensation did not resolve.\n\nOn morning of presentation, the patient called his father at\nwork, frantically saying that he had \"gotten everything at home\nwet, sticky\" and that he needed help to clean up. His father \ngot\nhome around 10:45 AM and found the patient sitting up in bed,\neyes closed, not responding to questions. Patient did babble to\nhis father that he \"needed an Ativan\". When EMS arrived, \npatient\nwas still not answering questions. He was taken to ___, where he was agitated, waving his arms around, hitting\nhis knees together over and over again. He was repeating words\n[e.g. \"my knees are banging\"]. Afterwards, he calmed down and\nwent back to his baseline, although he was sleepy. Father is \nnot\nsure whether the unresponsive episode was a seizure or not. He\nstates that he manages the patient's medications and there were\nno missed doses.\n\nAt the OSH, labs were notable for lactate 9.0. Head CT was\nobtained which was read as \"encephalomalacia of both occipital\nlobes posteriorly and medially. No acute hemorrhage or large\nvessel infarction seen. No masses identified. Tiny lacunar\ninfarction in right basal ganglia.\"\n\nFather states that over the last 2 weeks, because of the urinary\ndribbling sensation, patient has had increased agitation,\nespecially at night. It is gotten to the point where his father\nwould only get 3 or 4 hours of sleep per night, even though he\nhas to work during the day. On ___ evening, patient \nbecame\nvery agitated, yelling at his father, swearing at him and\npunching him. The next day, patient slept all day.\n\nFor his history of epilepsy, patient has a history of complex\npartial seizures with visual aura followed by GTC, as well as a\nsecond type of seizure consisting of staring, confusion, lip\nsmacking and mouth twitching. Father states that patient has \nnot\nhad any GTCs since starting Vimpat in ___. Prior to that, he\nhad been on Keppra and Lamictal, which were not as helpful. \nFather states that patient has not had a partial seizure for\nseveral months. Patient is prescribed lorazepam as needed, \nwhich\nfather states that patient has been taking intermittently when \nhe\nfeels like it. For example, when they are about to go out,\npatient would ask for Ativan due to fear that he would have a\nseizure in front of other people. Patient had taken about 19\npills of lorazepam over the past 2 months.\n\nHe was admitted to medicine service ___ after having\nshaking in multiple limbs and increased agitation. The episode\nconsisted of knees hitting together and arm shaking. At that\ntime, he was evaluated by neurology and psychiatry, who \nconcluded\nthat the movements were likely behavioral in origin. The \npatient\nwas admitted for placement due to caregiver burnout as the level\nof care he had been requiring was overwhelming for the family.\n\nSeizure semiology:\n-complex partial seizures with visual aura(decreased vision)\nfollowed by GTC\n-staring, confusion, lip smacking and mouth twitching. \n\n \nPast Medical History:\nMELAS diagnosed in ___ (3243 mutation)\nseizure disorder\nstroke-like episodes with visual deficits in ___, \ncortical blindness\nhearing impairment\ndepression\n\n \nSocial History:\n___\nFamily History:\nNo neurological disease, no one with known MELAS mutation\nSister healthy\n\n \nPhysical ___:\nADMISSION EXAM:\n===============\nTemperature 98.1 HR 75 BP 106/67 RR 1897% on room air\nPatient was lying in bed, sleeping. Hard of hearing, but will\nwake up to voice. Able to state full name, month as ___,\ndate as ___, year as ___, location as ___. Able to follow some commands but not others.\n\nPupils were 7mm ->4mm bilaterally. He is able to see motion but\ncannot count fingers. BTT bilaterally. Face appears symmetric,\nwith symmetric activation of smile.\nWith regards to extremities, patient was antigravity with good\nstrength in all 4 extremities. IP and biceps were ___\nbilaterally.\nCould not obtain reflexes as patient does not follow command to\nrelax. No clonus. He would move his extremities up and down.\n\nDISCHARGE EXAM:\n===============\n\nVitals: 24 HR Data (last updated ___ @ 432)\n Temp: 97.9 (Tm 98.4), BP: 102/66 (98-124/62-84), HR: 73\n(61-83), RR: 16 (___), O2 sat: 98% (95-100), O2 delivery: Ra,\nWt: 138.4 lb/62.78 kg \nGeneral: Young man, sitting up in bed, appears comfortable\nHEENT: MMM\nCV: warm and well-perfused\nPulm: breathing comfortably on room air\nExt: no ___ edema\n\nNeurologic:\nMS: awake, responds only to loud voices. Able to state his full\nname, location as ___ in ___, the year. He \nis\nable to follow some simple commands.\n\nCN: Pupils 6mm and equal. R eye esotropic. He is able to see\nmotion only. Face appears symmetric. Appears to have dystonic\nposturing of his neck toward the right. He has evidence of\nbruxism. \n\nMotor: Muscle bulk is normal. He has dystonic posturing of\nbilateral upper extremities. He moves all 4 extremities\nsymmetrically antigravity. \n\nDTRs: deferred\n___: deferred\nCoordination: deferred\nGait: deferred\n\n \nPertinent Results:\nADMISSION LABS:\n___ 07:10PM BLOOD WBC-6.7 RBC-4.33* Hgb-13.0* Hct-39.3* \nMCV-91 MCH-30.0 MCHC-33.1 RDW-12.6 RDWSD-41.6 Plt ___\n___ 07:10PM BLOOD Neuts-42.7 ___ Monos-10.8 Eos-2.5 \nBaso-0.6 Im ___ AbsNeut-2.85 AbsLymp-2.88 AbsMono-0.72 \nAbsEos-0.17 AbsBaso-0.04\n___ 07:10PM BLOOD Plt ___\n___ 07:25PM BLOOD ___ PTT-27.1 ___\n___ 07:10PM BLOOD Glucose-83 UreaN-22* Creat-0.8 Na-140 \nK-4.2 Cl-104 HCO3-24 AnGap-12\n___ 07:10PM BLOOD ALT-20 AST-25 AlkPhos-81 TotBili-0.4\n___ 09:05AM BLOOD ALT-22 AST-35 LD(LDH)-274* AlkPhos-80 \nTotBili-0.5\n___ 07:10PM BLOOD Lipase-26\n___ 07:10PM BLOOD Albumin-4.4 Calcium-9.3 Phos-2.1* Mg-2.2\n___ 07:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n___ 07:39PM BLOOD Lactate-2.5*\n \nBrief Hospital Course:\nSUMMARY:\n========\nMr. ___ is a ___ with PMH of MELAS c/b epilepsy, prior CVA \n(___) c/b cortical blindness, hearing impairment, cognitive \ndecline, who presented to the ED as a transfer from ___ \n___ after an episode of unresponsiveness. He was monitored \non EEG which showed no abnormal discharges. He was continued on \nhis home medications without change, including his ___ \ncocktail. He was discharged to follow-up with his outpatient \nneurologists Dr. ___ Dr. ___. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. ClonazePAM 2 mg PO QHS \n2. ClonazePAM 1 mg PO BID \n3. FLUoxetine 60 mg PO DAILY \n4. Gabapentin 1200 mg PO TID \n5. LACOSamide 200 mg PO BID \n6. LORazepam 1 mg PO Q4H:PRN seizure \n7. QUEtiapine Fumarate 100 mg PO QHS \n8. QUEtiapine Fumarate 50 mg PO DAILY:PRN agitation \n9. arginine oxoglurate 1500 mg oral QAM \n10. arginine oxoglurate 1000 mg oral QHS \n11. creatine monohydrate 5,000 mg oral DAILY \n12. coenzyme Q10 400 mg oral BID \n13. FoLIC Acid 5 mg PO BID \n14. Ascorbic Acid ___ mg PO BID \n15. Cyanocobalamin 25 mcg PO BID \n16. Pyridoxine 100 mg PO BID \n17. Riboflavin (Vitamin B-2) 100 mg PO BID \n18. Thiamine 100 mg PO BID \n\n \nDischarge Medications:\n1. arginine oxoglurate 1500 mg oral QAM \n2. arginine oxoglurate 1000 mg oral QHS \n3. Ascorbic Acid ___ mg PO BID \n4. ClonazePAM 2 mg PO QHS \n5. ClonazePAM 1 mg PO BID \n6. coenzyme Q10 400 mg oral BID \n7. creatine monohydrate 5,000 mg oral DAILY \n8. Cyanocobalamin 25 mcg PO BID \n9. FLUoxetine 60 mg PO DAILY \n10. FoLIC Acid 5 mg PO BID \n11. Gabapentin 1200 mg PO TID \n12. LACOSamide 200 mg PO BID \n13. LORazepam 1 mg PO Q4H:PRN seizure \n14. Pyridoxine 100 mg PO BID \n15. QUEtiapine Fumarate 50 mg PO DAILY:PRN agitation \n16. QUEtiapine Fumarate 100 mg PO QHS \n17. Riboflavin (Vitamin B-2) 100 mg PO BID \n18. Thiamine 100 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nMitochondrial encephalopathy and lactic acidosis with \nstroke-like symptoms (MELAS)\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\nIt was a pleasure taking care of you at ___!\n\nWHY DID YOU COME TO THE HOSPITAL?\n___ had an episode at home where you were unresponsive and your \ndad was worried for seizures.\n\nWHAT HAPPENED WHILE YOU WERE HERE?\nWe monitored your brain activity using EEG and found no abnormal \nbrain discharges.\n\nWHAT TO DO WHEN YOU LEAVE?\nGo to all your follow-up appointments.\nContinue to take all your medicines as prescribed, unchanged.\n\nThank you for allowing us to care for you,\nYour ___ Neurology Team\n \nFollowup Instructions:\n___\n" ]

[ "E8841", "G40209", "F329", "G40409", "I69319", "I69398", "H47619", "H9190" ]

[ "E8841: MELAS syndrome", "G40209: Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus", "F329: Major depressive disorder, single episode, unspecified", "G40409: Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus", "I69319: Unspecified symptoms and signs involving cognitive functions following cerebral infarction", "I69398: Other sequelae of cerebral infarction", "H47619: Cortical blindness, unspecified side of brain", "H9190: Unspecified hearing loss, unspecified ear" ]

[ "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\nacute onset right arm pain and color change, cold right upper \nextremity\n \nMajor Surgical or Invasive Procedure:\n___ right brachial cut down thrombectomy\n\n \nHistory of Present Illness:\nMs. ___ is an ___ woman who developed acute \nvertigo, diplopia, nausea as well as acute right arm pain and \nnumbness the day before presentation. She was brought to a \nreferring ___ Emergency Department where imaging of the \nhead and chest was obtained. This demonstrated a right PCA \nocclusion as well as a right axillary artery occlusion. The \npatient was started on a heparin drip and then transferred to \nour emergency room for further evaluation. Her neurologic \nsymptoms resolved within 30 minutes of\npresentation, and her right arm pain and numbness began to \nresolve. On arrival to the emergency room, the patient had full \nmotor and sensory intact in her right arm, but did not have \npalpable or dopplerable radial or ulnar pulses in the right arm. \n The decision was made to proceed with a surgical embolectomy of \nthe right upper extremity. The patient was found to be in new \nonset AFib upon presentation to the emergency room.\n\n \nPast Medical History:\nhypertension, glaucoma\n\n \nSocial History:\n___\nFamily History:\nNoncontributory\n \nPhysical Exam:\nPhysical Exam on admission:\nGEN: AOx2, uncomfortable\nHEENT: No scleral icterus, mucus membranes moist\nCV: RRR, No M/G/R\nPULM: Clear to auscultation b/l, No W/R/R\nABD: Soft, nondistended, nontender\nDRE: normal tone, no gross or occult blood\nExtremities: RUE pale, cool, and mottled, no appreciable motor \nor\nsensory deficits\nNEURO: ___ bilateral upper extremities, LLE ___ (baseline per\npt), RLE ___. \nPulses: R: non-dopplerable radial/ulnar/brachial, pre-occlusive\nthump on axillary doppler. L: palpable radial\n\nDISCHARGE PHYSCIAL EXAM:\n========================\n24 HR Data (last updated ___ @ 527)\n Temp: 98.0 (Tm 98.3), BP: 139/87 (118-152/69-96), HR: 81\n(71-86), RR: 18 (___), O2 sat: 97% (92-97), O2 delivery: 2L \n\n\nGENERAL: Alert and interactive. \nHEENT: Normocephalic, atraumatic. EOMI, PERRL. Sclera anicteric\nand without injection. \nCARDIAC: Irregular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: Slightly diminished breath sounds at bases, otherwise\nclear to auscultation. \nABDOMEN: Non distended, non-tender to deep palpation in all four\nquadrants. \nEXTREMITIES: Mild 1+ pitting edema to mid-calves bilaterally \nwith\ntenderness to palpation bilaterally. Pulses ___ 2+\nbilaterally. Staples in place at site of right upper extremity\ncutdown. Tenderness to palpation of left shoulder. \nSKIN: WWP. No rash.\nNEUROLOGIC: CN ___ intact. Grossly intact visual fields and\nvision bilaterally. No diplopia in lateral, superior or inferior\ngaze. ___ strength b/l upper extremities, ___ strength in\nbilateral lower extremities. AAOX3.\n\n \nPertinent Results:\nADMISSION LABS \n=============== \n___ 11:41PM %HbA1c-6.0 eAG-126\n___ 09:23PM TRIGLYCER-83 HDL CHOL-48 CHOL/HDL-4.4 \nLDL(CALC)-146*\n___ 09:23PM CHOLEST-211*\n___ 09:23PM BLOOD WBC-10.9* RBC-4.55 Hgb-13.3 Hct-43.7 \nMCV-96 MCH-29.2 MCHC-30.4* RDW-14.5 RDWSD-51.6* Plt ___\n___ 09:23PM BLOOD Glucose-166* UreaN-19 Creat-1.2* Na-145 \nK-4.8 Cl-107 HCO3-21* AnGap-17\n\nINTERVAL LABS \n============= \n___ 06:30AM BLOOD calTIBC-229* Ferritn-351* TRF-176*\n___ 06:30AM BLOOD TSH-7.8*\n___ 06:23AM BLOOD T3-73* Free T4-1.2\n___ 06:23AM BLOOD HIV Ab-NEG\n\nDISCHARGE LABS \n=============== \n___ 06:35AM BLOOD WBC-6.9 RBC-4.38 Hgb-12.8 Hct-42.4 MCV-97 \nMCH-29.2 MCHC-30.2* RDW-14.9 RDWSD-52.8* Plt ___\n___ 06:35AM BLOOD Glucose-110* UreaN-31* Creat-1.0 Na-146 \nK-4.0 Cl-97 HCO3-36* AnGap-13\n___ 06:35AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.1\n\nMICRO \n===== \n\n__________________________________________________________\n___ 11:00 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000 \nCFU/mL. \n\nIMAGING \n======== \n___ CT Head w/out contrast\nIMPRESSION: \n1. No acute intracranial findings including no intracranial \nhemorrhage. \n\n___ CXR\nIMPRESSION: \nMild patchy opacities in the lung bases most likely reflective \nof atelectasis in the setting of slightly low lung volumes, \nthough mild aspiration cannot be completely excluded in the \ncorrect clinical setting \n\n___ CTA Upper extremity with and without contrast\nIMPRESSION: \n1. Partially occlusive thrombus within the right axillary artery \nand fully \nocclusive thrombus within the right brachial artery just \nproximal to the \nantecubital fossa. \n2. Mild cardiomegaly with biatrial chamber enlargement. \n\n___ Portable abdomen\nIMPRESSION: \nNo convincing evidence for bowel obstruction. \n\n___ Stroke Protocol Brain MRI\nIMPRESSION: \n1. Study is severely degraded by motion. \n2. Punctate left periventricular frontal acute to subacute \ninfarct without \ndefinite evidence of hemorrhagic transformation. \n3. Question punctate right occipital acute to subacute infarct \nversus artifact without definite evidence of hemorrhagic \ntransformation. \n4. Atrophy, probable small vessel ischemic changesand probable \nchronic \ninfarcts as described. \n\n___ CXR\nIMPRESSION: \nLungs are low volume with small bilateral effusions left greater \nthan right. There is moderate cardiomegaly. There is mild \npulmonary vascular congestion. No pneumothorax. \n\n___ Carotid Ultrasound series complete\nIMPRESSION: \nRight ICA no stenosis. \nLeft ICA <40% stenosis. \n\n___ Transthoracic Echo \nIMPRESSION: Mild global biventricular hypokinesis. Severe mitral \nregurgitation. At least moderate\ntricuspid regurgitation. Moderate to severe pulmonary \nhypertension.\n\n___ Transthoracic Echo\nIMPRESSION: Mild global biventricular systolic dysfunction. Mild \nmitral regurgitation. Mild\npulmonary hypertension.\nCompared with the prior TTE ___ , the severity of mitral \nregurgitation is now lower. Estimated\npulmonary pressures are lower. Th other findings are similar.\n \nBrief Hospital Course:\nBRIEF HOSPITAL COURSE\n=======================\n___ y/o female with a PMH of HTN and HL who presented with a \npresumed cardioembolic R PCA stroke and right axillary artery \nthrombous secondary to new atrial fibrillation. On further \nworkup, she was found to have a newly reduced EF (45%) with \nsevere MR and underwent diuresis for acute heart failure \nexacerbation. On repeat TTE, EF was improved to 50% and MR was \nimproved to mild (1+). She was started a medical heart failure \nregimen and is planned for further outpatient workup of the \netiology of her new reduced EF as an outpatient. \n\nNew Medications: Toprol XL 200 mg, 81 mg ASA Daily, Apixaban 5 \nmg BID, atorvastatin 20 mg QHS, furosemide 20mg daily\nStopped medications: None\nFollow-ups: ___ cardiology, Stroke clinic, Vascular \nsurgery clinic. Will also need optho follow-up. \n\nTRANSITIONAL ISSUES\n====================\n[] Please obtain outpatient regadenason stress test. \n[] Please obtain outpatient sleep study for possible OSA. \n[] Please continue to manage outpatient diuretic regimen.\n[] TSH 7.8 here in the setting of acute illness. Free T4 1.4, T3 \n73. Please recheck ___ weeks after recovery.\n[] Please obtain patient's glasses for rehab.\n[] Patient was seen by ophthalmology while inpatient. They \nrecommended outpatient follow up for a cataract in her right \neye, which they felt was likely to be visually significant. They \nalso noted that IOP was 17 and 18 and she should follow-up with \nher outpatient eye doctor. \n[] Discharge weight 91kg (200.62lbs)\n\nMEDICINE HOSPITAL COURSE\n=========================\n# R PCA stroke\n# Right axillary artery embolism s/p embolectomy \n# Hypercholesterolemia\nPatient was in her usual state of health until ___. She ate \nlunch and fell asleep for a nap afterwards. Upon waking up from \nher nap at 1430, she noted diplopia, vertigo, nausea, as well as \nacute right arm pain and numbness with loss of motor \nfunction/coordination. She was brought to an OSH ED, where \nimaging was obtained showing right PCA occlusion on CTA Head and \nNeck as well as right axillary occlusion on CTA chest. She was \nstarted on a heparin drip and transferred to ___ ED for \nfurther evaluation. Her neurologic symptoms resolved within 30 \nmins, and her right arm regained motor and sensory function \nafter heparinization. On arrival in the ED, she was \nhemodynamically stable but lethargic and complaining of nausea. \nEKG notable for afib, which was a new diagnosis for the patient. \nCode Stroke was called - no neuro deficits identified on exam \n(except LLE weakness, baseline per patient) and repeat CT head \nobtained with no acute hemorrhage. She had resolved both her \ndiplopia and vertigo on admission, and remained neurologically \nintact without deficit prior to going to the operating room. Dr. \n___ the vascular surgery team performed a right brachial \ncut down and thrombectomy ___ am and afterward, Ms. \n___ had a palpable radial and ulnar pulse, and improved \nstrength and sensation in her RUE. Heparin gtt was held until 3 \nhours postop and then restarted at a low rate with a goal of \n40-50 for the new onset afib and to reduce risk of becoming \nsupratherapeutic and converting any new ischemic strokes to \nhemorrhagic strokes. The neurology stroke service was agreeable \nto restarting anticoagulation. She remained neurologically \nintact postoperatively, although she did have some initial \ndifficulty with postoperative agitation and nausea. Her diet was \nadvanced to regular. She was transferred to the medicine service \non the night of POD1. Both her PCA stroke and right axillary \nartery embolism were felt to be cardioembolic in nature, \nsecondary to new onset AFib. Stroke labs were as follows: HBA1c \n6, TSH 7.8, LDL 146 and Cholesterol 211 on fasting lipid panel. \nShe had a TTE with reduced EF as above, and carotid ultrasound \nwith no stenosis of right ICA and <40% stenosis of left ICA. \nGiven her limited territorial infarct and Afib, she was \nanticoagulated with a heparin drip under the guidance of \nVascular surgery and Neurology. Her heparin drip was converted \nto Apixaban on ___ given her CHADS2VASC of 8. She was allowed \nto autoregulate her BP for the first 48 hours after her stroke, \nbut was subsequently restarted on her home antihypertensives. \nShe was started on atorvastatin 20 mg qpm and ASA 81 mg. \n\n# Acute exacerbation of HFrEF \n# Mitral Regurgitation\nA TTE was performed as part of the workup for her newly \ndiagnosed atrial fibrillation (as below) which showed a reduced \nEF of 45% with 4+MR, 2+TR, mild global biventricular \nhypokinesis, ___, and moderate to severe pulmonary HTN. \nClinically, she complained of dyspnea and orthopnea and had a \nnew oxygen requirement, elevated JVD, and BNP 13912 all \nconsistent with an acute heart failure exacerbation. She was \ndiuresed with IV Lasix, restarted on her home lisinopril and her \nhome atenolol was replaced with metoprolol and uptitrated as \ntolerated. Cardiology was consulted for evaluation of new \nreduced ejection fraction. HIV negative, TSH 7.8, T3 73, Free T4 \n1.2, on studies consistent with acute inflammation. It was \nrecommended that a regadenason stress test be performed as an \noutpatient and she will follow up with cardiology. When she was \nfelt to be euvolemic, repeat TTE was performed which showed an \nimproved EF of 50% and mild MR.\n\n# Atrial Fibrilation\nShe was found to be in Afib on arrival to the ED. No clear \ninfectious precipitant was found as her UA was negative, UCx \ngrew a likely contaminant and her CXR was not suggestive of \npneumonia or pulmonary edema. TSH was mildly elevated however \nfree T4 was normal. Her new onset Afib was ultimately felt to be \nlikely related to new HFrEF with ___, although it was \nunclear whether her Afib may have preceded and contributed to \nher reduced EF. She was initially maintained on a heparin drip. \nOn ___, she was transitioned from a heparin drip to apixaban 5 \nmg bid given her CHADS2VASC of 8. Her home atenonol was \ndiscontinued and she was started instead on metoprolol, which \nwas uptitirated as tolerated to 200 mg Toprol-XL daily. Her \nmaintenance diuretic regimen was 20 mg po furosemide daily at \ndischarge. \n\n# Delirium \nPatient was intermittently confused early during her admission, \nconsistent with delirium, but improved after diuresis. \n\n# Visual Hallucinations: \nPatient was complaining of seeing intermittent colored lines and \nfigures in her vision, worse in her right eye. She described it \nas \"someone in my peripheral vision, with a pink shirt and blue \npants, but when I looked over, he was gone\" and \"colored \nconfetti floating up to the ceiling and disappearing.\" She was \nseen by ophthalmology who found her visual acuity to be OD \n___, PH ___ OS ___, PH ___ and identified a \nvisually significant cataract in her right eye. They felt that \nthese were most likely to be visual hallucinations. Her visual \nacuity was decreased while inpatient due to lack of glasses. \nOverall, these visual symptoms were felt to be possibly \nconsistent with ___ syndrome given her decreased \nvisual acuity, with a potential contribution of her recent PCA \nstroke. Other potential causes include delirium (although \npatient's mental status was clear otherwise) and dementia. \n\n# Left lower extremity pain: \nPatient complained of bilateral lower extremity tenderness to \npalpation of the skin. She was neurovascularly intact and there \nwas low suspicion for arterial embolus or DVT. Her symptoms were \nfelt to likely be secondary to peripheral edema, deconditioning, \nand prolonged time in bed. She was diuresed as above and \nencouraged to be out of bed and moving as much as possible. \n\nCHRONIC/STABLE ISSUES:\n======================\n#HTN \nHer home lisinopril and atenolol were originally held to allow \nher blood pressure to autoregulate for 48 hours after her \nstroke. Afterwards, she was restarted on her home lisinopril 40 \nmg. Her home atenolol was converted to metoprolol and the dose \nwas advanced as tolerated to 200 mg Toprol-XL daily. \n\n#Glaucoma\nShe was continued on her home lantoprost and timolol. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atenolol 100 mg PO DAILY \n2. Lisinopril 40 mg PO DAILY \n3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n4. Timolol Maleate 0.5% 1 DROP BOTH EYES BID \n\n \nDischarge Medications:\n1. Apixaban 5 mg PO BID \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 20 mg PO QPM \n4. Furosemide 20 mg PO DAILY \n5. Metoprolol Succinate XL 200 mg PO DAILY \n6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n7. Lisinopril 40 mg PO DAILY \n8. Timolol Maleate 0.5% 1 DROP BOTH EYES BID \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___ \n___)\n \nDischarge Diagnosis:\natrial fibrillation\nacute ischemic stroke - PCA\nRight axillary aretry thromboembolism\nheart failure with reduced ejection fraction\nmitral regurgitation\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt 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 because you had changes in \nyour vision. You developed a clot in your right arm, which led \nto you to be transferred to ___ from another hospital. \n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n==========================================\n- You were found to have a small stroke in your posterior \ncerebral artery and a clot in your right arm (axillary artery). \n- You were put on a medicine called heparin to prevent more \nclots from forming. This was initially given through you IV then \neventually you started a medicine called apixaban for the same \npurpose. This medicine is taken by mouth. \n- You had surgery to remove the clot from your right arm and \nrestore circulation. \n- You were found to be in atrial fibrillation. This condition \npredisposes you to developing clots in the heart, which can \nspread to other areas of the body (embolize) and cause problems. \nWe think that atrial fibrillation created clots which went to \nyour brain and right arm, explaining your presenting symptoms. \n- You had an echocardiogram to evaluate your heart function. \nThis showed that your heart is not working optimally (you have a \nreduced ejection fraction). \n- You had a number of tests to evaluate why your heart is not \nfunctioning well. Some of these tests will be completed as an \noutpatient. \n- Because your heart was not pumping well, fluid was building up \nin your lungs, making it heart for you to breath. This is called \nan acute heart failure exacerbation. \n- We gave you diuretics to remove excess fluid from your body \nand treat your heart failure. An echocardiogram was repeated \nwhen we felt we had removed all the excess fluid. This showed \nthat your heart was pumping blood better than it had been \nbefore. \n- We started you on a statin, a beta-blocker, a diruetic, and an \naspirin. These are important components of the treatment for \nheart failure. \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- You will need to follow up with Neurology (Stroke Clinic), \nVascular Surgery, Cardiology, and your primary care doctor. \n- Weigh yourself daily and call your physician if your weight is \nincreasing by more than 3lbs in one day or 5lbs in one week\n\nWe wish you all the best!\n\nSincerely, \nYour ___ Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I4891", "I63431", "I742", "J9601", "I110", "I5021", "F05", "E873", "I472", "I340", "I2722", "I428", "I6522", "E869", "E7800", "E039", "R29702", "R42", "R441", "R531", "H532", "H269", "H409", "T465X6A", "Y92019", "Z66", "Z96653" ]

[ "I4891: Unspecified atrial fibrillation", "I63431: Cerebral infarction due to embolism of right posterior cerebral artery", "I742: Embolism and thrombosis of arteries of the upper extremities", "J9601: Acute respiratory failure with hypoxia", "I110: Hypertensive heart disease with heart failure", "I5021: Acute systolic (congestive) heart failure", "F05: Delirium due to known physiological condition", "E873: Alkalosis", "I472: Ventricular tachycardia", "I340: Nonrheumatic mitral (valve) insufficiency", "I2722: Pulmonary hypertension due to left heart disease", "I428: Other cardiomyopathies", "I6522: Occlusion and stenosis of left carotid artery", "E869: Volume depletion, unspecified", "E7800: Pure hypercholesterolemia, unspecified", "E039: Hypothyroidism, unspecified", "R29702: NIHSS score 2", "R42: Dizziness and giddiness", "R441: Visual hallucinations", "R531: Weakness", "H532: Diplopia", "H269: Unspecified cataract", "H409: Unspecified glaucoma", "T465X6A: Underdosing of other antihypertensive drugs, initial encounter", "Y92019: Unspecified place in single-family (private) house as the place of occurrence of the external cause", "Z66: Do not resuscitate", "Z96653: Presence of artificial knee joint, bilateral" ]

[ "I4891", "J9601", "I110", "E039", "Z66" ]

[]

[ " \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:\nLLE swelling\n \nMajor Surgical or Invasive Procedure:\n___ - Left posterior tibial vein approach lysis catheter \nplacement \n___- venogram, penumbra, angiojet and left iliac stenting \n \nHistory of Present Illness:\n___ is a ___ year old woman with a history of DM2, HTN, \nwho presents with 2 days of LLE swelling. She fractured her left \ntoe three months ago, but only presented for evaluation 2 weeks \nago, and has been walking on it and has not been immobilized. \nShe does not have any history or family history of blood clots. \nAs far as travel goes, she did fly to ___ months ago. \n\n\nIn the ED, she was given 1L IVF and enoxaparin 70 mg. \n\nUpon arrival to the floor, denies chest pain, shortness of \nbreath. The leg swelling she noticed today when she work up \nwhich is why she came to the ED today. \n \nREVIEW OF SYSTEMS: \nA complete 10-point review of systems was performed and was\nnegative unless otherwise noted in the HPI. \n\n \nPast Medical History:\n- Hypertension\n- Diabetes Mellitus, Type 2\n \n \nSocial History:\n___\nFamily History:\n- No family history of blood clots\n- Brother: ___\n- Father: ___, MI (deceased ___ this)\n- Mother: ___ disease\n \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\nVitals: 1007 97.6 PO 137 / 90 77 18 100 Ra \nGENERAL: Appears well, stated age, comfortable, no acute \ndistress\nHEENT: NC/AT, no scleral icterus, MMM, oropharyngeal mucosa \nclear\nNECK: Supple\nLUNGS: CTAB, easy work of breathing\nHEART: RRR, no m/r/g\nABD: Soft, non-tender, non-distended. No abdominal bruits. \n+BS.\nEXT: LLE significant more swollen than the RLE, mild calf TTP,\nno pain with movement of the foot. Distal pulses and sensation\nand intact. \nSKIN: Warm, dry, intact. Bilateral xanthelasmas. \nNEURO: Strength ___ in the upper and lower extremities. CNII-XII\ngrossly intact. \nACCESS: PIVs (maintain 2 while on heparin gtt)\n \nDISCHARGE PHYSICAL EXAM\n24 HR Data (last updated ___ @ 1154)\n Temp: 98.8 (Tm 98.8), BP: 135/80 (123-150/70-84), HR: 75\n(73-86), RR: 12 (___), O2 sat: 100% (96-100), O2 delivery: Ra \n\nGENERAL: Appears well, pleasant, NAD\nHEENT: anicteric sclera; PERRLA, EOMI, OP clear, MMM, JVP wnl\nLUNGS: mild insp crackles b/l. no wheezing\nHEART: RRR, no m/r/g\nABD: Soft, non-tender, non-distended. No abdominal bruits. No\nflank hematomas. \nEXT: no swelling or tenderness at the left groin site where\ncatheter was, left leg almost the same size as right leg now,\ntender to palpation at left lateral ankle improved from two days\nago\nNEURO: AOx3. CNII-XII grossly intact. \n \nPertinent Results:\nADMISSION LABS\n___ 03:34AM BLOOD WBC-13.8* RBC-4.14 Hgb-12.6 Hct-39.1 \nMCV-94 MCH-30.4 MCHC-32.2 RDW-12.4 RDWSD-43.3 Plt ___\n___ 03:34AM BLOOD ___ PTT-26.6 ___\n___ 07:48PM BLOOD ___\n___ 03:34AM BLOOD Glucose-295* UreaN-30* Creat-1.2* Na-140 \nK-5.2* Cl-104 HCO3-23 AnGap-13\n___ 03:34AM BLOOD Calcium-10.0 Phos-4.7* Mg-1.5*\n\nINTERMITTENT PERTINENT LABS\n___ 02:40PM BLOOD WBC-11.3* RBC-3.35* Hgb-10.6* Hct-31.2* \nMCV-93 MCH-31.6 MCHC-34.0 RDW-12.3 RDWSD-42.0 Plt ___\n___ 02:44AM BLOOD WBC-10.8* RBC-2.23*# Hgb-6.9*# Hct-20.9*# \nMCV-94 MCH-30.9 MCHC-33.0 RDW-12.2 RDWSD-41.9 Plt ___\n___ 07:59AM BLOOD WBC-12.1* RBC-2.79*# Hgb-8.7*# Hct-26.1* \nMCV-94 MCH-31.2 MCHC-33.3 RDW-12.7 RDWSD-43.8 Plt ___\n___ 11:32AM BLOOD WBC-12.9* RBC-2.80* Hgb-8.9* Hct-26.1* \nMCV-93 MCH-31.8 MCHC-34.1 RDW-12.9 RDWSD-44.1 Plt ___\n___ 05:50AM BLOOD WBC-10.2* RBC-2.53* Hgb-7.8* Hct-23.4* \nMCV-93 MCH-30.8 MCHC-33.3 RDW-12.9 RDWSD-42.8 Plt ___\n___ 01:11PM BLOOD WBC-11.4* RBC-2.38* Hgb-7.7* Hct-22.0* \nMCV-92 MCH-32.4* MCHC-35.0 RDW-13.1 RDWSD-43.1 Plt ___\n\nDISCHARGE LABS\n___ 03:08AM BLOOD WBC-9.6 RBC-2.57* Hgb-8.3* Hct-24.3* \nMCV-95 MCH-32.3* MCHC-34.2 RDW-13.5 RDWSD-44.4 Plt ___\n___ 03:08AM BLOOD Glucose-78 UreaN-10 Creat-0.7 Na-142 \nK-4.4 Cl-106 HCO3-25 AnGap-11\n\nIMAGING AND DIAGNOSTICS \n___ BILAT LOWER EXT VEINS:\n1. Extensive deep vein thrombosis of the left lower extremity.\nCentral extent of the clot is uncertain and MRV the be \nconsidered\nfor further evaluation. \n2. Right lower extremity is normal. \n\n___ MRV LLE:\nIMPRESSION: \nOcclusive thrombus within the left common iliac vein extending \nthrough the \nleft external iliac vein into the left lower extremity veins as \nwell as the superior portion of the left internal iliac vein. \nImaging findings are most in keeping with ___. \n\n___ CT AP:\n1. No evidence of intraperitoneal or retroperitoneal hemorrhage. \n Residual\ncontrast in the collecting system, ureters and bladder related \nto recent\nprocedure.\n2. Prominent asymmetric edema involving the left gluteal and \nleft thigh soft tissues without discrete hematoma.\n\n___ CT LLE:\nIMPRESSION: \n1. No evidence of hematoma. \n2. Unchanged position of left common iliac vein stent. \n3. Moderate generalized edema throughout the left lower\nextremity. \n\n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman with T2DM on insulin, HTN, \nand recent left toe fracture with no significant immobility, who \npresented with LLE swelling and LLQ pain, found to an occlusive \nthrombus of the left common iliac vein extending into left \nexternal iliac, left lower extremity veins, and superiorly to \nleft internal iliac concerning for ___ Syndrome. She is \nnow s/p catheter directed lysis ___ and left iliac stenting \n___.\n\n#Occlusive and extensive left common iliac vein:\nPatient presented with left lower extremity swelling and pain. \nImaging showed an extensive occlusive left common iliac vein \nthrombus. The findings were consistent with ___ \nsyndrome. ___ was consulted and performed catheter directed lysis \non ___ and iliac vein stenting on ___. Of note, patient has \nnot had recent colonoscopy and imaging at last ED visit showed \nendometrial thickening, therefore cancer has not yet been ruled \nout as a trigger of hypercoagulability in the patient. She was \ntreated with a heparin gtt for blood thinning, and transitioned \nto apixaban. She will take apixaban 10 mg twice a day up until \n___ and 5 mg twice a day starting ___. Per ___, no indication \nfor aspirin or plavix because the stent was venous. She has \nfollow up with ___ scheduled at discharge.\n\n#Acute anemia:\nPatient with normal hemoglobin in the ___ on admission, but post \nlysis downtrended to mid 6s requiring blood transfusion. At this \ntime vitals were stable and CT AP showed no bleed. CT of the \nleft lower extremity also showed no bleed. Her h/h stabilized.\n\n#HTN:\nBlood pressures were stable in hospital in 110s-120s, with K \nhigh 4s and low 5s. Home losartan was discontinued.\n\n#Type 2 diabetes:\nContinued home lantus 30U at night, but many nights received 25U \nrather than 30 in the setting of being NPO. On the night of \n___ she received 30 units of regular insulin instead of 30U \nlantus. She was given 1AMP of dextrose, and the lowest her \nglucose went on q1h monitoring was 94 and 78 on BMP. RL6 was \nfiled.\n\nTRANSITIONAL ISSUES:\n- Discharged on apixaban 10 mg twice a day until ___ and \nthen 5 mg twice a day starting ___\n- ___ follow up scheduled ___\n- Due for colon cancer screening\n- Endometrial biopsy for thickening seen on CT ___, patient \nneeds an OBGYN and biopsy\n- Losartan discontinued as BPs controlled off of it in the \nhospital and potassium was in the high 4s/low 5s\n- Code: FULL\n- Contact: Son, ___, ___\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. MetFORMIN (Glucophage) 1000 mg PO BID \n2. GlipiZIDE 10 mg PO BID \n3. Glargine 30 Units Bedtime\n4. Losartan Potassium 50 mg PO DAILY \n5. Pravastatin 40 mg PO QPM \n\n \nDischarge Medications:\n1. Apixaban 10 mg PO BID Duration: 7 Days \nTake 10 mg BID for 7 days (___) and then 5 mg BID starting \n___ \nRX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth twice a day \nDisp #*80 Tablet Refills:*1 \n2. Apixaban 5 mg PO BID \nTake 10 mg BID for 7 days (___) and then 5 mg BID starting \n___. Glargine 30 Units Bedtime \n4. GlipiZIDE 10 mg PO BID \n5. MetFORMIN (Glucophage) 1000 mg PO BID \n6. Pravastatin 40 mg PO QPM \n7. HELD- Losartan Potassium 50 mg PO DAILY This medication was \nheld. Do not restart Losartan Potassium until your doctor tells \nyou to.\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nLeft common iliac thrombus\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\nIt was a pleasure caring for you during your hospitalization at \nthe ___.\n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n================================================\n- You were having pain and swelling in your left leg.\n\nWHAT WAS DONE FOR ME IN THE HOSPITAL?\n================================================\n- You were found to have a clot in the veins of your left upper \nleg/pelvis. \n- You were started on IV blood thinners to help prevent more \nclot from forming or growing.\n- You had a stent placed to help open the vein and received a \nmedication directly into the vein to break up the clot.\n- You were switched from IV to oral blood thinning medication \ncalled apixaban.\n\nWHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?\n================================================\n- Please take apixaban 10 mg twice a day up until ___ and 5 mg \ntwice a day starting ___. Continue to take this medication. If \nyou run out of the medication, please call your primary care \ndoctor immediately to refill it, as not taking it ___ cause a \nnew blood clot to form.\n- Please follow up with the interventional radiology team, as \nscheduled below.\n- Please talk to your primary care doctor about ordering a \ncolonoscopy, as this is recommended for your age group.\n- Please tell your primary care doctor that you need an OBGYN. \nThis is very important because imaging on your last \nhospitalization showed thickening of the lining of your uterus, \nand you will need this to be evaluated.\n\nWHAT ARE REASONS I SHOULD RETURN TO THE HOSPITAL?\n=================================================\n- If the pain in your left leg worsens, if the swelling in your \nleft leg returns, if you have any large bruises or bleeding from \nanywhere.\n- If you have any symptoms that concern you.\n\nWe wish you the best of luck in your health!\n\nWarmly,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "I82422", "D62", "N179", "I82412", "E119", "I10", "S92912D", "W2203XD", "E860", "Q968", "I82432" ]

[ "I82422: Acute embolism and thrombosis of left iliac vein", "D62: Acute posthemorrhagic anemia", "N179: Acute kidney failure, unspecified", "I82412: Acute embolism and thrombosis of left femoral vein", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "S92912D: Unspecified fracture of left toe(s), subsequent encounter for fracture with routine healing", "W2203XD: Walked into furniture, subsequent encounter", "E860: Dehydration", "Q968: Other variants of Turner's syndrome", "I82432: Acute embolism and thrombosis of left popliteal vein" ]

[ "D62", "N179", "E119", "I10" ]

[]

[ " \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 \nMajor Surgical or Invasive Procedure:\nNone. \n\n \nHistory of Present Illness:\n___ recently admitted for likely autoimmune related pericardial\neffusion now presenting with chest pain.\n\nOn recent admission ___, found to have large \ncircumferential\npericardial effusion (at ___ w/ c/f tamponade given ventricular\nbowing. Thought to be post-pericarditis from viral infection \n(influenza A +) vs. autoimmune etiology. Underwent\npericardiocentesis that drained 750 mL bloody fluid. Repeat ECHO\nshowed significant improvement in pericardial effusion after\ndrain removed, and was discharged on naproxen and colchicine.\nAlso treated with Tamiflu. \n\nPatient describes L sided pleuritic chest pain ___ when sitting\nup and ___ while lying down that started yesterday and has\nworsened today (___). She was driving home from work ___ when\nshe felt dizzy and had to stop driving for 20 minutes. No\ndyspnea, which is different from her past admission. No fever,\ncough, abdominal symptoms, recent weight gain, or other\ncomplaints. No sick contacts or other new exposures. She went to\nurgent care and was then sent to ___ where she had a CXR and \nCTA,\nthen sent to ___. \n\nShe is followed by Rheumatology as outpatient; they are \nconcerned\nfor a RA/SLE overlap process. Labwork has been notable for\npositive ___ 1:620, anti-dsDNA, CRP as high as 284, sed rate as\nhigh as 58, anti CCP and SSA Ab. Negative anti ___, RF, SSB,\nRNP. Normal pericardial fluid adenosine deaminase. Was recently\nstarted on hydroxychloroquine. She was also flu positive last\nadmission so there is concern this may have triggered autoimmune\nprocess.\n\nIn the ED...\n\n- Initial vitals:\nYest ___ 110 116/80 24 99% RA \nToday 00:03 98.2 104 125/81 20 97% RA \n\n- EKG: sinus tach, diffuse T wave flattening per my read\n\n- Labs/studies notable for:\n*beside echo per Cards fellow with mild-moderate pericardial\neffusion without signs of tamponade \n*pulsus measured at 14\n*CTA with effusion, cardiomegaly, no PE per my read\n*Hgb 7.6 (b/l), cardiac enzymes negative\n \n- Patient was given: home Plaquenil, colchicine, naproxen\n\n- Vitals on transfer: Today ___ 96 132/76 25 95% RA \n\nOn the floor she gave me the above history and has no acute\ncomplaints.\n\nREVIEW OF SYSTEMS: per HPI, otherwise negative\n\n \nPast Medical History:\n-Pericardial Effusion requiring pericardiocentesis in the \nsetting\nof influenza A and multiple positive autoimmune markers\n-Suspected SLE vs. RA\n-Microcytic Anemia\n-hypothyroidism\n-Asthma\n\n \nSocial History:\n___\nFamily History:\nHalf sister - AFib, PE\nMaternal Grandmother - DM\nFather's side largely unknown as patient is adopted\n \nPhysical Exam:\n===========================\nADMISSION PHYSICAL EXAM \n===========================\n\nVS: 98.1 PO 117 / 82 101 18 99 Ra\nGENERAL: NAD\nHEENT: anicteric sclera with no injection\nNECK: JVP at lower mandible with patient sitting up at 60\ndegrees, +HJR\nCV: Regular rhythm, tachycardic, S1/S2, no murmurs, gallops, or\nrubs\nPULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles\nGI: abdomen obese, soft, nondistended, nontender in all\nquadrants, no rebound/guarding \nEXTREMITIES: no pitting edema, warm\nNEURO: Alert, moving all 4 extremities with purpose, face\nsymmetric\nDERM: warm and well perfused, no excoriations or lesions, no\nrashes\n\n===========================\nDISCHARGE PHYSICAL EXAM \n===========================\n\nVS: 98.7 127/84 113 16 97 Ra \nPulsus < 10 (measured by Doppler) \n\nGENERAL: NAD\nHEENT: anicteric sclera with no injection\nCV: Regular rhythm, tachycardic, S1/S2, no murmurs, gallops, or\nrubs\nPULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles\nGI: abdomen obese, soft, nondistended, nontender in all\nquadrants, no rebound/guarding \nEXTREMITIES: no pitting edema, warm\nNEURO: Alert, moving all 4 extremities with purpose, face\nsymmetric\nDERM: warm and well perfused, no excoriations or lesions, no\nrashes\n \nPertinent Results:\n===================================\nADMISSION/DISCHARGE LABS \n===================================\n\n___ 12:00AM BLOOD WBC-9.2 RBC-4.14 Hgb-7.6* Hct-28.7* \nMCV-69* MCH-18.4* MCHC-26.5* RDW-28.2* RDWSD-68.1* Plt ___\n___ 12:00AM BLOOD Neuts-56.0 ___ Monos-14.8* \nEos-4.1 Baso-0.3 Im ___ AbsNeut-5.16 AbsLymp-2.26 \nAbsMono-1.36* AbsEos-0.38 AbsBaso-0.03\n___ 09:46AM BLOOD ___ PTT-32.8 ___\n___ 12:00AM BLOOD Glucose-88 UreaN-10 Creat-0.6 Na-138 \nK-3.9 Cl-105 HCO3-19* AnGap-14\n___ 12:00AM BLOOD ALT-15 AST-19 CK(CPK)-34 AlkPhos-71 \nTotBili-0.8\n___ 12:00AM BLOOD CK-MB-<1 cTropnT-<0.01\n___ 12:00AM BLOOD CRP-107.2*\n\n===================================\nIMAGING\n===================================\n\n___ echo \n\nThe left atrium is normal in size. The estimated right atrial \npressure is ___ mmHg. There is normal left\nventricular wall thickness with a normal cavity size. There is \nnormal regional and global left ventricular\nsystolic function. The visually estimated left ventricular \nejection fraction is >=65%. Normal right\nventricular cavity size with normal free wall motion. The aortic \nvalve leaflets (3) appear structurally\nnormal. The mitral valve leaflets appear structurally normal \nwith no mitral valve prolapse. The pulmonic\nvalve leaflets are not well seen. The tricuspid valve leaflets \nappear structurally normal. The estimated\npulmonary artery systolic pressure is normal. There is a small \ncircumferential pericardial effusion. There\nare no 2D or Doppler echocardiographic evidence of tamponade. \nThe pericardium is thickened and are\nnot suggestive of constriction. A left pleural effusion is \npresent.\nIMPRESSION: Small circumferential pericardial effusion with a \nthickened pericardium but no\nevidence of pericardial tamponade or constriction. Normal left \nventricular wall thickness, cavity\nsize, and regional/global systolic function. Left pleural \neffusion present.\nCompared with the prior TTE (images reviewed) of ___ , \nthere has been reaccumulation of the\npericardial effusion.\n \nBrief Hospital Course:\n================================\nTRANSITIONAL ISSUES \n================================\n[]CRP elevated again to 107.2, unclear if this represents true \nprogression of autoimmune disease or if she was inconsistently \ntaking the anti-inflammatory treatments as an outpatient as \nthere was some concern she may have missed doses and/or ran out \nof medication. \n[]Changed naproxen to indomethacin for treatment of pericardial \nchest pain. \n\n================================\nBRIEF SUMMARY \n================================\n\n___ is a ___ year old women with a recent diagnosis of \nautoimmune disease (unclear overlap syndrome of RA and lupus, \nalso known as \"rhupus\") after she was admitted from \n___ with a pericardial effusion in the setting of \nan influenza infection. The effusion was drained of 570cc of \nfluid on ___ given concern for tamponade (pericardial \npressures of 23) and the etiology was unclear (auto-immune vs. \ninfluenza infection). She had since been improving on \nanti-inflammatories under the care of the rheumatology team when \nshe had return of pericardial-like chest pain on ___. \n\nWhile she did have sinus tachycardia, her ECHO had no evidence \nof constriction or tamponade and the pulsus was <10 with a \nnormal appearing IVC (as such no fluids were administered). She \nwas discharged on a regimen of colchicine and indomethacin taper \n(25mg TID x 2w, 25mg BID x ___, and 25mg daily x2m). We felt like \nthe description of her chest pain was consistent enough with \npericarditis that other diagnoses such as PE did not need to be \npersued. \n\nShe has rheumatology and cardiology follow up in the coming \nmonths and will have a repeat ECHO next week to be followed up \nby Dr. ___ in cardiology. \n\nWe did note that there were some issues with medication \nadherence, mostly due to financial barriers, and we directed her \nto the Free Care through financial services. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Colchicine 0.6 mg PO BID \n2. Naproxen 500 mg PO Q12H \n3. Pantoprazole 40 mg PO Q24H \n4. Hydroxychloroquine Sulfate 200 mg PO BID \n\n \nDischarge Medications:\n1. Indomethacin 25 mg PO TID Duration: 2 Weeks \nRX *indomethacin 25 mg 1 capsule(s) by mouth as below Disp #*60 \nCapsule Refills:*3 \n2. Colchicine 0.6 mg PO BID \n3. Hydroxychloroquine Sulfate 200 mg PO BID \n4. Pantoprazole 40 mg PO Q24H \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPericarditis \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n===========================================\nWHY DID YOU COME TO THE HOSPITAL?\n===========================================\n-You were having chest pain \n\n===========================================\nWHAT HAPPENED AT THE HOSPITAL?\n===========================================\n-We think the pain is related to inflammation in the sac \nsurrounding the heart, also known as \"pericarditis\". It is \nunclear if this is related to the prior flu infection or the \nauto-immune disease. \n-We discovered the fluid around the heart was back, but not in a \ndangerous way that impaired the heart pumping function. \n-We changed the naproxen to indomethacin to help with the pain \n\n==================================================\nWHAT NEEDS TO HAPPEN WHEN YOU LEAVE THE HOSPITAL?\n==================================================\n-Have a repeat ultrasound of the heart on ___, at \n___. \n-Stop taking the naproxen since we are changing to indomethacin. \n\n \nFollowup Instructions:\n___\n" ]

[ "I319", "M329", "M069", "D509" ]

[ "I319: Disease of pericardium, unspecified", "M329: Systemic lupus erythematosus, unspecified", "M069: Rheumatoid arthritis, unspecified", "D509: Iron deficiency anemia, unspecified" ]

[ "D509" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nGentamicin / vancomycin\n \nAttending: ___.\n \nChief Complaint:\nAtrial fibrillation\n \nMajor Surgical or Invasive Procedure:\n___ - Left atrial appendage ligation with a 35 mm atrial \nclip via left mini thoracotomy.\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old man with a complicated past medical \nhistory including atrial fibrillation who was recently admitted \nwith BRBPR. He underwent colonoscopy on ___ which \ndemonstrated radiation proctitis and colonic AVMs for which \nthermal therapy was applied. Hematology was consulted and \nextensively discussed the risks of anticoagulation (patient has \nvery high risk of re-bleed) versus the benefits (patient has \nhigh risk of stroke based on past strokes and CHADS-VaSc of 5+). \nUltimately it was decided to restart Warfarin at his home dose \nwithout a bridge and he will follow up with outpatient providers \nto consider placement of Watchman device versus Atriclip. Prior \nto discharge, a\ntransesophageal echocardiogram was performed on ___ as part \nof the ___ evaluation and revealed no left atrial or left \natrial appendage thrombus.\n \nPast Medical History:\nAtrial Fibrillation \nDeep Vein Thrombosis\nDepression \nDiabetes Mellitus Type II\nEnd-Stage Renal Disease on PD \nGI Bleed\nH. Pylori \nHepatitis C treated with Zepatier\nHyperparathyrodism \nHypertension\nIdiopathic Thrombocytopenia\nIVC Filter\nLeft hallux amputation ___\nOsteomyelitis s/p left third toe amputation ___\nPeripheral Vascular Disease with multiple revascularization \nprocedures\nProstate Cancer treated with radiation \nRadiation Proctitis \nTransient Ischemic Attack\n \nSocial History:\n___\nFamily History:\nFather - CHF, died age ___ \nMother - diagnosed with diabetes mellitus at age ___.\nPaternal aunt and two sisters with ___ and a sister with \njuvenile diabetes died at ___. \nSiblings - 6 of 9 siblings with hypertension.\n \nPhysical Exam:\nAdmit Physical Exam:\nVital Signs sheet entries for ___: \nBP: a) 154/68 (left arm large cuff); b) 129/33. Heart Rate: a)\n62; b) 71. O2 Saturation%: a) 100 (room air); b) 100. Weight:\n155.0 (With Clothes; With Shoes). BMI: 21.6. Temperature: 98.0.\nResp. Rate: 16. Pain Score: 0.\n\nGeneral: ___ male in no acute distress\nSkin: Dry [x] intact [x] - well healed scar on left leg\nHEENT: PERRL [x] EOMI [x]\nNeck: Supple [x] Full ROM [x]\nChest: Lungs clear bilaterally [x]\nHeart: RRR [] Irregular [x] Murmur [] grade \nAbd: Soft [x] non-distended [x] non-tender [x] bowel sounds +, \n+ peritoneal dialysis catheter\nExtremities: Warm [x], well-perfused [x]; wearing protective \nboot on right foot\nEdema: None\nVaricosities: None \nNeuro: Grossly intact \nPulses\nFemoral Right: 2 Left: 2 (bilateral femoral bruits noted)\nRadial Right: 2 Left: 2\nCarotid Bruit: Right: soft bruit Left: none\n\nDischarge PE:\n___ Heart Rate: 75-102. O2 Saturation%: 96% room air\nWeight: 69.9kg (155/70.3kg preop).\nTemperature: 98.0. Resp. Rate: 16. \n\nGeneral: ___ male in no acute distress\nSkin: Dry [x] intact [x] - well healed scar on left leg\nHEENT: PERRL [x] EOMI [x]\nNeck: Supple [x] Full ROM [x]\nChest: Lungs clear bilaterally with decreased left base [x]\nLeft thoracotomy incision: healing well, clean/dry/intact\nHeart: RRR [] Irregular [x] Murmur [] grade ______ \nAbd: Soft [x] non-distended [x] non-tender [x] bowel sounds +\n+ peritoneal dialysis catheter\nExtremities: Warm [x], well-perfused [x] Edema: None\nNeuro: Grossly intact \nPulses\n___ Right: 2 Left: 2\nRadial Right: 2 Left: 2\n \nPertinent Results:\nSTUDIES:\nPA/LAT CXR ___:\nThere is no pneumothorax or pulmonary edema. Moderate left basal \natelectasis is worsened. Left pleural effusion is small. Mild \ncardiomegaly is improved. Hydro pneumoperitoneum is explained by \nperitoneal dialysis. \n\nECHO ___:\nPre-Procedure:\nNo spontaneous echo contrast is seen in the left atrial \nappendage.\nOverall left ventricular systolic function is mildly depressed \n(LVEF= 40 - 45%). with mild global free wall hypokinesis. There \nare complex (>4mm) atheroma in the descending thoracic aorta. \nThe aortic valve leaflets (3) are mildly thickened. There is no \naortic valve stenosis. No aortic regurgitation is seen. The \nmitral valve leaflets are moderately thickened. Trivial mitral \nregurgitation is seen. There is a very small pericardial \neffusion. \n\nPost-Procedure:\nThe ___ has been obliterated.\nThe rest of the exam is unchanged. \nLABS:\nAdmit:\n___ 05:31PM BLOOD WBC-7.4 RBC-3.57* Hgb-8.9* Hct-29.1* \nMCV-82 MCH-24.9* MCHC-30.6* RDW-19.9* RDWSD-57.7* Plt ___\n___ 05:31PM BLOOD ___ PTT-33.9 ___\n___ 05:31PM BLOOD Glucose-87 UreaN-83* Creat-15.2*# Na-135 \nK-6.2* Cl-93* HCO3-22 AnGap-26*\n___ 05:31PM BLOOD ALT-23 AST-18 AlkPhos-156* Amylase-223* \nTotBili-0.2\n___ 05:31PM BLOOD Lipase-75*\n___ 05:31PM BLOOD Albumin-3.0* Calcium-8.8 Phos-7.6* Mg-2.6\n___ 05:30PM BLOOD %HbA1c-6.6* eAG-143*\n\nDischarge:\n___ 06:05AM BLOOD WBC-13.8* RBC-3.55* Hgb-8.7* Hct-29.1* \nMCV-82 MCH-24.5* MCHC-29.9* RDW-20.2* RDWSD-60.2* Plt ___\n___ 02:14AM BLOOD ___\n___ 06:00AM BLOOD Glucose-64* UreaN-62* Creat-13.2* Na-134 \nK-4.4 Cl-90* HCO3-25 AnGap-23*\n___ 06:00AM BLOOD Mg-2.1\n___ 06:05AM BLOOD Phos-8.9* Mg-2.1\n\nMICRO:\n___ 12:11 pm DIALYSIS FLUID PERITONEAL DIALYSATE. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \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\n FLUID CULTURE (Final ___: NO GROWTH. \n.\n\n___ 01:30PM BLOOD WBC-6.4# RBC-3.55* Hgb-8.7* Hct-29.3* \nMCV-83 MCH-24.5* MCHC-29.7* RDW-19.4* RDWSD-57.5* Plt ___\n___ 01:30PM BLOOD Plt ___\n___ 01:30PM BLOOD Glucose-187* UreaN-59* Creat-12.8* Na-133 \nK-4.4 Cl-90* HCO3-24 AnGap-23*\n___ 01:30PM BLOOD Mg-2.1\n \nBrief Hospital Course:\nHe was admitted to the hospital on ___ from ___. \nHe was taken to the operating room on ___ and underwent Left \natrial appendage ligation with a 35 mm\natrial clip via left mini thoracotomy. Please see operative note \nfor full details. He tolerated the procedure well and was \nextubated in the PACU, alert and oriented, neurologically intact \nand breathing comfortably. He was admitted CVICU due to \nbradycardia with heart rate in the ___. His bradycardia resolved \nand he was in sinus rhythm and hemodynamically stable on no \ninotropic or vasopressor support. He was transferred to the \ntelemetry floor for further recovery. Per Dr. ___ will not \nbe continued on Coumadin due to GIB, and amiodarone was also not \nrecommended. Peritoneal dialysis was resumed. ___ drain in the \nchest was discontinued without complication. His home coreg was \nresumed but he developed orthostatic hypotension and was changed \nto short acting metoprolol for easier titration. He also \ndeveloped tachycardia and s atrial fibrillation and was \nrestarted on his home Digoxin regimen after 0.5 mg IV load on \n___. He should have digoxin level checked on ___. \nHis lantus has been decreased from 20 to 10 units daily. He was \nevaluated by the physical therapy service for assistance with \nstrength and mobility. By the time of discharge on POD 6 he was \nambulating freely, the wound was healing and pain was controlled \nwith oral analgesics. He was discharged to home with ___ and ___ \nservices in good condition with appropriate follow up \ninstructions.\n\n \nMedications on Admission:\n1. amLODIPine 10 mg PO DAILY \n2. Atorvastatin 20 mg PO QPM \n3. Calcitriol 0.5 mcg PO DAILY \n4. Carvedilol 12.5 mg PO BID \n5. Cinacalcet 30 mg PO DAILY \n6. Digoxin 0.125 mg PO 2X/WEEK (MO,TH) \n7. Epoetin ___ ___ u/2mL SC 1X/WEEK, ___ \n8. Glargine 20 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin\n9. Lactulose 30 mL PO Q8H:PRN constipation \n10. PARoxetine 10 mg PO DAILY \n11. sevelamer CARBONATE 1600 mg PO TID W/MEALS \n12. Warfarin 2.5-5 mg PO DAILY16 \n13. Ascorbic Acid ___ mg PO DAILY \n14. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes \n2. Docusate Sodium 100 mg PO BID \nhold for loose stools \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*60 Capsule Refills:*0 \n3. Metoprolol Tartrate 25 mg PO TID \nRX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a \nday Disp #*90 Tablet Refills:*1 \n4. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain - \nSevere \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*80 Tablet Refills:*0 \n5. Polyethylene Glycol 17 g PO DAILY \nhold for loose stools \nRX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by \nmouth daily Disp #*30 Packet Refills:*0 \n6. Sarna Lotion 1 Appl TP QID:PRN itching \n7. Senna 8.6 mg PO BID \nhold for loose stools \nRX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n8. Cinacalcet 30 mg PO EVERY OTHER DAY \n9. Glargine 10 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin \n10. PARoxetine 20 mg PO DAILY \nRX *paroxetine HCl 20 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*1 \n11. sevelamer CARBONATE 2400 mg PO TID W/MEALS \nRX *sevelamer carbonate [Renvela] 800 mg 3 tablet(s) by mouth \ntid w meals Disp #*270 Tablet Refills:*1 \n12. Ascorbic Acid ___ mg PO DAILY \n13. Aspirin EC 81 mg PO DAILY \n14. Atorvastatin 20 mg PO QPM \n15. Calcitriol 0.5 mcg PO DAILY \n16. Digoxin 0.125 mg PO 2X/WEEK (MO,TH) \ntake on ___ and ___ \n17. Epoetin ___ ___ u/2mL SC 1X/WEEK, ___ \n18. Lactulose 30 mL PO Q8H:PRN constipation \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n___ ___ ligation, AtriClip via Left thoracotomy \n\nAtrial fibrillation, History of Lower GI bleed, Radiation \nProctitis, Hypertension, Orthostatic hypotension, \nHypercholesteremia, Diabetes mellitus, PVD, ESRD on peritoneal \ndialysis, s/p failed transplant ___, History of DVT s/p IVC \nfilter, History of Stroke/TIA, ITP, Lung nodules, CT chest in \n___ showed RLL nodular opacities, History of MRSA, \nCataracts, Charcot foot, currently wearing a boot, History of \nProstate Cancer, Hyperparathyroidism, Chronic Hepatitis C, \nDepression \nPast Surgical History: s/p Left above knee popliteal to dorsalis \npedis bypass grafting, s/p IVC Filter, s/p right Renal \nTransplant \n\n \nDischarge Condition:\nAlert and oriented x3 non-focal \nAmbulating with steady gait\nIncisional pain managed with oral analgesics\nLungs: decreased left base\nIncisions: \nLeft thoracotomy - healing well, no erythema or drainage \nEdema - none\n\n \nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild \nsoap, no baths or swimming until cleared by surgeon. Look at \nyour incisions daily for redness or drainage\n\nPlease NO lotions, cream, powder, or ointments to incisions \n Each morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart \n\n No driving for approximately one month and while taking \nnarcotics, will be discussed at follow up appointment with \nsurgeon when you will be able to drive \nPlease call with any questions or concerns ___\n\n**Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n \nFollowup Instructions:\n___\n" ]

[ "I480", "N186", "T8619", "N2581", "I120", "E1121", "Z8546", "Z86718", "Z89412", "Z89422", "Z8673", "Z87891", "Y830", "Y929", "D631", "F329", "Z7901", "I951", "E1142", "E1151", "E1122", "Z992", "R001", "Y831", "Y92239", "D72829" ]

[ "I480: Paroxysmal atrial fibrillation", "N186: End stage renal disease", "T8619: Other complication of kidney transplant", "N2581: Secondary hyperparathyroidism of renal origin", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "Z8546: Personal history of malignant neoplasm of prostate", "Z86718: Personal history of other venous thrombosis and embolism", "Z89412: Acquired absence of left great toe", "Z89422: Acquired absence of other left toe(s)", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z87891: Personal history of nicotine dependence", "Y830: Surgical operation with transplant of whole organ as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "D631: Anemia in chronic kidney disease", "F329: Major depressive disorder, single episode, unspecified", "Z7901: Long term (current) use of anticoagulants", "I951: Orthostatic hypotension", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "Z992: Dependence on renal dialysis", "R001: Bradycardia, unspecified", "Y831: Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "D72829: Elevated white blood cell count, unspecified" ]

[ "I480", "Z86718", "Z8673", "Z87891", "Y929", "F329", "Z7901", "E1122" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nlisinopril / metoprolol\n \nAttending: ___.\n \nChief Complaint:\nCough, Dyspnea\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ man with severe AS, HFpEF, CAD, HTN, HLD, BPH, CKD\nstage III, DM2, who p/w dyspnea\n\nRecent discharge from ___ ___ for flash pulmonary edema\n___ HTN and severe AS, and mild overload. Found to have new\nsevere TR on TTE, discharged with plan for expedited outpatient\nTAVR work up. Discharged on Lasix 20mg 2x/week, saw outpatient\natrius cardiologist who increased to 3x/week. \n\nHe reports having increased fatigue, dyspnea on exertion\nyesterday as well as noticed increased lower extremity edema. He\ndenies fevers, chills, sore throat runny nose, myalgias, sick\ncontacts, chest pain, n/v, abd pain, dysuria. Notes some\nconstipation. He still currently smokes. He reports being\ncompliant with his medications and trying to adhere to low salt\ndiet. He denies hx of syncope and exertional angina. \n\n \nPast Medical History:\n- Type 2 Diabetes\n- Hypertension\n- Hyperlipidemia\n- Tobacco use (current) \n- CABG: None\n- PERCUTANEOUS CORONARY INTERVENTIONS: None\n- PACING/ICD: None\n- Severe AS\n- BPH\n- CKD stage III\n- Renal cysts\n- Glaucoma\n \nSocial History:\n___\nFamily History:\nFather had \"heart disease\" and passed away in his ___ - etiology\nnot clear Sister passed away from ? MI in ___. \nMother is ___ years of age and alive.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n======================== \nVITALS: 97.6 168/79 99 20 94% RA\nGeneral: Alert, oriented, no acute distress, ambulating and\nlaying at 30 degrees in RA. Speaking in full sentences \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL\nNeck: JVP difficult to assess, ?seeing carotid pulsation as\nopposed to venous\nCV: RRR. S1, S2. ___ systolic murmur heard throughout precordium\nLungs: Unlabored breathing. Decreased breath sounds at bases\nAbdomen: +BS. Soft, NTND \nGU: No foley \nExt: Warm, well perfused. ___ ___ edema\nSkin: Warm, dry, no rashes or notable lesions. \nNeuro: CNII-XII grossly intact. No focal deficits.\n\nDISCHARGE PHYSICAL EXAM\n=======================\nGeneral: Alert, oriented, no acute distress. \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI.\nNeck: no JVP elevation\nCV: RRR. S1, S2. ___ systolic murmur heard throughout precordium\nLungs: Normal work of breathing. Rales in mid lung fields.\nAbdomen: +BS. Soft, NTND \nGU: No foley \nExt: Warm, well perfused. no signs of edema\nSkin: Warm, dry, no rashes or notable lesions. \nNeuro: AAO x3. No focal neuro deficits.\n \nPertinent Results:\nADMISSION LAB RESULTS\n=====================\n___ 07:05PM BLOOD WBC-8.2 RBC-4.37* Hgb-12.6* Hct-39.1* \nMCV-90 MCH-28.8 MCHC-32.2 RDW-14.8 RDWSD-48.9* Plt ___\n___ 07:05PM BLOOD Glucose-143* UreaN-32* Creat-2.1* Na-140 \nK-4.3 Cl-104 HCO3-23 AnGap-13\n___ 07:05PM BLOOD Calcium-9.6 Phos-3.7 Mg-2.0\n\nDISCHARGE PHYSICAL EXAM\n=======================\n___ 06:10AM BLOOD WBC-6.6 RBC-3.89* Hgb-11.0* Hct-34.7* \nMCV-89 MCH-28.3 MCHC-31.7* RDW-15.1 RDWSD-49.8* Plt ___\n___ 06:22AM BLOOD Glucose-92 UreaN-37* Creat-2.1* Na-143 \nK-3.9 Cl-108 HCO3-23 AnGap-12\n___ 06:22AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.9\n\nSTUDIES\n=======\n___ CXR\nModerate pulmonary edema with trace bilateral pleural effusions. \n Bibasilarpatchy opacities, likely atelectasis. Redemonstration \nof left superior mediastinal widening with rightward tracheal \ndeviation attributable to known thyroid goiter.\n\n___ Ultrasound of Aorta and Branches\n1. The distal abdominal aorta demonstrates focal ectasia. This \nshould be \nfollowed with repeat US in ___ years. \n2. The assessment of the common iliac arteries is limited, but \nthere is no \ndefinite evidence of aneurysmal dilation on the portions that \nwere imaged. \n3. Polycystic kidneys. \n\n___ CTA Abdomen and Pelvis Wet Read\nCT chest: \nThe thyroid gland is incompletely visualized. Of the visualized \nthyroid gland, there is severe thyromegaly with a large left \nthyroid mass measuring approximately 5.9 x 7.1 x 7.4 cm \nresulting in rightward deviation and narrowing of the trachea.\n\nProminent left supraclavicular lymph node measuring 0.8 cm in \nshort axis without meeting CT size criteria for lymphadenopathy \n(302; 54). No axillary lymphadenopathy. There is mediastinal \nlymphadenopathy measuring up to 1.4 cm in short axis in aright \nparatracheal node (302; 139). \n\nThere is right hilar lymphadenopathy measuring up to 1.2 x 2.5 \ncm (302; 190). A prominent left hilar lymph node measures 1.1 x \n1.7 cm. \n\nThere is a large pericardial effusion, of unknown chronicity, \nincreased from ___ are moderate aortic valve \ncalcifications. There are mild coronary artery calcifications. \nThere are severe atherosclerotic calcifications and plaque in \nthe thoracic aorta.\n\nThere is bilateral pleural thickening posteriorly. No pleural \neffusion or pneumothorax. There is moderate bilateral \ncentrilobular and paraseptal emphysema. In the right lung apex, \nthere is an irregular pulmonary nodule measuring 1.1 x1.4 cm \n(302; 109), concerning for malignancy. A 8 mm nodule versus \natelectasis is noted in the right lower lobe (302; 350). There \nis mild bilateral pulmonary edema. There are secretions within \nthe right main bronchus. There is peribronchial wall thickening \nin bilateral lower lobes, which may be related to the pulmonary \nedema versus small airways inflammation. The right coronary \nartery arises from the left coronary cusp.\n\nCT abdomen:\nThere is a focal dissection in the infrarenal abdominal aorta \n(302; 555).\n\nThere is an infrarenal abdominal aortic aneurysm measuring up to \n2.9 cm just inferior to the take-off of the inferior mesenteric \nartery. A subcentimeter hyperenhancing foci in the liver is too \nsmall to characterize but may represent transient hepatic \nattenuating difference.\n\nThe spleen is unremarkable. The pancreas is unremarkable.\n\n1.3 cm right adrenal nodule is noted, similar to ___. \nThickening of the left adrenal gland without discrete nodule is \nagain noted.\n\nThere are bilateral innumerable hypodense lesions in the \nkidneys, the largest in the left kidney measuring 4.5 x 4.0 cm \nin the left lower pole, and the largest in the right kidney \nmeasuring 6.2 x 6.7 cm, are consistent with renal cysts, \ncorrelate with history of polycystic kidney disease or prior \nlithium use. \n\nThere are bilateral hyperdense lesions in the kidneys, likely \nrepresenting hyperdense cysts, many of which were seen \npreviously. No hydronephrosis. The visualized small bowel is \nnormal in caliber and wall thickness without evidence of \nobstruction. There is sigmoid diverticulosis without evidence of \ndiverticulitis. The appendix is normal. CT pelvis: The bladder \nis unremarkable. There is prostatomegaly measuring 7.2x 6.4 cm. \nNo free fluid is noted in the pelvis. \n\nNo inguinal or pelvic sidewall lymphadenopathy is noted. No \nretroperitoneal lymphadenopathy. No mesenteric lymphadenopathy. \nOsseous structures: An 8 mm sclerotic focus in the right femur \nis consistent with a bone island (302; 957), unchanged from \nprior. A 7 mm sclerotic focus in the right iliac bone is \nunchanged from ___. No suspicious lytic or sclerotic osseous \nlesions are identified.\n \n\n \nBrief Hospital Course:\nTRANSITIONAL ISSUES\n====================\n- Patient's diuretic increased to Lasix 40mg daily. Please \nmonitor daily weights, Cr, and electrolytes closely. \n- Discharge weight: 176 lbs. \n- Discharge Cr: 2.1\n- Please ensure that patient follows up with ___ structural \nheart team for TAVR. \n- The distal abdominal aorta demonstrates focal ectasia. This \nshould be followed with repeat US in ___ years. \n\nIMAGING TRANSITIONAL ISSUES\n===========================\nAfter the patient was discharged, a wet read of the CTA Abdomen \nand Pelvis returned. The patient was contacted regarding the \nresults, and an outpatient appointment was made for an echo the \nday after discharge. Please ___ the final read of CTA. See \nbelow for transitional issues from the wet read of the CAT:\n\n-severe thyromegaly with a large left thyroid mass measuring \napproximately 5.9 x 7.1 x 7.4 cm resulting in rightward \ndeviation and narrowing of the trachea.\n\n-Prominent left supraclavicular lymph node measuring 0.8 cm in \nshort axis without meeting CT size criteria for lymphadenopathy \n(302; 54). There is mediastinal lymphadenopathy measuring up to \n1.4 cm in short axis in aright paratracheal node (302; 139). \nThere is right hilar lymphadenopathy measuring up to 1.2 x 2.5 \ncm (302; 190). A prominent left hilar lymph node measures 1.1 x \n1.7 cm. \n\n-There is a large pericardial effusion, of unknown chronicity, \nincreased from ___ are moderate aortic valve \ncalcifications. There are mild coronary artery calcifications. \nThere are severe atherosclerotic calcifications and plaque in \nthe thoracic aorta.\n\n-There is an irregular pulmonary nodule measuring 1.1 x1.4 cm \n(302; 109), concerning for malignancy.\n\n-There is a focal dissection in the infrarenal abdominal aorta \n(302; 555).\n\n-There is an infrarenal abdominal aortic aneurysm measuring up \nto 2.9 cm just inferior to the take-off of the inferior \nmesenteric artery. \n\n-There are bilateral innumerable hypodense lesions in the \nkidneys, the largest in the left kidney measuring 4.5 x 4.0 cm \nin the left lower pole, and the largest in the right kidney \nmeasuring 6.2 x 6.7 cm, are consistent with renal cysts, \ncorrelate with history of polycystic kidney disease or prior \nlithium use. \n\nSUMMARY STATEMENT\n=================\nThe patient is a ___ man with severe AS, HFpEF, CAD, \nHTN, HLD, BPH, CKD stage III, DM2, who p/w dyspnea ___ HFpEF \nexacerbation iso severe AS. His respiratory status improved with \nIV diuresis. The structural heart team evaluated him while \ninpatient and determined that he should ___ as previously \nscheduled for further evaluation. He was discharged with PCP and \ncardiology ___. \n\nHOSPITAL COURSE BY PROBLEM\n==========================\n#Acute on chronic diastolic heart failure\n#Severe AS\nThe patient presented with acute dyspnea with elevated proBNP \nand CXR showing pulmonary edema in setting of severe AS and HTN. \nCath on ___ with mild non-hemodynamically significant CAD. EF \nof 65% TTE w/severe AS, severe TR, and moderate to severe MR. ___ \nvelocity 4.3, mean gradient 51, valvae area 0.6. Was evaluated \nby c-surg during last admission, determined to be a better \ncandidate for TAVR as TR/MR may not be as severe as originally \ndocumented. While inpatient this admission, the Cardiac surgery \nteam was re-consulted, and the patient was considered \nintermediate risk, scheduled for outpatient procedure on \n___. He was diuresed with IV Lasix 40mg daily, which was \ntransitioned to PO Lasix 40mg daily upon discharge. For \nafterload, his hydralazine 75mg TID and Irbesartan 300 mg were \nheld during the admission and at discharge given normotension. \nHe was continued on Verapamil 120 mg (reduced from 240 mg BID \nhome dosing). \n\n#CAD\nCoronary angiogram on ___ with mild non-hemodynamically \nsignificant CAD. He was continued on home Atorvastatin 40 mg \nPO/NG QPM and home ASA 81 mg.\n\n#HTN\nThe patient's blood pressure was well-controlled on verapamil \n120mg daily with SBPs in 120-150s. This is within range given \npatient's severe aortic stenosis as above. His home hydralazine, \nirbesartan, and HCTZ were held in the hospital and at discharge. \n\n\n#CKD III: \nBaseline creatinine per Atrius records 2.1. Cr was at baseline \nduring this hospitalization. \n\n#T2 Diabetes:\nDiet-controlled, recent A1c 6.6 in ___.\n\n#BPH:\nContinued home terazosin\n\n#Glaucoma\nContinued home brimonidine and latanoprost\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 40 mg PO QPM \n3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID \n4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n5. Terazosin 2 mg PO QHS \n6. Verapamil 240 mg PO Q12H \n7. HydrALAZINE 75 mg PO TID \n8. Hydrochlorothiazide 25 mg PO DAILY \n9. irbesartan 300 mg oral DAILY \n10. Furosemide 20 mg PO 3X/WEEK (___) \n\n \nDischarge Medications:\n1. Furosemide 40 mg PO DAILY \nRX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n2. Verapamil SR 120 mg PO Q24H \nRX *verapamil 120 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 40 mg PO QPM \n5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID \n6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n7. Terazosin 2 mg PO QHS \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n- CHF exacerbation\n- Type 2 Diabetes\n- Hypertension\n- Hyperlipidemia\n- Tobacco use (current) \n- Severe AS\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\nIt was a pleasure taking care of you at ___ \n___. \n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n- You were admitted to the hospital because you were having \nworsening shortness of breath. We think this was from your heart \nfailure.\n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n- We gave you IV medications to help remove some of the fluid \ncausing your shortness of breath.\n- You had a CT scan study done in preparation for your aortic \nvalve replacement later in ___. \n\nWHAT SHOULD I DO WHEN I GO HOME?\n- You should continue to take your medications as prescribed. \n- You should attend the appointments listed below. \n\n- Weigh yourself every morning. Call your doctor if your weight \ngoes up more than 3 lbs.\n\nWe wish you the best!\nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I130", "I5033", "E1122", "N183", "E785", "F17210", "N400", "I083", "H409" ]

[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5033: Acute on chronic diastolic (congestive) heart failure", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "E785: Hyperlipidemia, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "I083: Combined rheumatic disorders of mitral, aortic and tricuspid valves", "H409: Unspecified glaucoma" ]

[ "I130", "E1122", "E785", "F17210", "N400" ]

[]

[ " \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:\nseizure\n \nMajor Surgical or Invasive Procedure:\nIntubation ___\n \nHistory of Present Illness:\nMs. ___ is a ___ with PMH of right-sided breast cancer (ER+, \nHER-2/neu +, PR equivocal) s/p lumpectomy and radiation in \n___ found to have malignant pleural effusion and bone \nmetastasis in ___ now s/p 8 cycles Herceptin/petuzumab/taxol \nnow with brain metastases admitted recently for seizures, \npresenting to the ___ with seizures, intubated for airway \ncontrol.\n\nPt's husband started noticing a change in her behavior about ___ \ndays ago, she was generally more irritable, shorter temper. She \nhad generally been sleepy bordering on somnolent before this. On \nthe night prior to admission, she became acutely agitated, \nthrowing her husband out of the house, which is extremely \nunusual behavior for her. When he was unable to still \neffectively communicate with her the next morning, he called \n911. \n\nWhen EMS arrived, she had a seizure witnessed by EMS and family \nwhich self terminated. She then had a second seizure during \ntransport to the hospital which responded to a total of 4 mg \nAtivan. \n\nOn arrival to the ___ MD describes the pt as \"post-ictal\" \nThere was concern for pt's inability to protect airway and the \npt was intubated for airway control.\n\nNeuro-oncology was consulted in the ___, who recommended IV \ndexamethasone ___s valproic acid load of 1g, with \nlevels to follow.\n \n\nIn the ___, initial vitals: \n120 BP190/100 RR24 99% glucose155 \n \nExam notable for: Pupils equal round reactive, no gag on opiate \nplacement, withdrawing all extremities, abdomen soft, bilateral \nbreath sounds, satting 100% on nonrebreather\n\nLabs notable for: \nNa 133, K 3.5, Cl 92, HCO3 10, BUN 20, Cr 0.9, glucose 162, AG \n31\nLactate 14.1\nWBC 9.4, Hgb 12.2, plt 225\n___: 10.5 PTT: 26.5 INR: 1.0 \npH 7.25 pCO2 28 pO2 168 \n\nUA trace protein few bacteria\n\nImaging: \nNCHCT: No acute intracranial hemorrhage. No midline shift.\nScattered areas of parenchymal hypodensity bilaterally in this \npatient with known brain metastases, better assessed on brain \nMRI performed 1 day prior.\n\nCXR: ___: IMPRESSION: \nEndotracheal tube terminates 3.1 cm above the carina. Enteric \ntube in appropriate position. Left Port-A-Cath terminates in \nthe proximal right atrium/cavoatrial junction. Mild left base \natelectasis without definite focal consolidation \n\nPatient received: 4mg IV dexamethasone and 1g valproate\n\nUpon arrival to ___, the patient is intubated and sedated. \nFurther history was reviewed with the patient's husband. \n\nThe patient was not alert on initial arrival, but a few hours \nafter arrival she was sitting up and moving non-purposefully. \n\n \nPast Medical History:\n___ Right breast lump \n___ Mammography showed right breast mass (___)\n___ U/S of the axilla showed no LAD\n___ Right breast biopsy showed invasive lobular carcinoma,\npleomorphic variant, poorly differentiated, without\nlymphovascular invasion, ER+/PR-/HER2 3+\n___ TTE, EF 60-65% \n___ CT C/A/P showed small mediastinal lymph nodes, possibly\npost inflammatory, 5 mm hepatic hypodensity\n___ Breast MRI showed 44 mm irregular mass of the right \nupper\ninner quadrant corresponding to the known malignancy, focal\nlinear enhancement extended towards the nipple could reflect an\ninvolved duct, no axillary adenopathy\n___ Left breast biopsy \nPathology: fibroadenoma, no malignancy \n___ - ___ C1-C6 TCHP \n___ Right breast lumpectomy with SLNB \nPathology: residual invasive lobular carcinoma ER+/PR-/HER2- \n___ XRT \n___ Tamoxifen \n___ Trastuzumab-pertuzumab \n___ Admitted with SOB, found to have RLL mass, pleural\neffusions\n___ Thoracentesis revealed malignant cells in pleural fluid\nCytology: positive for cancer, ER+/PR-/HER2+\n___ 8 cycles Trastuzumab-pertuzumab-paclitaxel\n___ Brain MRI showed many lesions\n___ - ___ WBRT 10x3 Gy XRT to T10-L5 10x3 Gy\n___ C1 lapatinib/capecitabine \n___ Admission with seizure\n___ Brain MRI stable\n \n\nRelevant neuro-onc history: ___ - ___: WBRT 10x3 Gy XRT \nto T10-L5 10x3 Gy\n\n \nSocial History:\n___\nFamily History:\nShe has 2 daughters ages ___ and ___, both unaffected. She has 2\nunaffected brothers. Her mother died at ___ unaffected. A \nmaternal aunt had bladder cancer and 2 other maternal aunts had \nlongevity with no cancer. Her father had 4 sisters, no \nmalignancy. There is no pertinent family history of cancer. She \nis of ___ \nJewish descent. \n- her father has a cousin with breast cancer in her ?___, \nrelated through one man, possibly two but she's not sure\n-BRCA testing negative for ___ founder mutations \n\n \nPhysical Exam:\nAdmission Physical Exam:\n===========================\nVITALS: Reviewed in Metavision. \nGENERAL: Intubated, sedated, appears comfortable. \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: JVP not elevated, no LAD \nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSKIN: No obvious rashes \nACCESS: Peripheral IV\n\nDischarge exam:\n================\nExpired.\n \nPertinent Results:\nAdmission Labs:\n================\n\n___ 09:43AM BLOOD WBC-9.4 RBC-4.02 Hgb-12.1 Hct-37.6 MCV-94 \nMCH-30.1 MCHC-32.2 RDW-14.0 RDWSD-47.9* Plt ___\n___ 09:43AM BLOOD Plt ___\n___ 09:43AM BLOOD Glucose-162* UreaN-20 Creat-0.9 Na-133* \nK-3.5 Cl-92* HCO3-10* AnGap-31*\n___ 05:56PM BLOOD ALT-148* AST-64* LD(___)-317* CK(CPK)-77 \nAlkPhos-153* TotBili-0.4\n___ 09:43AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.1\n___ 11:35AM BLOOD Ammonia-54\n___ 05:56PM BLOOD Valproa-49*\n___ 10:04AM BLOOD ___ pO2-168* pCO2-28* pH-7.25* \ncalTCO2-13* Base XS--13\n___ 10:04AM BLOOD Lactate-14.1*\n\nImaging:\n==========\n++CT head ___\nNo acute intracranial hemorrhage. No midline shift. \n \nScattered areas of parenchymal hypodensity bilaterally in this \npatient with known brain metastases, better assessed on brain \nMRI performed 1 day prior. \n\n++CT Head ___\nStable appearance of the brain with scattered predominantly \nwhite matter \nhypoattenuation reflecting numerous intracranial metastases and \nassociated \nvasogenic edema better assessed on prior MRI. Evidence of \nhemorrhage or \ninfarction. \n\n++TTE ___\nThe left atrium is normal in size. No atrial septal defect is \nseen by 2D or color Doppler. The estimated right atrial pressure \nis ___ mmHg. Left ventricular wall thicknesses and cavity size \nare normal. Regional left ventricular wall motion is normal. \nLeft ventricular systolic function is hyperdynamic (EF>75%). \nRight ventricular chamber size and free wall motion are normal. \nThe aortic valve leaflets are mildly thickened (?#). There is no \naortic valve stenosis. No aortic regurgitation is seen. The \nmitral valve leaflets are mildly thickened. There is no mitral \nvalve prolapse. Trivial mitral regurgitation is seen. The \npulmonary artery systolic pressure could not be determined. \nThere is a small pericardial effusion. There are no \nechocardiographic signs of tamponade. \n\nMicrobiology:\n==============\n___ Urine culture negative\n___ Blood culture negative\n___ sputum culture - respiratory flora\n___ CSF - no growth\n___ Blood culture pending\n\n \nBrief Hospital Course:\n=================================\nICU COURSE\n\n___ with PMH of right-sided breast cancer (ER+, HER-2/neu +, PR \nequivocal) s/p lumpectomy, radiation, subsequent chemo for bone \nmets and malignant pleural effusions, widespread brain meds, \npresenting with seizure and admitted to ___ with AMS, intubated \nfor airway protection.\n\n# Seizure: had witnessed seizure at home, initially self \nterminated, then ___ seizure during transport by EMS requiring \n4mg Ativan for termination. She was intubated and admitted to \nICU. Neuro oncology c/s and she was treated with keppra, and \nsubsequently valproic acid. EEG did not show continued seizure, \nbut there was high clinical suspicion of ongoing subclinical \nseizure as explanation of persistent AMS. She continued to have \nencephalopathy so lacosamide was uptitrated. EEG was \ndiscontinued. She was eventually transitioned to CMO (see below) \nand AED's discontinued.\n\n# Hypoxic respiratory failure: intubated in setting of AMS \nfollowing seizure, for airway protection. She required minimal \nventilator settings. She was extubated ___. \n\n# Hypotension requiring pressor: she had intermittent \nhypotension following intubation initially attributed to \nsedation meds, requiring pressors briefly. After extubation, she \nagain had paroxysmal episodes of hypotension to MAP < 55 \nrequiring pressor. Cosyntropin stim test was negative. She was \ncovered empirically with broad antibiotics. It was felt that \nhypotension may be cerebral in origin. Pressors were turned off \nwhen patient was made CMO on ___.\n\n# Hyponatremia: she developed acute hyponatremia on ___, with \nelevated urine sodium consistent with SIADH vs. cerebral salt \nwasting. Renal was consulted. She was corrected with hypertonic \nsaline for slow correction over 24hrs. \n\n# Metastatic breast cancer with bone, pleural effusion, and \nbrain metastases\n# Goals of Care\nOn ___ patient appeared to be in worsening acute distress. She \nis unable to\nverbalize where her pain or discomfort is. Earlier in the \nafternoon her husband ___ informed ICU team that comfort \nshould be the main focus given her metastatic disease, \nencephalopathy, and visible suffering. Since her discomfort was \nprogressively worsening, ICU team discussed with family that \ncomfort would be sole priority. Palliative care was urgently \nnotified and arrived at patient bedside to help guide this \ntransition. Her oncologist, Dr. ___, was urgently notified of \nher worsening distress and also arrived to bedside immediately \nto offer support to the\nfamily. ___ husband, two daughters, are in agreement with \nCMO, as are the primary ICU team, oncology, and palliative care. \nShe was transferred to private room on general medicine service \non ___ AM.\n\n==================================\nFloor course:\n\n# CMO: comfort was maintained w/ dilaudid gtt, Tylenol PR PRN, \nand she passed away surrounded by family and friends.\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Dexamethasone 2 mg PO DAILY \n2. LevETIRAcetam 500 mg PO BID \n3. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n\n \nDischarge Medications:\nN/A - deceased.\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nMetastatic breast cancer complicated by brain metastases w/ \nseizures\n\n \nDischarge Condition:\nExpired.\n\n \nDischarge Instructions:\nn/a\n \nFollowup Instructions:\n___\n" ]

[ "C7931", "J9601", "G9340", "I959", "E872", "C782", "C7951", "E222", "G40802", "Z853", "Z515", "R740", "Z66", "Z781", "Z87891", "Z923" ]

[ "C7931: Secondary malignant neoplasm of brain", "J9601: Acute respiratory failure with hypoxia", "G9340: Encephalopathy, unspecified", "I959: Hypotension, unspecified", "E872: Acidosis", "C782: Secondary malignant neoplasm of pleura", "C7951: Secondary malignant neoplasm of bone", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "G40802: Other epilepsy, not intractable, without status epilepticus", "Z853: Personal history of malignant neoplasm of breast", "Z515: Encounter for palliative care", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "Z66: Do not resuscitate", "Z781: Physical restraint status", "Z87891: Personal history of nicotine dependence", "Z923: Personal history of irradiation" ]

[ "J9601", "E872", "Z515", "Z66", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: ORTHOPAEDICS\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nright subtrochanteric femur fracture\n \nMajor Surgical or Invasive Procedure:\nright trochanteric femoral nail \n\n \nHistory of Present Illness:\n___ presenting to the ED after a tripping over something at home\n(cant recall how he fell). Denies HS. Felt immediate right hip\npain. Denies pain elsewhere.\n \nPast Medical History:\nHTN, Ocular CA s/p removal of left eye, Sinus CA\n \nSocial History:\n___\nFamily History:\nnon-contributory\n \nPhysical Exam:\nExam:\nVitals: AVSS\nGeneral: Well-appearing, breathing comfortably\nRLE:\nIncision c/d/I, surrounding compartments soft \nStrength ___\nSILT \nRLE well perfused and warm\n \nPertinent Results:\n___ 08:35PM WBC-10.0 RBC-4.08* HGB-12.8* HCT-37.9* MCV-93 \nMCH-31.4 MCHC-33.8 RDW-13.1 RDWSD-44.2\n___ 08:35PM GLUCOSE-141* UREA N-21* CREAT-0.7 SODIUM-138 \nPOTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-25 ANION GAP-14\n \nBrief Hospital Course:\nHospitalization Summary (ED Admit)\nThe patient presented to the emergency department and was \nevaluated by the orthopedic surgery team. The patient was found \nto have right subtrochanteric femur fracture and was admitted to \nthe orthopedic surgery service. The patient was taken to the \noperating room on ___ for a TFN which the patient tolerated \nwell. For full details of the procedure please see the \nseparately dictated operative report. The patient was taken from \nthe OR to the PACU in stable condition and after satisfactory \nrecovery from anesthesia was transferred to the floor. The \npatient was initially given IV fluids and IV pain medications, \nand progressed to a regular diet and oral medications. The \npatient was given ___ antibiotics and anticoagulation \nper routine. The patient's home medications were continued \nthroughout this hospitalization. He received 2 units of PRBCs \npostoperatively and his Hct responded appropriately. The patient \nworked with ___ who determined that discharge to rehab was \nappropriate. The ___ hospital course was otherwise \nunremarkable.\n\nAt the time of discharge the patient's pain was well controlled \nwith oral medications, incisions were clean/dry/intact, and the \npatient was voiding/moving bowels spontaneously. A thorough \ndiscussion was had with the patient regarding the diagnosis and \nexpected post-discharge course including reasons to call the \noffice or return to the hospital, and all questions were \nanswered. The patient was also given written instructions \nconcerning precautionary instructions and the appropriate \nfollow-up care. The patient expressed readiness for discharge.\n\n \nMedications on Admission:\n1. Atenolol 25 mg PO DAILY\n2. Atorvastatin 10 mg PO QPM\n3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H\n4. Cetirizine 10 mg PO DAILY\n5. Cyanocobalamin 1000 mcg PO DAILY\n6. Escitalopram Oxalate 10 mg PO DAILY\n7. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE QHS\n8. Vitamin D ___ UNIT PO DAILY\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO TID \nRX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by \nmouth three times daily Disp #*100 Tablet Refills:*1 \n2. Docusate Sodium 100 mg PO DAILY \nhold for loose stools \nRX *docusate sodium 100 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0 \n3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain \ndon't drink or drive while taking \nRX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours as needed \nDisp #*30 Tablet Refills:*0 \n4. Atenolol 25 mg PO DAILY \n5. Atorvastatin 10 mg PO QPM \n6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H \n7. Cetirizine 10 mg PO DAILY \n8. Cyanocobalamin 1000 mcg PO DAILY \n9. Escitalopram Oxalate 10 mg PO DAILY \n10. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE QHS \n11. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nR subtrochanteric femur fracture\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\n\n \nDischarge Instructions:\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n- weightbearing as tolerated on right lower extremity\n\nMEDICATIONS:\n- Please take all medications as prescribed by your physicians \nat discharge.\n- Continue all home medications unless specifically instructed \nto stop by your surgeon.\n- Do not drink alcohol, drive a motor vehicle, or operate \nmachinery while taking narcotic pain relievers.\n- Narcotic pain relievers can cause constipation, so you should \ndrink eight 8oz glasses of water daily and take a stool softener \n(colace) to prevent this side effect.\n\nANTICOAGULATION:\n- Please take ASA 325mg daily for 4 weeks\n\nWOUND CARE:\n- You may shower. No baths or swimming for at least 4 weeks.\n- Any stitches or staples that need to be removed will be taken \nout at your 2-week follow up appointment.\n- Please remain in your dressing and do not change unless it is \nvisibly soaked or falling off.\n\nPhysical Therapy:\nActivity: Activity: Out of bed w/ assist\n Right lower extremity: Full weight bearing\n Left lower extremity: Full weight bearing\nEncourage turning, deep breathing and coughing qhour when awake.\n\nTreatments Frequency:\nper follow up with dr. ___\n \n___ Instructions:\n___\n" ]

[ "S7221XA", "I10", "W1809XA", "Y92019", "Z85840", "Z9001", "Z8522" ]

[ "S7221XA: Displaced subtrochanteric fracture of right femur, initial encounter for closed fracture", "I10: Essential (primary) hypertension", "W1809XA: Striking against other object with subsequent fall, initial encounter", "Y92019: Unspecified place in single-family (private) house as the place of occurrence of the external cause", "Z85840: Personal history of malignant neoplasm of eye", "Z9001: Acquired absence of eye", "Z8522: Personal history of malignant neoplasm of nasal cavities, middle ear, and accessory sinuses" ]

[ "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nChildren's Advil Allergy Sinus / Vicodin / ibuprofen / NSAIDS \n(Non-Steroidal Anti-Inflammatory Drug)\n \nAttending: ___.\n \nChief Complaint:\nrash\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\nMr. ___ is a ___ male with a history of UC\npreviously controlled without medication but with flare 3 weeks\nago requiring prednisone and remicaide (at ___ who presents\nwith a red rash in two places on his left lower extremity.\n\nA few days ago the patient noticed redness, soreness, and\nprogressive swelling at his left ankle as well as inner left\nthigh. This coincided with his son experiencing an illness with\nvomiting. The redness and swelling progressed, so he was seen by\nhis PCP ___ ___ and started on Keflex for cellulitis. His \nsymptoms\nstill progressed, and Bactrim was added on ___. Despite two oral\nantibiotics symptoms were still progressing, so his PCP saw him\nagain today. A lower extremity ultrasound that identified an\nenlarged inguinal lymph node but was negative for DVT. He \nreports\na subjective fever but denies any chest pain, SOB, cough,\nabdominal pain, nausea, vomiting, or diarrhea. His last bowel\nmovement was three days ago which is unusual for his UC. \n\nIn the ED he was hemodynamically stable and afebrile with a WBC\nof 22 compared to 20 two days ago and 19 at the time of \ndischarge\nfrom ___. He was given clindamycin IV.\n \nPast Medical History:\nULCERATIVE COLITIS - in remission for many years, recently w/ \nsevere flare requiring initiation of Remicade \n \nLACTOSE INTOLERANCE \n \nANEMIA \nH/O IGA NEPHROPATHY \n \nSocial History:\n___\nFamily History:\nRelative Status Age Problem Onset Comments \nMother MELANOMA \n\nFather HEALTHY \n\nMGM MYOCARDIAL ___ \n INFARCTION \n\nMGF CANCER ?stomach or \n pancreas \n\nPGF DIABETES TYPE II \n\n \nPhysical Exam:\nADMISSION EXAM:\n=================\n\nVITALS: ___ 2040 Temp: 98.2 PO BP: 108/65 HR: 82 RR: 18 O2\nsat: 97% O2 delivery: RA \nGENERAL: Alert and in no apparent distress\nEYES: Anicteric sclera\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nCV: Heart regular, no murmur\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\nMSK: Neck supple, moves all extremities\nSKIN: Erythema affecting the left ankle up into the shin. Shiny\nand was secondary exfoliation as the patient had been applying a\ncream. Towards the borders it takes the appearance of confluent\nred macules and even fine petechiae. He states it was warm but \nit\nis not now. At his inner thigh there is an area which appears\ndifferent than the shin. It is more of a confluence of petechiae\nand macules\nNEURO: Alert, oriented, speech fluent\nPSYCH: pleasant, appropriate affect\n\nDISCHARGE EXAM:\n====================\nDERM: \n-erythema on inner thigh completely gone. \n-Circumferential erythema on calf/shin is faded and almost \nentirely gone. \n-He has a residual orange-colored subcutaneous deposit on the \nposterior calf. The substance is hard and has micro-nodular \ntexture when palpated. This is of unclear etiology but it is not \nspreading and does not appear like any complication of \ncellulitis that I know of.\n \nPertinent Results:\nADMISSION LABS:\n\n___ 12:35PM BLOOD WBC-22.7* RBC-4.20* Hgb-13.5* Hct-41.2 \nMCV-98 MCH-32.1* MCHC-32.8 RDW-15.6* RDWSD-56.3* Plt ___\n___ 12:35PM BLOOD Neuts-92.6* Lymphs-2.8* Monos-3.6* \nEos-0.1* Baso-0.1 Im ___ AbsNeut-21.04* AbsLymp-0.64* \nAbsMono-0.83* AbsEos-0.02* AbsBaso-0.02\n___ 12:35PM BLOOD Glucose-92 UreaN-18 Creat-1.0 Na-131* \nK-4.6 Cl-93* HCO3-22 AnGap-16\n\nMICRO:\nBlood culture negative\n\n**********\n\nIMAGING/STUDIES:\n\n___ CHEST XRAY\nNo acute intrathoracic process.\n \nBrief Hospital Course:\nMr. ___ is a ___ male with a history of ulcerative \ncolitis previously controlled without medication but with flare \n3 weeks ago requiring prednisone and Remicade (at ___, who \npresents with a red rash in two places on his left lower \nextremity concerning for cellulitis.\n\n#CELLULITIS OF LLE\nErythema and swelling, which appears clinically consistent with \ncellulitis. He had a pattern of lymphangic spread to the medial \nthigh, which generally is suggestive of streptococcus pyogenes. \nHe was treated with IV vancomycin, which was then switched to IV \nAncef with ongoing improvement. He is discharged on Keflex. \nGiving a longer course (10 days total Abx) due to his slow \nimprovement and immunosuppressed status. \n\n#TINEA PEDIS\nClotrimazole cream for tinea pedis BID x4 weeks.\n\n#Rash\nThe patient has a residual orange-colored subcutaneous deposit \non the left posterior calf. The substance is hard and has \nmicro-nodular texture when palpated. This is of unclear etiology \nbut it is not spreading and does not appear like any \ncomplication of cellulitis that I know of. He is advised to not \nworry about it if it goes away, but to seek derm evaluation if \nit persists or spreads. \n\n#Ulcerative colitis:\nPatient with previously well controlled UC who recently was \ntreated at ___ with severe flare. He was started on Remicade, \nand on prednisone taper currently at 30mg daily.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. PredniSONE 30 mg PO DAILY \n\n \nDischarge Medications:\n1. Cephalexin 500 mg PO QID \n2. Clotrimazole Cream 1 Appl TP BID to fungal left foot \ninfection Duration: 4 Weeks \n3. PredniSONE 30 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nCellulitis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted for cellulitis of the left leg. You improved \n(slowly) with IV antibiotics. \n\nPlease take Keflex four times daily after discharge. I have \ngiven you a longer course of treatment than usual because your \nimmune system is suppressed to treat your recent UC flare and \nyour body is not very good at fighting infections right now.\n\nIf the redness spreads, or if you have fevers or chills, please \nsee a doctor for re-evaluation. If you feel like the infection \nis getting worse again, you should NOT get more Remicade unless \nGI tells you explicitly that it's OK. If you keep getting \nbetter, no specific follow up is needed and you can get Remicade \nas sheduled.\n \nFollowup Instructions:\n___\n" ]

[ "L03116", "K5190", "B353", "R21", "Z87891" ]

[ "L03116: Cellulitis of left lower limb", "K5190: Ulcerative colitis, unspecified, without complications", "B353: Tinea pedis", "R21: Rash and other nonspecific skin eruption", "Z87891: Personal history of nicotine dependence" ]

[ "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Cephalosporins / hazelnut / water chestnut / house \ndust mite / tree nuts / Topamax\n \nAttending: ___.\n \nChief Complaint:\nfevers\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ is a ___ yo man with relapsed aggressive NHL s/p\nautoSCT ablative/BEAM (___), who presents with fever to\n100.7F on day + 29. \n\nMr ___ in clinic ___ and was doing well apart from \nongoing\ntoothache of a left upper incisor. He saw his dentist the day\nprior to presentation and received extraction of the problematic\ntooth. \n\nAfterward, he reports he has increased pain in his front teeth\nwhen he bites down. He rates the pain as ___ and sharp, but it\nis not reproducible when he touches the area and there is no \ncold\nsensitivity. He has not noticed any drainage or swelling in the\nmouth. \n\nHe was otherwise in his USOH until this evening, when he began \nto\nfeel progressively more fatigued. He checked his temperature at \n8\npm and found it was 100.7F, prompting presentation to ED. He did\nnot take any antipyretics. \n\nOn arrival to ED, he had nausea with a small episode of clear\nyellowy emesis, which he attributes to motion sickness. He \ndenies\nsore throat, rhinorrhea, cough, chest pain, SOB, palpitations,\nabdominal pain, loose stool, dysuria, flank pain, ear ache,\nheadache. He was constipated x ___ days, but had a BM earlier in\nthe day after drinking prune juice. He did not notice a rash. No\nsick contacts. He has not missed any doses of his prophylactic\nmeds\n\nIn the ED: T max 101.7F | 100s-110s | 100s-120s/60s-70s | 98% \nRA.\nCXR was normal. Labs were unchanged from prior. He was given 1L\nNS, vanc/levaquin, and tylenol prior to admission. \n\nAll other review of systems are negative unless stated otherwise\n\n \nPast Medical History:\n- Extensive allergy to food and environmental (presents as rash)\n- wisdom teeth extraction \n- typhoid fever when a child\n- multiple dental implants\n- PE/DVT ___\n- Oral ulcer ___ biopsy\n- thyroid nodule ___\n- OSA on CPAP at home\n\nTREATMENT HISTORY:\n___ Cycle#1 DA-EPOCH Dose level 1\n___ IT MTX\n___ Cycle #1 Rituximab\n___ Cycle #2 DA-EPOCH Dose level 2 with bortezomib \n___\nCycle #2 Rituximab\n___ Cycle #3 DA-EPOCH Dose level 2 with bortezomib\n___ Cycle #3 Rituximab\n___ Cycle #4 DA-EPOCH Dose level 2 with bortezomib\n___ Cycle #4 Rituximab\n___ Cycle #5 DA-EPOCH Dose level 3 with bortezomib\n___ Cycle #5 Rituximab\n___ Cycle #6 DA-EPOCH Dose level 3 with bortezomib\n___ Cycle #6 Rituximab\n___ ID MTX 3500 mg/m2\n___ ID MTX 3500 mg/m2\n\nRELAPSED DISEASE:\n___ ICE Cycle#1 \n--___ Rituximab (infusion reaction)\n\n___ Rituximab Cycle #2\n-___ ICE cycle#2\n\n___ PET-CT CR\n \n___ Rituximab Cycle #3\n___ ICE Cycle#3 \n\n___ CD34/kg= 4.88e6\n\n___ Tooth extraction\n\n___ Transplant admission\n\n___ ASCT/ablative/BEAM \n\n \nSocial History:\n___\nFamily History:\nMother - CAD, hypertension, diabetes, see CKD, 19 pregnancies \ndied at age ___. Father - healthy died age ___. One sister \ndeceased in ___ from Breast cancer. One sister deceased at ___ \nfrom CAD. 4 remaining sisters are alive, with one sister age ___ \nwith Hodgkin lymphoma. 4 brothers are alive, 2 with known CAD. \nAll living in ___ or ___ and are between the ages of early \n___ to late ___.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVITALS: ___ 0352 Temp: 100.3 PO BP: 96/64 HR: 138 RR: 20 O2\nsat: 98% O2 delivery: ra \nGeneral: Tired appearing, pleasant middle aged man, resting in\nbed\nNeuro: Alert, oriented, provides clear and detailed history.\nPERRL, palate elevates symmetrically, ___ ___ strength\nHEENT: Face appears flushed. No scleral icterus. no tenderness \nto\npercussion over sinuses. Oropharynx- slightly dry mucus\nmembranes. No mucositis. Site of tooth extraction looks clean,\noverlying mucosa is pale, not inflamed/warm to touch. No\ndrainage. Teeth/gums are nontender to palpation\nCardiovascular: Tachycardic, regular, no murmurs\nChest/Pulmonary: Clear to auscultation bilaterally\nAbdomen: Soft, mildly tender over the epigastrum and left upper\nquadrant, no rebound, nondistended. Bowel sounds are audible\nPelvis/GU: No CVA tenderness\nExtr/MSK: No peripheral edema. WWP\nSkin: Torso and face pink and slightly warmer to touch compared\nto arms/legs. Blanchable. No raised papular areas\nAccess: POC, nontender to palpation\n\nDISCHARGE PHYSICAL EXAM:\nVITALS: ___ 1420 Temp: 99.5 PO BP: 104/76 HR: 100 RR: 18 O2 \nsat: 98%\nO2 delivery: ra \nGeneral: OOB to chair in no acute distress\nHEENT: No scleral icterus. no tenderness to percussion over \nsinuses. Oropharynx no OP lesions, dry mucus membranes. \nTenderness upper front teeth. No gum swelling, redness or \ndrainage. \nCardiovascular: RRR, no murmurs, rubs or gallops. \nPULM: Clear to auscultation bilaterally, no adventitious LS, \nnon-labored, normal effort. \nAbdomen: normoactive BS throughout, soft, non-tender, no \nrebound, nondistended. \nExtr/MSK: No peripheral edema. WWP\nSkin: no rashes or lesions\nNeuro: A&Ox3, PERRL, palate elevates symmetrically, CNII-VII \ngrossly intact\nAccess: POC, dressing CDI, insertion site without erythema or \ndrainage, nontender to palpation.\n \nPertinent Results:\nADMISSION LABS:\n----------------\n___ 10:40PM BLOOD WBC-4.8 RBC-3.46* Hgb-10.7* Hct-33.2* \nMCV-96 MCH-30.9 MCHC-32.2 RDW-19.9* RDWSD-68.8* Plt ___\n___ 10:40PM BLOOD Neuts-38.0 ___ Monos-32.5* \nEos-3.9 Baso-1.0 Im ___ AbsNeut-1.83 AbsLymp-1.16* \nAbsMono-1.57* AbsEos-0.19 AbsBaso-0.05\n___ 10:40PM BLOOD Glucose-105* UreaN-12 Creat-0.8 Na-139 \nK-4.2 Cl-105 HCO3-19* AnGap-15\n___ 10:40PM BLOOD ALT-21 AST-26 LD(LDH)-285* AlkPhos-61 \nTotBili-0.2\n___ 06:02AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.4*\n\nDISCHARGE LABS:\n-----------------\n___ 12:00AM BLOOD WBC-11.4* RBC-3.63* Hgb-11.0* Hct-34.8* \nMCV-96 MCH-30.3 MCHC-31.6* RDW-18.9* RDWSD-67.2* Plt ___\n___ 12:00AM BLOOD Neuts-71.0 Lymphs-11.7* Monos-12.0 \nEos-2.6 Baso-0.6 Im ___ AbsNeut-8.10* AbsLymp-1.34 \nAbsMono-1.37* AbsEos-0.30 AbsBaso-0.07\n___ 12:00AM BLOOD Plt ___\n___ 12:00AM BLOOD Glucose-132* UreaN-7 Creat-0.7 Na-140 \nK-4.0 Cl-103 HCO3-23 AnGap-14\n___ 12:00AM BLOOD ALT-22 AST-24 LD(LDH)-277* AlkPhos-73 \nTotBili-<0.2\n___ 12:00AM BLOOD Albumin-3.8 Calcium-8.7 Phos-3.7 Mg-1.___ year-old male with relapsed aggressive NHL s/p autoSCT \nablative/BEAM (___), who presented with fevers, tmax \n101.7F on Day + ___ s/p tooth extraction and new abdominal pain. \n\n#S/P AUTOLOGOUS STEM CELL TRANSPLANT\n#RELAPSED HIGH-GRADE B CELL LYMPHOMA: \nPET showed no avid lesions after completion of 3 cycles R-ICE, \nnow S/P ASCT with BEAM conditioning. Today is day +36. He \ncontinues on ppx with Acyclovir TID and Bactrim daily. \n\n#FEVER OF UNKNOWN ORIGIN\n#FEBRILE NEUTROPENIA\n#SIRS\n#EPIGASTRIC/LUQ ABDOMINAL PAIN\n#HHV-6 VIREMIA\n#HYPOTENSION\n#LACTIC ACIDEMIA\n#ORAL THRUSH:\nPt is s/p auto SCT (___). His transplant course was \ncomplicated by presumed ___ esophagitis and neutropenic \nfever. Fevers had resolved for x7 days then reoccurred. He was \ntreated with empiric abx, fevers resolved after pheresis line\nremoval on ___. Ultimately, fevers of unknown origin had been \nattributed to HHV-6 Viremia with most recent level undetectable \n___. Localizing s/s on admission included tooth pain and \nabdominal pain. He was pan cultured. No growth in BCx obtained \n___ and ___. U/A unremarkable and urine culture \nnegative. CXR without focal consolidation. Neutropenic on GCSF \n480mcg SX x1 given ___ with improvement in WBC. Labs were \nremarkable for lactic acidemia to 2.4 on admit, fluid \nresponsive, now WNL. Pt received a total of 4L IVF boluses for \nsoft systolic BP's in ___. Epigastric and LUQ abdominal pain \nwere relieved with bowel movement, previously there was c/f \npancreatitis given location and Amylase 114. Dental pain was \nconcerning for dental abscess or oral flora translocation, but \nCT sinus/mandible negative for abscess. Neutropenic ___ with \nANC 90 received GCSF 480mcg SC x1 with improvement in WBC. Pt \nwas pan scanned w/ CT Torso and Sinus Mandible ___, scans \nwere unremarkable for source of infection. He was started on \n___ ), Vancomycin (___), \nand Flagyl (___). Given resolution of fevers, IV \nabx were switched to Levaquin ___- )for possible soft \ntissue etiology d/t mouth pain. Due to persistent low grade \nfevers, panorex was obtained with a dental consult evaluation. \nPer dental evaluation ___, there is no evidence of acute \ndental infection at present time. Dentition is less likely a \nsource for the fever. Recommendation to seek dental care on \noutpatient bases. At discharge, he continues on Levoflaxacin for \nan additional 6 days (last dose ___. \n\n#R GASTROCNEMIUS VEIN THROMBUS\n#HX DVT/PE: \nPt with new RLE pain on palpation ___. LENIS negative for \nDVT bilaterally ___. On prior admission, had edema R>L \nprompted U/S which revealed a right gastrocnemius vein thrombus, \na deep muscular vein of the calf. Per clotting specialist, did \nnot feel it was likely that he would require anticoagulation \nonce counts recovered. U/S ___ did not reveal extension of \nthrombus, repeated U/S ___ showed no evidence of thrombus. \nLovenox was discontinued with count recovery and he was \nrestarted on home dose ASA. History of provoked DVT/PE in \n___, was treated with LMWH x10 months. He continues ASA 81mg \nPO daily at discharge. \n\nCHRONIC/STABLE/RESOLVED CONDITIONS\n=========================================\n\n#NAUSEA: Resolved. Likely secondary to abdominal pain and \nconstipation. Nausea was managed with PRN Zyprexa, Compazine and \nZofran. Monitored QTc while receiving the above agents, most \nrecent QTc=439 on ___. \n\n#CHRONIC PAIN/SCIATICA: Intermittent exacerbation noted in the \nsetting of other confounding pain episodes. He continues on \nfentanyl patch 0.25mcg q72hrs and tramadol PRN.\n\n#PLATELET TRANSFUSION REACTION: No reoccurrence since ___. \nDeveloped difficulty breathing 20 minutes following end of \nplatelet transfusion ___. He was managed with antihistamine \nwith relief of symptoms. Workup initiated with Blood Bank. No \nchanges in standard transfusion practices are recommended in \nthis patient at this time. \n\n#? ASTHMA: Patient without documented history of asthma but \nnotably taking Symbicort PRN at home. Also, taking ProAir at \nhome PRN. No current s/s of asthma. At discharge, will continue \nPRN Proair and Symbicort (budesonide-formoterol).\n\n#POSITIVE HEPATITIS B CORE ANTIBODY: Consistent with prior Hep B \nVirus exposure. Most recently HBV VL negative ___. Continue \nhome regimen with Entecavir 0.5mg qd for prophylaxis. \n\n#VITAMIN D DEFICIENCY: Most recent Vitamin D level=58 on \n___. Home Vitamin D supplementation continued at discharge.\n\n#ALLERGIC RHINITIS: Chronic, exacerbated with dust exposure. \nWell controlled on cetirizine 10mg PO daily. \n\n#OSA: No acute exacerbations. Not using CPAP inpatient.\n\nCORE MEASURES\n==============================\n#CODE: Full (presumed)\n#CONTACT: ___ (wife), ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol Inhaler ___ PUFF IH Q4H:PRN asthma \n2. Cetirizine 10 mg PO DAILY:PRN allergies \n3. Entecavir 0.5 mg PO DAILY \n4. Fentanyl Patch 25 mcg/h TD Q72H \n5. Acyclovir 400 mg PO TID \n6. Omeprazole 40 mg PO DAILY \n7. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line \n8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second \nLine \n9. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second \nLine \n10. Senna 8.6 mg PO BID:PRN Constipation - First Line \n11. Vitamin D ___ UNIT PO DAILY \n12. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation \ninhalation 1 PUFF ONCE DAILY \n13. OLANZapine (Disintegrating Tablet) 2.5 mg PO BID:PRN nausea \n14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n15. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n16. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. LevoFLOXacin 500 mg PO Q24H \nPlease continue to take daily through ___, then stop. \n2. ___ ___ UNIT PO QID \n3. Acyclovir 400 mg PO TID \n4. Albuterol Inhaler ___ PUFF IH Q4H:PRN asthma \n5. Aspirin 81 mg PO DAILY \n6. Cetirizine 10 mg PO DAILY:PRN allergies \n7. Entecavir 0.5 mg PO DAILY \n8. Fentanyl Patch 25 mcg/h TD Q72H \n9. OLANZapine (Disintegrating Tablet) 2.5 mg PO BID:PRN nausea \n\n10. Omeprazole 40 mg PO DAILY \n11. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line \n12. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second \nLine \n13. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second \nLine \n14. Senna 8.6 mg PO BID:PRN Constipation - First Line \n15. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n16. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation \ninhalation 1 PUFF ONCE DAILY \n17. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n18. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n-----------------\nNHL\nS/p AUTO SCT\nHYPOTENSION\nFEVERS OF UNKNOWN ORIGIN\nNAUSEA\nHHV-6 VIREMIA\n\nSECONDARY DIAGNOSIS\n--------------------\nASTHMA\nPOSITIVE HEPATITIS B CORE ANTIBODY\nCHRONIC/PAIN SCIATICA\nVITAMIN D DEFICIENCY\nHISTORY OF DVT/PE\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. ___,\nYou were admitted for fevers and low blood pressures. We started \nyou on antibiotics and your fevers resolved. You will be \ndischarged on an oral antibiotic, Levofloxacin. You were given \nIV fluids and your blood pressure normalized. Please check your \ntemperature 3 times a day at home and call us if you have a temp \nof 100.0 or greater. \n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "R509", "C8339", "B1910", "Z9484", "E872", "I959", "J45909", "M5430", "E559", "Z86718", "G4733", "R112" ]

[ "R509: Fever, unspecified", "C8339: Diffuse large B-cell lymphoma, extranodal and solid organ sites", "B1910: Unspecified viral hepatitis B without hepatic coma", "Z9484: Stem cells transplant status", "E872: Acidosis", "I959: Hypotension, unspecified", "J45909: Unspecified asthma, uncomplicated", "M5430: Sciatica, unspecified side", "E559: Vitamin D deficiency, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "G4733: Obstructive sleep apnea (adult) (pediatric)", "R112: Nausea with vomiting, unspecified" ]

[ "E872", "J45909", "Z86718", "G4733" ]

[]

[ " \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:\nshortness of breath\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with PMH of tracheobronchial \nmalacia s/p trachea-bonchoplasty (___), trach on ___, and \na T tube placed ___, as well as CHF with EF of 49%, COPD, \nAfib, RUE on apixaban, anxiety, and substance abuse who \npresented to the ED overnight on ___ with acute shortness of \nbreath starting at 0200. \n\nShe states she was waking up to go to the bathroom when she had \nextreme dyspnea. She initially had used her home NC O2 (which \nshe has for intermittent use, but is not on constantly) as well \nas an albuterol neb, without relief of her symptoms. She then \ncalled ___ and was brought ___. Her exam was significant for \nincreased work of breathing, diffuse crackles bilaterally and \ntachycardia. She was immediately placed on BiPAP at ___ at 40% \nFiO2 and given nitroglycerin, 1mg IV Lorazepam, and 40IV Lasix \n(she's on 20 torsemide every other day at home). \n\nLabs were significant for a VBG w/ pH of 7.23/ Co2 52/HCO3 23, a \nWBC of 21.3, H/H- H/H- 10.3/33.7, Plt-601, normal chem panel, a \nBNP of 799, and Lactate of 4.4. A chest x-ray showed diffuse \nvascular congestion with increased consolidation on the left. \nShe was empirically started on antibiotics with azithro and \ncefepime for presumed PNA. With BiPAP her symptoms improved, \nhowever, her O2 sats and symptoms were unable to tolerate coming \noff of the BiPAP. She was then admitted to the MICU for BiPAP \nrequirement. \n \n___ ED initial VS: HR- 126, BP-165/63, RR-31, O2-94% bipap \n \nLabs significant for: \n- VBG: pH 7.23 pCO2 52 pO2 53 HCO3 23; O2Sat: 77 \n- Lactate:4.4\n- BMP: Na-138, K-4.3, Cl-95, HCO3-21, Cr-1.1, BUN- 19, 260, \nAGap=22 \n- Trop-T: <0.01 \n- proBNP: 799\n- CBC: WBC- 21.3, H/H- 10.3/33.7, Plt-601 \n \nPatient was given: \n- IV Furosemide 20mg x2\n- IV LORazepam 1 mg \n- IV Azithromycin 500 mg \n- IV CefePIME (2 g ordered) \n\nImaging notable for: \n- CXR: 1. Moderate cardiomegaly with asymmetric pulmonary edema, \nleft greater than right is consistent w/ cardiac decompensation. \n2. Small bilateral pleural effusions, right greater than left. \n\nConsults: None \n\nVS prior to transfer: T-97.6, HR-69, BP-95/42, RR-21, O2-94% \nbipap \n\nOn arrival to the MICU, the patient was resting comfortably ___ \nbed on BiPAP. She stated that her breathing had significant \nimproved. \n \nPast Medical History:\n - Tracheo/cervical bronchomalacia s/p TBP ___, trach/PEG on \n___, and T-tube placement ___. \n - HFpEF + mild HFrEF (EF 49%) \n - atrial fibrillation \n - atrial tachycardia with rate-dependent LBBB \n - COPD/asthma \n - Moderate OSA(AHI 29) \n - HTN \n - Hypercholesterolemia \n - T2DM \n - GERD, ___ esophagus \n - Diverticulitis \n - RUE DVT ___ on apixiban \n - Rheumatoid arthritis \n - Restless leg syndrome \n - Depression \n - Polysubstance abuse \n \nSocial History:\n___\nFamily History:\nMother: Lung cancer, CHF\nFather: CHF\nAunt: ___ CA\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVITALS: Reviewed ___ Metavision\nGENERAL: Alert, oriented, no acute distress . On BiPAP. \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP not elevated, no LAD \nLUNGS: Crackles and intermittent wheezes ___ bilateral lung \nfields. \nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nNEURO: Alert and oriented x3. Conversant. \n\nDISCHARGE PHYSICAL EXAM\nAdmission Weight: 80.9kg (standing)\n___ Weight: 77.6 (standing) \nVitals: 98.8 PO 137 / 70 78 18 94 Ra \nGENERAL: AOx3, NAD \nHEENT: Normocephalic, atraumatic. Pupils equal, round, and\nreactive bilaterally. MMM \nNECK: Supple. No visible JVD at 45 degree angle. \nCARDIAC: RRR, normal S1 and S2, no murmurs/rubs/gallops. \nLUNGS: rhonchi at the bases bilaterally \nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation ___ all four quadrants. \nEXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial \n2+\nbilaterally.\nMSK: Tenderness to palpation of MCPs and wrists bilaterally, but\nno erythema or synovitis. No joint deformities of either hand.\nROM intact at wrist and elbow joints. Tenderness to palpation of\nbilateral ankle joints, ROM intact. Otherwise nontender.\nNEUROLOGIC: AOx3. Strength and sensation grossly intact. \n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 02:47AM WBC-21.3*# RBC-4.44 HGB-10.3* HCT-33.7* \nMCV-76* MCH-23.2* MCHC-30.6* RDW-15.9* RDWSD-43.8\n___ 02:47AM NEUTS-55 BANDS-2 ___ MONOS-13 EOS-4 \nBASOS-0 ___ MYELOS-0 AbsNeut-12.14* AbsLymp-5.54* \nAbsMono-2.77* AbsEos-0.85* AbsBaso-0.00*\n___ 02:47AM HYPOCHROM-NORMAL ANISOCYT-NORMAL \nPOIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-3+* POLYCHROM-NORMAL\n___ 02:47AM cTropnT-<0.01 proBNP-799*\n___ 02:47AM GLUCOSE-260* UREA N-19 CREAT-1.1 SODIUM-138 \nPOTASSIUM-4.3 CHLORIDE-95* TOTAL CO2-21* ANION GAP-22*\n___ 02:57AM O2 SAT-77\n___ 02:57AM LACTATE-4.4*\n___ 02:57AM ___ PO2-53* PCO2-52* PH-7.23* TOTAL \nCO2-23 BASE XS--6\n___ 03:00AM URINE UCG-NEGATIVE\n___ 03:00AM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 03:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100* \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-NEG\n___ 03:00AM URINE RBC-0 WBC-1 BACTERIA-FEW* YEAST-NONE \nEPI-0\n___ 03:00AM URINE GRANULAR-1* HYALINE-22*\n___ 03:00AM URINE MUCOUS-RARE*\n\nDISCHARGE LABS:\n===============\n___ 08:20AM BLOOD WBC-15.4* RBC-4.13 Hgb-9.4* Hct-31.3* \nMCV-76* MCH-22.8* MCHC-30.0* RDW-16.3* RDWSD-45.1 Plt ___\n___ 08:20AM BLOOD Plt ___\n___ 08:20AM BLOOD Glucose-214* UreaN-26* Creat-1.0 Na-140 \nK-4.2 Cl-96 HCO3-22 AnGap-22*\n___ 08:20AM BLOOD Calcium-10.0 Phos-5.6* Mg-2.6 Iron-26*\n___ 08:20AM BLOOD calTIBC-437 Ferritn-63 TRF-336\n\nMICRO:\n======\n__________________________________________________________\n___ 10:54 am SPUTUM Source: Induced. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n >25 PMNs and <10 epithelial cells/100X field. \n 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. \n ___ PAIRS AND CLUSTERS. \n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). \n\n RESPIRATORY CULTURE (Final ___: \n MODERATE GROWTH Commensal Respiratory Flora. \n GRAM NEGATIVE ROD(S). SPARSE GROWTH. \n OF TWO COLONIAL MORPHOLOGIES. \n GRAM NEGATIVE ROD #3. RARE GROWTH. \n__________________________________________________________\n___ 3:35 am BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n__________________________________________________________\n___ 3:00 am URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH. \n__________________________________________________________\n___ 2:47 am BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n__________________________________________________________\n___ 8:20 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__________________________________________________________\n___ 5:39 am BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: \n CANCELLED. Culture negative as of: ___ AT 0539. \n Test canceled/culture discontinued per: ___. \n PATIENT CREDITED. \n__________________________________________________________\n___ 4:15 am BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: \n CANCELLED. Culture negative as of: ___ AT 415. \n Test canceled/culture discontinued per: ___. \n PATIENT CREDITED. \n\nIMAGING:\n========\nCXR PA and Lateral ___:\nNo acute cardiopulmonary abnormality.\n\nCXR PA and Lateral ___:\nOverall hazy opacity of the left lung appears improved from \nprior exam,\nhowever there is persistent bilateral hazy opacity which likely \nrepresents\npersistent mild pulmonary edema. Blunting of the right \ncostophrenic angle and elevation of the right hemidiaphragm \nappears unchanged. No definite pleural effusion. No definite \nconsolidative opacity. Cardiomegaly appears unchanged. \nTracheostomy tube is not well visualized but likely ___ unchanged \npositions.\n\n \nBrief Hospital Course:\nPatient Summary for Admission:\n================================\nMs. ___ is a ___ female with PMH of tracheobronchial \nmalacia s/p trachea-bronchoplasty (___), trach on ___, \nand a T tube placed ___, as well as CHF with EF of 49%, \nCOPD, Afib, RUE on apixaban, anxiety, and substance abuse who \npresented to the ED overnight on ___ with acute shortness of \nbreath initially admitted to the MICU for new BiPAP requirement \nand transferred to the floor after improved respiratory status. \n\nACUTE Issues Addressed:\n=========================\n# Acute On Chronic Respiratory Distress: Patient's CXR on \nadmission notable for mild pulmonary edema, and ___ the setting \nof patient's reported weight gain and abdominal distension, \nacute respiratory insufficiency was felt to be secondary to an \nacute exacerbation of chronic diastolic failure. She was \ninitially placed on BiPAP and recieved 40mg IV lasix ___ and \n___. Patient was weaned from BiPAP on ___ on presentation to \nthe MICU. Also concern for infection driving respiratory failure \nso patient was treated for pneumonia with Azithromycin and \nCefepime. Given that the patient's symptoms improved with \ndiuresis and she had no evidence clinically of ongoing \ninfection, antibiotics were discontinued ___ and patient was \nstable for transfer to the medicine service. Respiratory status \nwas further managed with ongoing treatment for known COPD and \ntracheobronchial malacia. Patient continued home Albuterol, \nBenzonatate, Mucomyst, Fluticasone and T Tube maintenance under \nthe supervision of Interventional Pulmonology. Induced sputum \nculture showing 2+ GPCs ___ pairs and clusters, with 1+ GNRs, \nwith sparse growth on culture. Given ongoing leukocytosis and\ncough, and the patient's low respiratory reserve, patient \nstarted back on Levofloxacin for treatment of presumed CAP for a \ntotal treatment course of 5 days (day ___. However, given \nlong QTC of 590 and low suspicion for pneumonia, levofloaxacin \nstopped after three days. Patient given intermittent furosemide \n40mg IV boluses for volume overload and was discharged on \ntorsemide 20 mg PO daily. Patient discharged home with \nprescription for humidified air.\n\n# Hypotension \nPatient initially presented to the ED with hypertension, but \ndropped her BPs into ___ following administration of IV \nLorazepam. Unclear etiology of initial hypotension as infection \nseemed unlikely, but likely secondary to lorazepam. However \npatient's pressures improved and Clonidine, Diltiazem, and \nMetoprolol were restarted ___ after being held initially. \n\n# AFIB: After hypotension resolved, patient continued home \nDitliazem, Metoprolol. However, heart rates continued to be \nelevated so metoprolol succinate increased to 37.5 mg daily to \nbetter optimize diastolic heart failure and rate-dependent left \nbundle branch block. We continued anticoagulation with Apixaban.\n\n# HFrEF\n# Chronic systolic heart failure: \nMost recent prior echo ___ with Grade II LV diastolic \ndysfunction, mild to moderate MR, and LVEF of 49%. History \nconcerning for increasing weight, dyspnea. Patient received 40mg \nIV lasix intermittently. She also continued her home Metoprolol \nas above, aspirin and atorvastatin.\n\n#thrombocytosis: Patient with elevated platelet count of unclear \netiology. However, found to have iron deficiency anemia so \nstarted on ferrous sulfate upon discharge. ___ have also been \nreactive secondary to RA. \n\nCHRONIC ISSUES: \n# Rheumatoid Arthritis\nNot currently following with a rheumatologist. Has taken \nmultiple RA meds at various points ___ the past, including MTX, \nplaquenil, Enbril, and Humira. Not currently on a DMARD or \nbiologic.\nEndorsed significant bilateral MCP, wrist, and ankle pain, but \nno e/o synovitis on exam. We continued home naproxen, tramadol, \nTylenol, and heat packs PRN. Patient should see rheumatology as \nan outpatient. \n\n# Fibromyalgia\nWe continued home pregabalin 75mg PO TID\n\n# h/o RUE DVT: \nWe continued Apixaban \n\n# COPD: We continued on home albuterol, benzonatate, mucomyst \nand\nfluticasone \n\n# T2DM: We held home glimepride and gave Humalog insulin sliding \nscale as inpatient. \n\n# GERD: We continued home pantoprazole \n\n# DEPRESSION: We continued home Fluoxetine, Buspirone. We held \nhome PRN Klonopin and Ativan \n\n# RLS: We held home PRN Flexeril \n\n# Hyperlipidemia We continued home Atorvastatin \n\nTransitional issues:\n==================\n[ ] Patient is interested ___ trying Voltaren gel for her joint \npain upon discharge (couldn't while she was here given \nnon-formulary).\n[ ] Patient does not currently follow with a rheumatologist for \nher RA. Consider arranging follow up at discharge.\n[ ] increased torsemide to 20mg PO daily upon discharge. Per \npatient, she has needed a PO potassium supplement ___ the past \nwhile on a higher dose of torsemide.\n[ ] Please check Chem-10 three days post-discharge. If potassium \nis low, please initiate potassium repletion \n[ ] patient's metoprolol succinate XL increased from 25mg PO \ndaily to 37.5mg daily\n[ ] please check QTc within 1 week as discharge QTc was 590\n[ ] patient found to have iron deficiency anemia so started on \nferrous sulfate 325mg PO daily. Recommend rechecking iron \nstudies ___ ___ months to ensure resolution. \n[ ] please ensure all health maintenance including colonoscopy \nare completed given iron deficiency anemia\n[ ] please check platelets within 1 month to ensure that \nthrombocytosis resolves with iron replacement. Discharge \nplatelets 549.\n[ ] consider sleep apnea workup as cause of pulmonary issues \n[ ] Plan to set up humidified air to assist with secretions and \ncomfort with the intent to help prevent her multiple \nreadmissions\n\nHCP: ___ (sister)\nPhone number: ___ \n- Code: Full, Confirmed \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n2. Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB \n3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheeze \n4. Apixaban 5 mg PO BID \n5. Aspirin 81 mg PO DAILY \n6. Atorvastatin 80 mg PO QPM \n7. Benzonatate 100 mg PO TID:PRN cough \n8. BusPIRone 30 mg PO DAILY \n9. ClonazePAM 0.5 mg PO TID:PRN anxiety, insomnia \n10. CloNIDine 0.2 mg PO TID \n11. Cyclobenzaprine 5 mg PO HS:PRN spasm \n12. Diltiazem Extended-Release 360 mg PO DAILY \n13. FLUoxetine 60 mg PO DAILY \n14. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n15. LORazepam 1 mg PO Q8H:PRN breakthrough anxiety \n16. Metoprolol Succinate XL 25 mg PO DAILY \n17. Pantoprazole 40 mg PO Q24H \n18. Torsemide 20 mg PO EVERY OTHER DAY \n19. TraMADol 50 mg PO DAILY:PRN Pain - Moderate \n20. glimepiride 2 mg oral DAILY \n21. Naproxen 500 mg PO Q12H:PRN Pain - Moderate \n22. Pregabalin 75 mg PO TID \n\n \nDischarge Medications:\n1. Ferrous Sulfate 325 mg PO DAILY \nRX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*0 \n2. Metoprolol Succinate XL 37.5 mg PO DAILY \nRX *metoprolol succinate 25 mg 1.5 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0 \n3. Torsemide 20 mg PO DAILY \nRX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n5. Acetylcysteine 20% ___ mL NEB Q4H:PRN SOB \n6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheeze \n7. Apixaban 5 mg PO BID \n8. Aspirin 81 mg PO DAILY \n9. Atorvastatin 80 mg PO QPM \n10. Benzonatate 100 mg PO TID:PRN cough \n11. BusPIRone 30 mg PO DAILY \n12. ClonazePAM 0.5 mg PO TID:PRN anxiety, insomnia \n13. CloNIDine 0.2 mg PO TID \n14. Cyclobenzaprine 5 mg PO HS:PRN spasm \n15. Diltiazem Extended-Release 360 mg PO DAILY \n16. FLUoxetine 60 mg PO DAILY \n17. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n18. glimepiride 2 mg oral DAILY \n19. LORazepam 1 mg PO Q8H:PRN breakthrough anxiety \n20. Naproxen 500 mg PO Q12H:PRN Pain - Moderate \n21. Pantoprazole 40 mg PO Q24H \n22. Pregabalin 75 mg PO TID \n23. TraMADol 50 mg PO DAILY:PRN Pain - Moderate \n24.home devices\n ___\n\nplease provide patient with corrugated tubing, trach mask, drain \nbag, neb bottle, and 50 PSI compressor with 12 refills\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis:\nAcute on chronic respiratory distress\nAcute on chronic diastolic heart\nHeart failure with reduced ejection fraction\n\nSecondary diagnoses:\nAtrial fibrillation\nRight upper extremity deep vein thrombosis\nChronic obstructive pulmonary disease\nType 2 diabetes mellitus\nGastroesophageal reflux disease\nDepression\nRestless leg syndrome\nChronic pain\nHyperlipidemia\n\nSecondary Diagnosis:\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 because you were short of breath and you had \nevidence of a pneumonia/excess volume ___ your lungs.\n\nWHAT WAS DONE WHILE I WAS HERE?\nWe gave you antibiotics to treat your pneumonia. \nWe gave you BiPAP, a machine to help you breath. \nWe gave you medications to decrease the fluids ___ your lungs.\n\nWHAT SHOULD I DO NOW?\n-You should take your medications as instructed\n-You should go to your doctor's appointments as below\n-weigh yourself every morning, and call a doctor if your weight \ngoes up more than 3 lbs.\n\nWe wish you the best!\n-Your ___ Care Team\n\n \nFollowup Instructions:\n___\n" ]

[ "I5043", "J9622", "J9621", "I959", "Z930", "Z9981", "I4581", "I471", "I4891", "E119", "D473", "Z931", "G2581", "F329", "J449", "I110", "Z86718", "K219", "Z7902", "F419", "I447", "G4733", "E7800", "K2270", "M069", "Z87891", "D509", "M797", "T424X5A", "Y92239" ]

[ "I5043: Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure", "J9622: Acute and chronic respiratory failure with hypercapnia", "J9621: Acute and chronic respiratory failure with hypoxia", "I959: Hypotension, unspecified", "Z930: Tracheostomy status", "Z9981: Dependence on supplemental oxygen", "I4581: Long QT syndrome", "I471: Supraventricular tachycardia", "I4891: Unspecified atrial fibrillation", "E119: Type 2 diabetes mellitus without complications", "D473: Essential (hemorrhagic) thrombocythemia", "Z931: Gastrostomy status", "G2581: Restless legs syndrome", "F329: Major depressive disorder, single episode, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "I110: Hypertensive heart disease with heart failure", "Z86718: Personal history of other venous thrombosis and embolism", "K219: Gastro-esophageal reflux disease without esophagitis", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "F419: Anxiety disorder, unspecified", "I447: Left bundle-branch block, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E7800: Pure hypercholesterolemia, unspecified", "K2270: Barrett's esophagus without dysplasia", "M069: Rheumatoid arthritis, unspecified", "Z87891: Personal history of nicotine dependence", "D509: Iron deficiency anemia, unspecified", "M797: Fibromyalgia", "T424X5A: Adverse effect of benzodiazepines, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]

[ "I4891", "E119", "F329", "J449", "I110", "Z86718", "K219", "Z7902", "F419", "G4733", "Z87891", "D509" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPennicilin / Vancomycin / Latex\n \nAttending: ___.\n \nChief Complaint:\nTransfer for PFO evaluation\n \nMajor Surgical or Invasive Procedure:\ncapsule endoscopy ___\n \nHistory of Present Illness:\nMs. ___ is a ___ year old woman with extensive medical \nhistory including cirrhosis of unclear etiology, DM Type I, \nrecent L cerebellar infarct, DVT, GI bleed, who is transferred \nfrom ___ for PFO closure \nevaluation.\n\nMs. ___ had a recent prolonged hospitalization from ___ \nfor severe UTI, L cerebellar CVA, and Bilateral ___ DVTs treated \nwith heparin, with subsequent GI bleed requiring 3 units of \npRBCs. Colonoscopy demonstrated internal hemorrhoids but no \nclear focus of bleeding. She declined transfer to tertiary care \n___ aniography/embolization, and unfortunately left AMA.\n\nShe returned to ___ on ___ with cough, AMS, hypoxia to 83% \nrequiring non-rebreather in the ICU. CXR demonstrated pneumonia, \nand she was treated with levofloxacin with improvement. A CT \nangiogram was performed which was negative for PE. Repeat u/s of \nher lower extremities were negative for DVT. She was resumed on \nASA 81 and heparin 5000 BID on ___, and she was transferred to \n___ for evaluation of PFO repair in setting of DVTs and \ncontraindication for anticoagulation..\n\nOn admission, she reports feeling well with no complaints at all \naside from chronic left ankle pain due to multiple surgeries. \nShe is unable to provide much medical history, but is very \nconversant with a bright affect. She denies headache, weakness, \npresyncope, syncope, palpitations, chest pain, dyspnea, cough \nnausea, vomiting, diarrhea, constipation, hematochezia. She \nreports melena chronically, last occurring 5 days ago.\n \nPast Medical History:\n1. CARDIAC RISK FACTORS:\n- IDDM\n\n2. CARDIAC HISTORY: \n- CABG: None\n- PERCUTANEOUS CORONARY INTERVENTIONS: None\n- PACING/ICD: None\n- Aortic Stenosis\n\n3. OTHER PAST MEDICAL HISTORY: \nRecent left CVA (+ PFO and DVT) not anticoagulated \nRheumatic fever as a child \nCOPD\nGERD\nRecent GI bleed, hematemesis on prior admits, source unclear, \nEGD\n___ gastroduodenitis, no varices \nRecurrent UTIs - hx of E.coli \nMetabolic encephalopathy ranging from delirium with psychosis to\nobtundation\nBilateral ___ DVTs, now resolved by recent ultrasound \nLiver cirrhosis of unclear etiology\nPortal hypertension \nS/p splenectomy for her hereditary spherocytosis with secondary\nchronic leukocytosis and thrombocytosis\nPanic attacks\nSpinal stenosis \n\nSURGICAL HISTORY:\nWarthin's tumor - s/p excision\nRight knee arthroscopy \nAppendectomy\nTonsillectomy\nCholecystectomy\nTitanium cage inserted ___ \nS/p spinal fusion ___\nBilateral hip replacement ___\nAbductor muscle repair\nSpinal cord stimulator in ___ s/p removal ___\nLeft ankle fusion\n \nSocial History:\n___\nFamily History:\nFather with three heart attacks, passed away from heart attack \nat ___.\nMaternal aunt with ovarian cancer.\nMaternal aunt with lung cancer.\nNo family history of sudden cardiac death.\n \nPhysical Exam:\n======================\nADMISSION PHYSICAL EXAM\n======================\nVS: 98.5 BP 128/65 HR 110 RR 18 O2 92%ra\nGENERAL: Alert and oriented x 3, pleasant older woman in no \nacute distress, \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa. No xanthelasma. \n\nNECK: Supple without JVP elevation. IV in place in R neck.\nCARDIAC: Tachycardic, regular rhythm, III/VI SEM at upper \nsternal borders bilaterally\nLUNGS: Coarse breath sounds at both bases, otherwise lungs are \nclear, respirations are unlabored on room air \nABDOMEN: Her abdomen is obese, but quite soft without obvious \nascites. It is non-tender. \nEXTREMITIES: Her left leg is shortened and externally rotated. \nROM in her L ankle is significantly diminished. Her left leg is \nslightly larger in circumference than her right, and there is \ntrace pitting edema to her upper shin on the left. The right leg \nis non-edematous. Her dorsalis pedis and posterior tibial pulses \nare not palpable on my exam, but feet are well perfused. Her \nfeet are slightly cool to touch but no signs of ischemia. \nSKIN: There is no dermatologic stigmata of cirrhosis\nPULSES: Her radial pulses are 2+\nNEURO: She is alert, oriented, and does not appear altered in \nany way. Her cranial nerves are in tact. She has full strength \nin all extremities, though her L ankle exam is limited by pain.\n\n=====================\nDISCHARGE PHYSICAL EXAM\n=====================\nVitals: Tm 99, BP 106-115/47-63, HR 90-104, RR ___, O2Sat >96% \nRA \nGeneral: NAD, resting comfortably in bed \nHEENT: EOMI, PERRLA, OP clear, MMM \nCV: RRR, nl S1 and S2 no mrg \nLungs: CTAB without wheezing or rhonchi \nAbdomen: obese, soft, nt, nd, no hepatomegaly \nGU: Foley in place draining clear urine \nExt: No peripheral edema, wwp \nNeuro: AOx3, CN ___ intact grossly, moves all extremities \npurposefully \nSkin: No rash, scattered ecchymoses on upper ext \n\n \nPertinent Results:\n==============\nADMISSION LABS\n==============\n\n___ 09:20PM BLOOD WBC-16.0* RBC-2.70* Hgb-7.7* Hct-24.4* \nMCV-90 MCH-28.5 MCHC-31.6* RDW-19.1* RDWSD-62.1* Plt ___\n___ 09:20PM BLOOD Neuts-57.4 ___ Monos-13.4* \nEos-2.3 Baso-1.0 NRBC-0.3* Im ___ AbsNeut-9.20* \nAbsLymp-4.07* AbsMono-2.14* AbsEos-0.37 AbsBaso-0.16*\n___ 09:20PM BLOOD ___ PTT-29.4 ___\n___ 09:20PM BLOOD Glucose-248* UreaN-9 Creat-0.6 Na-132* \nK-3.8 Cl-103 HCO3-22 AnGap-11\n___ 09:20PM BLOOD ALT-20 AST-41* LD(LDH)-210 AlkPhos-151* \nTotBili-0.5\n___ 09:20PM BLOOD Albumin-1.8* Calcium-7.5* Phos-2.7 \nMg-1.5*\n\n==============\nINTERVAL LABS\n==============\n___ 07:40AM BLOOD WBC-33.0* RBC-2.33*# Hgb-6.6*# Hct-21.4*# \nMCV-92 MCH-28.3 MCHC-30.8* RDW-18.9* RDWSD-62.9* Plt ___\n___ 03:16AM BLOOD Neuts-90.8* Lymphs-3.5* Monos-4.1* \nEos-0.5* Baso-0.4 NRBC-0.1* Im ___ AbsNeut-27.62*# \nAbsLymp-1.06* AbsMono-1.25* AbsEos-0.15 AbsBaso-0.13*\n___ 04:10AM BLOOD Lactate-2.6*\n\n==============\nDISCHARGE LABS\n==============\n___ 06:09AM BLOOD WBC-16.6* RBC-2.83* Hgb-7.9* Hct-24.8* \nMCV-88 MCH-27.9 MCHC-31.9* RDW-17.9* RDWSD-57.2* Plt ___\n___ 06:09AM BLOOD Plt ___\n___ 04:07AM BLOOD Neuts-81.6* Lymphs-10.0* Monos-6.9 \nEos-0.1* Baso-0.8 NRBC-0.2* Im ___ AbsNeut-17.56* \nAbsLymp-2.16 AbsMono-1.48* AbsEos-0.03* AbsBaso-0.18*\n___ 06:09AM BLOOD Glucose-146* UreaN-8 Creat-0.6 Na-132* \nK-3.7 Cl-103 HCO3-22 AnGap-11\n___ 06:09AM BLOOD ALT-23 AST-68* AlkPhos-205* TotBili-0.9\n___ 06:09AM BLOOD Calcium-7.1* Mg-1.6\n\n==============\nIMAGING\n==============\n___ CXR Portable\nAs compared to recent study of 2 days earlier, cardiomediastinal \ncontours arestable. A nonspecific opacity in the left lower \nlobe has partially cleared and may be due to the patient's \nhistory of treated pneumonia. Superimposed linear atelectasis \nis present at the left base as well as a new focus of linear \natelectasis in the right juxta hilar region. No other relevant \nchange.\n\n___ Carotid Series Complete U/S:\nMild atherosclerosis with no flow limiting stenosis on either \nside.\n\n___ EEG:\nThis is an abnormal continuous ICU EEG monitoring study because \nof continuous focal slowing and slow posterior dominant rhythm \nin the right posterior quadrant. These findings are indicative \nof focal cerebral dysfunction, possibly structural in origin, in \nthe right posterior quadrant. This is superimposed on mild \ndiffuse background slowing, indicative of mild diffuse cerebral \ndysfunction, which is nonspecific as to etiology. No \nepileptiform discharges or electrographic seizures are present. \n\n___ CXR:\nIn comparison with the study of ___, there are lower lung \nvolumes. There is mild residual opacification at the left base, \nwhich could relate to the previously treated pneumonia or merely \nrepresent atelectatic changes. No new consolidation or \npulmonary vascular congestion. \n\n___ CT Head w/o Contrast:\n1. No acute intracranial hemorrhage. \n2. Paranasal sinus disease as described above. \n\n___ Abdominal Ultrasound:\n1. Coarsened and nodular liver, compatible with cirrhosis. \n2. Status post splenectomy and cholecystectomy. \n3. Small amount of ascites. \n \n\n___ CXR, Portable:\nRight PICC line tip is at the level of mid SVC. Heart size and \nmediastinum are stable. Lungs are clear. There is no pleural \neffusion or pneumothorax. \n\n___ EEG:\nThis ICU EEG study is abnormal as it shows continuous focal \nslowing in the right posterior quadrant together with a slowed \nposterior \ndominant rhythm. These findings indicate a focus of subcortical \ndysfunction in brain region, possibly related to a structural \nlesion. Background activity over the left hemisphere is normal \nwith a 9Hz posterior dominant rhythm. No epileptiform discharges \nor electrographic seizures are present. Compared with the \nprevious day's recording, this EEG identifies an improvement in \nbackground activity over the left hemisphere suggesting an \nelectrographic improvement in the mild encephalopathy noted \npreviously. \n\n==============\nSTUDIES\n==============\n___ TTE:\nImage quality is suboptimal. The left atrium is normal in size. \nThere is mild symmetric left ventricular hypertrophy. The left \nventricular cavity size is normal. Due to suboptimal technical \nquality, a focal wall motion abnormality cannot be fully \nexcluded. Left ventricular systolic function is hyperdynamic (EF \n= 75%). Tissue Doppler imaging suggests a normal left \nventricular filling pressure (PCWP<12mmHg). The right \nventricular free wall is hypertrophied. Right ventricular \nchamber size is normal with normal free wall contractility. The \nnumber of aortic valve leaflets cannot be determined. The aortic \nvalve leaflets are mildly thickened (?#). The aortic valve is \nnot well seen. There is mild aortic valve stenosis. No aortic \nregurgitation is seen. The mitral valve appears structurally \nnormal with trivial mitral regurgitation. The left ventricular \ninflow pattern suggests impaired relaxation. The pulmonary \nartery systolic pressure could not be determined. There is no \npericardial effusion. \n\n___ TTE Bubble Study:\nNo atrial septal defect is seen on color flow Doppler, but there \nis early appearance of agitated saline/microbubbles in the left \natrium/ventricle at rest most consistent with an atrial septal \ndefect or stretched patent foramen ovale (though a very proximal \nintrapulmonary shunt cannot be fully excluded). \n\n___ Capsule Endoscopy:\n1. Visualization limited by prep in the stomach and small bowel\n2. Gastric congestion, erythema and granularity\n3. Duodenal lymphangectasias\n4. Duodenal and jejunal angioectasias\n5. Hematin in the distal duodenum/early jejunum\n6. No active GI bleeding\n7. Consider push enteroscopy to evaluate area of hematin\n8. Obtain KUB to ensure capsule reaches cecum\n9. Rest of plan per inpatient GI team\n\n___ Small Bowel Enteroscopy:\nGrade A esophagitis in the distal esophagus. No varices were \nseen in the distal esophagus. Erythema, congestion and mosaic \nappearance in the stomach\nPolyps in the stomach body. A few small (~3mm) AVMs were seen in \nthe distal duodenum and proximal jejunum. Otherwise normal small \nbowel enteroscopy to proximal jejunum.\n\n \nBrief Hospital Course:\nMs. ___ is a ___ with hx of IDDM, recent L cerebellar CVA \nw/o residual deficit, PFO, b/l DVTs, severe GI bleeding with \nanticoagulation, transferred from OSH for PFO repair in setting \nof DVTs.\n\n#Sepsis secondary to bacterial gastroenteritis: Additionally, \nthe patient was transferred to the ICU one morning following \nbeing found unresponsive. At that time she was hypotensive, \nfebrile and tachycardic. She was transferred to the ICU, and \ntreated with albumin, IVF and broad spectrum antibiotics given \nher post-splenectomy state. Her vital signs improved rapidly \nwith the above interventions, and her mental status and fevers \nimproved with continued antibiosis. She was transferred back to \nthe floor, where her tobramycin and vancomycin were discontinued \nand she completed a 7d course for sepsis secondary to acute \nbacterial gastroenteritis with ciprofloxacin. She remained \nafebrile with a WBC at her baseline (___) upon discharge.\n\n# PFO and hx recent CVA: The patient was initially transferred \nfor evaluation for possible PFO closure in the setting of her \nh/o DVT. She had a repeat TTE which showed some early bubbles, \nconsistent with small ASD, PFO or very proximal intrapulmonary \nshunt. Her case was discussed with cardiology, who felt that for \nfurther evaluation was necessary prior to further intervention, \nwhich would begin with TTE. After discussion with the patient \nand cardiology, it was determined that the patient would require \ndual antiplatelet therapy for at least 6 months following PFO \nclosure, and that given her history of GI bleeding, would likely \nnot tolerate this intervention. The risk and benefits of going \nforward with the closure and the antiplatelet medication \nrequired vs conservative management was discussed with the \npatient and her husband. Following a conversation the patient \ndecided to forgo the closure work-up. Thus, it was decided to \nforgo further work-up for PFO closure and the patient was \ndischarged on ASA 81mg only.\n\n# Hx of b/l DVTs: recent CT angiography was negative for ___ \nduplex negative for DVTs. She is at risk for recurrent DVTs as \nshe is not currently on anticoagulation in setting of recent \nbleed. She remains on aspirin 81 mg daily, and anticoagulation \nwas held given the risks of ongoing bleeding from her GI tract. \n\n#GI Bleeding: The patient was transferred for ongoing GIB. She \nhad previously had endoscopies, colonoscopies and tagged RBC \nscans without a clear source identified. She had one episode of \nlarge melena, and required 2U pRBC's during her stay for drops \nin her hemoglobin. She underwent capsule endoscopy which showed \nsome AVM's in her duodenum and jejunum. This was further \nevaluated with push enteroscopy, which again showed 3 small \nAVM's with no active bleeding and she required no intervention \nfrom an endoscopic standpoint. Her blood counts stabilized, and \nshe was continued on her PPI as well as initiated on iron \nsupplementation for her anemia upon discharge. \n\n# Hx of L cerebellar CVA: Diagnosed on MRI brain and CT head. \nEtiology may be secondary to posterior circulation disease vs. \ncardioembolic event vs. DVT embolism thru PFO. TTE performed \nwithout evidence of significant valvular disease, though AV not \nwell visualized. She did not undergo further radiological head \nimaging on this admission. She did have EEGs which showed focal \nslowing in the area of her prior CVA but no epileptiform \ndischarges or evidence of active seizure activity. She was \nrestarted on home aspirin at the time of discharge.\n\n# Cirrhosis: Patient with concern for cirrhosis diagnosed on \noutside hospital imaging, with portal hypertension, and albumin \n1.5, INR 1.5. Unclear etiology. Hepatitis panel at OSH negative. \nHBsAg negative. HBcAb IgM neg. HCV ab neg. ___ Ab IgM neg. \nFerritin 25.7. Ceruloplasmin 17. Copper 70. Hereditary \nhemochromatosis DNA mutation negative. Right upper quadrant \nultrasound while here showed coarsened hepatic texture \nconcerning for advanced disease. She continued to have \ntransaminitis and coagulopathy with INR ranging 1.1 to 1.5. She \nwill require evaluation by outpatient a hepatologist and \npossible liver biopsy.\n\nCHRONIC ISSUES:\n# Diabetes Mellitus Type 1: Continued lantus, and Humalog \nsliding scale while in house\n\n# Hypothyroidism: Please continue levothyroxine 50mcg daily\n\n# HLD: Please continue simvastatin\n\n# COPD: Please continue duonebs as needed for respiratory \ndistress\n\n# Depression: Continued Zoloft\n\n# Chronic pain: Patient with chronic back pain for which she had \nbeen taking Zonisamide, baclofen and Nortriptyline. These were \nheld in the setting of altered mental status during her ICU and \nthey were held for the remainder of her admission. These should \nbe considered for re-initiation on an outpatient basis.\n\nTransitional issues\n -Pt had thyroid nodule identified on CT scan and should have a \nfollow-up ultrasound for further characterization (if she has \nnot had one previously)\n -Pt was scheduled for ENT f/u with ___ for a tongue mass \nidentified on her CT scan\n- The patient will need to be evaluated by a hepatologist for \nfurther work-up and probable liver biopsy for diagnosis of her \ncirrhosis. She had no varices seen on her endoscopy in house\n-Pt should have outpatient neurology follow-up in ___ for her \nprevious cerebellar stroke\n- The patient was continued on her ASA 81mg and we discussed \nlooking out for signs and symptoms of ongoing blood loss.\n- Pt was started on TID iron supplementation\n- After discussion with structural heart team regarding the \npatient's PFO, the patient would require further evaluation with \nTEE in order to conduct a proper risk/benefit assessment. At \nthis time, it does not appear that the benefits of closure \noutweigh the risks, particularly given that the patient would \nrequire 6 months of dual anti-platelet therapy after closure and \ngiven her current ___ medical conditions. She is unlikely \nto tolerate the dual antiplatelet tx necessary following PFO \nclosure as the source of her GI bleeding was not able to be \nidentified.\n-The patient will need her CBC checked at her outpatient PCP \nappointment\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Glargine 15 Units Bedtime\nInsulin SC Sliding Scale using novolog Insulin\n2. Zonisamide 100 mg PO DAILY Pain \n3. Ferrous Sulfate 325 mg PO BID \n4. Baclofen 10 mg PO TID \n5. Simvastatin 40 mg PO QPM \n6. Levothyroxine Sodium 50 mcg PO DAILY \n7. RISperidone 0.75 mg PO QHS \n8. Omeprazole 20 mg PO BID \n9. Sertraline 100 mg PO DAILY \n10. Diazepam 5 mg PO DAILY:PRN anxiety \n11. Nortriptyline 50 mg PO DAILY \n12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n13. Albuterol Inhaler ___ PUFF IH ONCE:PRN wheezing \n14. Potassium Chloride 20 mEq PO DAILY \n15. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Albuterol Inhaler ___ PUFF IH ONCE:PRN wheezing \n2. Aspirin 81 mg PO DAILY \n3. RISperidone 0.75 mg PO QHS \n4. Sertraline 100 mg PO DAILY \n5. Simvastatin 40 mg PO QPM \n6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n7. Levothyroxine Sodium 50 mcg PO DAILY \n8. Potassium Chloride 20 mEq PO DAILY \n9. Omeprazole 40 mg PO BID \n10. Glargine 15 Units Bedtime\nInsulin SC Sliding Scale using Novolog Insulin\n11. Ferrous Sulfate 325 mg PO TID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nGI bleed\nSepsis secondary to bacterial gastroenteritis\nCirrhosis\nPatent foramen ovale\nTongue mass\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nMs ___-\nYou were transferred to ___ for further evaluation and \ntreatment of your GI bleeding as well as for evaluation of the \nsmall hole in your heart (called a PFO). You had some ongoing \nbleeding while hospitalized, for which you required two blood \ntransfusions. You had a capsule study, which showed some small \nblood vessels in the wall of your small intestine. You then had \na small bowel enteroscopy, which showed similar, small blood \nvessels, none of which were bleeding. These small blood vessels \nare likely the source of your bleeding. You did not have any \nfurther signs of bleeding, and you were started on iron pills to \nhelp with rebuilding your iron stores. \n\nDuring your stay you had a period of confusion and fevers which \nwas treated with antibiotics. This was thought to possibly be \ndue to a transient infection in your blood stream from your GI \nsystem. You improved to your baseline with a short course of \nantibiotics. \n\nAdditionally you were evaluated by our cardiologists regarding \nclosure of your PFO. It was determined that, given you other \nmedical conditions, that your risk from this hole in your heart \nis low. We also discussed that if the hole were repaired you \nwould need potent blood thinning agents which would likely \nworsen your bleeding. Thus it was decided, with your input, that \nwe would hold off on pursuing closure of this hole.\n\nPlease take all your medications as described below and attend \nall follow-up appointments as listed. It was a pleasure being \npart of your care-\n\n-Your ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "K5521", "R6520", "G92", "A419", "K766", "D62", "E1040", "K7460", "J449", "K529", "Z23", "Z86718", "Z87891", "Z96643", "Z8673", "E039", "E785", "G8929", "R938", "Z794", "D580", "K209", "K3189", "K317", "F419", "F329" ]

[ "K5521: Angiodysplasia of colon with hemorrhage", "R6520: Severe sepsis without septic shock", "G92: Toxic encephalopathy", "A419: Sepsis, unspecified organism", "K766: Portal hypertension", "D62: Acute posthemorrhagic anemia", "E1040: Type 1 diabetes mellitus with diabetic neuropathy, unspecified", "K7460: Unspecified cirrhosis of liver", "J449: Chronic obstructive pulmonary disease, unspecified", "K529: Noninfective gastroenteritis and colitis, unspecified", "Z23: Encounter for immunization", "Z86718: Personal history of other venous thrombosis and embolism", "Z87891: Personal history of nicotine dependence", "Z96643: Presence of artificial hip joint, bilateral", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "E039: Hypothyroidism, unspecified", "E785: Hyperlipidemia, unspecified", "G8929: Other chronic pain", "R938: Abnormal findings on diagnostic imaging of other specified body structures", "Z794: Long term (current) use of insulin", "D580: Hereditary spherocytosis", "K209: Esophagitis, unspecified", "K3189: Other diseases of stomach and duodenum", "K317: Polyp of stomach and duodenum", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified" ]

[ "D62", "J449", "Z86718", "Z87891", "Z8673", "E039", "E785", "G8929", "Z794", "F419", "F329" ]

[]

[ " \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:\nAbdominal pain, melena\n \nMajor Surgical or Invasive Procedure:\nEGD\nColonoscopy \n\n \nHistory of Present Illness:\nHISTORY OF THE PRESENTING ILLNESS: \nMs. ___ is a ___ with a past medical history of RA on MTX \nand\nHumira, T2DM c/b peripheral neuropathy, GERD, HTN, HLD, and\ndiverticulosis who presents with a 2 day history of abdominal\npain associated with 1 episode suspected hematemesis and 3\nepisodes of melena. Per patient, on ___ she abruptly experienced\na sharp abdominal pain worst in RLQ which migrated to LLQ that\nwas not associated with food or position. On ___ she had 2\nepisodes of diarrhea that were black and was persistently\nnauseous and ultimately had 1 episode of black emesis. During\nthis time she was unable to take her home medications. She \ndenied\nany recent steroid or NSAID use. She states that although she \nhas\nhad similar abdominal pain intermittently in the past, she has\nnever had any black stools or emesis. She also denied any \ntrauma,\nCP, SOB, fevers, chills, weight changes, urinary difficulties,\nback pain, or changes in strength or sensation.\n\nIn the ED patient was afebrile and HDS. She received 2 large \nbore\nIVs and 40 mg pantoprazole IV. GI was consulted and stated the\nneed and timing of EGD would be based on clinical trajectory. \n\nIn the ED, initial vitals were: \nT: 96.8 HR: 91 BP: 123/78 RR:16 SaO2:100% RA \n\nIn the ED exam was notable for:\nConstitutional: Comfortable\nENT / Neck: Oropharynx within normal limits\nChest/Resp: Clear to auscultation\nCardiovascular: Regular Rate and Rhythm\nGI / Abdominal: Soft, Nontender\nRectal: Minimal stool in vault but heme positive at urgent care\nGU/Flank: No costovertebral angle tenderness\nMusc/Extr/Back: No cyanosis, clubbing or edema\nSkin: No rash\nNeuro: Speech fluent\nPsych: Normal mood, Normal mentation\n\nLabs notable for: \n\n___: 12.8 PTT: 26.2 INR: 1.2 \nHb: 9.0 HCT: 28.6 WBC: 6.9 Plt 142\nNa: 139 K:4.6 Cl:101 HCO3:26 BUN: 20 Cr: 1 Glucose:158\nLactate:1.5\n\nImaging was notable for: N/A \n\nPatient was given: \nIV pantoprazole 40 mg\n\nConsults: GI\n\nVS Prior to Transfer:\nT: 97.7 HR: 80 BP: 102/60 RR:18 SaO2:95% RA \n\nUpon arrival to the floor, patient corroborates history obtained\nin the ED. She mentions that she is no longer nauseous and \nstates\nthat she had one episode of black, formed stool this morning and\nno further emesis. Currently her only complaints are fatigue and\na HA which she attributes to not having eaten much since ___. \n\nROS: Positive per HPI. Remaining 10 point ROS reviewed and\nnegative \n\n \nPast Medical History:\nType 2 DM, insulin dependent, with peripheral neuropathy\nRA with secondary Sjogren Syndrome\nGERD\nOSA\nHLD\nHTN\nDiverticulosis \n \nSocial History:\n___\nFamily History:\nBrother has ___\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nVITAL SIGNS:\n24 HR Data (last updated ___ @ 1459)\nTemp: 97.58 (Tm 97.58), BP: 145/79, HR: 85, RR: 18, O2 sat: 96%,\nO2 delivery: RA \nGENERAL: Resting comfortably, in NAD. States she is hungry. \nHEENT: NC/AT. MMM. \nNECK: No LAD. No JVD. \nCARDIAC: Regular rate and rhythm, normal S1 and S2. No murmurs,\nrubs or gallops \nLUNGS: Clear to auscultation bilaterally with no wheezes, rales,\nor rhonchi\nABDOMEN: Soft, nondistended. Slightly tender to palpation in\nepigastrium, RLQ and LLQ. Normoactive bowel sounds heard in all \n4\nquadrants. No organomegaly appreciated \nEXTREMITIES: Warm, well perfused. No peripheral edema \nNEUROLOGIC: AAO3. Strength ___. Normal sensation.\nSKIN: No rashes or bruises \n\nDISCHARGE PHYSICAL EXAM\n=======================\nVitals: ___ @ 347 Temp: 98.1, BP: 140/75, HR: 77, RR: 18, \nO2 sat: 96% O2 delivery: ra \nGENERAL: NAD\nHEENT: AT/NC, anicteric sclera, MMM\nNECK: supple, no LAD\nCV: RRR, S1/S2, no murmurs, gallops, or rubs\nPULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles\nGI: abdomen soft, nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly\nEXTREMITIES: no cyanosis, clubbing, or edema\nPULSES: 2+ radial pulses bilaterally\nNEURO: Alert, moving all 4 extremities with purpose, face\nsymmetric\nDERM: Warm and well perfused, no excoriations or lesions, no\nrashes\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 11:50AM BLOOD WBC-6.9 RBC-3.07* Hgb-9.0* Hct-28.6* \nMCV-93 MCH-29.3 MCHC-31.5* RDW-13.6 RDWSD-45.7 Plt ___\n___ 11:50AM BLOOD Neuts-51.5 ___ Monos-4.4* Eos-1.5 \nBaso-0.3 Im ___ AbsNeut-3.55 AbsLymp-2.90 AbsMono-0.30 \nAbsEos-0.10 AbsBaso-0.02\n___ 11:50AM BLOOD Glucose-158* UreaN-20 Creat-1.0 Na-139 \nK-4.6 Cl-101 HCO3-26 AnGap-12\n___ 11:50AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.3*\n___ 11:55AM BLOOD Lactate-1.5\n\nMICROBIOLOGY\n============\nBLOOD CULTURE ___:\nNO GROWTH\n\nIMAGING\n=======\nColonoscopy ___:\nSevere diverticulosis of the whole colon, normal mucosa in the \nwhole colon and 10cm into the terminal ileum and internal \nhemorrhoids, Non-bleeding internal hemorrhoids\n\nEGD ___:\nA Zenker's diverticulum was seen in the upper esophagus, Grade A \nesophagitis in the distal esophagus, esophageal hiatal hernia, \nnormal muisa in the whole stomach, normal mucosa in the whole \nexamined duodenum\n\nOTHER PERTINENT LABS\n====================\n___ 07:00AM BLOOD WBC-5.8 RBC-3.17* Hgb-9.2* Hct-29.6* \nMCV-93 MCH-29.0 MCHC-31.1* RDW-13.3 RDWSD-45.3 Plt ___\n___ 09:30AM BLOOD WBC-5.3 RBC-3.08* Hgb-8.9* Hct-28.9* \nMCV-94 MCH-28.9 MCHC-30.8* RDW-13.4 RDWSD-45.1 Plt ___\n\nDISCHARGE LABS\n==============\n___ 07:00AM BLOOD WBC-5.0 RBC-3.37* Hgb-9.6* Hct-31.8* \nMCV-94 MCH-28.5 MCHC-30.2* RDW-13.5 RDWSD-45.2 Plt ___\n___ 07:00AM BLOOD Plt ___\n___ 07:00AM BLOOD Glucose-141* UreaN-7 Creat-0.8 Na-145 \nK-3.9 Cl-109* HCO3-22 AnGap-14\n\n \nBrief Hospital Course:\nTRANSITIONAL ISSUES\n===================\n[ ] Please ensure patient has repeat EGD on ___ AM\n[ ] Continue proton pump inhibitor twice a day for 6 to 8 weeks \n[ ] Repeat CBC in 1 week. If H/H continues to downtrend, to \nconsider capsule endoscopy.\n[ ] Patient started on ferrous sulfate prior to discharge \n\nBRIEF HOSPITAL COURSE\n=====================\n___ with PMH of RA on MTX and Humira, T2DM c/b peripheral \nneuropathy, GERD, HTN, HLD, and diverticulosis who presented \nwith melena and hematemesis for which she had EGD and \ncolonoscopy performed without active bleeding.\n\nACUTE ISSUES:\n=============\n#Anemia\n#GIB\n#Diverticulosis\nPatient endorsed a 2 day history of abdominal pain associated \nwith 2 episodes black diarrhea and 1 episode black emesis on ___ \nfollowed by 1 episode of formed dark stool on ___. Patient \ndenied any recent steroid or NSAID use. Her ASA was held. \nPatient remained HDS and her H/H was serially monitored with \nCBCs without the need for transfusion. She was started on IV \npantoprazole transitioned to po on discharge. GI was consulted \nand performed and EGD which revealed known Zenker's \ndiverticulum, known hiatal hernia and known irregular Z-line but \nwith Grade A esophagitis. Colonoscopy was preformed on ___ \nwhich revealed diverticulosis of the whole colon, normal colonic \nmucosa and internal hemorrhoids without active bleeding. \nDischarged on Ferrous sulfate. Discharge Hgb: 9.6\n\nCHRONIC ISSUES:\n===============\n#T2DM:\nPatient placed on ISS\n\n#HTN\nHome BP meds were held in the setting of acute GI bleed. \nRestarted on discharge. \n\n#HLD:\nContinued atorvastatin\n\n#RA\nReceives Humira and MTX weekly, received both medications on ___ \nlast. Continued folic acid 1 mg BID\n\nCORE MEASURES\n============= \n# CODE: Full \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Methotrexate 2.5 mg PO 1X/WEEK (___) \n2. Humira Pen (adalimumab) 40 mg/0.8 mL subcutaneous 1X/WEEK \n3. Hydrochlorothiazide 25 mg PO DAILY \n4. Atorvastatin 80 mg PO QPM \n5. Lisinopril 40 mg PO DAILY \n6. Omeprazole 20 mg PO DAILY \n7. Restasis 0.05 % ophthalmic (eye) Q12H:PRN \n8. Albuterol Inhaler 2 PUFF IH Q6H:PRN asthma \n9. Aspirin 81 mg PO DAILY \n10. Lantus U-100 Insulin (insulin glargine) 100 unit/mL \nsubcutaneous QHS \n11. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL \nsubcutaneous TID W/MEALS \n12. MetFORMIN (Glucophage) 750 mg PO BID \n\n \nDischarge Medications:\n1. Ferrous Sulfate 325 mg PO DAILY \nRX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth \nonce a day Disp #*30 Tablet Refills:*0 \n2. Pantoprazole 40 mg PO Q12H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp \n#*120 Tablet Refills:*0 \n3. Albuterol Inhaler 2 PUFF IH Q6H:PRN asthma \n4. Aspirin 81 mg PO DAILY \n5. Atorvastatin 80 mg PO QPM \n6. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL \nsubcutaneous TID W/MEALS \n7. Humira Pen (adalimumab) 40 mg/0.8 mL subcutaneous 1X/WEEK \n8. Hydrochlorothiazide 25 mg PO DAILY \n9. Lantus U-100 Insulin (insulin glargine) 100 unit/mL \nsubcutaneous QHS \n10. Lisinopril 40 mg PO DAILY \n11. MetFORMIN (Glucophage) 750 mg PO BID \n12. Methotrexate 2.5 mg PO 1X/WEEK (___) \n13. Restasis 0.05 % ophthalmic (eye) Q12H:PRN \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAcute upper GI bleed\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. ___, \nIt was a privilege caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n- You were in the hospital because of abdominal pain, vomiting \nblood, and having bloody bowel movements. \n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n-In the hospital you received and EGD which showed a known \nZenker's diverticulum, a known hiatal hernia and inflammation of \nthe esophagus without any active bleeding. \n-You also received a colonoscopy which showed diverticulosis and \nnon-bleeding internal hemorrhoids.\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n-Please continue to take all of your medications and follow-up \nwith your appointments as listed below.\n-If you notice any of the danger signs listed below please \ncontact your PCP or go to an emergency room immediately.\n\nWe wish you the best! \n\nSincerely, \nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "K210", "K920", "K921", "E1142", "D649", "M069", "I4581", "Z794", "K5750", "K449", "K225", "K648", "K228", "E785", "I10", "Z79899" ]

[ "K210: Gastro-esophageal reflux disease with esophagitis", "K920: Hematemesis", "K921: Melena", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "D649: Anemia, unspecified", "M069: Rheumatoid arthritis, unspecified", "I4581: Long QT syndrome", "Z794: Long term (current) use of insulin", "K5750: Diverticulosis of both small and large intestine without perforation or abscess without bleeding", "K449: Diaphragmatic hernia without obstruction or gangrene", "K225: Diverticulum of esophagus, acquired", "K648: Other hemorrhoids", "K228: Other specified diseases of esophagus", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "Z79899: Other long term (current) drug therapy" ]

[ "D649", "Z794", "E785", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins\n \nAttending: ___\n \nChief Complaint:\nabdominal pain\n \nMajor Surgical or Invasive Procedure:\nPTBD exchange ___\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year-old woman with history of CAD, \nhypertension, diabetes mellitus, NASH cirrhosis with DDLT \n(___) (on cyclosporine and mycophenolate) with aortic conduit \n\ncomplicated by biliary strictures s/p stenting and multiple \npercutaneous transhepatic biliary drain exchanges with recurrent \n\ncholangitis, pseudomonas bacteremia, on suppressive cipro, VRE \ninfections, and left hepatic abscess s/p drainage, who p/w\nabdominal pain and elevated ALP concerning for recurrent\ncholangitis.\n\nThe patient was recently discharged after being admitted for\nrecurrent cholangitis (___). During that admission she \nwas\nfound to have hepatic abscess which was drained with pigtail and\nhad persistent perihepatic collection. The patient's PTBD was\nuncapped with significant drainage to bag concerning for PTBD\ndysfunction. She was started on high dose ciprofloxacin and\nlinezolid and ultimately underwent cholangiogram with dilation \nof\nbiliary stricture and subsequent improved flow. The patient\nremained afebrile throughout her hospitalization. Her PTBD was\ncapped on ___ and she remained afebrile. ID recommended to\ncomplete a 2 week course of cipro 750mg BID and linezolid ___\nBID (last day ___ for treatment of MDR pseudomonas\n(sensitive to cipro and aminoglycosides only) and VRE (sensitive\nto linezolid only), followed by return to cipro 500mg daily for\nsuppression.\n\nShe represents today with acute onset of left-sided abdominal\npain. It is located in the left upper quadrant and radiates down\nto the left lower quadrant. The pain began ___ at 730 ___. It\nwas acute in onset. Dilaudid has helped while she has been here,\notherwise no agg/alleviating factors, sharp pain,persistent, \n___ this AM. She has had 4 episodes of NBNB vomiting. She\ndenies any fevers chills, chest pain, shortness of breath. \nDenies\nany urinary symptoms. \n\n In the ED, initial VS were: \n 10 97.5 71 152/65 16 99% RA \n Exam notable for: \n Gen: Comfortable \n HEENT: NC/AT. EOMI. \n Neck: No swelling. \n Cor: RRR. No m/r/g. \n Pulm: CTAB, Nonlabored respirations. \n Abd: Moderately tender in the left upper quadrant and left \nlower\nquadrant. No rebound, no guarding. \n Ext: No edema, cyanosis, or clubbing. \n Skin: No rash. \n Neuro: AAOx3. Gross sensorimotor intact. \n Psych: Normal mentation. \n Heme: No petechial \n Labs showed: \n 8.9 \n 5.1 >----< 177 \n 29.3 \n 135 98 33 \n ------------< 236 AGap=15 \n 5.5 22 1.2 \n ALT: 65 AP: 1000 Tbili: 1.0 Alb: 3.9 \n AST: 65 Lip: 15 \n ___: 15.3 PTT: 33.3 INR: 1.4 \n Lactate:1.9 \n Trop-T: <0.01 \n U/A notable for: Trace protein, 150 glucose \n Imaging showed: \n CT A/P \n 1. Heterogeneous enhancement of the liver is again seen, which\nappears similar in distribution to multiple priors, slightly \nmore\nconspicuous, likely due to phase of contrast. \n 2. Percutaneous drain terminates in the area of previously\ndescribed fluid collection adjacent to the falciform ligament. A\nsmall amount of residual fluid is seen within the falciform\nligament. No new fluid collections are seen. \n 3. PTBD is again seen, terminating in the duodenum, with\nunchanged mild intrahepatic biliary dilatation. Multiple foci of\nair within the biliary tree is consistent with recent ERCP. \n 4. Multiple borderline dilated fluid-filled loops of small \nbowel\nare seen in the right abdomen and pelvis, without a discrete\ntransition point to suggest obstructive process. \n 5. Unchanged small right pleural effusion. \n 6. Stable splenomegaly. \n Patient received: \n ___ 03:17 IV Morphine Sulfate 4 mg \n ___ 03:17 IV Ondansetron 4 mg \n \n General surgery was consulted. \n Per their evaluation: \n ___ with h/o NASH cirrhosis s/p DDLT with aortic conduit\n(___) c/b biliary anastomotic stricture s/p multiple ERCP w/\nstent exchanges and PTBD exchanges w/ recurrent cholangitis,\nbacteremia, and perihepatic abscess s/p drainage who p/w left\nsided abdominal pain. Patient is afebrile and hemodynamically\nstable without leukocytosis or significant LFT elevation.\nFurthermore, her exam is not concerning for an acute surgical\nprocess and her imaging shows resolved perihepatic fluid\ncollection without other identifiable sources of abdominal pain \n-\nthus the etiology of her pain remains unclear. However, given \nher\ncomplex history, she merits admission to Medicine for \nobservation\nand consideration of PTBD interrogation to rule out biliary\ncauses of her abdominal pain. \n Recommended: \n - no indication for surgical intervention at this time \n - recommend admission to Medicine for observation \n - would put PTBD to gravity and consider PTBD interrogation to\nrule biliary cause of pain \n Transfer VS were: \n Today ___ 71 152/65 16 99% RA \n \n On arrival to the floor, patient reports continued abdominal\npain. She says the pain is the same as what she had prior on\nearlier admission. She denies fevers, chills, change in drainage\nfrom JP drain, CP, SOB, diarrhea, constipation, dysuria. \n \n \nPast Medical History:\n-Idiopathic cirrhosis s/p DDLT with aortic conduit (___) with\npost-operative course complicated by biliary stricture and poor\ndrainage of the left biliary system s/p PTBD \n-Psychosis \n-Malnutrition- moderate\n-Hypertension\n-Diabetes mellitus- on insulin\n-HLD \n-Asthma\n \nSocial History:\n___\nFamily History:\nHTN - mother and father\nCAD - father\nNo significant family history of liver cancer\n \nPhysical Exam:\nAdmission Physical Exam:\n==================================\n VS: 0630 97.5 PO 166 / 73 69 18 97 Ra \n GENERAL: laying comfortably in NAD \n HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, \n\n MMM \n NECK: supple, no LAD, no JVD \n HEART: RRR, S1/S2, no murmurs, gallops, or rubs \n LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably \n\n without use of accessory muscles \n ABDOMEN: soft, TTP in LUQ, LLQ, nondistended. medial ___ drain &\nPTBD c/d/I without surrounding erythema. PTBD is capped. ___ \ndrain\nw/ scant fluid in JP \n EXTREMITIES: no cyanosis, clubbing, or edema \n PULSES: 2+ DP pulses bilaterally \n NEURO: A&Ox3, moving all 4 extremities with purpose \n SKIN: warm and well perfused, no excoriations or lesions, no \n rashes \n\nDISCHARGE PHYSICAL EXAM:\n==============================\n GENERAL: laying comfortably in NAD \n HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, \n\n MMM \n NECK: supple, no LAD, no JVD \n HEART: RRR, S1/S2, no murmurs, gallops, or rubs \n LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably \n\n without use of accessory muscles \n ABDOMEN: soft, nondistended, no TTP. Anchor drain c/d/I without\nsurrounding erythema. Anchor drain CAPPED. \n EXTREMITIES: no cyanosis, clubbing, or edema \n PULSES: 2+ DP pulses bilaterally \n NEURO: A&Ox3, moving all 4 extremities with purpose \n SKIN: warm and well perfused, no excoriations or lesions, no \n rashes \n \nPertinent Results:\nADMISSION LABS:\n==========================\n\n___ 01:09AM BLOOD WBC-5.1 RBC-3.46* Hgb-8.9* Hct-29.3* \nMCV-85 MCH-25.7* MCHC-30.4* RDW-16.8* RDWSD-51.3* Plt ___\n___ 01:09AM BLOOD Neuts-79.7* Lymphs-10.3* Monos-5.5 \nEos-3.5 Baso-0.4 Im ___ AbsNeut-4.09 AbsLymp-0.53* \nAbsMono-0.28 AbsEos-0.18 AbsBaso-0.02\n___ 01:13AM BLOOD ___ PTT-34.6 ___\n___ 01:09AM BLOOD Glucose-236* UreaN-33* Creat-1.2* Na-135 \nK-5.5* Cl-98 HCO3-22 AnGap-15\n___ 01:09AM BLOOD ALT-65* AST-65* AlkPhos-1000* TotBili-1.0\n___ 01:09AM BLOOD Lipase-15\n___ 01:09AM BLOOD cTropnT-<0.01\n___ 01:09AM BLOOD Albumin-3.9\n___ 09:05AM BLOOD Cyclspr-196\n___ 02:04AM BLOOD Lactate-1.9\n\nPERTINENT LABS:\n==============================\n\n___ 09:05AM BLOOD Cyclspr-196\n___ 05:36AM BLOOD Cyclspr-223\n___ 05:36AM BLOOD Cyclspr-204\n___ 05:51AM BLOOD Cyclspr-314\n___ 04:50AM URINE Blood-NEG Nitrite-NEG Protein-TR* \nGlucose-150* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG\n___ 10:18AM URINE Blood-NEG Nitrite-NEG Protein-30* \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG\n___ 04:50AM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-0\n___ 10:18AM URINE RBC-5* WBC-2 Bacteri-FEW* Yeast-NONE \nEpi-1\n___ 10:18AM URINE CastHy-7*\n___ 10:18AM URINE Hours-RANDOM Creat-126 Na-29\n___ 10:18AM URINE Osmolal-419\n\nSTUDIES:\n============================\nCT ABD & PELVIS WITH CONTRASTStudy Date of ___ 3:49 AM\nFINDINGS: \n \nLOWER CHEST: There is a small right pleural effusion with \ncompressive\natelectasis, unchanged from prior. No pericardial effusion.\n \nABDOMEN:\n \nHEPATOBILIARY: Heterogeneous attenuation of the liver \nparenchyma, primarily in\nthe right lobe, is similar to study dated ___. A \npercutaneous\ndrain terminates in the area of previously described fluid \ncollection adjacent\nto the false portal and ligament. Small amount of residual \nfluid is seen\nwithin the falciform ligament, without new fluid collections. A \npercutaneous\ntranshepatic biliary drain is again seen, terminating in the \nduodenum, with\nmild intrahepatic biliary dilatation. A small amount of air \nseen within the\nbiliary tree. The gallbladder is surgically absent. Chronic \nthrombosis of\nthe distal right portal venous branches again seen.\n \nPANCREAS: The pancreas has is atrophic, without evidence of \nfocal lesions or\npancreatic ductal dilatation. There is no peripancreatic \nstranding.\n \nSPLEEN: The spleen measures 15 cm, with attenuation throughout, \nwithout\nevidence of focal lesions.\n \nADRENALS: The right and left adrenal glands are normal in size \nand shape.\n \nURINARY: The kidneys are of normal and symmetric size with \nnormal nephrogram. \nThere is no evidence of focal renal lesions or hydronephrosis. \nThere is no\nperinephric abnormality.\n \nGASTROINTESTINAL: The stomach is unremarkable. Small bowel \nloops demonstrate\nnormal caliber, wall thickness, and enhancement throughout. \nCompared to most\nrecent prior, a migrated stent in the small bowel is no longer \nseen,\npresumably retrieved. There is a large amount of colonic stool. \n The appendix\nis normal.\n \nPELVIS: The urinary bladder and distal ureters are unremarkable. \n There is a\nsmall amount of free fluid in the pelvis.\n \nREPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal \nabnormality is\nseen.\n \nLYMPH NODES: There is no retroperitoneal or mesenteric \nlymphadenopathy. There\nis no pelvic or inguinal lymphadenopathy.\n \nVASCULAR: There is no abdominal aortic aneurysm. Mild \natherosclerotic disease\nis noted.\n \nBONES: There is no evidence of worrisome osseous lesions or \nacute fracture.\n \nSOFT TISSUES: A small umbilical hernia containing fat is noted.\n \nIMPRESSION: \n \n1. Heterogeneous enhancement of the liver is again seen, which \nappears similar\nto study dated ___, slightly more conspicuous. \nPresumably this\nis secondary to perfusional differences. If there is concern \nfor necrosis,\nMRI can performed.\n2. Percutaneous drain terminates in the area of previously \ndescribed fluid\ncollection adjacent to the falciform ligament. A small amount of \nresidual\nfluid is seen within the falciform ligament. No new fluid \ncollections are\nseen.\n3. PTBD is again seen, terminating in the duodenum, with \nunchanged mild\nintrahepatic biliary dilatation. Multiple foci of air within the \nbiliary tree\nis consistent with recent ERCP.\n4. Multiple borderline dilated fluid-filled loops of small bowel \nare seen in\nthe right abdomen and pelvis, without a discrete transition \npoint to suggest\nobstructive process.\n5. Unchanged small right pleural effusion.\n6. Stable splenomegaly.\n7. Stable hypoattenuation of the portal vein, with chronic \nthrombosis of a\ndistal right portal venous branch.\n\nEXCHANGE BILIARY DRG CATHStudy Date of ___ 8:47 AM\nTECHNIQUE: OPERATORS: Dr. ___, ___ attending, performed \nthe\nprocedure.\nANESTHESIA: Moderate sedation was provided by administrating \ndivided doses of\n50 mcg of fentanyl and 1 mg of midazolam throughout the total \nintra-service\ntime of 20 min during which the patient's hemodynamic parameters \nwere\ncontinuously monitored by an independent trained radiology \nnurse. 1% lidocaine\nwas injected in the skin and subcutaneous tissues overlying the \naccess site\nMEDICATIONS: As above\nCONTRAST: 20 ml of Optiray contrast.\nFLUOROSCOPY TIME AND DOSE: 5.9 min, 20 mGy\n \nPROCEDURE:\n1. Cholangiogram via existing biliary drain\n2. Over-the-wire cholangiogram through existing right \npercutaneous\ntranshepatic biliary drainage access.\n3. Balloon dilatation of distal CBD / ampulla (8 mm Conquest)\n4. Exchange of the existing percutaneous trans-hepatic biliary \ndrainage\ncatheter with a new ___ PTBD catheter.\n \nPROCEDURE DETAILS: Following the discussion of the risks, \nbenefits and\nalternatives to the procedure, written informed consent was \nobtained from the\npatient. The patient was then brought to the angiography suite \nand placed\nsupine on the exam table. A pre-procedure time-out was \nperformed per ___\nprotocol. The right/mid abdomen was prepped and draped in the \nusual sterile\nfashion. The procedure was performed with the presence of an \ninterpreter.\n \nInitial scout images showed biliary drain in the appropriate \nposition and an\nexisting abscess drain. The right tube was injected with dilute \ncontrast. The\nimages were stored on PACS.\n \nFollowing the subcutaneous injection of 1% lidocaine and \ninstillation of\nlidocaine jelly into the skin site, the right catheter was cut \nand ___\nwire was advanced through the catheter into the duodenum. A \npull back\ncholangiogram was then performed via a ___ sheath with findings \nas outlined\nbelow. Next, dilataiton of the distal CBD and ampulla was \npreformed with an 8\nmm Conquest balloon.\n \nThe catheter was removed over the wire and a 12 ___ \npercutaneous trans\nhepatic biliary drainage catheter was advanced into the \nduodenum. Side holes\nwere positioned above and below the level of obstruction to \nfacilitate\ninternal drainage. The wire and inner stiffener were removed, \nthe catheter was\nflushed, the loop was formed, the catheter was attached to a bag \nand sterile\ndressings were applied.\nThe patient tolerated the procedure well and there were no \nimmediate\npost-procedure complications.\n \nFINDINGS:\n \n \n1. Initial cholaniogram via the existing biliary drain \ndemonstrated patent\nintrahepatic sideholes but complete occlusion of the distal \ndrain without flow\ninto the duodenum.\n2. Over-the-wire cholangiogram demonstrated lilmited antegrade \nflow through\nthe ampulla. Cholangioplasty with an 8 mm Conquest balloon was \nperformed\nwithout a significant narrowing.\n3. Exchange / replacement with ___ internal-external biliary \ndrain with good\ncontrast flow into the duodenum at end.\n4. Falciform space abscess drain in appropriate position, not \ninterrogated.\n \nIMPRESSION: \n \nSuccessful exchange of existing percutaneous transhepatic \nbiliary drainage\ncatheter with new ___ catheter.\n\nABDOMEN (SUPINE ONLY) PORTStudy Date of ___ 4:32 ___\n \nFINDINGS: \n \nThere is a nonspecific bowel gas pattern with several nondilated \nair-filled\nloops of small bowel seen centrally. There is a copious amount \nof stool in\nthe colon. Air seen throughout the colon and within the rectum. \n Biliary\ndrain are seen. Clips are noted in the right upper quadrant. \nMild\ndegenerative changes are evident in the hips.\nPlease note the free air cannot be excluded on a supine \nradiograph.\n \nIMPRESSION: \n \nNonspecific bowel gas pattern. Copious amount of stool is seen \nthroughout the\ncolon.\n\nCHEST (PORTABLE AP) Study Date of ___ 5:45 ___ \nFINDINGS: \n \nThere are low lung volumes. There is no focal consolidation. \nThere is a \nstable right pleural effusion. The cardiomediastinal silhouette \nappears \nsimilar to previous. \n \nIMPRESSION: \n \nSmall right effusion. \n\n___ EXCHANGE BILIARY DRG CATH Study Date of ___ 1:18 ___ \n\n \nTECHNIQUE: OPERATORS: Dr. ___ \n___ and Dr. \n___ radiologist performed the procedure. Dr. ___ \n___ \nsupervised the trainee during the key components of the \nprocedure and has \nreviewed and agrees with the trainee's findings. \nANESTHESIA: Moderate sedation was provided by administrating \ndivided doses of \n75 mcg of fentanyl and 1.5 mg of midazolam throughout the total \nintra-service \ntime of 70 minutes during which the patient's hemodynamic \nparameters were \ncontinuously monitored by an independent trained radiology \nnurse. 1% lidocaine \nwas injected in the skin and subcutaneous tissues overlying the \naccess site \nMEDICATIONS: None \nCONTRAST: 40 ml of Optiray contrast. \nFLUOROSCOPY TIME AND DOSE: 18.8 min, 120 mGy \n \nPROCEDURE: \n1. Over-the-wire cholangiogram through existing right \npercutaneous \ntranshepatic biliary drainage access. \n2. Cone-beam CT cholangiogram \n3. Dilatation of mid-CBD anastamotic stricture upto 10 mm \n4. Dilatation of ampulla upto 10 mm \n5. Exchange of the existing percutaneous trans-hepatic biliary \ndrainage \ncatheter with a new 12 ___ internal/external PTBD catheter. \n \nPROCEDURE DETAILS: Following the discussion of the risks, \nbenefits and \nalternatives to the procedure, written informed consent was \nobtained from the \npatient. The patient was then brought to the angiography suite \nand placed \nsupine on the exam table. A pre-procedure time-out was \nperformed per ___ \nprotocol. The right abdomen was prepped and draped in the usual \nsterile \nfashion. \nInitial scout images showed biliary drain in the appropriate \nposition. The \nright tube was injected with dilute contrast. The images were \nstored on PACS. \n \nFollowing the subcutaneous injection of 1% lidocaine and \ninstillation of \nlidocaine jelly into the skin site, the right catheter was cut \nand ___ \nwire was advanced through the catheter into the duodenum. The \ncatheter was \nremoved over a wire and a ___ F x 25 cm bright tip sheath was \nadvanced. An \nantegrade cholangiogram was then performed with findings as \noutlined below. \nRotational cone-beam CT cholangiography was performed to help \ndelineate the \nanatomy. Multiplanar CT images were reconstructed and 3D \nvolume-rendered \nimages of the biliary anatomy required post-processing on an \nindependent \nworkstation under direct physician ___. These images \nwere used in the \ninterpretation, decision making for intervention and reporting \nof this \nprocedure. \n \nNext, a focal anastamotic stricture in the mid common bile duct \nwas dilated \nusing a 10 mm x ___ m Conquest balloon. Following this, the \nampulla was \nseparately dilated using a 10 mm x 40 mm Conquest balloon. The \nsheath was \nremoved and a ___ percutaneous transhepatic biliary catheter \nwas advanced \ninto the duodenum. The wire and inner stiffener were removed, \nthe catheter \nwas flushed, the loop was formed, the catheter was attached to a \nbag and \nsterile dressings were applied. \n \nThe existing ___ drain in the falciform collection was also \ninjected. Minimal \ncavity noted around the drain, and therefore the drain was \nremoved. \n \nThe patient tolerated the procedure well and there were no \nimmediate \npost-procedure complications. \n \nFINDINGS: \n \n \n1. Scout image of the abdomen demonstrates the ___ right \npercutaneous \ntranshepatic biliary drainage catheter in appropriate position. \nMidline \nabdominal drain is also noted in situ. \n2. Cholangiogram showing separate high-grade stenosis of the mid \ncommon bile \nduct at the level of the anastamosis and of the ampulla. This \nresults in \nprolonged stasis of the intrahepatic biliary contrast and \ndelayed emptying \ninto the duodenum. Serpiginous area of contrast filling lateral \nto the CBD \nrepresents the cystic duct remnant. \n3. After dilatation of the mid CBD and ampulla using a 10 mm \nballoon, there is \nimprovement in antegrade flow of contrast into the duodenum. \n4. Successful exchange of indwelling 12 ___ percutaneous \ntranshepatic \nbiliary drainage catheters with new 12 ___ internal external \nPTBD. \n5. Removal of ___ falciform drain. \n \nIMPRESSION: \n \n1. Successful cholangioplasty (10 mm) of high-grade mid CBD \n(anastomotic) and \nampullary stenosis. \n2. Successful exchange of existing percutaneous transhepatic \nbiliary drainage \ncatheters for a new 12 ___ internal/external biliary \ncatheter. \n3. Removal of falciform collection drain. \n\n MRCP W/O CONTRAST Study Date of ___ 10:28 AM \nFINDINGS: \n \nLower Thorax: Moderate right and trace left pleural effusions \nare similar to \n10 days prior. The lung bases are otherwise grossly clear. No \npericardial \neffusion. \n \nLiver: Status post liver transplant. Diffusion abnormality with \nassociated \nrelative T2 hyperintensity in the right hepatic lobe is in a \nsimilar to the \ngeographic region of hypoenhancement on prior CT (for example \n04:14, 42). A \nfalciform ligament drainage catheter has been removed. There \nremains a small \namount of T2 hyperintense fluid in the porta hepatis just \nposterior to the \nfalciform ligament measuring 2.4 x 1.4 cm (03:35). There is \ntrace ascites. \n \nBiliary: A right PTBD is again demonstrated, likely terminating \nin the \nduodenum as on prior CT. There is a new severe stricture \nspanning 1.2 cm in \nthe right anterior duct with post stenotic dilatation (8:2, \n03:25, 02:20). \nThe left intrahepatic bile ducts appear similar to prior MRCP, \nwith mild \nintrahepatic dilation. The common hepatic duct measures up to 1 \ncm just after \nthe anastomosis. There is moderate-to-severe narrowing of the \ncommon hepatic \nduct at the anastomosis, with poststenotic dilatation measuring \nup to 1 cm \n(8:2). \n \nPancreas: The pancreas is atrophic but with normal signal \nintensity. Two \nhyperintensities are demonstrated in the pancreatic tail \nmeasuring up to 4 mm, \nmost likely side branch IPMNs and are unchanged (03:33). \n \nSpleen: The spleen remains enlarged, measuring up to 15 cm. \nThere an \naccessory spleen in the hilum. \n \nAdrenal Glands: Adrenal glands are unremarkable. \n \nKidneys: Kidneys are of normal and symmetric size with normal \nsignal \nintensity. No focal lesions are demonstrated. Mild perinephric \nedema is \nnonspecific. \n \nGastrointestinal Tract: The imaged stomach, small and large \nbowel is \nunremarkable. \n \nLymph Nodes: No enlarged retroperitoneal or mesenteric lymph \nnodes. \n \nVasculature: No abdominal aortic aneurysm. Assessment of post \ntransplant \nvasculature is limited on this noncontrast study, and \nattenuation of the right \nportal vein is better assessed on the recent CT of ___. \n \nOsseous and Soft Tissue Structures: No suspicious osseous \nlesions. The soft \ntissues are unremarkable. \n \nIMPRESSION: \n \n \n1. Moderate-to-severe narrowing of the common hepatic duct near \nthe \nanastomosis with mild poststenotic dilation measuring up to 1 \ncm. \n2. New, severe stricture of a right anterior intrahepatic bile \nduct with \npoststenotic dilation. \n3. Diffusion abnormality in the right hepatic lobe corresponds \nto the region \nof heterogeneous hepatic enhancement, which may be related to \ncholangitis, \nhepatitis, or perfusion. \n4. 2.4 x 1.4 cm fluid loculation in the porta hepatis just \nposterior to the \nfalciform ligament reflects a small amount of residual fluid \nfrom the \npreviously demonstrated fluid collection. \n5. Cystic lesions in the pancreatic tail are most likely side \nbranch IPMNs. \nAttention on follow-up imaging is recommended. \n6. Unchanged moderate right and trace left pleural effusions. \n7. Trace ascites. \n8. Stable splenomegaly. \n\n ___ PERQ PLMT BILE DUCT STENT Study Date of ___ 2:58 \n___ \nTECHNIQUE: OPERATORS: Dr. ___ (Interventional Radiology \nFellow) and \nDr. ___ performed the \nprocedure. \nThe attending, Dr. ___ was present and supervising \nthroughout the \nprocedure. Dr. ___ radiologist, personally \nsupervised the \ntrainee during the key components of the procedure and reviewed \nand agreed \nwith the trainee's findings. \nANESTHESIA: Moderate sedation was provided by administrating \ndivided doses of \n75mcg of fentanyl and 1 point mg of midazolam throughout the \ntotal \nintra-service time of 30 minutes during which the patient's \nhemodynamic \nparameters were continuously monitored by an independent trained \nradiology \nnurse. 1% lidocaine was injected in the skin and subcutaneous \ntissues \noverlying the access site. \nMEDICATIONS: Fentanyl, Versed \nCONTRAST: 40 ml of Optiray contrast. \nFLUOROSCOPY TIME AND DOSE: 9.8 min, 102 mGy \n \nPROCEDURE: \n1. The scout image of the abdomen. \n2. Pull-back over the wire sheath cholangiogram. \n3. Placement of a 10 mm x 6 cm wall flex biliary, covered stent \nwithin the \ncommon bile duct. \n4. Plasty of the stent using an 8 mm balloon. \n5. Post stent placement and balloon plasty cholangiogram \nperformed through the \nsheath. \n6. Placement of a 12 ___ biliary anchor drain via the \nright-sided access. \n \nPROCEDURE DETAILS: \n \nFollowing the discussion of the risks, benefits and alternatives \nto the \nprocedure, written informed consent was obtained from the \npatient. The patient \nwas then brought to the angiography suite and placed supine on \nthe exam table. \nA pre-procedure time-out was performed per ___ protocol. The \nright abdomen \nwas prepped and draped in the usual sterile fashion. \nInitial scout images showed biliary drain in the appropriate \nposition. The \nright tubes were injected with dilute contrast. The images were \nstored on \nPACS. \n \n \nFollowing the subcutaneous injection of 1% lidocaine and \ninstillation of \nlidocaine jelly into the skin site, the right catheter was cut \nand an Amplatz \nwire was advanced through the catheter into the duodenum. The \ntube was \nremoved over the wire and a 9 ___ sheath was advanced over \nthe wire. A \npull back, sheath cholangiogram was then performed with findings \nas outlined \nbelow. \n \nBased on the findings of the pull-back cholangiogram, the \ndecision was made to \nplace a 10 mm x 6 cm wall flex biliary stent within the common \nbile duct. The \nstent was advanced over the wire into appropriate position and \ndeployed \nsuccessfully. Subsequently, an 8 mm balloon was used to dilate \nthe midportion \nof the stent. The balloon was removed and a cholangiogram was \nperformed \nthrough the sheath which demonstrated brisk flow of contrast \nthrough the newly \nplaced stent. \n \nSubsequently, a 12 ___ anchor drain was advanced over the \nwire with its \ndistal end terminating within the proximal right hepatic duct. \nThe wire and \ninner stiffener were removed and a small amount of contrast was \ninjected \nthrough the tube which demonstrated appropriate positioning and \nagain, \nexcellent flow through the common bile duct stent. The catheter \nwas flushed \nand secured in position. Sterile dressings were applied and the \nanchor drain \nwas capped. The patient tolerated the procedure well and there \nwere no \nimmediate postprocedure complications. \n \nFINDINGS: \n \n \n1. Scout image of the abdomen demonstrates indwelling internal \nexternal \nbiliary catheter in expected in appropriate position. \n2. As before, cholangiogram demonstrates high-grade stenosis of \nthe mid to \ndistal common bile duct at the level of the anastomosis. Only \nminimal \ncontrast is seen passing into the small bowel. \n3. Post stent deployment and plasty cholangiogram demonstrates \nexcellent flow \nof contrast through the stent into the small bowel as well as \nfilling of both \nthe right and the left intrahepatic ducts. \n4. Appropriate placement of a new 12 ___ anchor drain within \nthe \nright-sided access. \n \nIMPRESSION: \n \nSuccessful placement of a 10 mm x 6 cm wall flex biliary stent \nwithin the \ncommon bile duct to treat a high-grade stenosis of the mid to \ndistal CBD. \n \nSuccessful placement of a 12 ___ anchor drain on the right. \n\nCHEST PORT. LINE PLACEMENT Study Date of ___ 11:38 AM \n \nFINDINGS: \n \nThe tip of the right PICC line projects over the right atrium. \nIf a position \nat the cavoatrial junction is intended, the line must be pulled \nback by \napproximately 5 cm. Otherwise, there is no evidence of \nconsolidation, \neffusion, or pneumothorax. The cardiomediastinal silhouette is \nunremarkable. \n \nIMPRESSION: \n \nRight PICC line tip projected over the right atrium. If a \nposition at the \ncavoatrial junction is intended, the line must be pulled back by \napproximately \n5 cm. \n\nMICROBIOLOGY\n=============================\n___ 11:32 pm URINE Source: ___. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n PSEUDOMONAS AERUGINOSA. 10,000-100,000 CFU/mL. \n Piperacillin/Tazobactam test result performed by ___ \n___. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n PSEUDOMONAS AERUGINOSA\n | \nCEFEPIME-------------- =>64 R\nCEFTAZIDIME----------- =>64 R\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ 2 S\nMEROPENEM------------- =>16 R\nPIPERACILLIN/TAZO----- R\nTOBRAMYCIN------------ <=1 S\n\n___ 5:45 am BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: \n PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES. \n Piperacillin/Tazobactam test result confirmed by ___ \n___. \n Ceftolozane/tazobactam , CEFTAZIDIME/AVIBACTAM AND \nCOLISTIN\n Susceptibility testing requested by ___ (___) \nON\n ___. \n COLISTIN AND CEFTOLOZANE/TAZOBACTAM SENT TO ___ \nLABORATORIES FOR\n SUSCEPTIBILITY TESTING ON ___. \n CEFTAZIDIME/AVIBACTAM SENT TO LABORATORY SPECIALISTS \nFOR\n SUSCEPTIBILITY TESTING ON ___. \n Ceftolozane/tazobactam MIC OF ___ MCG/ML = \nIntermediate. \n COLISTIN MIC OF <=2 MCG/ML = SUSCEPTIBLE. \n Ceftolozane/tazobactam & COLISTIN SENSITIVITY TESTING \nPERFORMED BY\n ___. \n CEFTAZIDIME/AVIBACTAM MIC OF 64/4 MCG/ML = RESISTANT. \n CEFTAZIDIME/AVIBACTAM SENSITIVITY TESTING PERFORMED BY \nLABORATORY\n SPECIALISTS. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n PSEUDOMONAS AERUGINOSA\n | \nCEFEPIME-------------- =>64 R\nCEFTAZIDIME----------- =>64 R\nCIPROFLOXACIN--------- 2 I\nGENTAMICIN------------ <=1 S\nMEROPENEM------------- =>16 R\nPIPERACILLIN/TAZO----- =>128 R\nTOBRAMYCIN------------ <=1 S\n\n Aerobic Bottle Gram Stain (Final ___: \n GRAM NEGATIVE ROD(S). \n Reported to and read back by ___ AT 18:26 ON \n___. \n\n___ 4:50 am URINE Source: ___. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n PSEUDOMONAS AERUGINOSA. 10,000-100,000 CFU/mL. \n IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # \n___\n ___. \n PSEUDOMONAS AERUGINOSA. 10,000-100,000 CFU/mL. SECOND \nMORPHOLOGY. \n MEROPENEM test result performed by ___. \n Piperacillin/Tazobactam test result performed by ___ \n___. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n PSEUDOMONAS AERUGINOSA\n | \nCEFEPIME-------------- =>64 R\nCEFTAZIDIME----------- 8 S\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ <=1 S\nMEROPENEM------------- R\nPIPERACILLIN/TAZO----- R\nTOBRAMYCIN------------ <=1 S\n\n___ 1:38 pm URINE Source: ___. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n PSEUDOMONAS AERUGINOSA. 10,000-100,000 CFU/mL. \n Piperacillin/Tazobactam test result performed by ___ \n___. \n CEFTOLOZANE/TAZOBACTAM AND CEFTAZIDIME/AVIBACTAM SENT \nOUT TO\n REFERENCE LAB ON ___. REQUESTED BY ___ ___ \n___. \n CEFTOLOZANE/TAZOBACTAM MIC OF ___ MCG/ML Intermediate. \n CEFTOLOZANE/TAZOBACTAM SUSCEPTIBILITY PERFORMED BY ___ \n___\n ___. \n CEFTAZIDIME/AVIBACTAM MIC OF 64/4MCG/ML = RESISTANT. \n CEFTAZIDIME/AVIBACTAM SUSCEPTIBILITY PERFORMED BY \nLABORATORY\n SPECIALISTS, INC. ___. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n PSEUDOMONAS AERUGINOSA\n | \nCEFEPIME-------------- =>64 R\nCEFTAZIDIME----------- =>64 R\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ 8 I\nMEROPENEM------------- =>16 R\nPIPERACILLIN/TAZO----- R\nTOBRAMYCIN------------ 2 S\n\nDISCHARGE LABS:\n===========================\n\n___ 05:22AM BLOOD WBC-3.1* RBC-2.99* Hgb-8.3* Hct-25.9* \nMCV-87 MCH-27.8 MCHC-32.0 RDW-16.6* RDWSD-50.8* Plt ___\n___ 05:29AM BLOOD Neuts-70.9 Lymphs-15.0* Monos-7.9 Eos-5.3 \nBaso-0.3 Im ___ AbsNeut-2.41 AbsLymp-0.51* AbsMono-0.27 \nAbsEos-0.18 AbsBaso-0.01\n___ 05:22AM BLOOD ___ PTT-33.9 ___\n___ 05:22AM BLOOD Glucose-122* UreaN-19 Creat-0.8 Na-141 \nK-5.1 Cl-105 HCO3-23 AnGap-13\n___ 05:22AM BLOOD ALT-21 AST-18 AlkPhos-684* TotBili-0.9\n___ 05:22AM BLOOD Albumin-3.5 Calcium-9.2 Phos-3.6 Mg-1.7\n___ 04:10PM BLOOD Tobra-<0.3*\n \nBrief Hospital Course:\nMs. ___ is a ___ year-old woman with history of CAD, \nhypertension, diabetes mellitus, NASH cirrhosis with DDLT \n(___) (on cyclosporine and mycophenolate) with aortic conduit \ncomplicated by biliary strictures s/p stenting and multiple \npercutaneous transhepatic biliary drain exchanges with recurrent \ncholangitis, pseudomonas bacteremia, on suppressive cipro, VRE \ninfections, and left hepatic abscess s/p drainage, who p/w\nabdominal pain and elevated ALP concerning for \nrecurrentcholangitis.\n\n#Abdominal Pain \nAt last admission ___, presented with fevers/transaminitis \nconcerning for recurrent cholangitis; no abdominal pain at that \ntime. Previous bile cultures growing MDR pseudomonas sensitive \nonly to cipro & aminoglycosides as well as VRE sensitive to \nlinezolid. At that admission, RUQ U/S revealed persistent \nperihepatic collection which was drained, and PTBD uncapped with \nsignificant drainage to bag concerning for PTBD dysfunction. \nReceived cipro and linezolid, and underwent cholangiogram with \ndilation of stricture with subsequent improved flow, with \ncapping of PTBD on ___. \n\nOn this admission, pt afebrile and hemodynamically stable \nwithout leukocytosis with only mild LFT elevation above recent \nbaseline. Per ACS eval in ED, no concern for acute surgical \nprocess and her imaging showed resolved perihepatic fluid \ncollection without other identifiable sources of abdominal pain. \nCT A/P showed multiple borderline dilated fluid-filled loops of \nsmall bowel are seen in the right abdomen and pelvis, without \ndiscrete transition point, suggestive of obstructive process. \nPTBD found to be obstructed distally, so duodenum was dilated \nand PTBD was exchanged on ___. PTBD capped ___. Patient \ngiven aggressive bowel regimen ___ as well with multiple bowel \nmovements. Pain and nausea improved following these \ninterventions. Patient was continued on 2 week course of cipro \n750mg BID and linezolid ___ BID. Pt became febrile daily \n___, some leakage at PTBD. PTBD exchanged, CBD stricture \ndilated ___. Fevers continued, blood culture ___ positive \nfor MDR pseudomonas. Placement of a 10mm x 6cm Wallflex stent \nwithin the CBD as well as placement of a ___ anchor drain, \ncapped on ___. Blood ultures from ___ w/ PsA of different \nmorphology of urine culture PsA. This can be seen in patients \nwith multiple abx exposures. Antibiotic courses day 1 will be \n___, day of decompression. Linezolid ___ BID continued for 5 \nday course (___). Ceftolozane-Tazobactam 3 g IV Q8H, 14 \nday course (___). Tobramycin 7 mg/kg (400 mg) q48h, 14 \nday course (___) with weekly troughs. Increased ursodiol \nto 600mg BID in hopes this will decrease chance of future \nobstruction. ___ will evaluate stent with cholangiogram ___ and \npossibly remove anchor drain at that time.\n\n___\nCr elevated to 1.2 from baseline 0.9-1.0. Felt to be likely \nprerenal iso vomiting, and urine lytes c/w sodium avidity. \nImproved with additional fluids.\n\n#Idiopathic cirrhosis s/p DDLT ___\nWith aortic conduit (___) and stenosis of arterial graft of \nliver. Patient with multiple complications. Now more stable, \nthough with continued biliary strictures requiring PTBD drain. \nAdjusted cyclosporine dose based on level, goal 150-175. Goal \ndecreased ___ infection with goal 100-150. Continued MMF, \nbactrim, ASA. Increased ursodiol to 600 mg bid to try to \nminimize future obstructions. Immunosuppression regimen at time \nof discharge in transitional issues below.\n\nCHRONIC ISSUES \n# Psychosis: No evidence of psychosis during this admission. \nContinued olanzapine 7.5mg qhs\n\n# DM: HbA1c 5.4% in ___\nHome AM NPH initially held while NPO, then restarted as diet \nadvanced with ISS\n\n# HTN\nContinued metoprolol fractionated to 25 mg q6h. Continued \namlodipine 10mg daily\n\n# CAD\nContinued home metoprolol and aspirin\n\n# Hypothyroidism\nContinued home levothyroxine 50mcg daily\n\n# Asthma\nContinued home flovent and albuterol\n\n# GERD\nContinued home pantoprazole.\n\nTRANSITIONAL ISSUES\n===========================\n[] ___ cholangiogram and possible removal of anchor drain on ___\n[] Follow up with ID on ___\n[] PICC in place, should not be removed until cleared by ID\n[] F/u with Hepatology for ongoing monitoring, including \nmonitoring of immunosuppressive regimen. \n[] Weekly Lab draws per hepatolgoy \n[] Discharge antibiotic regimen: \n- Ceftolozane-Tazobactam 3 g IV Q8H, 14 day course (___)\n- Tobramycin 7 mg/kg (400 mg) q48h, 14 day course (___)\n[] Weekly tobramycin troughs, next to be drawn on ___ one hour \nprior to tobramycin dose\n[] Discharge Immunosuppression regimen:\n- MMF 360 mg bid\n- cyclosporine 150 mg bid\n\nFull Code\nName of health care proxy: ___ \nRelationship: sister \nPhone number: ___ \n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild \n2. amLODIPine 10 mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Clopidogrel 75 mg PO DAILY \n5. Docusate Sodium 100 mg PO BID \n6. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN Shortness of \nbreath \n7. Levothyroxine Sodium 50 mcg PO DAILY \n8. Multivitamins W/minerals 1 TAB PO DAILY \n9. Mycophenolate Sodium ___ 360 mg PO BID \n10. OLANZapine 7.5 mg PO QHS \n11. Pantoprazole 40 mg PO Q12H \n12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n13. Ursodiol 300 mg PO DAILY \n14. Vitamin D 1000 UNIT PO DAILY \n15. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob/wheeze/cough \n16. Magnesium Oxide 400 mg PO BID \n17. Ciprofloxacin HCl 750 mg PO Q12H \n18. Linezolid ___ mg PO Q12H \n19. CycloSPORINE (Neoral) MODIFIED 200 mg PO Q12H \n20. Metoprolol Succinate XL 100 mg PO DAILY \n21. NPH 10 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin\n\n \nDischarge Medications:\n1. Ceftolozane-Tazobactam 3 g IV Q8H \nthrough ___ \nRX *ceftolozane-tazobactam [Zerbaxa] 1.5 gram 3 g IV every 8 \nhours Disp #*30 Vial Refills:*0 \n2. Tobramycin 400 mg IV Q48H \nthrough ___ \nRX *tobramycin sulfate 40 mg/mL 400 mg IV every 48 hours Disp \n#*5 Vial Refills:*0 \n3. CycloSPORINE (Neoral) MODIFIED 150 mg PO Q12H \n4. NPH 10 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin \n5. Ursodiol 600 mg PO BID \nRX *ursodiol 300 mg 2 capsule(s) by mouth twice a day Disp #*120 \nCapsule Refills:*0 \n6. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild \n7. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob/wheeze/cough \n8. amLODIPine 10 mg PO DAILY \n9. Aspirin 81 mg PO DAILY \n10. Clopidogrel 75 mg PO DAILY \n11. Docusate Sodium 100 mg PO BID \n12. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN Shortness \nof breath \n13. Levothyroxine Sodium 50 mcg PO DAILY \n14. Magnesium Oxide 400 mg PO BID \n15. Metoprolol Succinate XL 100 mg PO DAILY \n16. Multivitamins W/minerals 1 TAB PO DAILY \n17. Mycophenolate Sodium ___ 360 mg PO BID \n18. OLANZapine 7.5 mg PO QHS \n19. Pantoprazole 40 mg PO Q12H \n20. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n21. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\nCholestasis secondary to percutaneous transhepatic biliary drain \nobstruction\nSECONDARY DIAGNOSIS\nIdiopathic cirrhosis\nHistory of Deceased Donor Liver Transplant\nBiliary Strictures\n -Psychosis \n -Malnutrition- moderate \n -Hypertension \n -Diabetes mellitus type 2\n -Hyperlipidemia\n -Asthma \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\n\nIt was a pleasure taking care of you during your stay at ___.\n\nWHY WAS I HERE?\n- You were having abdominal pain\n\nWHAT WAS DONE WHILE I WAS IN THE HOSPITAL?\n- Your bile drain was taken out and replaced\n- You were given medicines to help you to have bowel movements\n- You were given IV fluids\n- You were given antibiotics\n\nWHAT SHOULD I DO WHEN I LEAVE?\n- You should go to your appointment with interventional \nradiology and infectious disease \n- You should take your antibiotics as prescribed\n\nBe well!\n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "T85698A", "K831", "N179", "Z944", "R7881", "D6959", "I10", "E119", "B952", "B965", "K219", "I2510", "J45909", "T368X5A", "Y92230", "D649", "Z1624", "Y848", "Y92009" ]

[ "T85698A: Other mechanical complication of other specified internal prosthetic devices, implants and grafts, initial encounter", "K831: Obstruction of bile duct", "N179: Acute kidney failure, unspecified", "Z944: Liver transplant status", "R7881: Bacteremia", "D6959: Other secondary thrombocytopenia", "I10: Essential (primary) hypertension", "E119: Type 2 diabetes mellitus without complications", "B952: Enterococcus as the cause of diseases classified elsewhere", "B965: Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere", "K219: Gastro-esophageal reflux disease without esophagitis", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "J45909: Unspecified asthma, uncomplicated", "T368X5A: Adverse effect of other systemic antibiotics, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "D649: Anemia, unspecified", "Z1624: Resistance to multiple antibiotics", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]

[ "N179", "I10", "E119", "K219", "I2510", "J45909", "Y92230", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Ibuprofen\n \nAttending: ___.\n \nChief Complaint:\naltered mental status\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ ___ speaking with PMHx HIV, dementia, progressive\naphasia, MDD with psychotic features, prior suicide attempts,\ntransferred to ___ from nursing home for behavioral\ndysregulation and aggression on a ___.\n\nPer ED documentation of collateral from nursing facility, \npatient\nwas agitated, throwing things at staff, would not allow them to\ncome near her. Has apparently happened in the past when patient\nwas constipated. \n\nOf note, patient last geripsych hospitalization was ___ year ago \nat\n___. On previous admission, patient's outpatient\nneurologist Dr. ___ was very involved in care and med changes\nincluded d/c of valproate on ___. Continued home mirtazapine,\nmemantine, risperidone and perphenazine and clonazepam PRN. At\nlast hospitalization, patient was noted to have difficulty\nswallowing pills and would pocket them without swallowing. Has\nnot been taking meds regularly at her nursing home (___ \nLiving\nin ___. Per daughter, has had rapid decline over the last\nyear, and she expresses concerns that facility is not the best\nplace for her.\n\nIn the ED, patient was reportedly agitated and spitting. Got IM\nzyprexa and placed in soft restraints. Rectal exam revealed \nlarge\nstool burden, s/p manual disimpaction, miralax and enema x1. UA\nwith large leuks and bacteria, was not started on abx. It was\nnoted that when daughter was at the bedside, the patient was \nmore\nresponsive and redirectable. \n\nIn the ED:\n- Initial VS: T97.2 HR 73 BP 133/68 RR 16 O2 100%\n- Exam: comfortable appearing, makes eye contact and follows\ncommands though is non-verbal and muttering\n- Labs: normal CBC (WBC 6.8), wnl Chem other than K 6.6 (whole\nblood 5.8 --> 4.0), troponin negative x1, negative urine/serum\ntox, UA with large leuks, many bacteria, 5 WBC/hpf\n- Studies:\n -- CXR: bibasilar atelectasis (improved from prior),\notherwise no acute cardiopulmonary abnormality\n -- NCHCT: limited due to motion artifact but no obvious\nacute intracranial abnormality\n- Patient was given:\n -- 1L NS (___)\n -- Olanzapine 5 mg IM x2 ___ ___, ___ AM)\n -- Home bowel meds: Miralax x1, Fleet enema x1\n -- Other home meds ___ ___: Risperidone 2 mg PO,\nEmtricitabine-Tenofovir alafen 200 mg-25mg, Ralegravir 400 mg \nPO,\nMemantine 5 mg PO\n- Consults: \n -- Psychiatry - recommended work up for possible delirium\n -- Case management - daughter does not want pt to go back \nto\nnursing home\n\nVitals on transfer: T98.5 HR 92 BP 121/76 RR 18 O2 95% RA\n\nUpon arrival to the floor, patient was more calm, daughter was \nat\nbedside. Patient unable to express any symptoms, however \ndaughter\nstates she had complained of abd pain earlier today. Otherwise,\npatient occasionally mumbles to her daughter, intermittently\ncrying and upset at her daughter about something that happened\nearlier in the day. \n\nREVIEW OF SYSTEMS: Complete ROS obtained and is otherwise\nnegative.\n\nPAST MEDICAL HISTORY:\nHIV INFECTION \nDEPRESSION \nPSYCHOSIS \nPRIMARY PROGRESSIVE APHASIA \ns/p ECT in ___\nMultiple suicide attempts, since ___, most recently by OD in\n \nPast Medical History:\n- HIV\n- Frontotemporal dementia\n- Progressive aphasia \n- Essential HTN\n- Anxiety\n- Panic disorder w/ agoraphobia\n- MDD with severe psychotic features\n- History of SI, multiple attempts since ___, last in ___ via \nOD requiring ICU care\n- Obesity\n- Cognitive Impairment \n- Chronic constipation\n- Cervical radiculopathy\n \nSocial History:\n___\nFamily History:\n- Mother - heart condition\n- Daughter - HTN\n- Daughter - cervical dystonia, possible bipolar\n- Maternal aunt - alcohol abuse and depression\n- Paternal grandmother - psych condition, unknown\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nVITALS: T98.5 HR 92 BP 121/76 RR 18 O2 95% RA\nGENERAL: Alert, interactive with her daughter. Occasionally \ntears\nup and becomes agitated, shaking her arms, pulling at the \nbandage\non her arm near her IV\nEYES: NCAT. PERRL. Sclera anicteric and without injection. \nENT: MMM. No JVD.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nRESP: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing on RA.\nABDOMEN: soft, BS+, non-distended, non-tender in all four\nquadrants.\nMSK: No spinous process tenderness. No CVA tenderness. No\nclubbing or cyanosis. Trace pitting edema in ___ up to knees.\nPulses DP/Radial 2+ bilaterally.\nSKIN: Warm. No rash.\nNEUROLOGIC: AOx0. Gross movement of all extremities. Does not\nfollow commands. Reaches for daughters hands and squeezes them\nspontaneously. Occasionally shaking of upper extremities, \nappears\nvoluntary. \nPSYCH: does not respond to questions, occasionally mumbles to\ndaughter, makes hand movements which daughter interprets as\nwanting me to leave the bedside, occasionally tearful\n\nDISCAHRGE PHYSICAL EXAM:\n===========================\nVS: NO VITALS TODAY\nGEN: in chair in hallway, sounding agitated with screams\nPulm: comfortable on room air, not amenable to auscultation, no\nincreased WOB\nCV: deferred\nGI: deferred\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 12:34PM BLOOD WBC-6.8 RBC-4.40 Hgb-12.2 Hct-39.2 MCV-89 \nMCH-27.7 MCHC-31.1* RDW-15.9* RDWSD-51.7* Plt ___\n___ 12:34PM BLOOD Neuts-52.0 ___ Monos-8.1 Eos-2.8 \nBaso-0.3 Im ___ AbsNeut-3.55 AbsLymp-2.50 AbsMono-0.55 \nAbsEos-0.19 AbsBaso-0.02\n___ 12:34PM BLOOD Glucose-99 UreaN-5* Creat-0.7 Na-141 \nK-6.6* Cl-108 HCO3-22 AnGap-11\n___ 12:34PM BLOOD Calcium-9.4 Phos-3.6 Mg-2.0\n___ 12:34PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\\\n___ 12:34PM BLOOD CK-MB-2 cTropnT-<0.01\n\nNOTABLE INTERVAL LABS\n=====================\n___ 09:10PM BLOOD Albumin-2.8* Calcium-8.7 Phos-3.2 Mg-1.7\n___ 06:40AM BLOOD VitB12-727 Folate-8\n___ 06:40AM BLOOD TSH-2.3\n___ 06:40AM BLOOD Valproa-23*\n\nDISCHARGE LABS\n==============\nNO DISCHARGE LABS\n\nIMAGING\n=======\nCXR ___\nNo acute cardiopulmonary abnormality.\n\nCTH W/O CONTRAST ___\nMildly degraded evaluation secondary to motion. Within this \nlimitation, no\nacute intracranial abnormality.\n\nMICROBIOLOGY\n============\n___ 3:00 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n BETA STREPTOCOCCUS GROUP B. >100,000 CFU/mL. \n\n \nBrief Hospital Course:\nPATIENT SUMMARY\n===============\n___ is a ___ year old woman with a history of late-stage \nfrontotemporal dementia, major depressive disorder with \npsychotic features, HIV infection on HAART, and constipation who \ninitially presented with acute on chronic altered mental status \nand aggression at her nursing home in the setting of late stage \nfrontotemporal dementia, UTI, and constipation. \n\nHer hospital course was been complicated by agitation and \naggressive behavior requiring multidisciplinary team management \nwith the primary team, palliative care, and psychiatry. She had \nmultiple psychiatric medications trialed and titrated. She will \nbe discharged to inpatient hospice for continued assistance with \nsymptom management and medication titration.\n\nACUTE ISSUES\n============\n#Acute on chronic altered mental status\n#Agression\n#Frontotemporal dementia\nPatient has a history of dementia at baseline and known to \nbecome aggressive when she is constipated. Rectal examination \nwas notable for large stool burden, and urine culture was \npositive for GBS. These were considered possible causes of her \naltered state and were treated accordingly. It was also reported \nby her daughter that the patient was likely not getting her \nmedications regularly at the nursing home, and was noted to be \npocketing her pills. She was more compliant when taking her \nmedications when her daughter was present, who was very involved \nin her care during the hospital course. During episodes of acute \nagitation she received IM haldol to good effect. Given her fall \nrisk and danger to her self she was intermitently physically and \nchemically restrained. With the assistance of psychiatry and \npalliative care, her medications were adjusted to help with her \nepisodes of acute agitation. At time of discharge, she is on a \nregimen of Acetaminophen (Liquid) 650 mg PO/NG Q6H, \nChlorproMAZINE 50 mg PO/NG BID, Divalproex Sod. Sprinkles 500 mg \nPO BID, Haloperidol 2 mg IM Q8H:PRN severe agitation, \nMirtazapine 30 mg PO/NG QHS, RisperiDONE (Disintegrating Tablet) \n2 mg PO BID, RisperiDONE 1 mg PO BID:PRN mild agitation. \n\n#Mechanical fall\nSoon after arrival to the floor the patient rolled over her bed \nrailings and fell to the floor. The fall was not witnessed. She \nwas noted to be normocephalic, atraumatic however per protocol \nCT head without contrast was ordered. Due to severe agitation \nthis study was not obtained. Fortunately there was no change in \nher mental status or development of focal deficits during her \nadmission. Fall precautions were instituted and restraints \nplaced resulting in resolution of the patient's fall risk. \n\n#UTI\nOn admission urine noted to be growing GBS. This was treated \nwith a 3 day course of IV ceftriaxone. \n\n#Constipation\nNoted to have a large stool burden in the emergency department \non rectal exam. She was manually disimpacted and received an \nenema to good effect. Her home bowel regimen was resumed with no \nfurther episodes of constipation during her admission. \n\n#Hyperchloremic metabolic acidosis\nNoted soon after arrival to floor, believed to be in the setting \nof fecal losses after mobilization of stool in the emergency \ndepartment. Resolved during admission. \n\nCHRONIC ISSUES\n==============\n#Major depressive disorder with psychotic features\nHome perphenazine, mirtazapine, risperidone were continued \nduring admission.\n\n#HIV on HAART\nHAART was continued during the hospital course. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q6H:PRN \nindigestion \n2. Memantine 5 mg PO BID \n3. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - First Line \n\n4. Polyethylene Glycol 17 g PO DAILY \n5. Mirtazapine 30 mg PO QHS \n6. Perphenazine 8 mg PO QAM \n7. Perphenazine 16 mg PO QHS \n8. Raltegravir 400 mg PO BID \n9. RisperiDONE 2 mg PO BID \n10. Senna 8.6 mg PO BID \n11. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n12. Hydrocortisone Acetate Suppository ___ID:PRN \nhemorrhoid \n13. Bisacodyl ___AILY:PRN Constipation - Second Line \n14. Fleet Enema (Saline) ___AILY:PRN constipation \n15. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB \nPO DAILY \n\n \nDischarge Medications:\n1. ChlorproMAZINE 50 mg PO BID \n2. Divalproex Sod. Sprinkles 500 mg PO BID \n3. Haloperidol 2 mg IM Q8H:PRN severe agitation \n4. RisperiDONE 1 mg PO BID:PRN mild agitation \n5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n6. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q6H:PRN \nindigestion \n7. Bisacodyl ___AILY:PRN Constipation - Second Line \n8. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB \nPO DAILY \n9. Fleet Enema (Saline) ___AILY:PRN constipation \n10. Hydrocortisone Acetate Suppository ___ID:PRN \nhemorrhoid \n11. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - First \nLine \n12. Mirtazapine 30 mg PO QHS \n13. Polyethylene Glycol 17 g PO DAILY \n14. Raltegravir 400 mg PO BID \n15. RisperiDONE 2 mg PO BID \n16. Senna 8.6 mg PO BID \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n=================\nAcute on chronic altered mental status\nFrontotemporal dementia\n\nSECONDARY DIAGNOSIS\n===================\nUrinary tract infection\nConstipation\n\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\n\nIt was a privilege taking care of you at ___ \n___. \n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n===================================\n- You were confused.\n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n==========================================\n- You received medications to treat your constipation and your \nUTI\n- You were exihbiting unsafe behavior so you received \nmedications to calm you down.\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\nWe wish you all the best!\n\nSincerely, \nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "G3109", "G9341", "N390", "F0281", "E872", "F333", "R4701", "E870", "F05", "K5909", "Z515", "R1310", "Z781", "Z66", "Z21", "Z9181", "E878", "B951" ]

[ "G3109: Other frontotemporal dementia", "G9341: Metabolic encephalopathy", "N390: Urinary tract infection, site not specified", "F0281: Dementia in other diseases classified elsewhere with behavioral disturbance", "E872: Acidosis", "F333: Major depressive disorder, recurrent, severe with psychotic symptoms", "R4701: Aphasia", "E870: Hyperosmolality and hypernatremia", "F05: Delirium due to known physiological condition", "K5909: Other constipation", "Z515: Encounter for palliative care", "R1310: Dysphagia, unspecified", "Z781: Physical restraint status", "Z66: Do not resuscitate", "Z21: Asymptomatic human immunodeficiency virus [HIV] infection status", "Z9181: History of falling", "E878: Other disorders of electrolyte and fluid balance, not elsewhere classified", "B951: Streptococcus, group B, as the cause of diseases classified elsewhere" ]

[ "N390", "E872", "Z515", "Z66" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nback pain\n \nMajor Surgical or Invasive Procedure:\n___ L3-5 PLF\n\n \nHistory of Present Illness:\n___ female on Xarelto for PE (___) and early\nAlzheimer's presents with the above fracture s/p mechanical \nfall.\nOn ___, patient bent forward to pick up adult daughter with\nspecial needs, felt acute onset lower back pain. Since then, \npain\nhas been persistently severe, and now feels as though it is\nassociated with BLE weakness, as she found it difficult to\nambulate down stairs today. She required the assistance of EMS\nto take her to ___ because of her weakness. At ___,\nthey performed an MR ___ which showed a burst fracture of L4\nwith posterior involvement compressing the cauda equina. \nPatient\ndenies saddle anesthesia, loss of bowel or bladder function,\nfevers. \n\n \nPast Medical History:\nHistory of PE/DVT in ___, on rivaroxaban\nEarly Alzheimer's dementia, on donepezil \n \nSocial History:\n___\nFamily History:\nN/C\n \nPhysical Exam:\nGeneral: NAD. AAO x3. Lying awake in bed. \nSkin: warm, dry, no rash\nCV: RRR, s1 and S2 nl\nPulm: normal effort, lungs are clear\nAbd: soft, NT/ND, + BS\nWound: C/D/I. No swelling, redness, or warmth\nExtremities: calves are soft, no edema\nNeurologic: PERRL. Face symmetrical. Speech clear and fluent.\nTongue ML. EOMs intact. Negative pronator drift. Normal tone and\nbulk universally. \n \nMotor Strength:\n Delt Bi Tri BR WF/WE HI\nRight 5 5 5 5 5 5 \nLeft 5 5 5 5 5 5\n \n\n IP Quad Ham TA Gas ___\nRight 5 5 5 5 5 5 \nLeft 5 5 5 5 5 5\n\nSensation: intact to light touch\n\n \nBrief Hospital Course:\nPatient was admitted to Orthopedic Spine Service on ___ and \nunderwent the above stated procedure. Please review dictated \noperative report for details. Patient was extubated without \nincident and was transferred to PACU then floor in stable \ncondition. \n\n \n\nDuring the patient's course ___ were used for \npostoperative DVT prophylaxis. Intravenous antibiotics were \ncontinued for 24hrs postop per standard protocol. Initial postop \npain was controlled with oral and IV pain medication. Diet was \nadvanced as tolerated. Hospital course was otherwise \nunremarkable.\n\n \n\nNow, Day of Discharge, patient is afebrile, VSS, and neuro \nintact with improvement of radiculopathy. Patient tolerated a \ngood oral diet and pain was controlled on oral pain medications. \nPatient ambulated independently. Patient's wound is clean, dry \nand intact. Patient noted improvement in radicular pain. Patient \nis set for discharge to acute rehab in stable condition.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line \n3. Docusate Sodium 100 mg PO BID \n4. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - Second Line \n5. Sodium Polystyrene Sulfonate 30 gm PR ONCE \n6. Heparin 5000 UNIT SC BID \n7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate \n\n8. Donepezil 10 mg PO QHS \n\n \nDischarge Medications:\n1. Cyclobenzaprine 5 mg PO Q8H \nRX *cyclobenzaprine 5 mg 1 tablet(s) by mouth three times a day \nDisp #*80 Tablet Refills:*0 \n2. Senna 8.6 mg PO BID \n3. Acetaminophen 1000 mg PO Q8H \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ___ tablet(s) by mouth Q4-6h Disp #*80 Tablet \nRefills:*0 \n5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line \n6. Docusate Sodium 100 mg PO BID \n7. Donepezil 10 mg PO QHS \n8. Heparin 5000 UNIT SC BID \n9. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - Second Line \n \n10. Sodium Polystyrene Sulfonate 30 gm PR ONCE Duration: 1 Dose \n \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nl4 burst fracture\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nLumbar Decompression With Fusion:\n\nYou have undergone the following operation: Lumbar Decompression \nWith Fusion\n\n \n\n \n\nFollow-up Appointments \n•After you are discharged from the hospital and settled at home \nor rehab, please make sure you have two appointments: \n1.2 week post-operative wound check visit after surgery\n2.a post-operative visit with your surgeon for ___ weeks after \nsurgery. \n•You can reach the office at ___ and ask to speak \nwith your surgeon’s surgical coordinator/staff to schedule or \nconfirm your appointments\n\nWound Care\n•If not already done in the hospital, remove the incision \ndressing on day 2 after surgery. \n•You may shower day 3 after surgery. Starting on this ___ day, \nyou should gently cleanse the incision and surrounding area \ndaily with mild soap and water, patting it dry when you are \nfinished. \n•Some swelling and bruising around the incision is normal. Your \nmuscles have been cut, separated and sewn back together as part \nof your surgical procedure. You will leave the hospital with \nback discomfort from the surgical incision. As you become more \nactive and the incision and muscles continue to heal, the \nswelling and pain will decrease.\n•Have someone look at the incision daily for 2 weeks. Call the \nsurgeon’s office if you notice any of the following: \nIncreased redness along the length of the incision \n\nIncreased swelling of the area around your incision \n\nDrainage from the incision \n\nWeakness of your extremities greater than before surgery \n\nLoss of bowel or bladder control \n\nDevelopment of severe headache \n\nLeg swelling or calf tenderness \n \n \n\nFever above 101.5 \n \n•Do not soak or immerse your incision in water for 1 month. For \nexample, no tub baths, swimming pools or jacuzzi.\n\n \n\nActivity Guidelines \n•You MAY be given a RIGID BRACE that you will wear whenever \nsitting up, standing, or walking. You will wear it for ___ \nweeks after surgery. See the last page of these instructions for \ndetails on wearing the brace.\n•Avoid strenuous activity, bending, pushing or holding your \nbreath. For example, do not vacuum, wash the car, do large \nloads of laundry, or walk the dog until your follow-up visit \nwith your surgeon.\n•Avoid heavy lifting. Do not lift anything over ___ pounds for \nthe first few weeks that you are home from the hospital. \n•Increase your activities a little each day. Walking is good \nexercise. Plan rest periods and try to avoid hills if possible. \n Remember, exercise should not increase your back pain or cause \nleg pain. \n•Reaching: When you have to reach things on or near the floor, \nalways squat (bending the knees), rather than bending over at \nthe waist.\n•Lying down: when lying on your back, you may find that a pillow \nunder the knees is more comfortable. When on your side, a \npillow between the knees will help keep your back straight. \n•Sitting: should be limited to 40-60 minutes at a time for the \nfirst week. Slowly increase the amount of sitting time, \nremembering that it should not increase your back pain.\n•Stairs: use stairs only once or twice a day for the first week, \nor as directed by the surgeon. Climb steps one at a time, \nplacing both feet on the step before moving to the next one.\n•Driving: you should not drive for ___ weeks after surgery. You \nshould discuss driving with your surgeon /nurse practitioner \n/physician ___. You may ride in a car for short distances. \n When in the car, avoid sitting in one position for too long. \nIf you must take long car rides, do not ride for more than 60 \nminutes without taking a break to stretch (walk for several \nminutes and change position.).\n•Sexual activity: you may resume sexual activity ___ weeks after \nsurgery (avoiding pain or stress on the back).\n•Reduction in symptoms: patients who have experienced back and \nradiating leg pain for a short window of time before surgery \nshould anticipate a significant decrease in pre-operative \nsymptoms. If the pain has been present for a longer period \n(months to years), the pre-operative symptoms will recover on a \nmore gradual basis week by week. It is not practical to expect \nimmediate relief of symptoms. Routinely, pain will gradually \nimprove on a weekly basis, weakness on a monthly basis, and \nnumbness in a range of 6 months to ___ year. \n\nPhysical Therapy\n•Outpatient Physical Therapy (if appropriate) will not begin \nuntil after your post-operative visit with your surgeon. A \nprescription is needed for formal outpatient therapy. \n•You may be given simple stretching exercises or a prescription \nfor formal outpatient physical therapy, based on what your needs \nare after surgery. \n\nMedications\n•You will be given prescriptions for pain medications and stool \nsofteners upon discharge from the hospital.\n•Pain medications should be taken as prescribed by your surgeon \nor nurse practitioner/ physician ___. You are allowed to \ngradually reduce the number of pills you take when the pain \nbegins to subside. \n•If you are taking more than the recommended dose, please \ncontact the office to discuss this with a practitioner ___ \nmedication may need to be increased or changed).\n•Constipation: Pain medications (narcotics) may cause \nconstipation. It is important to be aware of your bowel habits \nso you ___ develop severe constipation that cannot be treated \nwith simple, over the counter laxatives.\n\nMost prescription pain medications cannot be called into the \npharmacy for renewal. The following are 2 options you may \nexplore to obtain a renewal of your narcotic medications:\n1.Call the office ___ days before your prescription runs out and \nspeak with office staff about mailing a prescription to your \nhome/pharmacy. (Prescriptions will not be sent by Fed Ex/UPS) \n2.Call the office 24 hours in advance and speak with our office \nstaff about coming into the office to pick up a prescription.\n•If you continue to require medications, you may be referred to \na pain management specialist or your medical doctor for ongoing \nmanagement of your pain medications \n•Avoid NSAIDS for ___ weeks post-operative. These medications \ninclude, but are not limited to the following:\n1.Non-steroidal Anti-inflammatory drugs: Advil, Aleve, Cataflam, \nClinoril, Diclofenac, Dolobid, Feldene, Ibuprofen, Indocin, \nMedipren, Motrin, Nalfon, Naprosyn, Nuprin, Relafen, Rufen, \nTolectin, Toradol, Trilisate, Voltarin\n\n \n\nBlood Clots in the Leg \n1.It is not uncommon for patients who recently had surgery to \ndevelop blood clots in leg veins. \n•Symptoms include low-grade fever, and/or redness, swelling, \ntenderness, and/or an \n•aching/cramping pain in your calf. \n•You should call your doctor immediately if you have these \nsymptoms. \n•To prevent blood clots in legs, try walking and/ or pumping \nankles several times during the day. \n•If the blood clot breaks free from the leg vein, it can travel \nto the lungs and cause severe breathing difficulty and/or chest \npain. If you experience this, call ___ immediately.\n\nQuestions\n•Any questions may be directed to your surgeon or physician \n___. \n1.During normal business hours (8:30am- 5:00pm), you can call \nthe office directly at ___. Turn around time for a \nphone call is 24 hours. After normal business hours, you can \ncall the on-call service and we will get back to you the next \nbusiness day.\n•If you are calling with an urgent medical issue, please tell \nthe coordinator that it is an “urgent issue” and needs to be \ndiscussed in less than 24 hours (i.e. pain unrelieved with \nmedications, wound breakdown/infection, or new neurological \nsymptoms).\n\n \n\nLumbar Corset or (TLSO) Brace Guidelines\n\n•You MAY have been given a rigid brace that you will wear for \n___ weeks after surgery. \n•You should put on your brace as you have been instructed by the \northotist (brace maker). Instructions will be reviewed in the \nhospital by the nursing staff and Physical Therapist. \n•It is a good idea to start practicing with your brace before \nsurgery (putting it on/taking it off, sitting, standing, \nwalking, and climbing steps with the brace) so you can assist \nwith your post-operative care in the hospital.\n•Keep the name and phone number of the person who fitted and \ndispensed your brace close by in case you need to have the brace \nchecked and/or adjusted. \n•You should always have a barrier between your surgical incision \nand the brace. For example, you may want to put on a light \nt-shirt and then the brace before getting dressed for the day. \n•During periods of rest, take off the brace and expose the \nincision to the air by lying on your side for a few hours. This \nwill reduce the chance of your wound breaking down. \n1.The brace must be worn at all times with the following 3 \nexceptions: 1.Lying flat in bed during a rest period or at \nnight to sleep.\n2.Getting out of bed at night to go to the bathroom, returning \nto bed immediately when you are finished.\n3.Showering. You may wish to use a shower chair to help prevent \nbending/twisting while bathing. You should have someone help \nwash your back and legs.\n\nPhysical Therapy:\nActivity: Activity: Ambulate twice daily if patient able\nTLSO brace\nTreatments Frequency:\neval wound daily\n \nFollowup Instructions:\n___\n" ]

[ "S32001A", "M47816", "M48061", "G300", "F0280", "W1830XA", "Z86711", "Z7901", "Z86718" ]

[ "S32001A: Stable burst fracture of unspecified lumbar vertebra, initial encounter for closed fracture", "M47816: Spondylosis without myelopathy or radiculopathy, lumbar region", "M48061: Spinal stenosis, lumbar region without neurogenic claudication", "G300: Alzheimer's disease with early onset", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "W1830XA: Fall on same level, unspecified, initial encounter", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants", "Z86718: Personal history of other venous thrombosis and embolism" ]

[ "Z7901", "Z86718" ]

[]

[ " \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:\nBRBPR\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\n___ year old woman with PMHx notable for CAD s/p PCI in ___, \nMCUS, h/o prior rectal bleeding thought to be due to \ndiverticulosis vs hemorrhoid but declines colonoscopy (admitted \n___, CAD/MI s/p BMS in ___, HTN, HLD, MGUS, and \nhypertrophic cardiomyopathy, presenting with 2 episodes of \nhematochezia at 3am this morning and then at 330am. Patient \nstates that she called EMS after the second episode. She had \nmild abdominal pain, which is now resolved.\n\nThe patient's son is present for the interview and reports that \nthe patient's PCP is aware of the rectal bleeding and the plan \nin the past has been to defer colonoscopy. However, whenever the \npatient has bleeding, she calls ___ regardless. Her son is \nconcerned that the patient is becoming increasingly forgetful \nwith age and requires a higher level of care than can be \nprovided at home. They currently have assistance from home \nhealth aids several days a week, and the son lives nearby. They \nhave looked into long term care at ___ and are hoping \nto transition there, although the patient herself is resistant.\n\nIn the ED, the patient's VS were stable and labs were notable \nfor stable Hct at 30. She had no further episodes of rectal \nbleeding.\n\nUpon arrival to the floor, she is comfortable. She denies abd \npain, n/v, diarrhea, or constipation. She denies lightheadedness \nor dizziness. No chest pain. Her bleeding has resolved.\n\nROS: As per HPI. Comprehensive 10 point ROS is otherwise \nnegative.\n\n \nPast Medical History:\n1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension\n2. CARDIAC HISTORY:\n-CABG: None\n-PERCUTANEOUS CORONARY INTERVENTIONS: ___ BSM to ___ LAD\n-PACING/ICD: None\n___ Left Heart Cath with 95% LAD lesion s/p BMS, 40% LCx, \n___ lesions in RCA. \n3. OTHER PAST MEDICAL HISTORY:\n- LVH w/ Mild outflow obstruction\n- MGUS\n- Iron def Anemia\n- Hiatal Hernia\n- Osteoporosis\n- BRBPR, admission with RBC transfusions in ___\nANEMIA \nCARDIOMYOPATHY\nCAD \nHIATAL HERNIA AND IRREG ESOPH MUCOSA \nHYPERCHOLESTEROLEMIA \nHYPERTENSION \nMGUS \nMURMUR \nOSTEOPOROSIS \nVITILIGO \nMYOCARDIAL INFARCTION \nHYPOTHYROIDISM \n\nEXTERNAL HEMORRHOIDS \nDIVERTICULOSIS/GI BLEED\n\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death. Sister died of MI in old age (patient not \nsure how old), had life long unknown cardiac condition.\n\n \nPhysical Exam:\nPhysical Exam:\nVitals: 97.6, 162/73, 56, 16, 98% on RA\nGen: NAD, lying in bed comfortably, AAOx3\nEyes: EOMI, sclerae anicteric\nENT: MMM, OP clear\nCV: RRR, no murmur\nPULM: normal effort, no accessory muscle use, lungs CTA ___.\nGI: soft, NT, ND, BS+\nGU: Foley catheter in place draining clear urine\nMSK: R hand/forearm splint in place. No significant kyphosis. No \npalpable synovitis.\nSkin: No visible rash. No jaundice.\nNeuro: AAOx3. Fluent speech, no facial droop.\nPsych: Full range of affect\n \nPertinent Results:\nLabs:\n___ 05:23AM BLOOD WBC-7.3 RBC-3.27* Hgb-9.9* Hct-30.7* \nMCV-94 MCH-30.3 MCHC-32.2 RDW-13.9 RDWSD-47.8* Plt ___\n___ 05:23AM BLOOD Neuts-61.6 ___ Monos-11.2 Eos-1.9 \nBaso-0.3 Im ___ AbsNeut-4.52 AbsLymp-1.81 AbsMono-0.82* \nAbsEos-0.14 AbsBaso-0.02\n___ 05:23AM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND \nK-PND Cl-PND HCO3-PND\n\nImaging: \nNone\n\n \nBrief Hospital Course:\n___ with CAD s/p MI and BMS in ___, HTN, diverticulosis and \nhemorrhoids, who presents with recurrent painless BRBPR. She is \nnot on anticoagulation. Her hematocrit and vital signs were \nstable in the ED, and her bleeding did not recur, so it is \nunclear why she was admitted. She was discharged last week for \nthe same complaint, and during that admission the risks and \nbenefits of colonoscopy were weighed and the patient chose to \ndefer intervention. She was discharged home to follow up with \nher PCP, who in the past has also supported conservative \nmanagement, watchful waiting. Nonetheless, the patient arrived \nto the floor asymptomatic with no further bleeding. The risks \nand benefits of colonoscopy were again discussed, and the \npatient preferred to defer intervention. She should not be \nadmitted to the hospital for rectal bleeding unless her \npreferences or risks of intervention change; this can be \ndiscussed with her PCP prior to admission as well.\n\nThe patient's son expressed concern about the patient's ability \nto care for herself. He remarked that the reason she keeps \ncoming to the hospital is because she is forgetful and easily \nconfused, calling 911 whenever she bleeds regardless of \ninstructions from her providers. She also had a mechanical fall \nat home recently and sustained a right thumb fracture. He \nexpressed wishes to have her admitted to ___ for STR as \na possible stepping stone for more long term care. Our case \nmanager worked on a bed for the patient, but there were none \navailable at ___. The patient and her son declined bed search \nfor other rehab beds and preferred discharge home with increased \nsupervision from her home ___ company until ___ has a \nbed. I spoke with the patient's PCP, who will help coordinate \noutpatient case management for the patient. She was evaluated by \n___, who recommend walker at all times. I talked to the patient's \northopedic office covering physician who explained that while \nshe should technically be non-weight bearing on the right arm \nfor her thumb fracture, the most important thing was \nimmobilization of and lack of pressure applied to the thumb. \nThese recommendations were discussed with the patient and her \nson, who felt that it was worth continuing the walker at home \nfor stability and fall prevention. Her thumb is currently \nimmobilized in a splint, and she has follow up with her \northopedist in the next 2 weeks. She will continue ___ at home. \n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Citalopram 20 mg PO DAILY \n4. Docusate Sodium 100 mg PO BID \n5. Levothyroxine Sodium 25 mcg PO DAILY \n6. Metoprolol Succinate XL 25 mg PO DAILY \n7. Senna 8.6 mg PO BID \n8. Ferrous Sulfate 325 mg PO DAILY \n9. Hydrocortisone (Rectal) 2.5% Cream ___AILY \n10. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Citalopram 20 mg PO DAILY \n4. Docusate Sodium 100 mg PO BID \n5. Ferrous Sulfate 325 mg PO DAILY \n6. Hydrocortisone (Rectal) 2.5% Cream ___AILY \n7. Levothyroxine Sodium 25 mcg PO DAILY \n8. Metoprolol Succinate XL 25 mg PO DAILY \n9. Multivitamins 1 TAB PO DAILY \n10. Senna 8.6 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nHematochezia\nInternal hemorrhoids\nDiverticulosis\nHypertension\nCoronary artery disease\nChronic microcytic anemia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear ___ were admitted to ___ for an episode of rectal bleeding. \n___ were found to have stable vital signs and stable blood \ncounts. We discussed the risks and benefits of colonoscopy, and \nagreed that an urgent procedure is not necessary at this time, \nand that the risks would ultimately outweigh the benefits. \nPlease discuss further management of your rectal bleeding with \nyour PCP.\nBest wishes,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "K921", "K648", "K5790", "D509", "I2510", "I10", "E785", "D472", "I422", "M810", "E039", "Z66", "I252", "Z955" ]

[ "K921: Melena", "K648: Other hemorrhoids", "K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding", "D509: Iron deficiency anemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "D472: Monoclonal gammopathy", "I422: Other hypertrophic cardiomyopathy", "M810: Age-related osteoporosis without current pathological fracture", "E039: Hypothyroidism, unspecified", "Z66: Do not resuscitate", "I252: Old myocardial infarction", "Z955: Presence of coronary angioplasty implant and graft" ]

[ "D509", "I2510", "I10", "E785", "E039", "Z66", "I252", "Z955" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Allergies/ADRs on File\n \nAttending: ___.\n \nChief Complaint:\nShortness of breath\n \nMajor Surgical or Invasive Procedure:\nNONE\n\n \nHistory of Present Illness:\n___ w/ COPD, CHF, DMII, presents after being found somnolent, \nhypercarbic and hypoxic, and is now being transferred to the \nMICU for acute hypercarbic hypoxic respiratory failure.\n\nThe pt complains that he has had increased shortness of breath \nrecently over the last few weeks. He has been having multiple \nepisodes of \"blacking out\" over the last few days, described as \nfalling asleep. He has also had some dull chest pain (present \nfor \"a while\") and a cough which is sometimes dry and sometimes \nproductive.\n\nHe has carried on with his daily activities and was on his way \nto the grocery store when he had another blacking out episode. \nHe was taken to ___ after being found somlnolent \nbut arousable. At that time, he was noted to have O2 sats in \n___. Denies injury, trauma, headache, nausea, vomiting, \ndiarrhea.\n\nNotably, the pt admits that he is non compliant with his \nmedications. He used to be seen by a PCP, prescribed meds such \nas Lasix and Metformin, but has not followed up due to \"no \ninsurance.\" His current only medication is an inhaler.\n\nOn arrival to ___, his ABG was notable for pH 7.26 and pCO2 \n74. He was placed on BiPAP, but did not tolerate on so was \nplaced on a non-rebreather. The patient was given Solumedrol \n125mcg IV x 2, DuoNebs, and Azithromycin before being \ntransferred to ___ ED for further management.\n\nIn ED at ___, initial VS: T 96.9, HR 94, BP 152/98, RR 16, O2 \n97% on NRB.\n\nLabs significant for: \n-WBC 10.1 (92.8% PMNs), Hbg 18.3, Plts 142\n-Repeat VBG: pH 7.18, pCO2 99, pO2 18, HCO3 39, lactate 1.9\n\nA CXR demonstrated multiple right posterior displaced rib \nfractures are noted, most of which have callus formation and \nbibasilar opacities may represent atelectasis, but difficult to \nexclude pneumonia.\n\nOn arrival to the MICU, pt was on the BiPAP and mentating OK. \nConfirmed the above story. No new symptoms\n \nREVIEW OF SYSTEMS: 10 point ROS done, and negative, unless \nstated above in HPI\n\n \nPast Medical History:\nCHF - formerly on diuretics\nDiabetes Mellitus - formerly on Metformin\nCOPD\nCAD\n\n \nSocial History:\n___\nFamily History:\nDenies known family history of CHF.\n \nPhysical Exam:\nADMISSION EXAM\n=====================\nGENERAL: Alert, oriented, in mild resp distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP to just below jawline at 30 degrees\nLUNGS: Rhonchi bilaterally as well as bilateral crackles. Prior \nthoracotomy scar on right lung \nCV: Regular rate and rhythm \nABD: soft, non-tender, non-distended\nEXT: Warm, well perfused. Bilateral 2+ lower extremity edema \nSKIN: Dirty fingernails bilaterally\nNEURO: Oriented x3 and answering questions appropriately, \nmoving all extremities\n\nDISCHARGE EXAM\n======================\nVITALS: 97.7 152/91 102 20 91 2.5 \nGENERAL: Alert, oriented, no increased work of breathing. \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP elevated. \nLUNGS: Crackles bilaterally ___ up the lungs. Prior thoracotomy\nscar on right lung \nCV: Regular rate and rhythm \nABD: soft, non-tender, non-distended\nEXT: Warm, well perfused. Bilateral 2+ lower extremity edema \nSKIN: Dirty fingernails bilaterally\nNEURO: Oriented x3 and answering questions appropriately, \nmoving\nall extremities\n \nPertinent Results:\nADMISSION LABS\n=====================\n___ 06:37PM ___ PO2-111* PCO2-57* PH-7.38 TOTAL \nCO2-35* BASE XS-7\n___ 03:00PM LACTATE-1.5 K+-5.3*\n___ 02:45PM GLUCOSE-283* UREA N-33* CREAT-1.0 SODIUM-136 \nPOTASSIUM-5.2* CHLORIDE-95* TOTAL CO2-32 ANION GAP-9*\n___ 02:45PM CALCIUM-8.7 PHOSPHATE-4.2 MAGNESIUM-1.8\n___ 05:30AM cTropnT-0.01\n___ 05:30AM CK-MB-8 proBNP-4918*\n___ 05:30AM WBC-10.1* RBC-5.91 HGB-18.3* HCT-59.2* \nMCV-100* MCH-31.0 MCHC-30.9* RDW-13.6 RDWSD-51.0*\n___ 05:30AM ___ PTT-35.4 ___\n___ 05:30AM PLT COUNT-142*\n\nMICROBIOLOGY\n======================\n___ 6:25 am BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n\n___ 12:51 pm URINE Source: ___. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH. \n\nIMAGING/STUDIES\n=======================\nTTE ___ \nThe left atrium is normal in size. No atrial septal defect is \nseen by 2D or color Doppler. The estimated right atrial pressure \nis at least 15 mmHg. There is mild symmetric left ventricular \nhypertrophy with normal cavity size. There is mild regional left \nventricular systolic dysfunction with hypokinesis of the basal \ninferior and inferoseptal and mid to distal inferior/ \ninferolateral/ lateral walls. The remaining segments contract \nnormally (LVEF = 40 %). Doppler parameters are indeterminate for \nleft ventricular diastolic function. The right ventricular \ncavity is moderately dilated with moderate global free wall \nhypokinesis. There is abnormal septal motion/position consistent \nwith right ventricular pressure/volume overload. The aortic \nvalve leaflets (3) are mildly thickened but aortic stenosis is \nnot present. No aortic regurgitation is seen. The mitral valve \nleaflets are mildly thickened. There is no mitral valve \nprolapse. Physiologic mitral regurgitation is seen (within \nnormal limits). The tricuspid valve leaflets are mildly \nthickened. There is moderate pulmonary artery systolic \nhypertension. There is an anterior space which most likely \nrepresents a prominent fat pad. \n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with \nmild regional dysfunction c/w CAD. Moderately dilated right \nventricle with moderate free wall hypokinesis. Moderate \npulmonary hypertension. \n\nCXR ___ IMPRESSION: \nMultiple right posterior displaced rib fractures are noted, most \nof which have callus formation. Bibasilar opacities may \nrepresent atelectasis, but difficult to exclude pneumonia, \ncorrelate clinically.\n \nMild pulmonary edema.\n \nInterval progression of mild cardiomegaly since ___.\n \nBrief Hospital Course:\n___ w/ COPD, CHF, DMII, who presented after being found \nsomnolent, hypercarbic and hypoxic, and was transferred to the \nMICU for acute hypercarbic hypoxic respiratory failure.\n \n# Acute Hypoxic Hypercarbic Respiratory Failure: Patient was \nadmitted to the MICU for respiratory failure after being found \nsomnolent in his car. He was felt to have a combined COPD and \nCHF exacerbation. He was treated with BiPAP then weaned to \nhigh-flow nasal cannula before weaned to regular nasal cannula. \nCOPD and CHF were treated as below. At discharge, patient was \nstill requiring 2L NC and noted to desat to 63% on RA while \nambulating. \n\n# COPD exacerbation\nPatient likely developed a COPD exacerbation in the setting of \nnot having all of his meds x few months and due to CHF \nexacerbation. He was treated with IV steroids on ___ then \ntransitioned to PO prednisone for a total 5 day course. He was \ngiven standing Duonebs and PRN albuterol nebs. He was also \ntreated with an empiric course for CAP with CTX/azithromycin (D1 \n= ___. He completed 4 days of ceftriaxone/azithro while \ninpatient and was given a prescription for 1 tablet to complete \na 5-day course of azithromycin at discharge. He was given \nprescriptions for home inhalers and nebulizers at discharge. \n\n# CHF exacerbation\n# CAD\nOn admission, patient had evidence of fluid overload on exam in \naddition to orthopnea and dyspnea on exertion. He had a \ntransthoracic echocardiogram which showed mild symmetric left \nventricular hypertrophy with mild regional dysfunction c/w CAD. \nModerately dilated right ventricle with moderate free wall \nhypokinesis. Moderate pulmonary hypertension. LVEF = 40 %. \nPatient was started on ASA 81 mg and atorvastatin 80 mg for his \nCAD. Patient responded well to Lasix while hospitalized. He was \nstill volume overloaded when he chose to leave AMA. He was \ndischarged on lasix 40mg PO BID. \n\n# Diabetes: A1C was 11.2%. He was treated with Insulin, Lantus \nand sliding scale. Restarted metformin 1g BID at discharge. \n\nOn ___, patient chose to leave AMA despite on-going hypoxemia \n(desatted to 63% on RA while ambulating and refusing home O2 \ntherapy) and volume overload. He understood the risks of leaving \nincluding worsening respiratory failure and death. Additionally, \npatient has no PCP that he currently follows with. Patient was \nurged to establish care with a PCP. He was discharged ___ \nprescriptions for his COPD inhalers, ASA, atorvastatin, \nmetformin and lasix for his multiple ___ medical \nissues. He will need full work up of his CAD/cardiac ischemia \nand diabetes. Additionally will need to follow his volume status \non standing oral lasix. \n\nEmergency Contact: Son ___ ___ \n\n \n___ on Admission:\nHe reports he was not taking any meds on admission\n \nDischarge Medications:\n1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze, SOB \nRX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb inh Q4H:PRN \nDisp #*30 Vial Refills:*2 \n2. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath \nRX *albuterol sulfate [ProAir HFA] 90 mcg ___ puff inh Q4H:PRN \nDisp #*1 Inhaler Refills:*2 \n3. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet \nRefills:*2 \n4. Atorvastatin 20 mg PO QPM \nRX *atorvastatin 20 mg 1 tablet(s) by mouth Everyday at bedtime \nDisp #*30 Tablet Refills:*2 \n5. Azithromycin 250 mg PO Q24H \nRX *azithromycin 250 mg 1 tablet(s) by mouth DAILY Disp #*1 \nTablet Refills:*0 \n6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \nRX *fluticasone-salmeterol 113 mcg-14 mcg/actuation 1 puff inh \ntwice a day Disp #*1 Inhaler Refills:*2 \n7. Furosemide 40 mg PO BID \nRX *furosemide 40 mg 1 tablet(s) by mouth Twice Daily Disp #*60 \nTablet Refills:*2 \n8. MetFORMIN (Glucophage) 1000 mg PO BID \nRX *metformin 1,000 mg 1 tablet(s) by mouth Twice Daily Disp \n#*60 Tablet Refills:*2 \n9. Tiotropium Bromide 1 CAP IH DAILY \nRX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap \ninh DAILY Disp #*30 Capsule Refills:*2 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAcute Hypoxic Hypercarbic Respiratory Failure\nCOPD Exacerbation\nCHF exacerbation \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\nWHY WAS I HOSPITALIZED?\n-You were brought to the hospital after you were found to be \nconfused, having trouble breathing, and having chest pain.\n\nWHAT HAPPENED WHILE I WAS HOSPITALIZED?\n-You were found to have a COPD exacerbation and you were given \nmedications to help with your breathing in addition to \nantibiotics and steroids.\n-You were cared for in the ICU for close monitoring of your \nbreathing.\n-You were found to have fluid on your lungs and given \nmedications to help with removing fluid.\n- You are choosing to leave the hospital against medical advice. \nYou still have extra fluid on your lungs and need extra oxygen \nto help you breathe.\n\nWHAT YOU NEED TO DO WHEN YOU GO HOME:\n- Please take all of your medicines as prescribed. \n- It is very important you make an appointment with a primary \ncare doctor to follow up on your medical issues. \n- You may call our primary care office, called Healthcare \nAssociates at ___.\n\n \nFollowup Instructions:\n___\n" ]

[ "I5033", "J9601", "J9602", "J189", "J441", "J440", "E118", "I2720", "Z9114", "I2510", "Z7984", "E875" ]

[ "I5033: Acute on chronic diastolic (congestive) heart failure", "J9601: Acute respiratory failure with hypoxia", "J9602: Acute respiratory failure with hypercapnia", "J189: Pneumonia, unspecified organism", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "J440: Chronic obstructive pulmonary disease with (acute) lower respiratory infection", "E118: Type 2 diabetes mellitus with unspecified complications", "I2720: Pulmonary hypertension, unspecified", "Z9114: Patient's other noncompliance with medication regimen", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z7984: Long term (current) use of oral hypoglycemic drugs", "E875: Hyperkalemia" ]

[ "J9601", "I2510" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nIodinated Contrast Media - Oral and IV Dye\n \nAttending: ___.\n \nChief Complaint:\nchest pain and DOE\n \nMajor Surgical or Invasive Procedure:\nCardiac catheterization with balloon angioplasty, ___\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old gentleman with ESRD on HD, CAD s/p\nmultiple PCI (LM PCI in ___ c/b restenosis in ___ s/p DES and\nPTCA of jailed LCX, and DES x2 to LAD in ___, and severe\npreviously asymptoatmic AS, presenting from ___ with 3\ndays of severe DOE and CP, found to have elevated trop to 0.2 \nand\nBNP > 14000.\n\nHe was in usual state of health until 3 days ago when he\nexperienced severe exertional chest pain and dyspnea similar to\nprior MI. This chest pain only occurred with exertion and was\nrelieved at rest. He was not able to walk across the room \nwithout\nsitting down. At baseline, he is able to go up stairs and\ncomplete activities without any shortness of breath or chest\npain. He had no lightheadedness, palpitations, orthopnea, PND, \nor\n___ swelling. \n\nHe presented to ___ where he was found to have\ntroponin elevation to 0.28 and BNP of > 14K. CXR revealed no\npulmonary edema or pleural effusion or consolidation (per my\nread). He was transferred to ___ for further management\nand potential intervention.\n\nIn the ___, hew was afebrile with BP 120s-140s/60s-80s and HR in\n___, satting well on room air. EKG revealed atrial bigeminy\nvs wenkebach, no ST elevations, ST depressions in V4-6. Troponin\nwas 0.31 with flat MB. Cardiology was consulted. He was given\nheparin bolus and gtt, atorvastatin, and carvedilol.\n\nOn arrival to the floor, patient reports no chest pain or\nshortness of breath.\n \nREVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as\nper HPI \n\n \nPast Medical History:\n- Hypertension\n- Hyperlipidemia\n- HFrEF with recovered EF (EF > 55%)\n- NSTEMI with LM and 3VD s/p LM PCI in ___ c/b restenosis in\n___ s/p DES and PTCA of jailed LCX, and unstable angina in\n___ s/p DES x2\n- Severe aortic stenosis\n- Obesity\n- Hard of hearing\n- Depression\n- ESRD on HD MWF, left AV fistula\n- Hypothyroidism\n \n\n \nSocial History:\n___\nFamily History:\nNo family history of kidney disease. Mother had diabetes \n___.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n=========================== \nVS: 97.6 141/62 73 18 97 Ra \nGENERAL: No apparent distress\nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,\nMMM \nNECK: supple, no LAD, no JVD \nHEART: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly \nEXTREMITIES: no cyanosis, clubbing, or edema \nPULSES: 2+ DP pulses bilaterally \nNEURO: A&Ox3, moving all 4 extremities with purpose \nSKIN: warm and well perfused, no excoriations or lesions, no \nrashes \n\nDISCHARGE PHYSICAL EXAM\n===========================\nVitals: 97.5 PO 110 / 60 65 18 97 RA \nGENERAL: No apparent distress, appears well\nHEENT: AT/NC, anicteric sclera, pink conjunctiva, MMM, \noropharynx\nclear\nNECK: supple\nHEART: RRR, S1/S2, ___ holosystolic murmur best hear over RUSB,\nno gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: nondistended, nontender in all quadrants, no\nrebound/guarding\nEXTREMITIES: no cyanosis, clubbing, or edema. L arm AV acess-\npalpable thrill, +bruit. R hand with sensation intact and good\ngrip strength. 2+ radial and DP pulses bilaterally. R femoral\naccess with bandage c/d/I, no hematoma or swelling, no overlying\nerythema or TTP. No bruits. ___ motor and sensation.\nSKIN: warm and well perfused\n\n \nPertinent Results:\nADMISSION LABS\n====================\n___ 08:09PM BLOOD WBC-7.7 RBC-3.80* Hgb-11.3* Hct-34.5* \nMCV-91 MCH-29.7 MCHC-32.8 RDW-18.0* RDWSD-59.8* Plt ___\n___ 08:09PM BLOOD Neuts-64.2 ___ Monos-11.7 Eos-2.0 \nBaso-0.5 Im ___ AbsNeut-4.92 AbsLymp-1.60 AbsMono-0.90* \nAbsEos-0.15 AbsBaso-0.04\n___ 08:09PM BLOOD ___ PTT-28.4 ___\n___ 08:09PM BLOOD Glucose-84 UreaN-52* Creat-6.0*# Na-143 \nK-4.7 Cl-101 HCO3-25 AnGap-17\n___ 08:09PM BLOOD ALT-8 AST-14 AlkPhos-64 TotBili-0.4\n\nPERTINENT LABS\n===================\n___ 08:09PM BLOOD CK-MB-2 cTropnT-0.31*\n___ 08:09PM BLOOD cTropnT-0.30*\n___ 02:02AM BLOOD CK-MB-2 cTropnT-0.29* ___\n___ 07:15AM BLOOD CK-MB-2\n___ 08:09PM BLOOD Albumin-3.9 Calcium-8.8 Phos-3.0 Mg-2.2\n\nIMAGING\n====================\n___ Cardiovascular Brief Preliminary Cath Note \nDominance: Right\nThe LMCA is normal with a widely patent prior stent.\nThe LAD had an 80% focal instent restenosis at the origin of the \nLAD. Other prior mid LAD stents are widely patent.\nThe Circumflex has an ostial 50-70% stenosis (unchanged from \nprior angiograms). The RCA has ostial approximately 50% disease \n(unchanged from prior angiograms)\n\n___ Cardiovascular ECHO \nThe left atrial volume index is normal. There is mild symmetric \nleft ventricular hypertrophy with normal cavity size. There is \nmild global left ventricular hypokinesis (LVEF = 45%). Tissue \nDoppler imaging suggests an increased left ventricular filling \npressure (PCWP>18mmHg). Right ventricular chamber size and free \nwall motion are normal. The ascending aorta is mildly dilated. \nThere are three aortic valve leaflets. The aortic valve leaflets \nare severely thickened/deformed. There is severe aortic valve \nstenosis (valve area <1.0cm2). Trace aortic regurgitation is \nseen. The mitral valve leaflets are mildly thickened. There is \nno mitral valve prolapse. An eccentric, anteriorly-directed jet \nof mild (1+) mitral regurgitation is seen. Due to the eccentric \nnature of the regurgitant jet, its severity may be significantly \nunderestimated (Coanda effect). There is borderline pulmonary \nartery systolic hypertension. There is a trivial/physiologic \npericardial effusion. \n\n IMPRESSION: Mild global left ventricular systolic dysfunction. \nSevere aortic stenosis. At least mild mitral regurgitation. \nMildly dilated ascending aorta.\n\n Compared with the prior study (images reviewed) of ___, \nLV function is less vigorous. Aortic valve gradients are lower, \nsecondary to lower LV stroke volume, but the calculated aortic \nvalve area is similar. \nMICROBIOLOGY\n\nDISCHARGE LABS\n==================\n___ 06:00AM BLOOD WBC-6.6 RBC-3.39* Hgb-10.0* Hct-31.0* \nMCV-91 MCH-29.5 MCHC-32.3 RDW-17.0* RDWSD-56.8* Plt ___\n___ 06:00AM BLOOD Neuts-78.1* Lymphs-12.0* Monos-9.0 \nEos-0.0* Baso-0.3 Im ___ AbsNeut-5.18 AbsLymp-0.80* \nAbsMono-0.60 AbsEos-0.00* AbsBaso-0.02\n___ 06:00AM BLOOD Plt ___\n___ 06:00AM BLOOD ___ PTT-28.5 ___\n___ 06:00AM BLOOD Glucose-133* UreaN-47* Creat-5.5*# Na-137 \nK-5.0 Cl-95* HCO3-24 AnGap-18\n___ 06:00AM BLOOD Calcium-8.2* Phos-4.7* Mg-2.1\n \nBrief Hospital Course:\nMr. ___ is a ___ year old gentleman with ESRD on HD, CAD s/p \nmultiple PCI and severe previously asymptoatmic AS, admitted for \nacute severe DOE and CP, found to have NSTEMI, now s/p cardiac \ncatheterization with balloon angioplasty.\n\nACUTE ISSUES\n=========================\n# NSTEMI\nPatient has history of CAD with multiple stents (LM PCI in ___ \nc/b restenosis in ___ s/p DES and PTCA of jailed LCX, and DES \nx2 to LAD in ___. Presented with typical angina symptoms, \nwith initial EKG significant for atrial bigeminy vs ___, \nno ST elevations, and ST depressions in V4-6. Troponin peaked at \n0.31, with CKMB 2. Patient received IV heparin and his home \naspirin, atorvastatin, carvedilol, and Plavix. Pt underwent \ncardiac catheterization on ___ with balloon angioplasty to \n80% focal instent restenosis at the origin of the LAD. No \nadditional stents were placed.\n\n#HFrEF- Patient presented with acute onset dyspnea on exertion \nwith pro BNP elevated at ___. However, patient was euvolemic, \nand had CXR with low suspicion for pulmonary edema or pleural \neffusion or consolidation. Symptoms likely secondary to NSTEMI. \nTTE on this admission ___ showed LVEF 45% with mild global \nleft ventricular systolic dysfunction. Also consistent with \nknown severe aortic stenosis and at least mild mitral \nregurgitation. Mildly dilated ascending aorta. Given current \nactive hemodialysis and resolution of symptoms, diuresis was \ndeferred.\n\n# Severe aortic stenosis- Patient was previously planned for \nTAVR workup/evaluation, but given resolution of angina with LAD \nstent in ___, decision was made to monitor aortic stenosis at \nthat time. TTE on this admission showed aortic valve peak \nvelocity of 3.2 m/sec and peak gradient of 42 mm Hg, with mean \ngradient of 25 mm Hg and aortic valve of 0.8cm^2. Given no \nsignificant increase in severity of stenosis on TTE and \nimprovement in symptoms after cath, plan at this time is for \noutpt follow up with Dr. ___.\n\n# ESRD on HD \n- MWF HD- patient received dialysis ___. Home nephrocaps was \ncontinued.\n\nCHRONIC ISSUES\n# Hypothyroid - continued home levothyroxine \n# Depression - continued home paroxetine\n# HTN - continue homed amlodipine and carvedilol\n\nTRANSITIONAL ISSUES\n===========================\n[] Discharge weight is 87 kg (191.8 lb). \n[] Discharge creatinine 5.5.\n[] Continue outpatient monitoring for status of aortic stenosis, \nas above\n[] Given femoral access for cardiac catheterization on ___, \nactivity precautions:\n- No driving for 48 hours \n- Avoid valsalva \n- No lifting >2 pounds for 24 hours and no more than 8 pounds \nfor\n48 hours after that, no more than 10 lbs x 1 week \n- Avoid wrist extension for 5 days \n\n#CODE: Full (presumed) \n#CONTACT: Daughter ___ is HCP, ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 5 mg PO 4X/WEEK (___) \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Calcium Acetate 1334 mg PO TID W/MEALS \n5. Carvedilol 12.5 mg PO BID \n6. Clopidogrel 75 mg PO DAILY \n7. Levothyroxine Sodium 25 mcg PO DAILY \n8. PARoxetine 30 mg PO DAILY \n9. B Complex-Vitamin B12 (vitamin B complex) 1000 mcgs oral \nDAILY \n10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest Pain \n11. ___ Caps (B complex with C#20-folic acid) 1 mg oral DAILY \n\n \nDischarge Medications:\n1. amLODIPine 5 mg PO 4X/WEEK (___) \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. B Complex-Vitamin B12 (vitamin B complex) 1000 mcgs oral \nDAILY \n5. Calcium Acetate 1334 mg PO TID W/MEALS \n6. Carvedilol 12.5 mg PO BID \n7. Clopidogrel 75 mg PO DAILY \n8. Levothyroxine Sodium 25 mcg PO DAILY \n9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest Pain \n10. PARoxetine 30 mg PO DAILY \n11. ___ Caps (B complex with C#20-folic acid) 1 mg oral DAILY \n\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nNSTEMI\nHFrEF\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (cane).\n\n \nDischarge Instructions:\nDear Mr. ___ \n\nIt was a pleasure taking care of you at the ___ \n___! \n\nWhy was I admitted to the hospital? \n-You were admitted because you had chest pain and difficulty \nbreathing. \n\nWhat happened while I was in the hospital? \n- While you were here you received medications to protect your \nheart. You also underwent a procedure which found a blockage in \none of the arteries of your heart, and the procedure cleared up \nthe blockage.\n- You also received imaging (\"TRANSTHORACIC ECHOCARDIOGRAM\") of \nyour heart which showed that your heart is not as strong as it \nwas before. It did not show any significant change in your \naortic stenosis.\n- While you were here you also received dialysis on your regular \nschedule\n\nWhat should I do after leaving the hospital? \n- Please continue your current hemodialysis schedule.\n- Please take your medications as listed in discharge summary \nand follow up at the listed appointments. \n- Your discharge weight is 87 kg (191.8 lb). Please weight \nyourself every day and call your doctor if your weight goes up \nby more than 3 lbs.\n- Please follow up with your primary care doctor.\n- Please follow up with your cardiologist.\n\nBecause of your procedure, please:\n- No driving for 48 hours \n- Avoid bearing down (val___) \n- No lifting >2 pounds for 24 hours and no more than 8 pounds \nfor\n48 hours after that, no more than 10 lbs x 1 week \n- Avoid wrist extension for 5 days \n\nThank you for allowing us to be involved in your care, we wish \nyou all the best! \n\n Your ___ Healthcare Team \n \n\n \nFollowup Instructions:\n___\n" ]

[ "T82855A", "I214", "I472", "I132", "I5022", "N186", "I083", "I2510", "Y929", "Y848", "E039", "D649", "F329", "Z87891", "Z992" ]

[ "T82855A: Stenosis of coronary artery stent, initial encounter", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "I472: Ventricular tachycardia", "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "I5022: Chronic systolic (congestive) heart failure", "N186: End stage renal disease", "I083: Combined rheumatic disorders of mitral, aortic and tricuspid valves", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Y929: Unspecified place or not applicable", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "E039: Hypothyroidism, unspecified", "D649: Anemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Z87891: Personal history of nicotine dependence", "Z992: Dependence on renal dialysis" ]

[ "I2510", "Y929", "E039", "D649", "F329", "Z87891" ]

[]

[ " \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 \nMajor Surgical or Invasive Procedure:\nNone\nattach\n \nPertinent Results:\nAdmission labs:\n====================\n\n___ 10:25AM BLOOD WBC-4.6 RBC-3.78* Hgb-11.7* Hct-35.1* \nMCV-93 MCH-31.0 MCHC-33.3 RDW-13.1 RDWSD-44.5 Plt ___\n___ 10:25AM BLOOD Glucose-111* UreaN-16 Creat-1.1 Na-129* \nK-5.5* Cl-94* HCO3-18* AnGap-17\n___ 05:48AM BLOOD ___ PTT-36.6* ___\n___ 06:00AM BLOOD ALT-26 AST-29 AlkPhos-67 TotBili-0.5\n___ 10:25AM BLOOD Calcium-9.4 Phos-2.9 Mg-1.6\n___ 03:50PM BLOOD Ammonia-22\n\nDischarge labs:\n======================\n\n___ 05:43AM BLOOD WBC-5.0 RBC-3.81* Hgb-11.8* Hct-35.6* \nMCV-93 MCH-31.0 MCHC-33.1 RDW-13.3 RDWSD-45.7 Plt ___\n___ 05:43AM BLOOD Glucose-94 UreaN-20 Creat-1.2 Na-135 \nK-4.2 Cl-94* HCO3-23 AnGap-18\n___ 05:48AM BLOOD proBNP-688*\n___ 05:43AM BLOOD Calcium-10.0 Phos-4.0 Mg-1.9\n\nImaging:\n======================\n___ TTE\nEF 69% \nSuboptimal image quality. Mild symmetric left ventricular \nhypertrophy with\nnormal cavity size and global biventricular systolic function. \nMild aortic regurgitation. Mild mitral regurgitation with normal \nvalve morphology.Mildly dilated thoracic aorta. Unable to\nquantify pulmonary artery systolic pressure.\nCompared with the prior TTE (images reviewed) of ___, the \nseverity of aortic regurgitation is now increased.\n\nCLINICAL IMPLICATIONS: The patient has a mildly dilated \nascending aorta. Based on 2010ACCF/AHA Thoracic Aortic \nGuidelines, a follow-up echocardiogram is suggested in ___ \nyears.\n\n___ Focused abdominal u/s: no ascites\n\n___ CT head:\nNo acute intracranial abnormality on noncontrast CT head. \nSpecifically, no evidence of acute large territory infarct or \nintracranial hemorrhage. No mass effect. \n\n \nBrief Hospital Course:\nMr. ___ is a ___ with history of alcoholic cirrhosis, \nSIADH,\nand Depression/anxiety presenting from PCP office for \nhyponatremia. Improved with fluid restriction. ___ from \nadherence to fluid restriction with improvmenet on decreasing \nLasix dose. \n\nACUTE ISSUES: \n=============\n# Acute on chronic symptomatic hyponatremia\n#___\nChronic hyponatremia felt to be in the setting of SIADH though\nmay have a component of hyponatremia from underlying known\ncirrhosis. Improved with fluid restriction. Educated patient on \nimportance of adherence to restriction. \n\n___\nBaseline Cr 0.8 per ___ records. Increased in the setting of\nstrict volume restriction in patient while on furosemide ___\nand losartan. HRS unlikely as no ascites. Improved with decrease \nof Lasix with plan for Lasix 20mg daily. Resumed losartan on day \nof discharge. \n\n# Alcoholic cirrhosis\nCirrhotic morphology of liver on prior abdominal ultrasound and\nfibroscan with evidence of cirrhosis. No ascites on u/s ___. \nNo ascites. Last EGD in ___ and discussed importance of repeat. \nScheduled to follow up with Liver in ___. Advised to stop \nalcohol use. No other evidence of decompensation. \n\n#Dyspnea \nTTE with intact EF and LVH. BNP mildly elevated though \nunreliable in the setting of cirrhosis. Could consider \noutpatient stress testing. \n\nCHRONIC ISSUES:\n================ \n# Anxiety/depression\n- Continue home lorazepam and hydroxyzine daily:PRN for anxiety\n\n# Normocytic anemia \nBaseline Hgb. History of alcohol use. \n\n# GERD- Continue home PPI BID \n\n# Allergic rhinitis- Continue home fluticasone nasal spray BID \nand cetirizine 10mg\nBID\n\nTransitional Issues:\n============================\n[] Repeat Na at PCP follow up\n[] Lasix dose decreased to 20mg daily, assess volume and Cr at \nfollow up for adjustments accordingly\n[] Overdue for EGD in the setting of cirrhosis\n[] Consider cardiac stress test for dyspnea \n[] Mildly dilated ascending aorta. Based on ___ ACCF/AHA \nThoracic Aortic Guidelines, a follow-up echocardiogram is \nsuggested in ___ years.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. ipratropium bromide 42 mcg (0.06 %) nasal Q6H:PRN \n2. Fluticasone Propionate NASAL 2 SPRY NU BID \n3. Cetirizine 10 mg PO BID \n4. Losartan Potassium 50 mg PO DAILY \n5. Gabapentin 600 mg PO QHS \n6. Docusate Sodium 100 mg PO QHS \n7. Omeprazole 40 mg PO BID \n8. Atenolol 50 mg PO QPM \n9. Furosemide 20 mg PO EVERY OTHER DAY \n10. Cyanocobalamin 1000 mcg PO DAILY \n11. Multivitamins 1 TAB PO DAILY \n12. LORazepam 0.5 mg PO TID:PRN anxiety \n13. FoLIC Acid 1 mg PO DAILY \n14. HydrOXYzine 50 mg PO BID:PRN anxiety \n15. Furosemide 40 mg PO EVERY OTHER DAY \n\n \nDischarge Medications:\n1. Furosemide 20 mg PO DAILY \nRX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n2. Atenolol 50 mg PO QPM \n3. Cetirizine 10 mg PO BID \n4. Cyanocobalamin 1000 mcg PO DAILY \n5. Docusate Sodium 100 mg PO QHS \n6. Fluticasone Propionate NASAL 2 SPRY NU BID \n7. FoLIC Acid 1 mg PO DAILY \n8. Gabapentin 600 mg PO QHS \n9. HydrOXYzine 50 mg PO BID:PRN anxiety \n10. ipratropium bromide 42 mcg (0.06 %) nasal Q6H:PRN \n11. LORazepam 0.5 mg PO TID:PRN anxiety \nRX *lorazepam [Ativan] 0.5 mg 1 ml by mouth TID PRN Disp #*20 \nTablet Refills:*0 \n12. Losartan Potassium 50 mg PO DAILY \n13. Multivitamins 1 TAB PO DAILY \n14. Omeprazole 40 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nHyponatremia\nAcute kidney injury \n\nSecondary diagnosis:\nAlcoholic cirrhosis\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\n====================== \nDISCHARGE INSTRUCTIONS \n====================== \nDear Mr. ___, \nIt was a privilege caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n- You were admitted to the hospital because of concern for low \nsodium levels\n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- You were on fluid restriction (1.5 Liters) with improvement of \nyour sodium levels\n- You had a mild kidney injury that improved with decreasing \nyour Lasix dose\n- Your had an echo that showed chronic changes to your heart \nthat could be causing some shortness of breath\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n- Please measure your fluid intake and make sure it is 1.5 L or \nless daily to avoid having low sodium levels\n- Strat taking Lasix 20mg daily on ___\n- measure your weight daily and call your primary care office if \nyou have gained > ___ lb \n- Please avoid all alcoholic drinks as this will worsen your \ncirrhosis \n- You will need to follow up with your liver doctors for ___ \nrepeat endoscopy \n-Please continue to take all of your medications and follow-up \nwith your appointments as listed below. \n\nWe wish you the best! \nSincerely, \nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "E222", "G9341", "N179", "I10", "F329", "F419", "D649", "K219", "R600", "J309", "K7030", "R0600" ]

[ "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "G9341: Metabolic encephalopathy", "N179: Acute kidney failure, unspecified", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "D649: Anemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "R600: Localized edema", "J309: Allergic rhinitis, unspecified", "K7030: Alcoholic cirrhosis of liver without ascites", "R0600: Dyspnea, unspecified" ]

[ "N179", "I10", "F329", "F419", "D649", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\n___ Coronary artery bypass graft x 3\n \nHistory of Present Illness:\n___ has a h/o HTN, dyslipidemia, DM, and hypothyroidism and has \nhad a several month history of increasing chest pain. He had a \n+ETT in ___ and was sent to\nthe ___ ED by his cardiologist. He ruled out for an MI and \nunderwent cardiac cath on ___ which revealed severe 2 vessel \nCAD. He was transferred to ___ for surgical evaluation.\n \nPast Medical History:\nHypertension\nNIDDM\nHyperlipidemia\nDepression\nHemorrhoids\nClaudication\nHOH\nBPH\nGERD\nHypothyroidism\ncurrent smoker\nBilateral shoulder surgery ___ years ago\ns/p chole\n \nSocial History:\n___\nFamily History:\nFather died at ___ of CVA\nMother died at ___ of old age\nBrother died at ___ of cardiac disease\n \nPhysical Exam:\nAdmission PE: \nVital Signs and Intake/Output:\nTcurrent 98.3: B/P: 107-114/60 HR/Rhythm: 54-58 SR \nRR: 20 SaO2: 96% RA FSBG: 105-196\n\nPhysical Examination:\nGeneral/Neuro: NAD [x] A/O x3 [] non-focal [] \nCardiac: RRR [x] Irregular [] Nl S1 S2 []\nLungs: CTA [x] No resp distress []\nAbd: NBS [x]Soft [] ND [] NT []\nExtremities: no CCE[x] Pulses doppler [] palpable [] \n.\nDischarge Exam:\nTemp: 99.0 PO BP: 99/59 L Sitting HR: 75 RR: 18 O2\nsat: 95% O2 delivery: Ra FSBG: 179 \nWeight 67.9kg\n\nPhysical Examination:\nGeneral/Neuro: NAD [x] A/O x3 [x] non-focal [x] \nCardiac: RRR [x] Irregular [] Nl S1 S2 []\nLungs: CTA [x] No resp distress [x]\nAbd: NBS [x]Soft [x] ND [x] NT [x]\nExtremities: no CCE[x] Pulses doppler [] palpable [x] \nWounds: Sternal: CDI [x] no erythema or drainage [x]\n Sternum stable [x] Prevena []\n \n\n \nPertinent Results:\nEcho ___:\nResults \n\nMeasurements \n\nNormal Range \n\nLeft Ventricle - Inferolateral Thickness: *2.1 cm 0.6 - 1.1 \ncm \nLeft Ventricle - Diastolic Dimension: 4.4 cm <= 5.6 cm \nLeft Ventricle - Systolic Dimension: 2.6 cm \nLeft Ventricle - Fractional Shortening: 0.41 >= 0.29 \nLeft Ventricle - Ejection Fraction: 55% to 60% >= 55% \nAorta - Ascending: 2.2 cm <= 3.4 cm \n \nFindings \nLEFT ATRIUM: No spontaneous echo contrast in the body of the ___. \nNo mass/thrombus in the ___. No spontaneous echo contrast \nis seen in the ___. \n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. \n\nLEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. \nNormal regional LV systolic function. Overall normal LVEF \n(>55%). \n\nRIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic \nfunction. \n\nAORTA: Normal ascending, transverse and descending thoracic \naorta with no atherosclerotic plaque. Normal ascending aorta \ndiameter. Normal descending aorta diameter. \n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No \nAS. No AR. \n\nMITRAL VALVE: No MS. ___ (1+) MR. \n\n___ VALVE: No TS. Mild [1+] TR. \n\nPERICARDIUM: No pericardial effusion. \n\nREGIONAL LEFT VENTRICULAR WALL MOTION: \n\nBasal InferoseptalBasal AnteroseptalBasal Anterior\nBasal InferiorBasal InferolateralBasal Anterolateral Mid \nInferoseptalMid AnteroseptalMid Anterior\nMid InferiorMid InferolateralMid Anterolateral Septal \nApexAnterior Apex\nInferior ApexLateral Apex Apex \n \n N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic \n\nConclusions \n No spontaneous echo contrast is seen in the body of the left \natrium. No mass/thrombus is seen in the left atrium or left \natrial appendage. No spontaneous echo contrast is seen in the \nleft atrial appendage. There is moderate symmetric left \nventricular hypertrophy. The left ventricular cavity size is \nnormal. Regional left ventricular wall motion is normal. Overall \nleft ventricular systolic function is normal (LVEF>55%). Right \nventricular chamber size is normal with normal free wall \ncontractility. The ascending, transverse and descending thoracic \naorta are normal in diameter and free of atherosclerotic plaque \nto XX cm from the incisors. The aortic valve leaflets (3) appear \nstructurally normal with good leaflet excursion and no aortic \nstenosis or aortic regurgitation. There is no aortic valve \nstenosis. No aortic regurgitation is seen. Mild (1+) mitral \nregurgitation is seen. There is no pericardial effusion. \n Post bypass\n The biventricular function is preserved .There is no regional \n___ motion abnormality.The rest of the exam is unchanged\n The thoracic aorta is intact\n.\nName: ___ ___ No: ___\n\nDate: ___\n\nDate of Birth: ___ Sex: M\n\nSurgeon: ___, MD ___\n\nPREOPERATIVE DIAGNOSIS: Coronary artery disease.\n\nPOSTOPERATIVE DIAGNOSIS: Coronary artery disease.\n\nPROCEDURE: Coronary artery bypass grafting x 3 with the left\ninternal mammary artery to the left anterior descending artery\nand sequential reverse saphenous vein graft to the first and\nsecond obtuse marginal artery.\n\nASSISTANT: ___, M.D., surgical resident and ___, PA-C\n\nANESTHESIA: General.\n\nCROSS CLAMP TIME: 53 minutes.\n\nPUMP TIME: 66 minutes.\n\nCOMPLICATIONS: None.\n\nINDICATIONS: This is a ___ male who has\nseveral-months history of increasing chest pain. He had a\npositive exercise stress test. He underwent a cardiac\ncatheterization, which demonstrated three-vessel coronary\nartery disease. He was transferred here for further\nmanagement. Coronary artery bypass grafting was recommended\nto the patient and he consented to proceed.\n\nDESCRIPTION OF PROCEDURE: After the patient was placed under\nanesthesia and intubated, his chest, abdomen and lower\nextremities were prepped with chlorhexidine and draped in\nusual fashion. The intraoperative transesophageal\nechocardiogram showed normal left ventricular function without\nsignificant valvular abnormalities. The greater saphenous\nvein was harvested endoscopically from the left leg from the\ngroin down to the calf. The majority of the vein was varicose\nin nature, but had one long length to use, which I was\nplanning on sequencing to the first and second obtuse marginal\nartery. While the saphenous vein was being harvested, a\nmedian sternotomy was made. The left pleural space was\nopened. The left internal mammary artery was dissected off\nthe chest wall with electrocautery. The patient was given\n5000 units of heparin intravenously. The distal artery was\ndivided and there was excellent flow seen. The artery was\nabout 1.25 mm in diameter. Papaverine solution was injected\ndown the artery and a clip was applied distally. The\npericardium was opened up. The aorta was palpated and this\nwas free of calcifications. The patient was fully heparinized\nprior to inserting the aortic cannula, venous cannula, and\nantegrade cardioplegic catheter. We went on bypass. The\naorta was cross clamped and the heart was arrested with\nantegrade cardioplegia. I examined the lateral wall and\nidentified the first and second obtuse marginal artery. The\nsecond obtuse marginal artery was opened up. This was a 1-mm\nvessel to which I anastomosed the saphenous vein in\nend-to-side fashion with running Prolene sutures. The flow\ndown this graft was 60 mL per minute. I then opened up the\nfirst obtuse marginal artery and this was a 1.5-mm vessel. I\nmade a corresponding longitudinal venotomy on the previous\nvein graft and anastomosed the vein to the artery in a\nside-to-side fashion with running Prolene sutures. The flow\ndown this graft was 100 mL per minute. Throughout the case, I\ngave an intermittent antegrade cardioplegia as well as\ncardioplegia down the completed vein graft. A slit was made\nin the left pericardium where I brought out the internal\nmammary artery. I opened up the left anterior descending\nartery in the mid portion and this was a 1.5-mm vessel to\nwhich I anastomosed the internal mammary artery in an\nend-to-side fashion with running Prolene sutures. The patient\nwas rewarmed. I punched a hole in the aorta for proximal\nanastomosis of the vein graft. The cross-clamp was released\nwith aortic root vented. Atrial and ventricular pacing wires\nwere placed. The heart resumed beating. The patient was\nventilated. The patient came off bypass without any\ndifficulties. The intraoperative transesophageal\nechocardiogram showed preserved biventricular function. \nProtamine was given to reverse the heparin. The cannulas were\nremoved. Three chest tubes were inserted, one in the left\npleural space and two in the anterior mediastinum. The\npericardium was reapproximated around the internal mammary\nartery and around the aorta. The sternum was closed with\nstainless steel wires. The rectus fascia and the subcutaneous\ntissues were closed in two layers with running Vicryl sutures.\nThe skin was closed with running subcuticular Monocryl\nsutures. Dermabond was placed over the incisions. The\npatient left the operating room, intubated and in stable\ncondition.\n\n ___, MD ___\nI was physically present during all critical and key portions of\nthe procedure and immediately available to furnish services \nduring\nthe entire procedure, in compliance with CMS regulations.\n.\nEXAMINATION: Chest x-ray \n \nINDICATION: ___ year old man status CABG//eval for effusion \n \nTECHNIQUE: Chest PA and lateral \n \nCOMPARISON: Chest x-ray ___ \n \nIMPRESSION: \n \nThere are low lung volumes. This causes crowding of the \nbronchovascular \nmarkings and exaggeration of heart size. Mild atelectatic \nchanges are seen at the lung bases. There is a small left \npleural effusion. The heart is at the upper limits of normal in \nsize. The aorta is atherosclerotic. The right IJ catheter \nappears stable in position. Sternal wires appear intact. \nDegenerative changes are seen in the spine.\n. \nAdmission labs:\n___ 02:07PM BLOOD WBC-8.3 RBC-4.53* Hgb-14.0 Hct-41.9 \nMCV-93 MCH-30.9 MCHC-33.4 RDW-12.1 RDWSD-40.9 Plt ___\n___ 02:50PM BLOOD Neuts-70.0 ___ Monos-3.9* Eos-1.4 \nBaso-0.5 Im ___ AbsNeut-6.87* AbsLymp-2.27 AbsMono-0.38 \nAbsEos-0.14 AbsBaso-0.05\n___ 02:07PM BLOOD ___ PTT-33.8 ___\n___ 02:07PM BLOOD Glucose-115* UreaN-18 Creat-1.0 Na-143 \nK-4.2 Cl-101 HCO3-27 AnGap-15\n___ 02:07PM BLOOD ALT-11 AST-12 LD(LDH)-179 AlkPhos-140* \nTotBili-0.4\n___ 02:07PM BLOOD Albumin-4.5 Calcium-9.8 Phos-4.4 Mg-1.6\n___ 02:07PM BLOOD %HbA1c-6.3* eAG-134*\n___ 11:56AM BLOOD Glucose-118* Lactate-2.0 Na-137 K-4.0 \nCl-105\n___ 11:56AM BLOOD Hgb-11.9* calcHCT-36\n.\nDischarge Labs:\n___ 05:21AM BLOOD WBC-9.4 RBC-2.77* Hgb-8.7* Hct-26.1* \nMCV-94 MCH-31.4 MCHC-33.3 RDW-12.3 RDWSD-42.6 Plt ___\n___ 05:21AM BLOOD Plt ___\n___ 05:21AM BLOOD Glucose-111* UreaN-20 Creat-0.9 Na-138 \nK-4.5 Cl-99 HCO3-27 AnGap-12\n___ 04:33AM BLOOD Mg-1.9\n \nBrief Hospital Course:\nMr. ___ was transferred from ___ to ___ for surgical \nmanagement of his coronary artery disease. Upon admission he was \nmedically managed while undergoing pre-operative work-up. On \n___ he was taken to the operating room where he underwent a \ncoronary artery bypass graft x 3. Please see operative note for \nsurgical details. Following surgery he was transferred to the \nCVICU for invasive monitoring in stable condition. Later this \nday he was weaned from sedation, awoke neurologically intact and \nextubated, breathing comfortably, and hemodynamically stable. \nBeta blocker was initiated and the patient was gently diuresed \ntoward the preoperative weight. The patient was transferred to \nthe telemetry floor for further recovery. Chest tubes and pacing \nwires were discontinued without complication. The patient was \nevaluated by the Physical Therapy service for assistance with \nstrength and mobility. By the time of discharge on POD 4 the \npatient was ambulating freely, the wound was healing and pain \nwas controlled with oral analgesics. The patient was discharged \nto ___ in good condition with appropriate follow up \ninstructions.\n\n \n \nMedications on Admission:\nCholecalciferol ___ units PO daily\nHCTZ 25 mg PO daily\nLevothyroxine 150 mcg daily\nLisinopril 40 mg PO daily\nMetformin 500 mg PO daily\nNTG SL PRN\nOxybutynin ER 10 mg PO daily\nPravastatin 40 mg PO daily\nZantac 150 mg PO BID\nSertraline 25 mg PO daily\nFlomax 0.8 mg PO daily\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H \n2. Aspirin EC 81 mg PO DAILY \n3. Atorvastatin 40 mg PO QPM \n4. Docusate Sodium 100 mg PO BID \n5. Furosemide 20 mg PO DAILY Duration: 5 Days \n6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol \n7. Glucose Gel 15 g PO PRN hypoglycemia protocol \n8. Insulin SC \n Sliding Scale\n\nFingerstick QACHS\nInsulin SC Sliding Scale using REG Insulin \n9. Metoprolol Tartrate 6.25 mg PO BID \n10. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain: \nmoderate/severe \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*60 Tablet Refills:*0 \n11. Potassium Chloride 20 mEq PO BID Duration: 5 Days \n12. Senna 8.6 mg PO BID:PRN Constipation - First Line \n13. Levothyroxine Sodium 150 mcg PO DAILY \n14. MetFORMIN (Glucophage) 500 mg PO DAILY \n15. Oxybutynin 10 mg PO DAILY \n16. Ranitidine 150 mg PO BID \n17. Sertraline 25 mg PO DAILY \n18. Tamsulosin 0.8 mg PO QHS \n19. Vitamin D ___ UNIT PO DAILY \n20. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication \nwas held. Do not restart Hydrochlorothiazide until seen by \nCardiologist \n21. HELD- Lisinopril 40 mg PO DAILY This medication was held. \nDo not restart Lisinopril until seen by Cardiologist \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nCoronary artery disease s/p Coronary artery bypass graft \nPast medical history:\nHypertension\nNIDDM\nHyperlipidemia\nDepression\nHemorrhoids\nClaudication\nHOH\nBPH\nGERD\nHypothyroidism\ncurrent smoker\nBilateral shoulder surgery ___ years ago\ns/p chole\n \nDischarge Condition:\nAlert and oriented x3, non-focal\n Ambulating, gait steady\n Sternal pain managed with oral analgesics\n Sternal Incision - healing well, no erythema or drainage\n Edema trace\n\n \nDischarge Instructions:\nPlease shower daily -wash incisions gently with mild soap, no \nbaths or swimming, look at your incisions daily\n Please - NO lotion, cream, powder or ointment to incisions\n Each morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart\n No driving for approximately one month and while taking \nnarcotics\n\nClearance to drive will be discussed at follow up appointment \nwith surgeon\n No lifting more than 10 pounds for 10 weeks\n\nEncourage full shoulder range of motion, unless otherwise \nspecified\n **Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n Females: Please wear bra to reduce pulling on incision, avoid \nrubbing on lower edge\n \nFollowup Instructions:\n___\n" ]

[ "I2510", "I10", "E785", "E119", "E039", "K219", "Z720" ]

[ "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "E119: Type 2 diabetes mellitus without complications", "E039: Hypothyroidism, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z720: Tobacco use" ]

[ "I2510", "I10", "E785", "E119", "E039", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nBreak-through seizure\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nThis is a ___ year old man with a history of a low grade glioma\ns/p resection complicated by refractory seizures despite AED\nadherence leading to left temporal lobectomy on ___. Since\n___, he has continued his AED regimen of LACOSamide 200 mg\nBID, lamotrigine 250 mg BID, clobazam 10 mg BID, and lorazepam 1\nmg PRN. \n\nHe recently had follow-up with both the neurosurgical team and\nwith the Epilepsy team and was found to have a stable exam.\nHowever, he was noted to have a post-surgical left temporal\nhygroma with CT imaging demonstrating possible dural\ncommunication. He was asymptomatic at this time and the decision\nwas made to continue to watch him. \n\nThree days ago, he developed a piercing headache, sharp through\nhis left temporal region. This has been constant, if not \nsteadily\nworsening ever since. His pain is not positional. No photophobia\nor phonophobia. He has had no recent sicknesses, endorses no \nneck\nstiffness, and has been adherent with his AED regimen. \n\nYesterday evening, he suddenly had a generalized tonic clonic\nseizure, without his typical aura. Per his wife, he was noted to\nbe sitting on the couch and suddenly fall, with tongue biting \nbut\nwithout incontinence. Unlike his seizures prior to his surgical\nresection, this seizure was without any aura. The episode lasted\nless than 1 minute followed by the patient going limp then\nthrashing in non-rhythmic way (total event lasted ~ 3 minutes).\nWife was particularly concerned at the duration of his \npost-ictal\nstate, which lasted ~ 15 minutes and was characterized by\nnonsensical speech. W Specifically, wife notes that he was\ndisoriented to year (\"1817\") and president and that ee had\ntrouble speaking in full-sentences. Wife says that it is \natypical\nfor him to have such a prolonged post-ictal state. His typical\nperiod of aphasia with his prior semiology lasted for 1 minute.\nWife gave him 1 mg ativan when she thought it was safe for him \nto\ntake PO. Although they typically don't call after he has\nseizures, wife concerned as this was his first seizure since his\nsurgical resection on ___. \n\nOn ___ reports having a headache for the past 3 days\nthat he describes as left-sided and piercing, as if directly\npiercing into surgical site. He has been adherent with his AEDs\nand has not had any recent sicknesses or change in his pattern \nof\nsleep. On chart review, in last follow-up was on ___ with\nDr. ___ was noted to have fluid collection over\nsurgical site. He did not have a headache at this time. CT\ndemonstrated increased size of fluid collection at craniotomy\nsite. MRI brain without and with gadolinium was recommended to\nevaluate whether there is direct communication with cystic area\nat the left middle cranial fossa, and integrity of the dura. \n \nPast Medical History:\n-Left frontotemporal brain tumor, ganglioglioma on pathology \nfrom OSH, s/p subtotal resection in ___\n-Symptomatic epilepsy\n\nNon-AED Medications\n-Melatonin 3mg qhs for insomnia\n\n \nSocial History:\n___\nFamily History:\nNo family history of epilepsy. No other brain tumors in\nfamily, though lung ca, breast ca, and father w/ CABG @ ___. \n \nPhysical Exam:\nEXAM ON ADMISSION:\n=================\n\nVitals: T97.7 HR75 RR18 101/63\n\nGeneral: Awake, cooperative, NAD.\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx\nNeck: Supple, no carotid bruits appreciated. No nuchal rigidity\nPulmonary: Lungs CTA bilaterally without R/R/W\nCardiac: RRR, nl. S1S2, no M/R/G noted\nAbdomen: soft, NT/ND, normoactive bowel sounds, no masses or\norganomegaly noted.\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. Pt was able to\nregister 3 objects and recall ___ at 5 minutes. There was no\nevidence of apraxia or neglect.\n-Cranial Nerves:\nII, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without\nnystagmus. Normal saccades. VFF to confrontation. Visual acuity\n___ bilaterally. Fundoscopic exam revealed no papilledema,\nexudates, or hemorrhages.\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 and SCM bilaterally.\nXII: Tongue protrudes in midline.\n-Motor: Normal bulk, tone throughout. No pronator drift\nbilaterally.\nNo adventitious movements, such as tremor, noted. No asterixis\nnoted.\n Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___\nL 5 ___ ___ 5 5 5 5 5 5 5\nR 5 ___ ___ 5 5 5 5 5 5 5\n-Sensory: No deficits to light touch, pinprick, cold sensation,\nvibratory sense, proprioception throughout. No extinction to \nDSS.\n-DTRs:\n Bi Tri ___ Pat Ach\nL 2 2 2 3 1\nR 2 2 2 2 1\nPlantar response was flexor bilaterally.\n-Coordination: No intention tremor, no dysdiadochokinesia noted.\nNo dysmetria on FNF or HKS bilaterally.\n-Gait: Good initiation. Narrow-based, normal stride and arm\nswing. Able to walk in tandem without difficulty. Romberg\nabsent.\n\nEXAM ON DISCHARGE:\n==================\nUnchanged\n \nPertinent Results:\nLABS:\n___ 05:30AM BLOOD WBC-11.1* RBC-4.03* Hgb-12.7* Hct-37.2* \nMCV-92 MCH-31.5 MCHC-34.1 RDW-12.5 RDWSD-42.4 Plt ___\n___ 05:30AM BLOOD Neuts-54.9 ___ Monos-7.8 Eos-2.8 \nBaso-0.5 Im ___ AbsNeut-6.08 AbsLymp-3.72* AbsMono-0.86* \nAbsEos-0.31 AbsBaso-0.05\n___ 05:30AM BLOOD Glucose-102* UreaN-14 Creat-0.9 Na-141 \nK-4.1 Cl-103 HCO3-23 AnGap-15\n___ 05:30AM BLOOD ALT-27 AST-18 AlkPhos-47 TotBili-0.3\n___ 05:30AM BLOOD Albumin-4.1 Calcium-9.4 Phos-4.1 Mg-2.2\n\nMRI with and without contrast ___:\nFINDINGS: \n \nPostoperative change anterior left temporal lobectomy. Adjacent \npostoperative changes.\n \nT2 signal abnormality, cephaly malacia cystic changes of the \nanterior left\ntemporal lobe near the surgical margin, extending into the \nposterior left sub insula, left para hippocampal gyrus is more \nprominent compared to prior, may be sequela postsurgical \nischemic changes, underlying inflammatory or infectious process. \n Remnant left hippocampus is atrophic and not FLAIR \nhyperintense.\n \nWell-defined extracranial fluid collection seen deep to the \ntemporalis muscle. This measures approximately 8.6 x 7.8 x 2.7 \ncm (AP by SI by TV) in maximum ___, similar to the prior \nexamination. There is extension of collection intracranially, \nwith its extension extending extra axially\nunderneath the left temporal lobe. No associated restricted \ndiffusion.\n \nPostsurgical volume loss of the left hippocampal formation is \nsimilar to the prior examination, with persistent asymmetric \ndecreased size of the left mammillary body. No frank abnormal \nsignal seen within the left mammillary body or residual \nhippocampus.. There is interval volume loss left hemisphere.\n \nThe ventricles and sulci are otherwise grossly unchanged and \nunremarkable in appearance. There is no evidence for acute \nintracranial hemorrhage or\ninfarction. No abnormal enhancement is seen. The dural venous \nsinuses remain patent.\n \nThe paranasal sinuses and mastoid air cells are clear. The \nglobes are\nunremarkable bilaterally.\n \nIMPRESSION:\n1. Postsurgical change anterior left temporal lobectomy.\n2. Extracranial fluid collection, with apparent connection to \nextra-axial\nspace at the left middle cranial fossa.. No restricted \ndiffusion.\n3. Interval worsened parenchymal abnormality anterior temporal \nlobe, extending into sub insula, with cystic changes, may be \nsequela of ischemia. \nInflammatory, infectious process is probably less likely.\n \nBrief Hospital Course:\nMr. ___ is a ___ year old man with history of complex partial \nseizures, occasionally with secondary generalization, in setting \nof glioma now s/p resection x2 with post surgical complication \nof hygroma. He was admitted for workup of a seizure breakthrough \nevent that was not a typical seizure, as it did not begin with \nan aura or start with a simple etiology followed by secondary \ngeneralization. Imaging notable for hygroma on left with \npossible intracranial communication, representing potential site \nfor dural membrane irritation or abscess formation, which could \nbe epileptogenic. His seizure breakthrough event may be \nconcerning in the setting of a new symptomatic headache and his \nknown hygroma. \nNon-con head CT at outside hospital was without significant \nchange in his post-surgical hygroma. MRI w and wo contrast \nshowed an extracranial fluid collection, with apparent \nconnection to extra-axial space at the left middle cranial \nfossa. There was no restricted diffusion. There was also \ninterval worsening in the parenchymal abnormality anterior \ntemporal lobe, extending into subinsula, with cystic changes \nthought to be the sequela of ischemia, less likely inflammatory, \ninfectious process. Dr. ___ neurosurgery reviewed the \nimages and did not think this represented infection. They \nrecommended outpatient follow-up with Dr. ___ the \npatient will arrange. \n\nHis breakthrough seizure was treated with an increase in the \ndose of his clobazam from 10 mg BID to 10mg qAM and 15 mg qPM. \nHe was monitored on this increased regimen and remained seizure \nfree without adverse effects or notable drowsiness. \n\nTransitional Issues:\n- follow-up with Dr. ___ as arranged prior to admission\n- follow-up with neurosurgery\n- follow-up AED levels (collected on admission)\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. LACOSamide 200 mg PO BID \n2. LamoTRIgine 250 mg PO BID \n3. Clobazam 10 mg PO BID \n4. LORazepam 1 mg PO ONCE:PRN seizure \n\n \nDischarge Medications:\n1. Clobazam 10 mg PO QAM \n2. Clobazam 15 mg PO QHS \nRX *clobazam [Onfi] 10 mg ___ tablet(s) by mouth as directed \nDisp #*75 Tablet Refills:*1 \n3. LACOSamide 200 mg PO BID \n4. LamoTRIgine 250 mg PO BID \n5. LORazepam 1 mg PO ONCE:PRN seizure \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nBreakthrough seizure \nSubgaleal fluid collection\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 admitted to ___ with a breakthrough seizure. The \ncause of this was not clear as you had no signs of infection and \nyou did not miss doses of your medications. We increased the \ndose of your Clobazam at night time to help better control your \nseizures. \n\nMedication changes:\nINCREASE Clobazam to 10mg in the morning and 15mg at night\nCONTINUE Lamotrigine 250mg twice a day\nCONTINUE Lacoasmide 200mg twice a day\n\nYou were evaluated by neurosurgery who recommended an MRI of the \nbrain to see if there was any fluid collection in the brain. It \ndid not appear that this was the case. The fluid collection \nseems to be outside the brain. You should call Dr. ___ office \nto discuss plans for follow-up. \n\nYou should follow-up with Dr. ___ at the appointment listed \nbelow. \n\nI did discuss the findings with you on the MRI - the possibility \nof a connection of the fluid collection outside of your brain \nwith the inside of your brain, that there were some changes in \nthe left temporal lobe (new compared to the prior MRI done post \noperatively) which is suggestive of some \nischemic changes, and the slight enlargement of the ventricles. \nWe did reconsult the neurosurgeons and they did not feel there \nwas anything urgent and asked you followup with Dr. ___.\n\nIt was a pleasure taking care of you, \nYour ___ Neurologists\n \nFollowup Instructions:\n___\n" ]

[ "G40419", "G9782", "D181", "F17210", "G4700", "Y838", "Y929", "Z85841" ]

[ "G40419: Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus", "G9782: Other postprocedural complications and disorders of nervous system", "D181: Lymphangioma, any site", "F17210: Nicotine dependence, cigarettes, uncomplicated", "G4700: Insomnia, unspecified", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "Z85841: Personal history of malignant neoplasm of brain" ]

[ "F17210", "G4700", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nMethotrexate / ciprofloxacin / chlorhexadine\n \nAttending: ___\n \nChief Complaint:\nabdominal pain, hematochezia \n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ with hx of RA, diverticulosis s/p R hemicolectomy (___),\nchronic R foot plantar ulcer, recent discharge following\nmechanical fall sustaining multiple lacs, presents with 1 day of\nLLQ abdominal pain a/w bloody diarrhea.Symptoms started \nyesterday\nAM. She estimates > 10 loose bowel movements. Towards the end\nthere has been blood on tissue paper. LLQ pain is ___\nintensity. No vomiting but some nausea currently. Able to\ntolerate PO's at home. Symptoms feels like previous\ndiverticulitis. \n \n-In the ED, initial vitals were: T 98.3 HR 100 BP 153/93 RR 18\nSpo2 95% RA \n-Exam notable for diminished breath sounds at bases, +LLQ\ntenderness, no guarding or rebound, + maroon colored stool on\nrectal exam guaiac positive, 1 external hemorrhoid, LLE \ndressings\nin place, RLE unna boot, malodorous discharge R foot dressing\nsaturated; Dressing and unna boot was removed and underlying\nulceration appears clean, non-infected \n-Labs showed WBC 14.4, H/H 12.0/38.2, K 3.2, Cr 0.9, INR 1.0,\nLFTs and lipase were unremarkable \n-Abd CT demonstrated colitis predominantly involving the sigmoid\ncolon and splenic flexure, with possible colitis versus\nunderdistention of the descending colon. \n-Received Potassium Chloride 40 mEq IV x1 \n-Transfer VS were: HR 101 BP 152/74 RR 20 SpO2 98% RA \nDecision was made to admit to medicine for further management. \n \nOn arrival to the floor, patient reports that her abdominal pain\nis mostly subsided and most severe in the LLQ. She has no\ncurrent n/v. She denies any recent sick contacts although she\nhas been living at an ALF. She has not had any recent\nantibiotics, no travel. She has had no dysuria. She denies\nhaving any orthostatic symptoms but feels quite fatigued. She\nhas no other acute medical complaints.\n \nReview of systems: \nAs per HPI, otherwise negative in detail \n\n \nPast Medical History:\n# Cholangitis - secondary to biliary stricture in ___ s/p \nPTBD/dilation, now removed, stricture path benign\n# Recurrent intrahepatic biliary duct strictures \n# Rheumatoid arthritis - severe seropositive and erosive with \nmultiple deformities; on 10mg prednisone and hydroxychloroquine \n\n# Laparoscopic cholecystectomy around ___ in ___ \n# Chronic right foot ulcer - followed by podiatry; debrided \n___ s/p foot surgery in ___ and s/p skin graft \n# HTN \n# Diverticulitis status post perforation and colostomy with \ncolostomy takedown in ___ \n# SBOs requiring lysis of adhesions in ___ and ___, and more \nrecent SBO managed conservatively in ___.\n# Peripheral artery disease: ~20% carotid stenosis\n# Restrictive ventilatory defect and right diaphragmatic \nparalysis\n# Restless leg syndrome - on carbidopa-levodopa\n# Complex sleep-disordered breathing (bilevel HS ___\n# IBS \n# Cervical spondylolysis\n# Lumbar spinal stenosis\n# Carpal tunnel syndrome\n# Right leg and foot melanoma s/p resection\n \nSocial History:\n___\nFamily History:\nSister with celiac disease, two aunts with liver cancer, IBS in \nthe family.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nGeneral: Alert, oriented, elderly female lying in bed in no \nacute\ndistress \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,\nMMdry, good dentition \nNECK: nontender supple neck, no LAD, no JVD \nCARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: soft, midline incision c/d/I. +BS. mild ttp of LLQ\nwithout any rebound or guarding\nEXTREMITIES: Hands bilaterally with ulnar deviation and fingers\nwith ___ neck deformities. BLE wrapped with 2+ edema to knees\nwith ulcer of plantar aspect of R midfoot (wrapped)\nPULSES: 2+ DP/TP pulses bilaterally \nNEURO: AOx3, grossly nonfocal \n\nDISCHARGE PHYSICAL EXAM:\nVital Signs: 98.2, 118/73, 72, 20, 95% on RA\nI/O: no BMs o/n\nGeneral: Alert, oriented, elderly female sitting up in bed \neating\nbreakfast in no acute distress with soft collar in place \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,\nMMdry, good dentition \nNECK: nontender supple neck, no LAD, no JVD \nCARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: soft, midline incision c/d/I. +BS. No ttp of LLQ\nwithout any rebound or guarding\nEXTREMITIES: Hands bilaterally with ulnar deviation and fingers\nwith ___ neck deformities. BLE wrapped with 2+ edema to knees\nwith ulcer of plantar aspect of R midfoot (wrapped)\nPULSES: 2+ DP/TP pulses bilaterally \nNEURO: AOx3, grossly nonfocal \n \nPertinent Results:\nADMISSION LABS\n==============\n___ 02:30AM GLUCOSE-104* UREA N-24* CREAT-0.9 SODIUM-141 \nPOTASSIUM-3.2* CHLORIDE-99 TOTAL CO2-27 ANION GAP-18\n___ 02:30AM ALT(SGPT)-<5 AST(SGOT)-22 ALK PHOS-90 TOT \nBILI-0.3\n___ 02:30AM LIPASE-44\n___ 02:30AM ALBUMIN-3.5\n___ 02:30AM WBC-14.4* RBC-3.94 HGB-12.0 HCT-38.2 MCV-97 \nMCH-30.5 MCHC-31.4* RDW-14.6 RDWSD-52.1*\n___ 02:30AM NEUTS-86.3* LYMPHS-7.6* MONOS-4.7* EOS-0.8* \nBASOS-0.2 IM ___ AbsNeut-12.43* AbsLymp-1.10* AbsMono-0.68 \nAbsEos-0.11 AbsBaso-0.03\n___ 02:30AM PLT COUNT-220\n___ 02:30AM ___ PTT-24.5* ___\n\nIMAGING\n========\nCT ABD & PELVIS WITH CO ___ \nIMPRESSION: \nColitis predominantly involving the sigmoid colon and splenic\nflexure, with possible colitis versus underdistention of the\ndescending colon. This is a nonspecific finding, and can be due\nto infectious, inflammatory, or ischemic etiology. No inflamed\ndiverticulum is identified. \n\nMICROBIOLOGY\n=============\n___ BCx x 2 pending\n___ UCx negative\n___ BCx x 2 pending\n___ C. diff POSITIVE\n___ Stool cultures pending\n\nDISCHARGE LABS\n==============\n___ 06:45AM BLOOD WBC-7.5 RBC-3.46* Hgb-10.3* Hct-33.9* \nMCV-98 MCH-29.8 MCHC-30.4* RDW-14.9 RDWSD-53.9* Plt ___\n___ 06:45AM BLOOD Glucose-98 UreaN-19 Creat-0.8 Na-144 \nK-4.4 Cl-105 HCO3-29 AnGap-14\n___ 06:45AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.___ with hx of RA, diverticulosis s/p R hemicolectomy (___), \nchronic R foot plantar ulcer, recent discharge following \nmechanical fall sustaining multiple lacs, presents with 1 day of \nLLQ abdominal pain a/w bloody diarrhea found to have abd CT \nfindings concerning for colitis. \n \n# Abdominal Pain/Diarrhea. Improved. Patient presented with \nLLQ abdominal pain associated with 24 hrs of bloody diarrhea \nprior to admission. CT abdomen showed inflammatory changes of \nthe sigmoid colon and splenic flexure concerning for colitis. \nUpon admission, her diarrhea resolved. Given her improvement of \nsymptoms, antibiotics were initially held. However, stool \nculture returned C. diff positive for which she was placed on PO \nvancomycin. The patient was initially placed on bowel rest, but \nher diet was successfully advanced to a regular diet.\n \n# Hematochezia: Resolved. Patient with hematochezia in the \nsetting of diarrhea. On admission, patient hemodynamically \nstable, H/H 12.0/38.2. Stool guiaic positive in ED. Unclear when \nshe had her last colonoscopy. Deferred GI evaluation given \nresolution of her hematochezia. Her Hgb was at baseline during \nher hospitalization so any bleeding she had prior to admission \nwas no clinically significant. \n \n# Hypokalemia: Resolved. K 3.2 on admission, received potassium \n40 mEq IV in ED. Likely in the setting of diarrhea/GI losses. \n \n#RA: Continued home Plaquenil and prednisone per outpatient \nRheumatologist. Continued APAP, diclofenac for pain.\n \n#HTN. Held home triamterene-HCTZ for now.\n \n#hx of biliary strictures: sees Dr. ___ biliary stricture\nc/b cholangitis . Continued home ursodiol \n \n#GERD: continued omeprazole \n \n#RLS: continued carvidopa-levodopa \n \n#OSA: continued nocturnal BiPAP \n\n# Neuropathic ulcers/wounds. Pt followed as outpatient by \nPodiatry. Per discussion with Podiatry team, will plan to have \npatient be taken to the ___ clinic at ___ \nfollowing discharge for Unna boot placement (has this done\n1x/week) and will provide cab voucher so she can go back to her \nALF from clinic. \n \n \n***TRANSITIONAL ISSUES***\n- Patient to be seen in ___ clinic at ___ \nfollowing discharge for Unna boot placement as described above.\n- Home triamterene-HCTZ held at discharge.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 500 mg PO 5X/DAY \n2. Carbidopa-Levodopa (___) 1 TAB PO QHS \n3. Docusate Sodium 100 mg PO BID \n4. Fluticasone Propionate NASAL 2 SPRY NU QHS \n5. GuaiFENesin ___ mL PO QHS:PRN cough \n6. Hydroxychloroquine Sulfate 200 mg PO BID \n7. Loratadine 10 mg PO QHS:PRN congesetion \n8. Omeprazole 40 mg PO DAILY \n9. PredniSONE 5 mg PO BID \n10. Sodium Chloride Nasal ___ SPRY NU QHS:PRN congestion \n11. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY \n12. Ursodiol 300 mg PO TID \n13. Vitamin D 1000 UNIT PO DAILY \n14. Align (Bifidobacterium infantis) 4 mg oral DAILY \n15. diclofenac sodium 75 mg oral DAILY \n16. Quin B Strong (B complex-C-folic acid-Zn) 500-400-15 \nmg-mcg-mg oral DAILY \n17. Psyllium Wafer 1 WAF PO DAILY \n18. Calcium Citrate + D (calcium citrate-vitamin D3) 630 mg \ncalcium - 200 units other oral DAILY \n\n \nDischarge Medications:\n1. Vancomycin Oral Liquid ___ mg PO Q6H \nRX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours \nDisp #*42 Capsule Refills:*0 \n2. Acetaminophen 500 mg PO 5X/DAY \n3. Align (Bifidobacterium infantis) 4 mg oral DAILY \n4. Calcium Citrate + D (calcium citrate-vitamin D3) 630 mg \ncalcium - 200 units other oral DAILY \n5. Carbidopa-Levodopa (___) 1 TAB PO QHS \n6. diclofenac sodium 75 mg oral DAILY \n7. Docusate Sodium 100 mg PO BID \n8. Fluticasone Propionate NASAL 2 SPRY NU QHS \n9. GuaiFENesin ___ mL PO QHS:PRN cough \n10. Hydroxychloroquine Sulfate 200 mg PO BID \n11. Loratadine 10 mg PO QHS:PRN congesetion \n12. Omeprazole 40 mg PO DAILY \n13. PredniSONE 5 mg PO BID \n14. Psyllium Wafer 1 WAF PO DAILY \n15. Quin B Strong (B complex-C-folic acid-Zn) 500-400-15 \nmg-mcg-mg oral DAILY \n16. Sodium Chloride Nasal ___ SPRY NU QHS:PRN congestion \n17. Ursodiol 300 mg PO TID \n18. Vitamin D 1000 UNIT PO DAILY \n19. HELD- Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY This \nmedication was held. Do not restart Triamterene-HCTZ (37.5/25) \nuntil you see your primary care physician\n\n \n___:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n___ diarrhea\nNeuropathic ulcer\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure caring for you at ___ \n___. You were admitted to the hospital for bloody \ndiarrhea. You underwent a CT scan which showed that you have \ncolitis (inflammation of certain parts of your large bowel). \nYour stool cultures showed that you have C. diff. You were \nstarted on oral vancomycin for treatment of this infection. \n\nPlease follow-up with your outpatient providers as instructed \nbelow. Following your discharge, as discussed with you and the \nPodiatry team, you will go to the ___ clinic for \nexchange of your Unna boot.\n\nThank you for allowing us to participate in your care. Best \nwishes for your recovery.\n\nSincerely,\nYour ___ medical team\n \nFollowup Instructions:\n___\n" ]

[ "A047", "L97419", "K830", "G629", "K921", "M069", "I10", "G2581", "M47892", "M4806", "Z85820", "E876", "K219", "G4733", "Z7952" ]

[ "A047: Enterocolitis due to Clostridium difficile", "L97419: Non-pressure chronic ulcer of right heel and midfoot with unspecified severity", "K830: Cholangitis", "G629: Polyneuropathy, unspecified", "K921: Melena", "M069: Rheumatoid arthritis, unspecified", "I10: Essential (primary) hypertension", "G2581: Restless legs syndrome", "M47892: Other spondylosis, cervical region", "M4806: Spinal stenosis, lumbar region", "Z85820: Personal history of malignant melanoma of skin", "E876: Hypokalemia", "K219: Gastro-esophageal reflux disease without esophagitis", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z7952: Long term (current) use of systemic steroids" ]

[ "I10", "K219", "G4733" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nmorphine / Penicillins / tomato / Toradol\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain, nausea/vomiting, diarrhea\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ is a ___ woman with a history of Crohn's \ndisease on budesonide s/p partial small and large bowel \nresections, polysubstance abuse who presented to the ED with \ndiarrhea, nausea, vomiting, and abdominal pain. \n\nIn the ED, initial VS were: 95.3 ___ 24 98%RA. She was \nhypertensive to as high as 194/111. She was given Tylenol IV, \nhaloperidol, and lorazepam. She was also given 1L NS. A KUB \nshowed non-obstructive patterns. She was transferred to medicine \nfor further management. \n\nOn arrival to the floor, she is sleeping soundly and needs to be \nawoken in order to proceed with the interview. She reports 2 \ndays of nausea and being unable to keep anything down. She did \nnot have any bloody vomit. She also developed worsening \nabdominal pain all over her stomach and an increase in watery, \nnon-bloody BMs from 3/d to 5-6/d. She had chills but no fever. \nAt baseline, she has all-over stomach pain. \n\nOf note, she was hospitalized from ___ with abdominal \npain and underwent endoscopy, colonoscopy, and MRE to assess \nCrohn's disease activity. MR-E showed stable disease with some \nworsening in narrowing of the anastomosis but without signs of \nobstruction. EGD demonstrated erosion in the antrum consistent \nwith gastritis and ulcers likely due to cocaine use. Colonoscopy \ndemonstrated few ulcers at neo-TI but no inflammation in neo-TI. \nShe continued on budesonide 9mg PO daily, Simethicone 40mg QID, \nand Zofran PRN\nwith cholestyramine for diarrhea with plan for outpatient GI \nfollow-up. Because of this extensive work-up, upon arrival to \nthe ED, this was deferred. \n\nAlso, during that hospitalization, she was hypertensive and HCTZ \nwas added to her lisinopril. \n \nREVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as \nper HPI. Additionally, she denies headache, vision changes, \nswelling in her legs, change to her urine patterns. \n\n \nPast Medical History:\n# HTN, Crohn's, COPD\n# Substance abuse - tob, cocaine\n# Benign heart murmur\n# Depression/anxiety\n# Hep C since ___ treated with harvoni.\n# chronic pain, osteoporosis\n# Ex-lap, ___ SB rsxn, diverting ileostomy (___) ___ \n# Ileostomy take down ___\n \nSocial History:\n___\nFamily History:\nFather died of MI at age ___. Mother died of ___ cirrhosis. Two \nout of four children has Crohn's.\n \nPhysical Exam:\nVITALS: Temp: 98.2 PO BP: 159/99 HR: 84 RR: 18 O2 sat: 96% O2 \ndelivery: RA \nGENERAL: NAD, sleeping for most of the day. \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva \nNECK: supple, no LAD, no JVD \nHEART: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably \nwithout use of accessory muscles \nABDOMEN: nondistended, nontender on light palpation (endorses \nttp but not reproducible and non-focal, but no visible grimacing \n/ pain), no rebound/guarding, no hepatosplenomegaly \nEXTREMITIES: no cyanosis, clubbing, or edema \nPULSES: 2+ DP pulses bilaterally \nNEURO: A&Ox3 \nSKIN: warm and well perfused, no excoriations or lesions, no \nrashes \n \nPertinent Results:\nOn Admission: \nWBC: 4.4K; Hgb: 13.0; Hct: 39.2; MCV: 88; Plt: 228K \nN:41.3 L:44.7 M:11.0 E:2.5 Bas:0.5 Absneut: 1.81 Abslymp: 1.96 \nAbsmono: 0.48 Abseos: 0.11 Absbaso: 0.02\nCRP: 4.7\nLactate:2.0\nNa: 138 K: 5.2Cl: 100Cr: 1.4BUN: 11Gluc: 96 AGap=16\nCa: 9.2 Mg: 2.0 P: 2.7\nSerum ASA, EtOH, Acetmnphen, TricycNegative\n\n___ KUB \nFINDINGS: Prominent loop of bowel in the right lower quadrant \nis compatible with lateral blind-ending colonic loop seen on \nprior CT scan in ___ and is similar in appearance. There are no \ndilated air-filled loops of small bowel. No abnormal air-fluid \nlevels. No free intraperitoneal air. Severe degenerative changes \nnoted at the left hip as seen on prior. \nIMPRESSION: Nonobstructive bowel gas pattern. \n\nPrior to discharge: \nNa: 143K: 4.3 Cl: 104 CO2: 27 Cr: 1.1 BUN: 14Gluc: 116 \nAGap=12\nMg: 2.1\n \nBrief Hospital Course:\nMs. ___ is a/n ___ female with past medical history of \nCrohn's disease, polysubstance abuse who presented with acute on \nchronic diarrhea, nausea, and abdominal pain with recent \nextensive GI workup without e/o active Crohn's and currently \nwith reassuring inflammatory markers and unrevealing basic \ninfectious workup. \n\n#Acute on chronic abdominal pain #Nausea/Vomiting #Diarrhea \n#History of Crohn's disease - CRP is down from her most recent \nhospitalization, afebrile, without leukocytosis or evidence of \ndehydration. Abdominal Xray on admission reassuring with \nnon-obstructive bowel gas pattern. Spoke with GI yesterday who \nadvised that her recent workup from last hospital admission \nspeaks against IBD flare. Differential includes IBS, infectious \ngastroenteritis or substance-induced functional abdominal pain. \nSymptoms of worsening pain and diarrhea possibly secondary to \nopiate withdrawal from inpatient opiates but no active opiates \nin outpatient setting. Had clear conversation with patient that \nwe will not be treating her abdominal pain with opiates due to \nconcern for worsening cycle of delayed gastric emptying followed \nby recurrent pain and diarrhea after discharge. Furthermore, \ngiven chronic nature of symptoms, opiates are not indicated and \nin fact, she has been weaned off of opiates in the outpatient \nsetting with no consistent outpatient follow-ups in the past \nyear at least. Continue to avoid opiates, also avoiding NSAIDs \ngiven known h/o IBD. She had good response to haldol given in \nthe ED on initial presentation and on patient request, she later \nreceived a couple of doses of Haldol 2.5 mg po for continued \ncomplaints of nausea, but will not prescribe on discharge as \npatient is on multiple QTc prolonging medications.\nContinued supportive care with cholestyramine 4gm PO BID, \ndipehnoxylate-atropine 1 tab PO q6hr PRN diarrhea, simethicone \nas needed. Continued omeprazole 40mg BID (dose increase during \nlast admission). Also continued budesonide 9mg PO daily. She \nwill follow up in GI clinic after discharge as scheduled with \nDr. ___ to establish outpatient GI care. \n\n#Acute Kidney Injury: Mildly elevated creatinine and depressed \nrenal clearance on admission in the setting of vomiting, \ndiarrhea and decreased oral intake. This improved to baseline \nafter initial intravenous hydration. After first day on the \nwards, her renal function continued to improve and remained \nstable with oral hydration only. \n\n#Uncontrolled Hypertension - poorly controlled at baseline, \nsuspect related to noncompliance and lack of follow up in the \noutpatient setting. Home medications include lisinopril 40, and \nshe was recently started on HCtZ 12.5 during recent admission. \nThose were held on current admission in the setting of mild ___ \non presentation. She was started on amlodipine 5mg daily on \nadmission with BP overall improved but still moderately elevated \n(with an isolated BP reading in the 90's systolic, but otherwise \n140-170). After resolution of her initial Acute Kidney Injury, \nher home lisinopril was resumed, and she was continued on the \nnewly started amlodipine which will replace the \nhydrochlorothiazide on discharge. \n\n#Polysubstance abuse: Discussed cocaine use, along with \nuncontrolled hypertension and history of stroke as a result of \nher drug use. She is not interested in stopping. She was \nencouraged to do so. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB \n2. Budesonide 9 mg PO DAILY \n3. Citalopram 40 mg PO QHS \n4. ClonazePAM 2 mg PO BID:PRN anxiety \n5. ClonazePAM 1 mg PO DAILY \n6. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea \n7. Fluticasone Propionate 110mcg 2 PUFF IH BID \n8. Lidoderm (lidocaine) 5 % topical DAILY \n9. Lisinopril 40 mg PO DAILY \n10. Multivitamins 1 TAB PO DAILY \n11. Omeprazole 40 mg PO BID bloating, acid reflux, gastritis \n12. Simethicone 40 mg PO QID \n13. Vitamin D 1000 UNIT PO DAILY \n14. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n15. Cholestyramine 4 gm PO BID \n16. Hydrochlorothiazide 12.5 mg PO DAILY \n17. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia \n18. Gabapentin 800 mg PO TID \n\n \nDischarge Medications:\n1. amLODIPine 5 mg PO DAILY \nRX *amlodipine 5 mg 1 tablet by mouth Daily Disp #*30 Tablet \nRefills:*0 \n2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n3. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB \n4. Budesonide 9 mg PO DAILY \n5. Cholestyramine 4 gm PO BID \n6. Citalopram 40 mg PO QHS \n7. ClonazePAM 2 mg PO BID:PRN anxiety \n8. ClonazePAM 1 mg PO DAILY \n9. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea \n10. Fluticasone Propionate 110mcg 2 PUFF IH BID \n11. Gabapentin 800 mg PO TID \n12. Lidoderm (lidocaine) 5 % topical DAILY \n13. Lisinopril 40 mg PO DAILY \n14. Multivitamins 1 TAB PO DAILY \n15. Omeprazole 40 mg PO BID bloating, acid reflux, gastritis \n16. Simethicone 40 mg PO QID \n17. Vitamin D 1000 UNIT PO DAILY \n18. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAcute on chronic abdominal pain, diarrhea, nausea/vomiting\nIrritable Bowel Syndrome\nChronic Inflammatory Bowel Disease without evidence of active \nflare\nAcute Kidney Injury\nUncontrolled Hypertension\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nWhat is irritable bowel syndrome? — Irritable bowel syndrome, or \n\"IBS,\" is a condition that causes belly pain and problems with \nbowel movements. Some people with the condition have frequent, \nwatery bowel movements (diarrhea). Others do not have enough \nbowel movements (constipation). Some patients switch back and \nforth between diarrhea and constipation.\n\nWhat are the symptoms of IBS? — Symptoms include:\n\n___ pain and cramps, related to a bowel movement\n\n___ or constipation (some people switch back and \nforth between diarrhea and constipation)\n\n___\n\n___\n\nIs there a test for IBS? — No, there is no specific test. But \nyour doctor or nurse can figure out if you have IBS by asking \nyou a few questions, and by running tests to make sure you do \nnot have something other than IBS. Lots of medical conditions \ncan cause the same symptoms as IBS. So it is important that your \ndoctor or nurse checks the other possibilities.\n\nWhat can I do to feel better? — You can:\n\n___ a diary to keep track of what you ate each day, \nwhat you did, and how you felt. That way, you can figure out if \nanything you do or eat makes your symptoms better or worse.\n\n___ eating foods that might be making your IBS worse. \nStart by giving up foods that give you gas, and then give up \nmilk, ice cream, and other foods that have traces of milk for 2 \nweeks. Ask your doctor or nurse for advice on which foods can \nmake IBS worse.\n\n___ more fiber, if you have constipation. You can do this \nby eating more fruits and vegetables. Or you can take fiber \npills or powders. (If eating more fiber makes symptoms worse, \ncut back on the fiber.)\n\n___. Do something active for 20 to 60 minutes, 3 to \n5 days a week. Studies show this helps improve IBS symptoms.\n\nHow is IBS treated? — Medicines can ease the symptoms of IBS. \nBut no treatment can cure the condition. Counseling might also \nhelp with IBS, because stress and worry can make the condition \nworse.\n\nThe medicines that can help with IBS symptoms include:\n\n___ to ease diarrhea\n\n___ to ease constipation\n\n___ – These medicines work by blocking pain. \nWhen used to treat IBS, they are given at a much lower dose than \nwould normally be given to treat depression.\n\n___ called \"antispasmodics\"\n\n___ – These medicines sometimes help with \nbloating and diarrhea in some people.\n\nWhat will my life be like? — Most people with IBS have the \ncondition for the rest of their life. Even so, most people find \nways to improve their symptoms. The key is to keep working with \nyour doctor or nurse until the two of you find an approach that \nworks.\n \nFollowup Instructions:\n___\n" ]

[ "R109", "G8929", "R112", "R197", "K589", "K5090", "N179", "I10", "F1490", "F1120", "Z7289", "M810", "B1920", "Z66", "R45851", "Z915", "Z9049", "J449", "F17210", "R011", "F329", "F419" ]

[ "R109: Unspecified abdominal pain", "G8929: Other chronic pain", "R112: Nausea with vomiting, unspecified", "R197: Diarrhea, unspecified", "K589: Irritable bowel syndrome without diarrhea", "K5090: Crohn's disease, unspecified, without complications", "N179: Acute kidney failure, unspecified", "I10: Essential (primary) hypertension", "F1490: Cocaine use, unspecified, uncomplicated", "F1120: Opioid dependence, uncomplicated", "Z7289: Other problems related to lifestyle", "M810: Age-related osteoporosis without current pathological fracture", "B1920: Unspecified viral hepatitis C without hepatic coma", "Z66: Do not resuscitate", "R45851: Suicidal ideations", "Z915: Personal history of self-harm", "Z9049: Acquired absence of other specified parts of digestive tract", "J449: Chronic obstructive pulmonary disease, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "R011: Cardiac murmur, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified" ]

[ "G8929", "N179", "I10", "Z66", "J449", "F17210", "F329", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nDepakote\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nNone\n\nattach\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 08:30AM BLOOD WBC-3.3* RBC-3.06* Hgb-8.1* Hct-25.1* \nMCV-82 MCH-26.5 MCHC-32.3 RDW-17.2* RDWSD-51.5* Plt ___\n___ 08:30AM BLOOD Neuts-26.3* Lymphs-55.5* Monos-14.3* \nEos-2.4 Baso-0.9 Im ___ AbsNeut-0.86* AbsLymp-1.82 \nAbsMono-0.47 AbsEos-0.08 AbsBaso-0.03\n___ 08:30AM BLOOD Glucose-81 UreaN-9 Creat-1.0 Na-125* \nK-4.2 Cl-91* HCO3-19* AnGap-15\n___ 08:30AM BLOOD ALT-29 AST-39 LD(LDH)-225 AlkPhos-90 \nTotBili-0.3\n___ 08:30AM BLOOD TotProt-7.7 Albumin-4.0 Globuln-3.7\n___ 03:50PM BLOOD Calcium-9.0 Phos-4.1 Mg-1.9 Cholest-196\n___ 08:30AM BLOOD Osmolal-339*\n___ 03:50PM BLOOD ASA-NEG ___ Acetmnp-NEG \nTricycl-NEG\n___ 08:47PM BLOOD Lactate-4.2*\n\nPERTINENT LABS:\n===============\n___ 03:50PM BLOOD VitB12-502\n___ 09:28AM BLOOD %HbA1c-5.3 eAG-105\n___ 03:50PM BLOOD Triglyc-56 HDL-117 CHOL/HD-1.7 LDLcalc-68\n___ 03:50PM BLOOD Osmolal-322*\n___ 09:15PM BLOOD Osmolal-283\n___ 01:11AM BLOOD Osmolal-275\n___ 06:16AM BLOOD Osmolal-273*\n___ 03:50PM BLOOD TSH-0.32\n___ 09:28AM BLOOD Cortsol-15.2\n___ 03:20PM BLOOD IgG-1885* IgA-501* IgM-54\n___ 01:34AM BLOOD Lactate-1.7\n\n___ 11:30AM URINE Hours-RANDOM UreaN-<6 Creat-26 Na-<20\n___ 06:08AM URINE Hours-RANDOM Na-67\n___ 09:04PM URINE Hours-RANDOM Na-79\n___ 04:40PM URINE Hours-RANDOM Na-47\n___ 11:30AM URINE Osmolal-159\n___ 06:08AM URINE Osmolal-237\n___ 09:04PM URINE Osmolal-491\n___ 04:40PM URINE Osmolal-599\n___ 05:23AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG \ncocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG\n___ 11:30AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG \ncocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG\n\nMICROBIOLOGY:\n=============\n___ 11:30 am URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: < 10,000 CFU/mL. \n___ 11:30AM URINE Color-Colorless Appear-CLEAR Sp \n___\n___ 11:30AM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-6.0 \nLeuks-NEG\n___ 09:04PM URINE RBC-2 WBC-0 Bacteri-NONE Yeast-NONE Epi-0\n\n___ 08:30AM BLOOD WBC-3.3* Lymph-56* Abs ___ CD3%-90 \nAbs CD3-1672 CD4%-18 Abs CD4-327* CD8%-69 Abs CD8-1272* \nCD4/CD8-0.26*\n\nIMAGING:\n========\nCT Head W/O Contrast, ___:\n1. No acute intracranial hemorrhage. \n2. Chronic lacunar infarcts involving the left basal ganglia. \n3. Mild periventricular and subcortical white matter disease. \n4. Age inappropriate cerebral and cerebellar atrophy. \n\nCT C-Spine W/O Contrast, ___:\n1. No acute cervical spine fracture. \n2. Mild degenerative changes of the cervical spine most \nsignificant at C6-7 unchanged from previous CT. \n3. Bilateral lung apex paraseptal emphysema. \n\nCXR, ___:\nNo acute cardiopulmonary abnormality.\n\nR Ankle X-ray, ___:\n1. No acute fracture, dislocation or significant degenerative \nchanges of the right ankle. \n2. If there is high clinical concern for a cuboid or fifth \nmetatarsal \nfracture, further evaluation may be performed with radiographs \nof the foot. \n\nDISCHARGE LABS:\n===============\n___ 06:16AM BLOOD WBC-6.0 RBC-3.51* Hgb-9.1* Hct-29.7* \nMCV-85 MCH-25.9* MCHC-30.6* RDW-18.4* RDWSD-55.1* Plt ___\n___ 06:16AM BLOOD Glucose-80 UreaN-11 Creat-1.3* Na-135 \nK-4.4 Cl-93* HCO3-22 AnGap-20*\n___ 06:16AM BLOOD Calcium-10.0 Phos-4.8* Mg-1.7\n\n \nBrief Hospital Course:\nTRANSITIONAL ISSUES:\n \n====================\n \n[] Ensure Hepatitis B vaccination (Borderline sAb, +cAb) \n \n[] Follow up sodium, ensuring it remains within normal limits \n \n[] Follow up alcohol use disorder, patient referred to \noutpatient program\n \n[] Follow up HIV, on this admission CD 4 count 327; PCP \nprophylaxis continued given need for >3 months of CD4 count >200 \nalthough per outpatient RN he can likely stop this \n \n[] Ensure patient is up-to-date with age appropriate cancer \nscreening, especially given history of HIV\n \n[] Consider PFTs given evidence of emphysema noted on imaging\n \n[] Please refer to Cognitive Neurology for concern for cognitive \ndecline \n \n\n \nCODE: Full code\n \nCONTACT: ___ \n \nRelationship: mother \n \nPhone number: ___ \n \n\n \nBRIEF HOSPITAL SUMMARY:\n \n=======================\n \nMr. ___ is a ___ year old M w/ hx of HIV/AIDS, untreated \nHCV, EtOH use disorder, HTN, and GERD who presented after a \nfall, found to have severe hyponatremia likely secondary to beer \npotomania as well as SIADH. Patient was treated with fluid \nrestriction, nutrition supplementation, and salt tabs with \nimprovement in his sodium. \n \n\n \nACUTE ISSUES: \n \n============= \n \n# Hypotonic hyponatremia\n \n# High osmolar gap, resolved \n \n# ___\n \nPatient initially admitted with a hyperosmolar hyponatremia of \n125. On admission, patient was intoxicated with a positive serum \nalcohol level. Lipid panel, SPEP and UPEP were unremarkable. \nPatient noted with a normal AM cortisol, A1C, and TSH. \nToxicology was consulted given elevated Osm gap on admission, \nbut their suspicion for toxic ingestion was low given positive \nserum alcohol level otherwise. Repeat serum osmolality revealed \nhypoosmolality, making his hyponatremia consistent with poor \nsolute intake and beer potomania. Repeat urine osmolality and \nurine sodium revealed a picture growingly consistent with SIADH. \nPatient was fluid restricted to 1.5L/day and was started on salt \ntabs with improvement in his sodium. On discharge, sodium was \n135. \n \n\n \n# Confusion\n \n# Lacunar strokes \n \n# Concern for cognitive decline \n \nPatient initially admitted with confusion in the setting of \nhyponatremia as well as acute intoxication with alcohol. Patient \nnoted to be at high risk for Wernicke's given history of alcohol \nuse. CT on admission noted with chronic changes and strokes read \nas lacunar and small vessel disease in nature which may have \ncontributed to his initial confusion. He was started on aspirin \nand atorvastatin 40 mg. He was also started on IV thiamine as \nwell as multivitamin with minerals. He was continued on his home \nfolic acid. Vitamin B12, A1C and lipid panel were within normal \nlimits. \n \n\n \n# Malnutrition\n \nPatient noted with low BMI on admission and in light of his \nhistory of alcohol use, nutrition was consulted. He was \ncontinued on multivitamin as above and received Ensure Enlive \nsupplementation. Patient assured us that he has adequate \nresources for food at home and has friends who ___ for him. \n \n\n \n# EtOH use disorder\n \nPatient with a long standing history of alcohol use. On \nadmission, patient states that he drinks ___ oz beers per \nday on average. Given this intake and history of withdrawal \nseizures, patient received phenobarbital in the ED and once more \non the unit. He was further monitored on CIWA but scored no \nhigher than a 9, and did not receive further benzodiazepines or \nphenobarbital. Patient was continue ___ thiamine, folic acid, \nand multivitamin as above. Social work was consulted and \nreferred patient to an intensive outpatient program. \n \n\n \n# Fall\n \n# Head strike\n \n# Rib pain\n \n# R ankle pain\n \nPatient initially presented to the ED in the context of a fall. \nHe had a CT head and CT c-spine without evidence of acute \npathology. Imaging did reveal prior rib fractures. Patient also \nendorsed R ankle/foot pain, but x-ray of this area revealed no \nfractures or dislocations. Patient worked with ___ and was \noffered crutches, but he refused. He was treated with Tylenol \nand small dose oxycodone, both of which he largely refused, as \nwell as a lidocaine patch. He otherwise was able to weight bear \nand ambulate without difficulty. \n \n\n \n# Fevers\n \n# Chills\n \n# 20 lb weight loss \n \n# HIV/AIDS\n \nPatient with a long standing history of AIDS with prior CD4 \ncount <200. He also related a recent history of fevers and 20 lb \nweight loss. Throughout admission he was afebrile with stable \nvital signs and white count. Repeat CD4 count was 327 on this \nadmission. He did not receive any antibiotics given absence of \nsuspicion for ongoing infection otherwise. He was continued on \nhis home HIV regimen including PCP prophylaxis with atovaquone. \nHe can likely discontinue PCP prophylaxis if his CD4 count has \nbeen >200 for long enough. \n \n\n \n# Emphysema\n \nSeen on imaging. Denies tobacco use history. Patient received \nalbuterol nebs q4h PRN. \n \n\n \nCHRONIC ISSUES: \n \n=============== \n \n# GERD\n \nContinued home pantoprazole\n \n\n \n# Glaucoma\n \nContinued home latanoprost drops\n \n\n \n# Iron deficiency anemia\n \nAt baseline. Continued home iron supplement, but made it QOD \nrather than daily dosing.\n \n\n \nPRIMARY CARE:\n \n___, ___\n \n___\n \n___\n \nCOMPLEX CARE AT ___\n \nRN from ___, ___ ___ \n\n>30 minutes spent on complex discharge \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Dolutegravir 50 mg PO DAILY \n2. Pantoprazole 40 mg PO Q24H \n3. Multivitamins 1 TAB PO DAILY \n4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n5. Ferrous Sulfate 325 mg PO EVERY OTHER DAY \n6. FoLIC Acid 1 mg PO DAILY \n7. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB \nPO DAILY \n8. Thiamine 100 mg PO DAILY \n9. Atovaquone Suspension 750 mg PO 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. Atorvastatin 40 mg PO QPM \nRX *atorvastatin 40 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet \nRefills:*0 \n3. Multivitamins W/minerals 1 TAB PO DAILY \nRX *multivitamin,tx-minerals 1 tablet(s) by mouth once a day \nDisp #*30 Capsule Refills:*0 \n4. Sodium Chloride 1 gm PO TID \nRX *sodium chloride 1 gram 1 tablet(s) by mouth three times a \nday Disp #*90 Tablet Refills:*0 \n5. Atovaquone Suspension 1500 mg PO DAILY \nRX *atovaquone 750 mg/5 mL 10 ml by mouth once a day Refills:*0 \n6. Dolutegravir 50 mg PO DAILY \nRX *dolutegravir [Tivicay] 50 mg 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*0 \n7. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB \nPO DAILY \nRX *emtricitabine-tenofovir alafen [Descovy] 200 mg-25 mg 1 \ntablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 \n8. Ferrous Sulfate 325 mg PO EVERY OTHER DAY \nRX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth \nevery other day Disp #*15 Tablet Refills:*0 \n9. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \nRX *latanoprost 0.005 % 1 drop at bedtime Refills:*0 \n11. Pantoprazole 40 mg PO Q24H \nRX *pantoprazole 40 mg 1 drp by mouth once a day Disp #*30 \nTablet Refills:*0 \n12. Thiamine 100 mg PO DAILY \nRX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a \nday Disp #*30 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\n==================\nMechanical fall\nBeer potomania \nSIADH\n\nSECONDARY DIAGNOSES:\n====================\nAlcohol use disorder\nAIDS\n\n \nDischarge Condition:\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\nMental Status: Confused - sometimes.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nIt was a pleasure taking care of you at the ___ \n___! \n\nWhy was I admitted to the hospital? \n===================================\n- You were admitted because you had a fall and were found with \nlow sodium. \n\nWhat happened while I was in the hospital? \n==========================================\n- You were treated for low sodium and on discharge your sodium \nlevel was much improved. \n\n- You met with our social workers who helped arrange for \noutpatient programs for you to attend.\n\nWhat should I do after leaving the hospital? \n============================================\n- Please take your medications as listed in discharge summary \nand follow up at the listed appointments. \n\n- Please do not drink more than 1.5 liters per day. \n\nThank you for allowing us to be involved in your care, we wish \nyou all the best! \n\nSincerely,\n\nYour ___ Healthcare Team\n \nFollowup Instructions:\n___\n" ]

[ "E222", "E440", "I10", "K219", "Z21", "B1920", "R0781", "S0990XA", "W19XXXA", "Z9181", "Y929", "H409", "D509", "R509", "Z6820", "S93401A", "F10229", "J439", "R410", "Z8673" ]

[ "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "E440: Moderate protein-calorie malnutrition", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "Z21: Asymptomatic human immunodeficiency virus [HIV] infection status", "B1920: Unspecified viral hepatitis C without hepatic coma", "R0781: Pleurodynia", "S0990XA: Unspecified injury of head, initial encounter", "W19XXXA: Unspecified fall, initial encounter", "Z9181: History of falling", "Y929: Unspecified place or not applicable", "H409: Unspecified glaucoma", "D509: Iron deficiency anemia, unspecified", "R509: Fever, unspecified", "Z6820: Body mass index [BMI] 20.0-20.9, adult", "S93401A: Sprain of unspecified ligament of right ankle, initial encounter", "F10229: Alcohol dependence with intoxication, unspecified", "J439: Emphysema, unspecified", "R410: Disorientation, unspecified", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits" ]

[ "I10", "K219", "Y929", "D509", "Z8673" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nPenicillins / erythromycin base\n \nAttending: ___.\n \nChief Complaint:\nabdominal pain\n \nMajor Surgical or Invasive Procedure:\nEUS\nlaparoscopic cholecystectomy\n\n \nHistory of Present Illness:\n___ with hx HTN, DM, urinary incontinence, ADHD admitted to\nmedicine with choledocholithiasis. She reports acute onset RUQ\npain with nausea ___ when she went to ___\nshe left to go to the birth of her grandchild at ___. Then went to ___ where she was found to have\nrising LFT's and a CBD of 3.3 mm. She was transferred for ERCP.\nShe then underwent MRCP which showed normal CBD with no filing\ndefect. Her LFTs were elevated including alt 1500 ast 1800 alk\nphos 175. She reports continued pain since her admission. \n\n \nPast Medical History:\nMHx:\nHypertension\nDiabetes mellitus II\nUrinary incontinence\nADHD\n\nSHx: ___\nFamily History:\nFAMILY HISTORY: NC\n\n \nPhysical Exam:\nGeneral: comfortable NAD\n___: RRR\nPulm: no respiratory distress\nabdomen: soft, NT, ___ scar and a scar from a prior\nlaparoscopic surgery\nExt: WWP\n \nPertinent Results:\n___ 07:10AM BLOOD WBC-6.0 RBC-5.39* Hgb-13.8 Hct-43.5 \nMCV-81* MCH-25.6* MCHC-31.7* RDW-12.8 RDWSD-36.4 Plt ___\n___ 05:23AM BLOOD WBC-5.9 RBC-5.12 Hgb-13.1 Hct-41.0 \nMCV-80* MCH-25.6* MCHC-32.0 RDW-12.7 RDWSD-36.4 Plt ___\n___ 06:30AM BLOOD WBC-6.0 RBC-5.13 Hgb-13.4 Hct-41.5 \nMCV-81* MCH-26.1 MCHC-32.3 RDW-12.6 RDWSD-36.7 Plt ___\n___ 06:35AM BLOOD WBC-4.1 RBC-4.90 Hgb-12.6 Hct-39.7 \nMCV-81* MCH-25.7* MCHC-31.7* RDW-12.7 RDWSD-37.2 Plt ___\n___ 01:10PM BLOOD WBC-6.1 RBC-4.96 Hgb-12.9 Hct-39.8 \nMCV-80* MCH-26.0 MCHC-32.4 RDW-12.7 RDWSD-36.3 Plt ___\n___ 01:10PM BLOOD Neuts-50.9 ___ Monos-8.6 Eos-4.4 \nBaso-0.8 Im ___ AbsNeut-3.12 AbsLymp-2.15 AbsMono-0.53 \nAbsEos-0.27 AbsBaso-0.05\n___ 07:10AM BLOOD Glucose-138* UreaN-10 Creat-0.7 Na-143 \nK-4.8 Cl-102 HCO3-25 AnGap-16\n___ 05:23AM BLOOD Glucose-108* UreaN-9 Creat-0.7 Na-141 \nK-4.4 Cl-104 HCO3-27 AnGap-10\n___ 06:30AM BLOOD Glucose-132* UreaN-10 Creat-0.7 Na-141 \nK-4.8 Cl-103 HCO3-27 AnGap-11\n___ 06:35AM BLOOD Glucose-149* UreaN-6 Creat-0.7 Na-144 \nK-4.8 Cl-106 HCO3-26 AnGap-12\n___ 07:10AM BLOOD ALT-471* AST-172* AlkPhos-142* \nTotBili-0.7\n___ 05:23AM BLOOD ALT-442* AST-107* AlkPhos-139* \nTotBili-0.8\n___ 06:30AM BLOOD ALT-611* AST-149* AlkPhos-159* \nTotBili-0.8\n___ 06:35AM BLOOD GGT-___*\n___ 01:10PM BLOOD Lactate-2.4*\n\n MRCP (MR ABD ___ Study Date of ___ 10:45 AM \n\n \n1. Mild hepatic steatosis. No suspicious focal liver lesions \nwithin \nlimitations of motion artifact. \n2. No evidence of intra or extrahepatic biliary dilatation. \n3. Cholelithiasis without evidence of choledocholithiasis. \n \n\n \nBrief Hospital Course:\n#Symptomatic cholelithiasis\n#Transient choledocholithiasis\n#Hepatocellular injury\nPresented initially with cholestasis, hepatocellular injury, and \nCBD dilation on US. By the time MRCP was performed, no CBD \ndilation or stone in CBD was present. A stone was seen in the \ncystic duct. She underwent EUS which also showed no CBD stone or \ndilatation. Transaminases, alk phos, and bili have since been \ntrending down until today with AST, ALT, and alk phos unchanged \nfrom yesterday. She continues to experience intermittent RUQ \npain. Viral hepatitis serologies negative. Had mildly elevated \nlactate on presentation, ischemic hepatitis is also possible. \nHer ___ returned positive at 1:80. IgG was normal and anti-SM \nnegative.\n- ACS planning add-on cholecystectomy today\n- Interestingly her AST and ALT were higher (>1000) on \npresentation than is typically seen in CBD obstruction, \nespecially transient CBD obstruction. MRCP had shown mild \nsteatosis. After recovery from her cholecystectomy it would be \nhelpful to measure her liver enzymes and ___ as this auto \nantibody alone is nonspecific. If concern remains for autoimmune \nhepatitis. anti-liver/kidney microsomal-1 antibodies \n(anti-LKM-1), anti-soluble liver/liver pancreas antigen \n(anti-SLA) and anti-actin antibodies (AAA) should be measured\n\nCHRONIC/STABLE PROBLEMS:\n#Hypertension: currently normotensive; continued home metoprolol \nin divided doses with holding parameters\n#DMII: continued home metformin and ISS, ___\n#Urinary incontinence: continued home oxybutynin\n#Hyperlipidemia: held home atorvastatin until LFTs improve\n\nShe was taken to the operating room on ___ for a \nlaparoscopic cholecystectomy. \nThe operation was uncomplicated and the patient was transferred \nto the ACS service portoperatively. After an uncomplicated stay \nin the PACU she was taken to the surgical floor where she did \nwell, tolerating a regular diet, pain well controlled with \nTylenol with no nausea. She was ready to be discharged on POD1. \n\nPain was well controlled. Diet was progressively advanced as \ntolerated to a regular diet with good tolerability. The patient \nvoided without problem. During this hospitalization, the patient \nambulated early and frequently, was adherent with respiratory \ntoilet and incentive spirometry, and actively participated in \nthe plan of care. The patient received subcutaneous heparin and \nvenodyne boots were used during this stay.\n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating a regular \ndiet, ambulating, voiding without assistance, and pain was well \ncontrolled. The patient was discharged home without services. \nThe patient received discharge teaching and follow-up \ninstructions with understanding verbalized and agreement with \nthe discharge plan.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Oxybutynin 10 mg PO DAILY \n2. MethylPHENIDATE (Ritalin) 10 mg PO DAILY:PRN ADHD sx \n3. Metoprolol Succinate XL 50 mg PO DAILY \n4. Atorvastatin 40 mg PO QPM \n5. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n6. Omeprazole 40 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Docusate Sodium 100 mg PO BID \n3. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN BREAKTHROUGH PAIN \nno drinking or driving while taking this medication \nRX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every six \n(6) hours Disp #*7 Tablet Refills:*0 \n4. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n5. Senna 8.6 mg PO BID:PRN Constipation - First Line \n6. Atorvastatin 40 mg PO QPM \n7. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n8. MethylPHENIDATE (Ritalin) 10 mg PO DAILY:PRN ADHD sx \n9. Metoprolol Succinate XL 50 mg PO DAILY \n10. Omeprazole 40 mg PO DAILY \n11. Oxybutynin 10 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\ncholedocholithiasis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted to the hospital with acute cholecystitis. You \nwere taken to the operating room and had your gallbladder \nremoved laparoscopically. You tolerated the procedure well and \nare now being discharged home to continue your recovery with the \nfollowing instructions.\n \nPlease follow up in the Acute Care Surgery clinic at the \nappointment listed below.\n \nACTIVITY:\n \no Do not drive until you have stopped taking pain medicine and \nfeel you could respond in an emergency.\no You may climb stairs. \no You may go outside, but avoid traveling long distances until \nyou see your surgeon at your next visit.\no Don't lift more than ___ lbs for 4 weeks. (This is about \nthe weight of a briefcase or a bag of groceries.) This applies \nto lifting children, but they may sit on your lap.\no You may start some light exercise when you feel comfortable.\no You will need to stay out of bathtubs or swimming pools for a \ntime while your incision is healing. Ask your doctor when you \ncan resume tub baths or swimming.\n \nHOW YOU MAY FEEL: \no You may feel weak or \"washed out\" for a couple of weeks. You \nmight want to nap often. Simple tasks may exhaust you.\no You may have a sore throat because of a tube that was in your \nthroat during surgery.\no You might have trouble concentrating or difficulty sleeping. \nYou might feel somewhat depressed.\no You could have a poor appetite for a while. Food may seem \nunappealing.\no All of these feelings and reactions are normal and should go \naway in a short time. If they do not, tell your surgeon.\n \nYOUR INCISION:\no Tomorrow you may shower and remove the gauzes over your \nincisions. Under these dressing you have small plastic bandages \ncalled steri-strips. Do not remove steri-strips for 2 weeks. \n(These are the thin paper strips that might be on your \nincision.) But if they fall off before that that's okay).\no Your incisions may be slightly red around the stitches. This \nis normal.\no You may gently wash away dried material around your incision.\no Avoid direct sun exposure to the incision area.\no Do not use any ointments on the incision unless you were told \notherwise.\no You may see a small amount of clear or light red fluid \nstaining your dressing or clothes. If the staining is severe, \nplease call your surgeon.\no You may shower. As noted above, ask your doctor when you may \nresume tub baths or swimming.\n \nYOUR BOWELS:\no Constipation is a common side effect of narcotic pain \nmedications. If needed, you may take a stool softener (such as \nColace, one capsule) or gentle laxative (such as milk of \nmagnesia, 1 tbs) twice a day. You can get both of these \nmedicines without a prescription.\no If you go 48 hours without a bowel movement, or have pain \nmoving the bowels, call your surgeon. \n \nPAIN MANAGEMENT:\no It is normal to feel some discomfort/pain following abdominal \nsurgery. This pain is often described as \"soreness\". \no Your pain should get better day by day. If you find the pain \nis getting worse instead of better, please contact your surgeon.\no You will receive a prescription for pain medicine to take by \nmouth. It is important to take this medicine as directed. o Do \nnot take it more frequently than prescribed. Do not take more \nmedicine at one time than prescribed.\no Your pain medicine will work better if you take it before your \npain gets too severe.\no Talk with your surgeon about how long you will need to take \nprescription pain medicine. Please don't take any other pain \nmedicine, including non-prescription pain medicine, unless your \nsurgeon has said its okay.\no If you are experiencing no pain, it is okay to skip a dose of \npain medicine.\no Remember to use your \"cough pillow\" for splinting when you \ncough or when you are doing your deep breathing exercises.\nIf you experience any of the following, please contact your \nsurgeon:\n- sharp pain or any severe pain that lasts several hours\n- pain that is getting worse over time\n- pain accompanied by fever of more than 101\n- a drastic change in nature or quality of your pain\n \nMEDICATIONS:\nTake all the medicines you were on before the operation just as \nyou did before, unless you have been told differently.\nIf you have any questions about what medicine to take or not to \ntake, please call your surgeon.\n\n \nFollowup Instructions:\n___\n" ]

[ "K8043", "I10", "K760", "R32", "E119", "E785", "Z87891", "F909", "K710" ]

[ "K8043: Calculus of bile duct with acute cholecystitis with obstruction", "I10: Essential (primary) hypertension", "K760: Fatty (change of) liver, not elsewhere classified", "R32: Unspecified urinary incontinence", "E119: Type 2 diabetes mellitus without complications", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "F909: Attention-deficit hyperactivity disorder, unspecified type", "K710: Toxic liver disease with cholestasis" ]

[ "I10", "E119", "E785", "Z87891" ]

[]

[ " \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:\nCC: ___ and homicidal ideation\nAdmitted for: pneumonia\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\n___ w/ EtOH abuse, history of frequent SI, homelessness, who \npresented intoxicated with EMS report that he was having \nsuicidal and homicidal ideation.\n\nOn arrival to the ED, vitals were: HR 120, BP 114/72, RR 16, \nSpO2 97% on RA, temp 99.2. Seen by psych after he sobered up; \nthey felt that he did not need inpatient psychiatric admission \nand was not an imminent threat to himself or others. \n\nHe was given 30 mg of valium for EtOH withdrawal. He complained \nof a dragging cough and was found on CXR to have PNA and was \ngiven CTX/azithro. \n\nREVIEW OF SYSTEMS\nGEN: denies fevers/chills\nCARDIAC: denies chest pain or palpitations\nPULM: complains of cough; no acute dyspnea\nGI: denies n/v, denies change in bowel habits\nGU: denies dysuria or change in appearance of urine\nFull 14-system review of systems otherwise negative and \nnon-contributory. \n\n \nPast Medical History:\nAlcohol use disorder\nPTSD\nMood disorder (patient reports he has bipolar)\nChronic auditory and visual hallucinations\nRecurrent suicidal ideation with negative history of suicide \nattempts\nAnxiety\nHTN\nArthritis\nhx of right TKR \nHLD\nShoulder injury 5 days ago s/p fall.\n \nSocial History:\n___\nFamily History:\nMultiple family members with alcohol use disorders.\n \nPhysical Exam:\nAdmission PE\nGEN: obese M in NAD; well-kept appearance\nHEENT: EOMI, sclerae anicteric, MMM, OP clear\nNECK: No LAD, no JVD\nCARDIAC: RRR, no M/R/G\nPULM: normal effort, no accessory muscle use, LCAB. Slight \ncrackles at L base.Prolonged expiratory time.\nGI: soft, NT, ND, NABS\nMSK: No visible joint effusions or deformities.\nDERM: No visible rash. No jaundice.\nNEURO: AAOx3. No facial droop, moving all extremities.\nPSYCH: Full range of affect\nEXTREMITIES: WWP, no edema\n\nDischarge PE:\n97.7 138 / 90 98 20 92 Ra \nGen: NAD, resting comfortably in bed\nHEENT: EOMI, PERRLA, MMM, OP clear\nCV: RRR nl s1s2 no m/r/g\nResp: Left lower lung field rhonchi, otherwise clear\nAbd: soft, NT, ND +BS\nExt: no c/c/e\nSkin: warm, dry no rashes\nNeuro: no significant tremor, AAOx3, CN II-XII intact, ___ \nstrength throughout\n \nPertinent Results:\nBlood alcohol 190\nUDS positive only for benzos (after receiving valium)\n\nWBC-9.5 RBC-4.25* HGB-12.1* HCT-36.5* MCV-86 MCH-28.5 MCHC-33.2 \nRDW-13.9 RDWSD-43.1 PLT COUNT-304\n\nGLUCOSE-139* UREA N-13 CREAT-0.8 SODIUM-145 POTASSIUM-3.8 \nCHLORIDE-109* TOTAL CO2-23 ANION GAP-17\n\n2v CXR ___:\nLeft lower lobe consolidation concerning for pneumonia.\n\nDischarge labs:\n___ 07:45AM BLOOD WBC-7.0 RBC-4.56* Hgb-12.6* Hct-38.5* \nMCV-84 MCH-27.6 MCHC-32.7 RDW-14.0 RDWSD-42.7 Plt ___\n___ 07:45AM BLOOD Glucose-108* UreaN-10 Creat-0.8 Na-141 \nK-4.3 Cl-103 HCO3-27 AnGap-15\n___ 07:45AM BLOOD ALT-19 AST-23 AlkPhos-111 TotBili-0.___ w/ EtOH abuse, history of frequent SI, homelessness, who \npresented intoxicated with EMS report that he was having \nsuicidal and homicidal ideation. Seen by psych who felt that he \ndid not need inpatient psychiatric admission; however, he was \nfound to have PNA and possible EtOH withdrawal so was admitted \nfor these.\n\n#CAP\nPatient complained of cough for the past two months. Infiltrate \nincidentally found on CXR. He was started on ceftriaxone and \nazithromycin, reports stable cough and improved dyspnea. \n- D/c on Levaquin for total ___lcohol abuse\n#Possible Alcohol withdrawal\nBased on the amount he drinks he would seem to be at risk for \nsevere alcohol withdrawal. He did not have significant \nwithdrawal here, was put on CIWA but only received 1 dose of \nValium. Alert and oriented without significant tremor on \ndischarge. Counseled on importance of alcohol cessation. He was \nseen by social work multiple times in ED recently, repeat \nevaluation deferred.\n\n#Suicidal ideation\nSeen by psychiatry who felt his symptoms had resolved when he \nsobered up. He has been trialed on numerous psych meds but is \nchronically non-adherent as an outpatient and is on no meds. \n-Follow-up with outpatient providers\n\n___ gastritis: Continue omeprazole BID\n\n#HL: continue atorvastatin, aspirin 81 mg\n\n#DVT PPx\n- SQH\n\n#Dispo: discharged without services, offered him assistance with \ngetting to a shelter but he does not want to go to a shelter at \nthis time saying they are overcrowded and filled with drugs.\n \nMedications on Admission:\nDenies taking any regular medications as an outpatient\n \nDischarge Medications:\n1. Levofloxacin 500 mg PO Q24H Duration: 4 Days \nRX *levofloxacin 500 mg 1 tablet(s) by mouth once a day Disp #*4 \nTablet Refills:*0 \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 40 mg PO QPM \n4. Omeprazole 20 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAlcohol intoxication\nSuicidal ideation\nCommunity acquired pneumonia\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted with alcohol intoxication and saying you \nwanted to hurt yourself. You were seen by the psychiatry team \nwho recommended up following with your outpatient providers. \nYou were found to have a pneumonia and were started on \nantibiotics.\n \nFollowup Instructions:\n___\n" ]

[ "F10239", "J189", "F1410", "R45851", "F315", "F4310", "F419", "R45850", "Z590", "Z915", "I10", "M1990", "Z96651", "E785", "S4990XA", "W19XXXA", "Z9181", "Y929", "K2950" ]

[ "F10239: Alcohol dependence with withdrawal, unspecified", "J189: Pneumonia, unspecified organism", "F1410: Cocaine abuse, uncomplicated", "R45851: Suicidal ideations", "F315: Bipolar disorder, current episode depressed, severe, with psychotic features", "F4310: Post-traumatic stress disorder, unspecified", "F419: Anxiety disorder, unspecified", "R45850: Homicidal ideations", "Z590: Homelessness", "Z915: Personal history of self-harm", "I10: Essential (primary) hypertension", "M1990: Unspecified osteoarthritis, unspecified site", "Z96651: Presence of right artificial knee joint", "E785: Hyperlipidemia, unspecified", "S4990XA: Unspecified injury of shoulder and upper arm, unspecified arm, initial encounter", "W19XXXA: Unspecified fall, initial encounter", "Z9181: History of falling", "Y929: Unspecified place or not applicable", "K2950: Unspecified chronic gastritis without bleeding" ]

[ "F419", "I10", "E785", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nciprofloxacin\n \nAttending: ___.\n \nChief Complaint:\nabdominal pain/fever\n \nMajor Surgical or Invasive Procedure:\n1. PTBD Exchange\n2. Balloon Cholangioplasty / Sphincteroplasty\n\n \nHistory of Present Illness:\n___ with PMH of Roux en Y gastric bypass ___ ___, multiple \nSBOs requiring resection, cholecystectomy, and ampullary \nstenosis \ns/p PTCD with multiple rounds of dilation recently admitted for \nabdominal pain and placement of PCBD conversion of ampullary \ndrain who presents 3 days after discharge with progressive \nabdominal pain, fevers to 101 and purulent drainage from her \ncholecystostomy site.\n\nNote, patient just had ___ Guided placement of internal/external \nampullary drain on ___\n\n___ the ED, initial vitals:\n98.9 78 125/71 18 100% RA \nExam notable for non-toxic-appearing \nLabs were significant for normal WBC count, alk phos 121, BUN/Cr \n___\nCT A/P:\n1. Interval development of small subcapsular fluid collection \n(1.2 x 2.2 x 2.4cm) along the PTBD as it exits the liver \nanteriorly, likely representing biloma though cannot exclude \nabscess.\n2. Small volume ascites.\n___ the ED, she received IV cipro/flagyl, morphine, dilaudid and \n2L NS IV. \n\nCurrently, she reports pain/edema and red/pruritic rash over \nleft wrist when she received ciprofloxacin ___ the ED. ROS \npositive for nausea, no emesis. OK PO intake, although pain is \nworse with eating. Her R-sided abdominal pain and epigastric \npain both radiate to eh back. No cough, dyspnea, chest pain, \nalthough she feels like she can't take a deep breath due to \npain. \n \nROS: \nAs per HPI. Remaining 10-point ROS negative. \n \nPast Medical History:\n# ampullary stenosis\n -___: ERCP (___) \n -___: PTBD (___) \n -___: Upsize of internal hepatobiliary catheter and balloon \n\nsphicteroplasty (___) \n# Papillary thyroid cancer - s/p total thyroidectomy & radiation \n\n___ \n# RNY Gastric bypass - ___, lost 130 pounds (___) \n# SBR for SBO/intussusception - ___ ___\n# Cervical cancer s/p partial hysterectomy ___, total \nhysterectomy & BSO ___ \n# Pre-cancerous colonic polypectomy ___ \n# Lumpectomy of left breast - ___ \n# Cholecystectomy ___, removed for polyps, surgical path \nreportedly normal \n# Umbilical Hernia \n# Seizures - occurred 3 times ___ ___ after large caffeine \ningestion, no seizures since \n# Vasovagal syncope, on fludrocortisone \n# Asthma \n# Spinal fusion L3-S1 - ___ c/b epidural hematoma vs. \nthrombosis \n# Neuropathy ___ left lower leg and foot (s/p spinal fusion) \n# Fibromyalgia vs. Complex Regional Pain Syndrome \n# MRSA infection of ankle (___) \n \nSocial History:\n___\nFamily History:\nMother - ___ strokes, first ___ ___\nFather - MI ___ ___\nBrother - died of lung cancer (smoker)\nGrandparents - colon cancer, prostate cancer\nAunt - breast cancer\n\n \nPhysical Exam:\n>> ADMISSION PHYSICAL EXAM: \nVS: 98.4 72 149/72 17 98RA\nGEN: Alert, lying ___ bed, appears uncomfortable\nHEENT: Moist MM, anicteric sclerae, no conjunctival pallor \nNECK: Supple without LAD \nPULM: Generally CTA b/l without wheeze or rhonchi \nCOR: RRR (+)S1/S2 no m/r/g \nABD: Soft, non-distended. PTBD site ___ epigastrium \nerythematous/indurated & exquisitely tender to palpation with \npurulent material on gauze. Bag with bilious fluid. Abdomen very \ntender over epigastrium and RUQ. Unable to elicit peritoneal \nsigns due to sensitivity. Mild TTP over R CVA\nEXTREM: Warm, well-perfused, no edema \nNEURO: CN II-XII grossly intact, motor function grossly normal \n.\n>> DISCHARGE PHYSICAL EXAM: \nVitals: T 98.2 135 / 63 69 18 99 RA\nGeneral: Alert, oriented x 3, comfortable. \nHEENT: MMM, anicteric sclera, no conjunctival pallor. \nNeck: No cervical LAD. \nLungs: CTAB/L, no adventitial sounds heard. \nCardiac: RRR, S1, S2, no extra sounds. \nAbdomen: Soft, PTBD ___ the epigastrum, dressing intact. Improved \nerythema at drainage site, with minimal surrounding drainage \naround site. Tenderness improved ___ the RUQ, and the epigastric. \nNo CVA tenderness. \nExtremities: Warm, no ___ edema bilaterally. \nNEURO: CN II-XII grossly intact, motor function grossly normal \n \nPertinent Results:\n>> ADMISSION LABS: \n___ 12:45PM BLOOD WBC-7.1 RBC-4.19 Hgb-12.1 Hct-39.3 MCV-94 \nMCH-28.9 MCHC-30.8* RDW-14.8 RDWSD-50.4* Plt ___\n___ 12:45PM BLOOD Glucose-85 UreaN-7 Creat-0.7 Na-140 K-4.6 \nCl-102 HCO3-30 AnGap-13\n___ 12:45PM BLOOD ALT-27 AST-28 AlkPhos-121* TotBili-0.4 \nDirBili-0.2 IndBili-0.2\n___ 12:45PM BLOOD Albumin-3.5 Calcium-8.6 Phos-4.4 Mg-2.0\n___ 12:50PM BLOOD Lactate-1.7\n.\n>> DISCHARGE LABS: \n___ 06:15AM BLOOD WBC-6.3 RBC-4.12 Hgb-11.9 Hct-38.5 MCV-93 \nMCH-28.9 MCHC-30.9* RDW-14.7 RDWSD-50.0* Plt ___\n___ 06:15AM BLOOD Neuts-47.7 ___ Monos-7.2 Eos-5.4 \nBaso-1.0 Im ___ AbsNeut-2.99 AbsLymp-2.41 AbsMono-0.45 \nAbsEos-0.34 AbsBaso-0.06\n___ 06:15AM BLOOD ALT-19 AST-27 AlkPhos-99 TotBili-0.1\n___ 06:15AM BLOOD Calcium-8.1* Phos-4.1 Mg-1.9\n___ 06:15AM BLOOD Glucose-74 UreaN-10 Creat-0.7 Na-140 \nK-4.0 Cl-107 HCO3-22 AnGap-15\n.\n>> MICROBIOLOGY: \n__________________________________________________________\n___ 8:40 pm BILE\n\n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. \n ___ PAIRS. \n\n FLUID CULTURE (Preliminary): \n GRAM POSITIVE COCCUS(COCCI). SPARSE GROWTH. \n\n ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. \n__________________________________________________________\n___ 12:45 pm BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n__________________________________________________________\n___ 6:09 am URINE Source: ___. \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___ 5:55 am BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n__________________________________________________________\n___ 11:50 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n.\n>> PERTINENT REPORTS: \n___ ABD & PELVIS WITH CO:\n1. Interval development of small subcapsular fluid collection \n(1.2 x 2.2 x 2.4\ncm) along the PTBD as it exits the liver anteriorly, likely \nrepresenting\nbiloma though cannot exclude abscess.\n2. Small volume ascites.\n. \n___ CATH REPLACE: \n \nFINDINGS:\n.\n1. Preprocedure ultrasound demonstrating 2.3 x 2.0 x 0.7 cm \nsubcapsular\ncollection surrounding the hepatic entry site of the existing \ncatheter.\n2. Initial cholangiograms demonstrating narrowing at the level \nof the ampulla\nwith poor antegrade flow of contrast.\n3. 12 mm balloon sphincteroplasty (prolonged inflation for 5 \nmin) with a waist\ninitially noted at the level of the ampulla, with improved flow \non\npost-sphinteroplasty cholangiogram.\n4. Ultrasound and fluoroscopy guided aspiration subcapsular \ncollection with\nminimum amount of fluid returned. No significant fluid was \nidentified ___ this\nlocation at the completion of procedure.\n5. Successful exchange of 12 ___ PTBD catheter with a new 12 \n___ PTBD\ncatheter.\n.\nIMPRESSION: \n.\n1. Successful exchange of existing 12 ___ PTBD catheter with \na new 12\n___ PTBD catheter.\n2. Successful performance of 12 mm balloon \ncholangioplasty/sphincteroplasty\n3. Percutaneous aspiration of 2 cm perihepatic collection \nsurrounding the\nliver entry site of the existing catheter, with minimal fluid \naspirated.\n.\n \nBrief Hospital Course:\nMs. ___ is a ___ year old female, with past history of \nRoux-en-Y Gastric Bypass ___ ___, Multiple SBOs requiring \ncholecystectomy, and ampullary stenosis s/p PTCD with multiple \nrounds of dilation recently admitted for abdominal pain and \nplacement of PCBD conversion of ampullary drain who presents \nwith progressive abdominal pain, fevers to 101 and purulent \ndrainage from her cholecystostomy site 3 days after returning \nfrom the hospital. \n.\n>> ACTIVE ISSUES: \n# Possible recurrent biliary obstruction\n abdominal wall cellulitis at site of biliary drain\n\nUpon admission, given concern for prior PTBD manipulation, \npatient underwent CT Abdomen scan which was remarkable for a \nsubcapsular fluid collection along the PTBD as it exited the \nliver anteriorly, concerning for a biloma but could not exclude \nabscess. Patient also was found to have small volume ascites. \nGiven this, patient underwent immediate uncapping of her PTBD \ndrain, and then underwent procedure on ___: Exchange of the \nexisiting PTBD catheter with a new catheter, and performance of \ndilation with cholangioplasty / sphincteroplasty. Patient also \nhad percutaneous aspiration of perihepatic collection with \nminimal fluid aspirated. Cultures returned negative ___ blood. \nPatient's abdominal pain improved with tube replacement, and \nfelt that ampulla had been stenosed, and that repeated dilation \nhas been only moderately successful. Patient underwent \nsuccessful capping trial on ___, and given stability, \npatient stable for discharge. Pain regimen was converted from IV \nDilaudid to oxycodone, and was dispensed #30 tablets after \nverification with PMP. Furthermore, patient was found to have \nredness at drainage site concerning for abdominal wall \ncellulitis, and therefore initially treated with broad spectrum \nantibiotics, narrowed to TMP-SMX to complete course. Wound care \nsupplies were given to patient, along with prescriptions for \nrefills. \n. \n>> CHRONIC ISSUES: \n# Constipation: Given increased narcotic load for abdominal \npain, patient placed on aggressive regimen and had several bowel \nmovements during hospital stay prior to discharge. \n. \n# Depression: Patient was continued on home citalopram. \n. \n# Vasovagal Syncope: Patient was continued on home \nfludrocortisone. Patient did not have any hemodynamic \ninstability during hospital stay. \n. \n# Chronic Pain / Fibromyalgia: Patient was continued on home \ngabapentin. \n. \n# Papillary Thyroid Cancer s/p Resection: Patient continued on \nhome levothyroxine supplement. \n. \n>> TRANSITIONAL ISSUES: \n# Cellulitis: Please complete TMP-SMX antibiotic course until \n___\n# PTBD: Please continue to maintain PTBD drain site, and check \nCBC, Chem-7, and LFTs upon discharge follow-up. \n# Pain Regimen: Patient was given oxycodone, and bowel regimen \nupon discharge for maintenance of pain. PMP checked prior to \nprescription.\n# Pending Labs: Please f/u blood culture obtained ___ (No \ngrowth upon discharge).\n# CODE STATUS: Full\n# CONTACT: HCP ___ ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q4H \n2. Citalopram 20 mg PO BID \n3. Docusate Sodium 100 mg PO BID:PRN constipation \n4. Fludrocortisone Acetate 0.1 mg PO DAILY \n5. Fludrocortisone Acetate 0.05 mg PO QHS \n6. Gabapentin 800 mg PO QHS \n7. Levothyroxine Sodium 137 mcg PO DAILY \n8. Multivitamins 1 TAB PO DAILY \n9. Omeprazole 20 mg PO DAILY \n10. Polyethylene Glycol 17 g PO DAILY \n11. Vitamin D 3000 UNIT PO DAILY \n12. Cal-Citrate (calcium citrate-vitamin D2) ___ mg oral TID \n13. Cyanocobalamin 100 mcg PO DAILY \n14. grape seed oil (bulk) 100 mg PO DAILY \n15. Melatin (melatonin) 10 mg oral QHS \n16. Bisacodyl ___AILY \n17. Senna 8.6 mg PO BID \n18. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q4H \n2. Bisacodyl ___AILY \n3. Citalopram 20 mg PO BID \n4. Cyanocobalamin 100 mcg PO DAILY \n5. Docusate Sodium 100 mg PO BID:PRN constipation \n6. Fludrocortisone Acetate 0.1 mg PO DAILY \n7. Fludrocortisone Acetate 0.05 mg PO QHS \n8. Gabapentin 800 mg PO QHS \n9. Levothyroxine Sodium 137 mcg PO DAILY \n10. Omeprazole 20 mg PO DAILY \n11. Polyethylene Glycol 17 g PO DAILY \n12. Senna 8.6 mg PO BID \n13. Vitamin D 3000 UNIT PO DAILY \n14. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain \nRX *oxycodone 5 mg 1 tablet(s) by mouth every ___ hours Disp \n#*30 Tablet Refills:*0\n15. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days \nRX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by \nmouth twice daily Disp #*6 Tablet Refills:*0\n16. Cal-Citrate (calcium citrate-vitamin D2) ___ mg oral TID \n17. grape seed oil (bulk) 100 mg PO DAILY \n18. Melatin (melatonin) 10 mg oral QHS \n19. Multivitamins 1 TAB PO DAILY \n20. Medipore H (adhesive tape) 3 X 10 topical DAILY \nPlease dispense 1 Roll \nRX *adhesive tape 1\" X ___ yard Apply dressing daily Disp #*1 \nPackage Refills:*2\n21. Gauze Pad (gauze bandage) 4 X 4 topical DAILY \nRX *gauze bandage 4\" X 4\" Apply dressing daily Disp #*2 Package \nRefills:*2\n22. Tech\nSplit Drain Sponge \nICD 10: 87.51 Duration: Ongoing\nPlease dispense split-drain sponge, 1 Box to apply daily\nRefill: 2\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS: 1. Ampullary Stricture with PTBD Drain\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___ was a pleasure taking care of you during your hospital stay \nat ___. You were hospitalized \nfor concern of your biliary drain, and underwent a procedure by \nthe Interventional Radiology Team to dilate and help this drain \nmore effectively. While here, we were able to control your pain \nwith pain relievers, and started you on antibiotics because we \nwere concerned for a skin infection near your drain entry site. \nPlease continue to take all of your home medications as \nprescribed. Please follow-up with your primary care physician, \nand the interventional radiology team as an outpatient. \n\nTake Care,\nYour ___ Team. \n \nFollowup Instructions:\n___\n" ]

[ "T85590A", "R188", "Y832", "Y929", "T8579XA", "R55", "J45909", "G8929", "F329", "K5909", "T40605A", "Y92019", "E890", "M797", "Z9884", "Z85850", "Z8541", "Z87891" ]

[ "T85590A: Other mechanical complication of bile duct prosthesis, initial encounter", "R188: Other ascites", "Y832: Surgical operation with anastomosis, bypass or graft as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "T8579XA: Infection and inflammatory reaction due to other internal prosthetic devices, implants and grafts, initial encounter", "R55: Syncope and collapse", "J45909: Unspecified asthma, uncomplicated", "G8929: Other chronic pain", "F329: Major depressive disorder, single episode, unspecified", "K5909: Other constipation", "T40605A: Adverse effect of unspecified narcotics, initial encounter", "Y92019: Unspecified place in single-family (private) house as the place of occurrence of the external cause", "E890: Postprocedural hypothyroidism", "M797: Fibromyalgia", "Z9884: Bariatric surgery status", "Z85850: Personal history of malignant neoplasm of thyroid", "Z8541: Personal history of malignant neoplasm of cervix uteri", "Z87891: Personal history of nicotine dependence" ]

[ "Y929", "J45909", "G8929", "F329", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nTegaderm / oxaliplatin\n \nAttending: ___\n \nChief Complaint:\nElective Admission for Chemotherapy Densensitization\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMs. ___ is a ___ female with rectal cancer \non FOLFOX who presents today for elective admission for \noxaliplatin desensensitization.\n\nDuring C3D1 on ___, 15 min into the oxaliplatin infusion, she \ndeveloped flushing, sensation of tongue swelling, chest \ntightness, facial erythema tachycardia, hives on arms and \nabdomen, all within 15 minutes of the infusion. Her symptoms \nresolved after ___ min with benadryl, pepcid. She saw Dr. ___ \nin clinic on ___ and was concerned about a possible IgE \nmediated reaction and advised to receive future oxaliplatin \ninfusions via inpatient desensitization protocol.\n \nShe last underwent desens on ___ without issues. She has been \nfeeling well since her last admission. Has received her home \ncapecitabine which is planning to be started with radiation \ntherapy later this month. \n\nOf note, she does report one episode of BRBPR after last chemo \ncycle, with a small amount of rectal blood. She denies \nfevers/chills, dizziness/lightheadedness, weakness/numbness, \nshortness of breath, cough, hemoptysis, chest pain, \npalpitations, abdominal pain, nausea/vomiting, diarrhea, \nhematemesis, melena, dysuria, hematuria, and new rashes.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \nONC ID T3 N2 rectal cancer. tumor cells display intact\nexpression of MLH-1, PMS-2,\nMSH2 and MSH6; \nTreatment pathway : NAC: 4C of FOLFOX --> Xeloda/RXT --> Surgery\n.\nRXT: in ___ --> Dr. ___ \n___: Dr. ___ (___) \n\nFOLFOX C1/C2--> imaging: Reduction of primary disease\nFOLFOX C3 = ___: DELAYED due to thrombocytopenia; r/s for\n___ --> REACTION to the oxaliplatin --> therefore never got\ntrue C3 \nCT scan ___ - decrease in disease\nNEW C3 with oxaliplatin: C3D1 = ___ -inpatient desensef\nC3D15 = ___ ___ Inpatient \nc4D1 = ___ ___ Inpatient\nC4D15 = ___ ___ Inpatient \nCT scan scheduled \n\nPAST MEDICAL HISTORY: \nRectal cancer as above\nCeliac disease\n \nSocial History:\n___\nFamily History:\nMaternal grandmother with breast cancer at the age of ___. \nMaternal grandfather with prostate cancer. Paternal grandfather \nwith liver disease.\n \nPhysical Exam:\nPHYSICAL EXAM: \nVitals: 24 HR Data (last updated ___ @ 1415)\n Temp: 98.6 (Tm 98.6), BP: 116/75 (93-123/54-76), HR: 62 (56\n(sleeping)-62), RR: 18 (___), O2 sat: 98% (97-98), O2\ndelivery: RA, Wt: 140.5 lb/63.73 kg\nGENERAL: Lying comfortably in bed, NAD\nHEENT: Clear OP without lesions or thrush\nEYES: PERRL, anicteric\nNECK: supple, no JVD\nRESP: No increased WOB, no wheezing, rhonchi or crackles\n___: RRR, no murmurs\nGI: soft, non-tender, no rebound or guarding\nEXT: no edema, warm\nSKIN: dry, no obvious rashes\nNEURO: alert, fluent speech. PERRL, EOMI. \nACCESS: POC without overlying erythema, dressing C/D/I\n \nPertinent Results:\nADMISSION LABS: \n___ 02:43PM BLOOD WBC: 5.6 RBC: 3.98 Hgb: 13.0 Hct: 37.1\nMCV: 93 MCH: 32.7* MCHC: 35.0 RDW: 16.1* RDWSD: 53.6* Plt Ct: \n89*\n___ 02:43PM BLOOD Neuts: 51.5 Lymphs: ___ Monos: 13.2* \nEos:\n2.9 Baso: 0.5 Im ___: 1.1* AbsNeut: 2.86 AbsLymp: 1.71 AbsMono:\n0.73 AbsEos: 0.16 AbsBaso: 0.03 \n___ 02:43PM BLOOD UreaN: 6 Creat: 0.5 Na: 140 K: 3.8 Cl: \n106\nHCO3: 22 AnGap: 12 \n___ 02:43PM BLOOD ALT: 45* AST: 57* AlkPhos: 111* TotBili:\n0.3 \n\nMICROBIOLOGY: None new.\n\nIMAGING: None new.\n \nBrief Hospital Course:\nMs. ___ is a ___ female with rectal cancer \non FOLFOX who presents for elective admission for oxaliplatin \ndesensensitization.\n\n# Encounter for Antineoplastic Therapy:\n# Allergy Status to Chemotherapy:\n# Rectal Cancer: Plan for 4 cycles of FOLFOX. Here for C4D15\n- completed 12-step/3 bag protocol ordered as per Dr. ___ \nwithout complications\n- Patient to return tomorrow for remainder of chemo\n- planning for repeat imaging as an outpatient after this cycle, \nfollowed by radiation therapy\n\n#Thrombocytopenia\nAppears to have started since initiation of chemotherapy, as low \nas 58 in ___. Likely in setting of antineoplastic therapy.\n- CTM, transfuse for plts <10 or <50 if actively bleeding\n\n#BRBPR\nSeems to have stopped now, suspect in setting of \nthrombocytopenia and rectal cancer. Hgb of ___ yesterday. No \nsigns or symptoms of symptomatic anemia.\n- CTM as outpatient, transfuse for Hgb <7\n\n#Transaminitis\nMildly elevated since initiation of chemotherapy, possibly ___ \nFOLFOX, though most recent imaging also raises concern of fatty \nliver. Planning for repeat CT as outpatient without contrast to \nbetter evaluate liver parenchyma for fatty liver disease. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Cetirizine 10 mg PO ASDIR \n2. Cyanocobalamin 1000 mcg PO DAILY \n3. Ferrous Sulfate 325 mg PO DAILY \n4. LORazepam 0.5 mg PO DAILY:PRN anxiety \n5. Multivitamins 1 TAB PO DAILY \n6. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n\n \nDischarge Medications:\n1. Cetirizine 10 mg PO ASDIR \n2. Cyanocobalamin 1000 mcg PO DAILY \n3. Ferrous Sulfate 325 mg PO DAILY \n4. LORazepam 0.5 mg PO DAILY:PRN anxiety \n5. Multivitamins 1 TAB PO DAILY \n6. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nEncounter for Antineoplastic Therapy\nAllergy Status to Chemotherapy\nRectal Cancer\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of you at the ___ \n___. You were admitted to the hospital for \nyour chemotherapy which you tolerated well.\n\nPlease follow-up for the remained of your chemotherapy tomorrow.\n\nAll the best,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C20", "Z888", "K900", "D696", "R740", "F17210" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C20: Malignant neoplasm of rectum", "Z888: Allergy status to other drugs, medicaments and biological substances", "K900: Celiac disease", "D696: Thrombocytopenia, unspecified", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]

[ "D696", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins\n \nAttending: ___.\n \nChief Complaint:\nconfusion, gait instability\n \nMajor Surgical or Invasive Procedure:\nLumbar puncture\n\n \nHistory of Present Illness:\nMs. ___ is a pleasant ___ w/ T2DM, gout, Meniere's and stage \nIV\nEGFR+ adenocarcinoma of the RU lung dx ___, with mets to\nmediastinal/cervical/retroperitoneal LNs, liver, and brain s/p\nWBRT ___, who progressed on Erlotinib now on\nCarboplatin/Pemetrexed ___, w/ recent brain MRI ___\nrevealing new mets (planning on CK), who is p/w for weakness for\n1 day. \n\nPatient notes for the past several weeks she has been ambulating\nat home independently using a walker. This morning, she had\ndifficulty getting out of bed from feeling weak. She did not \nfeel\nstable on her feet even with walker. She denied any lower\nextremity pain, back pain, abdominal pain.\n\nPatient was hospitalized at ___ from ___ for\nright shoulder pain and RUQ pain. She was discharged on \nincreased\nprednisone of 20 mg daily and increased oxycontin and dilaudid.\n___ her pain was improved and pred dec to 10 mg on ___ and\n___, but husband gave her 20mg today given 1 day hoping to\nhelp her feel better.\n\nIn ED: Received 1L NS, 0.5 Clonazepam, 20 Oxycontin, 17 g\nMiralax, 17.2 Senna, 200 Colace, 2 PO dilaudid. Head CT was\nnegative for ICH and CXR concerning for increased density of R\nsuprahilar consolidation. \n\nOf note, she has not moved her bowels in 1.5 weeks (normally\nevery 3 days) despite miralax/colace/senna daily. She denied any\nabd pain or n/v.\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: PER OMR\nMrs. ___ is a ___ year old woman with history of Meniere's\ndisease, NIDDM, gout, complaining of ___ weeks of rib pain,\nweight loss, and anorexia, who went to see her PCP in early \n___\nwith complaints of rib pain. She had a CXR that showed a right\nlung mass and associated infiltrate/atelectasis. She was sent to\n___ to have expedited work-up. There further imaging studies\nrevealed two small segmental pulmonary emboli and a 3.5cm right\nupper lobe mass with right suprahilar lymph node and\npost-obstructive infiltrate. The lower cuts of the CT showed\ndiffuse liver lesions. Additionally, brain MRI revealed several\nbrain lesions suggestive of metastatic disease. On ___ she\nunderwent a percutaneous liver biopsy which was consistent with\nmetastatic adenocarcinoma of the lung. On ___ she underwent \na\nEBUS and had ballooning of the RUL performed (no stent was\nplaced) and FNA of 4R station LN and RUL mass, both consistent\nwith adenocarcinoma. She was discharged from the hospital on\n___ and was started on WBRT which she completed on \n___.\n\nOn ___ she was started on Erlotinib 150 mg daily.\n \nOn ___ patient was admitted with generalized weakness and\nabdominal pain. Had imaging studies performed which showed\nimprovement in the disease burden. Symptoms improved over time\nand she was discharged on ___.\n\nRe-staging CT scans on ___ revealed disease progression in\nthe lung and liver.\n\nOn ___ patient underwent bronchoscopy and biopsy with Dr.\n___.\n\nPAST MEDICAL HISTORY:\n- History of Melanoma s/p excisional biopsy in ___ denies \nany\nassociated lymph nodes, excised at ___)\n- 2 uncomplicated C-Sections\n- Meniere's Disease, left ear with better hearing\n- Diabetes, on oral medications, recently d/c'ed due to anorexia\n- gout, last flare about a month ago\nNo history of bleeding diathesis or thrombotic disease. \n- Metastatic lung cancer\n- DVT and PE - diagnosed in ___\n\n \nSocial History:\n___\nFamily History:\nMother died from lung cancer at age ___ (non-smoker). \n \nPhysical Exam:\nGeneral: NAD, resting in bed, conversational but intermittently \nnonsensical and drifting back to sleep\nVS: no longer checking pt CMO\nHEENT: + hearing aids, MM sl dry, no OP lesions\nCV: RR, NL S1S2 no S3S4 no murmur\nPULM: CTAB, No C/W/R, No respiratory distress\nABD: BS+, soft, nontender, no palpable masses or HSM\nLIMBS: WWP, no ___, no tremors\nSKIN: No rashes on the extremities\nNEURO: oriented to person, place only, follows commands, ___, \nEOMI,\nface symmetric, no nystagmus, moves all extremities against\nresistance, not able to get up w/o assistance due to ataxia. \nsensation intact to light touch.\n \nPertinent Results:\nADMISSION LABS:\n___ 07:30PM BLOOD WBC-9.9 RBC-2.88*# Hgb-7.9*# Hct-25.6*# \nMCV-89 MCH-27.4 MCHC-30.9* RDW-13.7 RDWSD-42.7 Plt ___\n___ 07:30PM BLOOD Neuts-85.4* Lymphs-5.9* Monos-7.3 \nEos-0.0* Baso-0.1 Im ___ AbsNeut-8.48* AbsLymp-0.59* \nAbsMono-0.72 AbsEos-0.00* AbsBaso-0.01\n___ 10:20PM BLOOD ___ PTT-30.5 ___\n___ 07:30PM BLOOD Glucose-186* UreaN-13 Creat-0.6 Na-136 \nK-4.2 Cl-99 HCO3-24 AnGap-17\n___ 07:30PM BLOOD ALT-65* AST-52* CK(CPK)-17* AlkPhos-298* \nTotBili-0.3\n___ 07:30PM BLOOD Calcium-8.2* Phos-3.0 Mg-1.9\n___ 07:30PM BLOOD TSH-0.48\n___ 07:11PM BLOOD Lactate-1.4\n\nIMAGING:\n\nNC HCT ___\n1. No intracranial hemorrhage.\n2. Lesions on recent brain MRI concerning for metastatic disease\nnot identifiable on noncontrast CT.\n3. Stable meningioma abutting the left temporal lobe.\n\nCXR ___\nThere is opacity in the right upper lobe compatible with known\nlung cancer. The overall extent of consolidation appears\nincreased in the short interval raising potential concern for a\npostobstructive pneumonia. Subtle opacity is linear in the left\nlower lung which may represent atelectasis. No large effusion or\npneumothorax. Cardiomediastinal silhouette is unchanged. Bony\nstructures are intact.\n\nMRI ___ (few days prior to admission)\n1. Study is mildly degraded by motion. \n2. Numerous new punctate bilateral hemisphere supratentorial\nlesions concerning for new areas of metastases. \n3. Question new left cerebellar area of metastatic disease \nversus\nartifact. \n4. Interval progression of previously noted left temporal\nenhancing lesion. \n5. Redemonstration of numerous grossly stable supratentorial\nenhancing lesions. \n6. Grossly stable left temporoparietal and left frontal\nextra-axial homogeneously enhancing masses, suggestive of\nmeningiomas.\n\nCYTOLOGY \nDIAGNOSIS:\nCEREBROSPINAL FLUID:\nNEGATIVE FOR MALIGNANT CELLS.\nLymphocytes and monocytes.\n\n \nBrief Hospital Course:\n___ w/ T2DM, gout, Meniere's and stage IV EGFR+ adenocarcinoma \nof\nthe RU lung dx ___, with mets to brain,\nmediastinal/cervical/retroperitoneal LNs, liver, s/p WBRT \n___,\nwho progressed on Erlotinib now on Carboplatin/Pemetrexed ___, w/ recent brain MRI ___ revealing new mets, who is p/w\nfor progressive weakness, balance difficulty and inability\nambulate. \n\n#Goals of care - After discussion w/ family and Dr ___\nhas elected not to pursue further treatment for metastatic NSCLC\nincluding deferring CK to brain mets that was scheduled for this\n___. Wants to go home w/ her family, per husband she has\nstated she wants to die at home and they want to care for her.\n- Pt followed by palliative care in past and appreciate inpt\nconsult\n- home hospice services were arranged, pts daughter, son and \nhusband will be caring for her\n\n#Weakness/Balance difficulty/AMS - has known recurrent\nmetastatic CNS disease following WBRT w/ plan for CK this ___.\nDiscussed w/ neuro-onc and rad-onc, while there is new lesion in\ncerebellum all new mets are small and unlikely sole cause of her\nacute decline. Concerning for leptomeningeal involvement vs \ncord\nimpingement. Exact etiology unclear\n- T/L spine MRI not c/w cord impingement\n- LP for CSF cytology negative although cannot r/o on one tap\nalone. \n- no further intervention pursued given goals of care as above\n\n#UTI - UA w/ notable pyuria, started cipro cx thus far NGTD,\nunlikely contributing to MS changes as never had signs of \nsepsis. Will complete ___rain metastases - Pt had surveillance MRI just prior to\nadmission showing recurrent lesions post WBRT. Was seen by\nRad-Onc and Neuro-Onc w/ plan to proceed w/ CK this week. have\nnow cancelled CK per pts wishes\n\n#Metastatic NSCLC - ___ progressed on erlotinib, has completed 1\ncycle ___. Cont to have progression in primary mass\nand mets on further imgaging since admission. Overall prognosis\nweeks to months\n- cont prednisone 10 (had worsening side effects on lower dose)\n- cont dronabinol prn\n- cont clonazepam TID prn\n- cont oxycontin and dilaudid prn\n\n#Anemia of Neoplastic Disease\nBaseline Hg 11, 7.9 on admission. Guaiac negative and brown \nstool\nin ED. No obvious source of bleeding. Likely ___ chemo.\n- received 1U PRBCs ___ and stable\n\n#Transaminitis - mild enzyme elevation, overall stable. has \nliver\nmets, also possible chemo effect \n- avoid hepatotoxins\n\n#Constipation - in setting of starting oxycontin\nable to pass larg BM after increasing bowel reg\n- cont senna/colace and prn miralax while able to take PO\n- Milk of magnesia, Mg Citrate PRN\n\n#Urinary Retention - noted on arrival. Likely multifactorial:\nnarcotics, not-ambulating, and constipation. NO spinal cord\ninvolvement on t/L MRI\n- foley placed. removed day prior to discharge per pt request \nand able to void but w/ some incontinence. if has retention at \nhome or incontinence w/ skin irritation plan to replace\n\n#Hx PE - held lovenox for LP, resumed ___. family request to\ncont to prevent clots. Prior PE resolved on most recent CT \nchest,\ndiscussed risk of bleeding and discomfort of injxn may outweigh\nbenefit at this time. however they wish to cont but agreeable to \nlower to\npreventive dose and stop if pt no longer interactive\n\n#T2DM\n- no longer on orals due to anorexia\n- pt requests to stop BG checks\n\n#Depression\n- cont sertraline\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 325-650 mg PO Q6H:PRN pain \n2. ClonazePAM 0.5 mg PO TID \n3. Dronabinol 2.5 mg PO BID \n4. Enoxaparin Sodium 90 mg SC DAILY \n5. Multivitamins W/minerals 1 TAB PO DAILY \n6. omeprazole 40 mg oral DAILY \n7. Ondansetron 8 mg PO Q8H:PRN nausea \n8. PredniSONE 10 mg PO DAILY \n9. Sertraline 75 mg PO DAILY \n10. Docusate Sodium 100 mg PO BID \n11. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H \n12. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n13. Senna 8.6 mg PO BID:PRN constipation \n14. MetFORMIN (Glucophage) 500 mg PO DAILY \n15. HYDROmorphone (Dilaudid) ___ mg PO Q2H:PRN breakthrough pain \n\n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN pain \n2. ClonazePAM 0.5 mg PO TID:PRN anxiety \n3. Dronabinol 2.5 mg PO BID:PRN nausea \n4. Enoxaparin Sodium 40 mg SC Q24H \nplease stop if is causing pain or patient is no longer \ninteractive \n5. HYDROmorphone (Dilaudid) ___ mg PO Q2H:PRN breakthrough pain \nRX *hydromorphone 2 mg ___ tablet(s) by mouth every 4 hours Disp \n#*90 Tablet Refills:*1\n6. Omeprazole 20 mg PO DAILY \n7. Ondansetron 8 mg PO Q8H:PRN nausea \n8. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H \nRX *oxycodone [OxyContin] 20 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*1\n9. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n10. PredniSONE 10 mg PO DAILY \n11. Senna 8.6 mg PO BID:PRN constipation \n12. Sertraline 75 mg PO DAILY \n13. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \ncan be added if other stool softeners are not helping \nRX *bisacodyl 5 mg ___ tablet(s) by mouth daily prn Disp #*30 \nTablet Refills:*0\n14. Ciprofloxacin HCl 500 mg PO Q12H \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day \nDisp #*7 Tablet Refills:*0\n15. MetFORMIN (Glucophage) 500 mg PO DAILY \n16. Multivitamins W/minerals 1 TAB PO DAILY \n17. Docusate Sodium 100 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nWeakness\nBalance difficulty\nAltered mental status \nUrinary tract infection\nMetastatic lung cancer\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Lethargic but arousable.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear ___ it was a pleasure caring for you during your stay at \n___. You were admitted with balance difficulty, weakness and \nsome confusion. You had a head CT that was stable and there was \nno infection or cancer cells in the spinal fluid tested. While \nsome of our tests were not definitive, overall this was related \nto worsening lung cancer. Unfortunately we do not have more \ngood treatments for this. You also had a urine infection and \nwill continue on antibiotics for a few more days. You have \nchosen to go home with your family and hospice services and we \nknow you will be well taken care of there. \n \nFollowup Instructions:\n___\n" ]

[ "C3411", "N390", "C787", "C772", "C770", "C7931", "R630", "C771", "D630", "E119", "M109", "Z515", "K5909", "T402X5A", "Y929", "R339", "Z86711", "Z7901", "F329", "Z66", "R740", "Z9221", "Z6823", "Z86718", "Z85820", "Z801", "Z87891" ]

[ "C3411: Malignant neoplasm of upper lobe, right bronchus or lung", "N390: Urinary tract infection, site not specified", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C772: Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes", "C770: Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck", "C7931: Secondary malignant neoplasm of brain", "R630: Anorexia", "C771: Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes", "D630: Anemia in neoplastic disease", "E119: Type 2 diabetes mellitus without complications", "M109: Gout, unspecified", "Z515: Encounter for palliative care", "K5909: Other constipation", "T402X5A: Adverse effect of other opioids, initial encounter", "Y929: Unspecified place or not applicable", "R339: Retention of urine, unspecified", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants", "F329: Major depressive disorder, single episode, unspecified", "Z66: Do not resuscitate", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "Z9221: Personal history of antineoplastic chemotherapy", "Z6823: Body mass index [BMI] 23.0-23.9, adult", "Z86718: Personal history of other venous thrombosis and embolism", "Z85820: Personal history of malignant melanoma of skin", "Z801: Family history of malignant neoplasm of trachea, bronchus and lung", "Z87891: Personal history of nicotine dependence" ]

[ "N390", "E119", "M109", "Z515", "Y929", "Z7901", "F329", "Z66", "Z86718", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nZestril / Hydrochlorothiazide / Monopril / Vioxx / Celebrex / \nMobic / Motrin / Bactrim / Keflex\n \nAttending: ___.\n \nChief Complaint:\nchest pain\n \nMajor Surgical or Invasive Procedure:\n___ Coronary catheterization via the right radial artery, \nwith Synergy DESx1 of proximal LCX and PTCA of small OM branch\n\n \nHistory of Present Illness:\n___ year old female with history of DM, HTN, HLD, pAFib on\nrivaroxaban, HFpEF, and CAD s/p multiple PCI and CABG in ___\n(LIMA to LAD, RIMA to RCA, RA to OM) and a recent cath which\nshowed patent grafts with severe native coronary disease\ntransferred from OSH with chest pain. \n\nPatient presented to OSH on ___ with intermittent, typical \nCP\nfor 1 week. Chest pain is typically associated with standing up\nand relieved with lying down. She has been having ongoing\ndiarrhea, with ___ watery stools/day. This started back in the\nfall and she was eventually diagnosed with colitis. This \nrecurred\nabout 1 month ago and has been getting worse since. She was\nrecently started on budesonide by her outpatient GI doctors \nwhich\nshe thinks is helping marginally to decrease the number of \nstools\nfrom ___ down to closer to ___. Stools are beige in\ncolor and very water. Non bloody. Never treated with \nantibiotics.\n\nRegardless, she states that she gets orthostatic from all the\ndiarrhea and that's why she gets chest pain with standing\n(associated with tachycardia and lightheadness). This morning \nfor\nsome reason she had 9 stools before lunch time and then when she\nwent to stand up she experienced her typical chest pain but it\ndid not remit when she sat back down. Pain decreased as pressure\n___, continuous right sided radiating to the right neck. She\ntook 3 SLN with minimal relief. She knew her BP was going to be\nlow after taking nitro so she called EMS. When they arrived she\nSBP was in the ___, asymptomatic. She received 4x 81mg ASA en\nrout to OSH and pain eventually resolved spontaneously after\nabout 45 minutes.\n\nUpon presentation at OSH, vitals signs were 97.8, 106/62, 77, \n18,\n99RA. Labs were notable for CBC 11.7/13.4/39.6/470, Chem7: K 4,\nCr 0.8, Trp <0.01. EKG per report showed NSR with new TWI\ninferiorly and laterally. Patient was started on heparin gtt\n(held ___ dose of apixiban), given 50mg metoprolol succinate and\ntransferred to ___ for further management. Discussion with Dr.\n___, plan to cath in the morning on ___. At the time of\ntransfer, patient was chest pain free. \n\nOf note, patient had a recent admission in ___ for \nunstable\nangina. During this admission, she underwent persantine MIBI\nwhich showed a partially reversible anteroseptal perfusion\ndefect. Her recent cath from St. E's did not correlate with this\ndefect and given multiple co-morbidities, and risk of \nprocedural,\nPCI was deferred in favor of medical therapy. Noted in the d/c\nsummary was \"if symptoms recur rotablade and PCI of the LCx/OM\ncan be considered and her films will be in Lifeimgae for our\nintevrentionalists to review.\" \n\nOn arrival to the floor, patient reports that she is chest pain\nfree. She provides the history as above. She is planning for \ncath\nwith Dr. ___. She reports that she had an EGD earlier\nthis week on ___, given increased reflux symptoms and ongoing\ndiarrhea. She has only taken 2x doses of apixiban total this\nweek. She also reports ongoing vomiting and nausea with her\ndiarrhea resulting in frequently not being able to take other\nmedications such as imdur or metoprolol. \n\n \nPast Medical History:\n- CAD s/p multiple PCI and CABG in ___ (LIMA to LAD, RIMA to \nRCA, RA to OM); recent LHC ___ with patent grafts with severe \nnative coronary disease\n- Afib on rivaroxaban\n- HFpEF\n- DM\n- HTN\n- HLD\n- PVD\n- Obesity \n \nSocial History:\n___\nFamily History:\nCAD (brother died VF arrest at ___, father had first MI at age \n___, had 4V bypass mid ___, died in ___, mother had MI in ___, \ndied in ___, also had multiple sclerosis) DM2, HTN.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVS: 98.6, 91/67, 87 16 95 RA\n \nGENERAL: NAD, sitting upright in bed, thin appearing \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,\nMMM\nNECK: supple, no LAD, no JVD \nHEART: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: nondistended, nontender in all quadrants, +BS, no\nrebound/guarding, abdominal aorta easily palpated and prominent\npulsation \nEXTREMITIES: trace pretibial edema, WWP \nPULSES: 2+ DP pulses bilaterally \nNEURO: A&Ox3, moving all 4 extremities with purpose \nSKIN: warm and well perfused, no excoriations or lesions, no\nrashes \n\nDISCHARGE PHYSICAL EXAM\nVS: 97.9 95-128/52-77 HR69-99 RR16 98% Ra \nTELEMETRY: no events \nWEIGHT:66.9 kg (147.49 lb) \nADMISSION WEIGHT: 66.18 kg\nI/O: 960/800 NET: 160\nPHYSICAL EXAM: \nGENERAL: NAD, sitting upright in bed, thin appearing \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,\nMMM, tan skin\nNECK: supple, no LAD, neck veins flat\nHEART: distant heart sounds, S1/S2, ___ SEM with radiation to\ncarotids, no gallops, or rubs.\nLUNGS: CTAB\nABDOMEN: nondistended, nontender in all quadrants, +BS, no\nrebound/guarding, abdominal aorta easily palpated and prominent\npulsation \nEXTREMITIES: wwp, 2+ edema to mid tibias ___ \nPULSES: 2+ DP pulses bilaterally \nNEURO: A&Ox3, moving all 4 extremities with purpose \nSKIN: warm and well perfused, no excoriations or lesions, no\nrashes\n\n \nPertinent Results:\nADMISSION LABS\n\n___ 11:40PM BLOOD WBC-7.5 RBC-3.86* Hgb-12.3 Hct-36.7 \nMCV-95 MCH-31.9 MCHC-33.5 RDW-15.6* RDWSD-55.1* Plt ___\n___ 11:40PM BLOOD Neuts-53.8 ___ Monos-15.2* \nEos-1.7 Baso-0.7 Im ___ AbsNeut-4.04 AbsLymp-2.12 \nAbsMono-1.14* AbsEos-0.13 AbsBaso-0.05\n___ 11:40PM BLOOD ___ PTT-31.4 ___\n___ 11:40PM BLOOD Glucose-109* UreaN-23* Creat-0.8 Na-142 \nK-4.6 Cl-107 HCO3-23 AnGap-12\n___ 11:40PM BLOOD CK-MB-4 cTropnT-<0.01\n___ 11:40PM BLOOD Calcium-8.4 Phos-4.4 Mg-1.3*\n\nPERTINENT IMAGING\n___ CXR\nIMPRESSION: \nNo acute cardiopulmonary process.\n\n___ L HEART CATH REPORT\nCoronary Anatomy\nDominance: Right\n * Left Main Coronary Artery\nThe LMCA is normal\n* Left Anterior Descending\nThe LAD has diffuse moderate proximal and mid disease. The \ndistal \nLAD is known \nto be supplied by a patent LIMA graft. \nCircumflex\nThere is a proximal 90% stenosis (not appreciated on prior \nangiogram ___ There is probably a previous stent in this \nsegment which could\nnot be clearly defined. Just distal to this lesion there are\nprevious stents extending into a large OM2 branch. There is \ndisease in stent which does not appear significant. The distal \nLCX beyond OM2 is stented with diffuse severe disease. A small \nmore proximal OM branch has 90% ostial stenosis. All of these \nfindings except the proximal severe lesion are unchanged from \n___.\n* Right Coronary Artery was not injected since this was known to \nbe grafted without significant disease\n\nInterventional Details\n The left main was engaged with a ___ Fr XB 3.5 guide and \nangiography performed as noted. A Prowater wire was advanced \ninto the distal LCX and\nthe severe proximal lesion dilated with a 3.0 balloon and \nstented \nwith a 3.0x12 Synergy postdilated to 3.0 mm at 22 atm with no \nresidual, normal flow. The wire was then redirected into the \nsmall OM branch with the 90% ostial stenosis. This was \ndilated with a 1.5, then a 2.0 balloon with normal flow but 70% \nresidual stenosis. This vessel was too small to \nstent.\n\n___ 06:24AM BLOOD CRP-130.5*\n___ 06:35AM BLOOD TSH-1.7\n___ 06:35AM BLOOD Osmolal-291\n\nDISCHARGE LABS\n\n___ 06:20AM BLOOD WBC-8.9 RBC-3.50* Hgb-11.0* Hct-33.2* \nMCV-95 MCH-31.4 MCHC-33.1 RDW-15.0 RDWSD-52.5* Plt ___\n___ 06:20AM BLOOD Plt ___\n___ 06:20AM BLOOD Glucose-118* UreaN-13 Creat-0.5 Na-140 \nK-5.0 Cl-104 HCO3-25 AnGap-11\n___ 06:24AM BLOOD ALT-12 AST-10 LD(LDH)-160 AlkPhos-131* \nTotBili-0.2\n___ 06:24AM BLOOD calTIBC-111* ___ Ferritn-100 \nTRF-85*\n\n \nBrief Hospital Course:\nSUMMARY:\n==========================\n___ year old female with history of DM, HTN, HLD, pAFib on \napixaban, HFpEF, and CAD s/p multiple PCI and CABG in ___ (___ \nto ___, ___ to RCA, RA to OM) and a recent catheterization \nwhich showed patent grafts with severe native coronary disease \ntransferred from OSH with chest pain in the setting of severe \northostatic hypotension from profuse diarrhea. She was \ntransferred for coronary catheterization and had DESx1 of \nproximal LCX and PTCA of small OM branch.\n\nACTIVE ISSUES:\n==========================\n\n#Unstable angina: history of CAD s/p PCI x16 and CABG in ___ \nrecent cardiac angiography with 80% stenosis OM1 and 70% \nstenosis LCx. In the setting of hypotension from diarrhea, the \npatient was developing recurrent chest pain that would resolve \nonce she sat or lied down due to the fact that she was markedly \northostatic. Troponins negative and no significant EKG changes. \nUnderwent coronary catheterization via the right radial artery, \nwith DESx1 of proximal LCX and PTCA of small OM branch, started \non clopidogrel. Chest pain free even with hypotension. She will \nremain on clopidogrel and rivaroxiban per the PIONEER AF-PCI \ntrial protocol which has shown to reduce bleeding events in this \npatient population.\n\n#Orthostatic hypotension:\n#Diarrhea:\nMs. ___ has a history of collagenous colitis and presented with \nsevere diarrhea. Recently stated on budesonide in combination \nwith lomotil and loperamide but was having up to 10 loose watery \nstools daily. On admission, she was found to have orthostatic \nvital signs. She was volume resuscitated as appropriate. Her \nisosorbide was discontinued following the PCI and her metoprolol \nwas decreased from 50mg to 25mg. Due to orthostatic intolerance, \nGI service was consulted, who recommended multiple laboratory \nexaminations as a thorough work up for her diarrhea, which were \nsent. Her diarrhea had decreased significantly by discharge.\n\n#Paroxysmal atrial fibrillation, CHADSVASC:5 Pt was on apixaban \n5mg PO BID on admission, but she was switched to rivaroxiban 15 \nmg as above for dual effect.\n\n#Heart failure with preserved ejection fraction: LVEF = 54 %\nPatient takes furosemide 40 mg PO as needed at home. She did not \nrequire diuresis during this admission, and PO Lasix was held in \nthe setting of orthostasis.\n\nCHRONIC ISSUES:\n==========================\n#Type II Diabetes Mellitus: Metformin was held on admission, \nmaintained on ISS in the hospital\n#Hypertension: Blood pressure as reviewed above. Did not require \nany antihypertensives.\n#Dyslipidemia: Her home atorbastain 10 mg was increased to 40 mg \nin the setting of ACS.\n#Chronic back pain: continued home oxycodone 5mg\n\nTRANSITIONAL ISSUES:\n=====================================\n#CODE: Full (presumed)\n#CONTACT: Sister, ___ ___\nDRY/DISCHARGE WEIGHT: 66.9 kg (147.49 lb)\n\nMEDICATIONS STOPPED:\nIsosorbide mononitrate 30mg daily\nApixiban 5 mg BID\n\nMEDICATIONS CHANGED:\nYou now take 40 mg atorvastatin daily\n\nMEDICATIONS ADDED:\nClopidogrel 75mg PO daily\nRivaroxiban 15 mg daily\nZofran 4 mg PO Q8H PRN for nausea\n\n[ ] Please discuss potential for Watchman device in this pt to \nobviate the need for anticoagulation with afib given bleeding \nrisk with concurrent antiplatelet therapy.\n[ ] Pt should remain on rivaroxiban indefinitely\n[ ] Pt should remain on Plavix indefinitely or until \ndiscontinued by cardiologist.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Budesonide 9 mg PO DAILY \n3. Calcium Carbonate 500 mg PO DAILY \n4. Vitamin D 1000 UNIT PO DAILY \n5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n6. LOPERamide 4 mg PO QID:PRN dairrhea \n7. Furosemide 40 mg PO DAILY:PRN edema \n8. Escitalopram Oxalate 20 mg PO DAILY \n9. Diphenoxylate-Atropine 1 TAB PO BID:PRN diarrhea \n10. Atorvastatin 10 mg PO QPM \n11. Magnesium Oxide 400 mg PO BID \n12. MetFORMIN (Glucophage) 1000 mg PO BID \n13. Metoprolol Succinate XL 50 mg PO BID \n14. Multivitamins 1 TAB PO DAILY \n15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n16. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID \n17. Nexium 40 mg Other DAILY \n18. Vitamin B Complex 1 CAP PO DAILY \n19. Cyanocobalamin 500 mcg PO DAILY \n20. Xyzal (levocetirizine) 5 mg oral QPM \n21. Apixaban 5 mg PO BID \n\n \nDischarge Medications:\n1. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis \nRX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*6 \n2. Ondansetron 4 mg PO Q8H:PRN nausea \nRX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp \n#*30 Tablet Refills:*2 \n3. Pantoprazole 40 mg PO Q24H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*4 \n4. Rivaroxaban 15 mg PO DINNER \nRX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth daily with \ndinner Disp #*30 Tablet Refills:*6 \n5. Atorvastatin 40 mg PO QPM \n6. Budesonide 9 mg PO DAILY \n7. Calcium Carbonate 500 mg PO DAILY \n8. Cyanocobalamin 500 mcg PO DAILY \n9. Diphenoxylate-Atropine 1 TAB PO BID:PRN diarrhea \n10. Escitalopram Oxalate 20 mg PO DAILY \n11. Furosemide 40 mg PO DAILY:PRN edema \n12. LOPERamide 4 mg PO QID:PRN dairrhea \n13. Magnesium Oxide 400 mg PO BID \n14. MetFORMIN (Glucophage) 1000 mg PO BID \n15. Metoprolol Succinate XL 50 mg PO BID \n16. Multivitamins 1 TAB PO DAILY \n17. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n18. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO BID \n19. Vitamin B Complex 1 CAP PO DAILY \n20. Vitamin D 1000 UNIT PO DAILY \n21. Xyzal (levocetirizine) 5 mg oral QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY:\n=============\nCAD\nUnstable angina\nFlare of collagenous colitis\n\nSECONDARY:\n=============\nAtrial fibrillation\nHeart failure with preserved ejection fraction\nType II Diabetes Mellitus\nHypertension\nDyslipidemia\nPeripheral vascular disease \nBack pain\n\n \nDischarge Condition:\nLevel of Consciousness: Alert and interactive.\nMental Status: Clear and coherent.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to ___ \nbecause you were orthostatic from profuse diarrhea with \nassociated chest pain. You needed a cardiac catheterization and \na stent was placed in the left circumflex vessel of your heart. \nAfter the procedure, you were chest pain free. We started you on \nClopidogrel (Plavix) to prevent a clot forming in your stent. \nYou met with a physical therapist who recommends that you \nparticipate in an outpatient cardiac rehabilitation. \n\nYou were having a flare of your colitis and had several episodes \nof diarrhea. This caused your blood pressure to become quite \nlow, and you required several liters of intravenous fluids. It \nis important that you see your primary care doctor within 1 week \nof discharge. You should also see a gastroenterologist to \ndetermine a better regimen for your diarrhea. We have arranged \nan appointment for you. Please talk to your cardiologist and \ngastroenterologist about your use of pantoprazole. \n\nIt is very important to take all of your heart healthy \nmedications, particularly the Clopidogrel, also known as Plavix. \nThis medication keeps the stent in the vessels of the heart open \nand helps reduce your risk of having a future heart attack. If \nyou stop this medication or miss ___ dose, you risk causing a \nblood clot forming in your heart stents, and you may die from a \nmassive heart attack. Please do not stop taking this medication \nwithout talking to your heart doctor, even if another doctor \ntells you to until you talk to your cardiologist.\n\nWe have made some other changes to your medication list, so \nplease take the medications as directed until you see your \ndoctor.\n\nIt was a pleasure taking part in your care. We wish you all the \nbest with your health!\n\nSincerely,\nThe team at ___\n\n \nFollowup Instructions:\n___\n" ]

[ "I25110", "E43", "I110", "I5032", "E1151", "I480", "K52831", "E785", "Z7902", "Z951", "I951", "Z87891", "G8929", "M549", "E8342", "E8809", "Z6821" ]

[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "E43: Unspecified severe protein-calorie malnutrition", "I110: Hypertensive heart disease with heart failure", "I5032: Chronic diastolic (congestive) heart failure", "E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene", "I480: Paroxysmal atrial fibrillation", "K52831: Collagenous colitis", "E785: Hyperlipidemia, unspecified", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z951: Presence of aortocoronary bypass graft", "I951: Orthostatic hypotension", "Z87891: Personal history of nicotine dependence", "G8929: Other chronic pain", "M549: Dorsalgia, unspecified", "E8342: Hypomagnesemia", "E8809: Other disorders of plasma-protein metabolism, not elsewhere classified", "Z6821: Body mass index [BMI] 21.0-21.9, adult" ]

[ "I110", "I5032", "I480", "E785", "Z7902", "Z951", "Z87891", "G8929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \niodine\n \nAttending: ___.\n \nChief Complaint:\nAcute Asthma Exacerbation\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ year old Male with atrial fibrillation on apixaban, chronic \ndiastolic heart failure, who presents with dyspnea and wheezing. \nThe patient had a recent bout of bronchitis on ___ and treated \nwith albuterol and guaifenesin. He was unable to understand how \nto use inhaler properly and so was not using it at home. \n\nHe presented to ___ on ___ complaining of worsening dyspnea \nwith SAO2 in the ___. He was tachycardic in the 120s in atrial \nfibrillation with rapid ventricular response. He was given \nmultiple nebulizer treatments, and 60mg of prednisone but \nremained dyspneic. \n\nHe was referred to the ___ ED. In the ED, initial vitals were: \nT 97.6 HR 89 BP 99/69 RR 18 O2 99%RA. Exam with bilateral \nwheezing and rhonchi. No pronounced peripheral edema. In \naddition had a chest x-ray which was negative for an infiltrate, \nand 25mg PO metoprolol and 3 rounds of duonebs.\n\nOn the floor, the morning after arrival, he feels improved at \nthe moment. He denies any fever or chills. He has rhinorrhea, \nnasal congestion, and a nonproductive cough. He denies any \nnausea or vomiting but does have occasional diarrhea which is \nlong standing.\n \nPast Medical History:\nHypertension\nLong QT\nHyperlipidemia\nCKD Stage 2\nHypothyroidism\nCerebral palsy\nSleep apnea\nGERD\nMorbid obesity\nAnxiety\nConstipation\n \nSocial History:\n___\nFamily History:\nFather Cancer - ___ Diabetes - Type II\n \nPhysical Exam:\nADMISSION EXAM\n================\nVitals - T:99.1 BP: 144/86 HR: 105 RR: 20 02 sat: 98RA \n GENERAL: Pleasant, in NAD \n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No \nscleral icterus. PERRLA/EOMI. MMM \n CARDIAC: irregularly irregular rhythm, normal rate. Normal S1, \nS2. No murmurs, rubs or gallops. JVP unable to be assessed given \nbody habitus \n LUNGS: diffuse wheezing throughout, poor air movement \n ABDOMEN: NABS. Soft, NT, ND \n EXTREMITIES: edema 1+ to mild shins \n SKIN: No rashes/lesions, ecchymoses. \n NEURO: A&Ox3. Appropriate. CN ___ grossly intact. ___ strength \nthroughout. Normal coordination. Gait assessment deferred \n PSYCH: Listens and responds to questions appropriately, \npleasant \n \n\nDISCHARGE EXAM\n=================\nVitals -97.3 ___ ___ 20 99 ra\n GENERAL: Pleasant, in NAD, sleeping comfortably. \n HEENT: Normocephalic, atraumatic. No conjunctival pallor. No \nscleral icterus. PERRLA/EOMI. MMM \n CARDIAC: irregularly irregular rhythm, normal rate. Normal S1, \nS2. No murmurs, rubs or gallops. JVP unable to be assessed given \nbody habitus \n LUNGS: poor air movement, no wheezing or rhonchi. \n ABDOMEN: NABS. Soft, NT, ND \n EXTREMITIES: edema 1+ to mild shins \n SKIN: No rashes/lesions, ecchymoses. \n NEURO: A&Ox3. Appropriate. CN ___ grossly intact. ___ strength \nthroughout. Normal coordination. Gait assessment deferred \n PSYCH: Listens and responds to questions appropriately, \npleasant \n \nPertinent Results:\nADMISSION LABS\n====================\n___ 10:00AM BLOOD WBC-10.2* RBC-4.77 Hgb-14.0 Hct-44.4 \nMCV-93 MCH-29.4 MCHC-31.5* RDW-13.6 RDWSD-46.1 Plt ___\n___ 08:30PM BLOOD WBC-7.7 RBC-4.92 Hgb-14.4 Hct-45.7 MCV-93 \nMCH-29.3 MCHC-31.5* RDW-13.5 RDWSD-46.0 Plt ___\n___ 08:30PM BLOOD Neuts-87.0* Lymphs-10.3* Monos-1.4* \nEos-0.3* Baso-0.1 Im ___ AbsNeut-6.65* AbsLymp-0.79* \nAbsMono-0.11* AbsEos-0.02* AbsBaso-0.01\n___ 10:00AM BLOOD ___ PTT-31.2 ___\n___ 09:06PM BLOOD ___ PTT-33.0 ___\n___ 10:00AM BLOOD Glucose-139* UreaN-31* Creat-1.5* Na-144 \nK-3.8 Cl-102 HCO3-27 AnGap-19\n___ 08:30PM BLOOD Glucose-127* UreaN-25* Creat-1.4* Na-143 \nK-4.6 Cl-103 HCO3-27 AnGap-18\n___ 08:30PM BLOOD proBNP-299*\n___ 10:00AM BLOOD Calcium-10.0 Phos-4.1 Mg-1.6\n___ 08:30PM BLOOD Calcium-10.0 Phos-4.1 Mg-1.8\n\nMICRO\n====================\n___ 06:46 \nReport Comment: \nSource: Nasopharyngeal swab \n VIRAL, MOLECULAR \nInfluenza A by PCR NEGATIVE W \nInfluenza B by PCR NEGATIVE W \n\nIMAGES/STUDIES\n=====================\nCHEST (PA & LAT) Study Date of ___ 9:10 ___ \nIMPRESSION: \nLimited, negative. \n\nDISCHARGE LABS\n====================\n___ 06:12AM BLOOD WBC-12.0* RBC-4.64 Hgb-13.6* Hct-43.0 \nMCV-93 MCH-29.3 MCHC-31.6* RDW-13.4 RDWSD-45.3 Plt ___\n___ 06:12AM BLOOD Glucose-99 UreaN-27* Creat-1.2 Na-142 \nK-4.3 Cl-103 HCO3-28 AnGap-15\n___ 06:12AM BLOOD Calcium-9.4 Phos-4.3 Mg-2.___ Male with history of cerebral palsy, atrial fibrillation on \napixaban, diastolic congestive heart failure, who presents with \nwheezing and dyspnea at rest thought to be an acute asthma.\n\n# Acute Asthma exacerbation: While there is no formal \ndocumentation of asthma due to his inability to perform the \nPFTs, patient's presentation consistent with acute asthma - \ndiffuse wheezing, dyspnea, poor air movement. However, patient \nwas satting in high ___ on room air. Patient treated with \nPrednisone 40mg daily x 5 days and Azithromycin x 5 days, \nduonebs Q6h. Patient will need to use nebulizers rather than \nMDIs as there is a compliance issue given his ability to \nunderstand MDIs (will have nebulizer machine delivered to home). \nHis wheezing and dyspnea improved. No wheezing or dyspnea on day \nof discharge.\n\n# Atrial Fibrillation with rapid ventricular response: Patient \ntriggered on ___ morning with rates up to 180, likely in setting \nof not receiving metoprolol overnight and in the AM as well as \nhis acute illness. The patient denied any SOB, palpitations, \ndiaphoresis, dizziness, light-headedness during the trigger. \nPatient was treated with IV Diltiazem 10mg push and his home PO \nDiltiazem and Metoprolol. Apixaban was continued. Patient \nmonitored closely on telemetry. Patient had another episode of \nAtrial fibrillation with RVR (HR in 170s) likely in the setting \nof holding Metoprolol again for SBP < 100. This time he was \ntreated with 5mg IV Metoprolol with decrease of HR to ___. \nDiltiazem was changed to long acting 360mg, and Metoprolol long \nacting 100mg formulations, and were administered at different \ntimes to avoid lower BPs. In addition, Furosemide was changed \nfrom 20mg every other day to 10mg daily to avoid lower BPs. \nPatient tolerated medication changes well with HRs in the \n___. His SBP remained at baseline which was ___ - 110s. \n\nCHRONIC ISSUES\n# Primary Hypertension: Continued lisinopril. \n# Chronic Diastolic heart failure: Preserved EF: >55%. Continue \nhome furosemide. \n# BPH without obsruction: Continue home tamsulosin and \nfinasteride. \n# Depression/anxiety: Continue home risperidone, bupropion. Held \nhome lorazepam unless needed for anxiety to reduce risk of \ndelirium. Continue after discharge. \n# Hyperlipidemia: Continue home atorvastatin. \n# Hypothyroidism: Continue home levothyroxine. \n# GERD: Continue home Omeprazole. \n\nTRANSITIONAL ISSUES\n======================\n[ ] Nebulizer machine Rx and faxed, to be delivered to home\n[ ] Patient will benefit from nebulizer treatments for than MDIs \nas they are more user-friendly\n[ ] Can consider repeating PFTs as outpatient\n[ ] Diltiazem changed to long acting: 360mg ER\n[ ] Metoprolol changed to long acting: 100mg XL\n[ ] Lasix decreased from 20 mg to 10 mg every other day\n\n# Full code\n# Contact: ___ (sister) ___\n\n# Full code\n# Contact: ___ (sister) ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. PredniSONE 10 mg PO DAILY \n2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze, SOB \n3. RISperidone 2 mg PO QAM \n4. RISperidone 3 mg PO QPM \n5. Tamsulosin 0.4 mg PO QHS \n6. Metoprolol Tartrate 25 mg PO TID \n7. Lisinopril 5 mg PO DAILY \n8. Furosemide 20 mg PO EVERY OTHER DAY \n9. Finasteride 5 mg PO DAILY \n10. Diltiazem 120 mg PO TID \n11. Atorvastatin 20 mg PO QPM \n12. Apixaban 5 mg PO BID \n13. Lorazepam 0.5 mg PO DAILY:PRN anxiety \n14. Acetaminophen 650 mg PO Q6H:PRN pain \n15. Polyethylene Glycol 17 g PO DAILY \n16. BuPROPion (Sustained Release) 150 mg PO BID \n17. Omeprazole 20 mg PO DAILY \n18. Levothyroxine Sodium 25 mcg PO DAILY \n\n \nDischarge Medications:\n1. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing \nRX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 every \nsix (6) hours Disp #*6 Ampule Refills:*0\n2. Lorazepam 0.5 mg PO DAILY:PRN anxiety \n3. Machine\nNebulizer Machine \n\nPlease provide machine as patient unable to use inhalers due to \nhealth condition. \n4. Acetaminophen 650 mg PO Q6H:PRN pain \n5. Apixaban 5 mg PO BID \n6. Atorvastatin 20 mg PO QPM \n7. BuPROPion (Sustained Release) 150 mg PO BID \n8. Finasteride 5 mg PO DAILY \n9. Levothyroxine Sodium 25 mcg PO DAILY \n10. Lisinopril 5 mg PO DAILY \n11. Omeprazole 20 mg PO DAILY \n12. Polyethylene Glycol 17 g PO DAILY \n13. RISperidone 2 mg PO QAM \n14. RISperidone 3 mg PO QPM \n15. Tamsulosin 0.4 mg PO QHS \n16. Furosemide 10 mg PO EVERY OTHER DAY \nRX *furosemide [Lasix] 20 mg 0.5 (One half) tablet(s) by mouth \nevery other day Disp #*15 Tablet Refills:*0\n17. Diltiazem Extended-Release 360 mg PO DAILY \nRX *diltiazem HCl 360 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n18. Metoprolol Succinate XL 100 mg PO DAILY \nRX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n====================\nAsthma exacerbation\n\nSECONDARY DIAGNOSIS\n====================\nHTN \n Afib \n CHF \n cerebral palsy \n Long QT \n HL \n CKD \n Hypothyroidism \n Sleep apnea \n GERD \n Morbid obesity \n Anxiety \n Constipation \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\nIt was a pleasure to care for you at ___. You came to the \nhospital with shortness of breath and wheezing, which your \ndoctors believe it was due to an episode of asthma that could \nhave been triggered by a viral illness. \n\nYou treated you with breathing treatments, steroids, and \nantibiotics to help the inflammation in your lungs. You have \nfinished your course of antibiotics and steroids and do not need \nto continue these after discharge.\n\nWhile you were in the hospital, your heart rate was fast in a \nrhythm called atrial fibrillation. Your cardiac (heart) \nmedications were adjusted and you should follow up with your \ncardiologist on ___. Your water pill (Lasix) was also \ndecreased as you did not need as strong a dose. \n\nPlease follow up with your primary care doctor. \n\nTake care. We wish you a fast recovery.\n\nSincerely,\n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "J45901", "I5032", "N179", "I959", "I4891", "E6601", "G809", "I4581", "Z23", "E785", "E039", "G4733", "K219", "F419", "K5900", "I129", "N182", "F329", "N400", "J069", "Z6838" ]

[ "J45901: Unspecified asthma with (acute) exacerbation", "I5032: Chronic diastolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "I959: Hypotension, unspecified", "I4891: Unspecified atrial fibrillation", "E6601: Morbid (severe) obesity due to excess calories", "G809: Cerebral palsy, unspecified", "I4581: Long QT syndrome", "Z23: Encounter for immunization", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "K219: Gastro-esophageal reflux disease without esophagitis", "F419: Anxiety disorder, unspecified", "K5900: Constipation, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N182: Chronic kidney disease, stage 2 (mild)", "F329: Major depressive disorder, single episode, unspecified", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "J069: Acute upper respiratory infection, unspecified", "Z6838: Body mass index [BMI] 38.0-38.9, adult" ]

[ "I5032", "N179", "I4891", "E785", "E039", "G4733", "K219", "F419", "K5900", "I129", "F329", "N400" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nEpilepsy, increased seizure frequency \n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\nMs. ___ is a ___ right-handed female with a history of \nEEG-confirmed generalized epilepsy, presenting for inpatient EEG \nmonitoring and medication management.\n\nHer first seizure was at age ___. She was writing an exam when \nher right hand started jerking. She soon lost consciousness, \nthen according to witnesses she fell to the ground and her right \narm continued to shake. The whole episode lasted 5 minutes, \nafter which she woke up and felt completely at baseline. She \ndenied any pre-ictal or post-ictal symptoms such as dizziness, \nnausea,\nweakness, or headache. She has had three other similar episodes: \nonce sometime during college (several years ago), then about ___ \nyears ago, then most recently in ___. Each episode \nlasted less than 5 minutes. She says that every few days she \nwill feel her right arm start to shake. She then becomes worried \nthat a seizure is coming on and takes some clobazam and goes for \na walk, after which symptoms do not progress.\n\nShe also describes episodes ___ times per day, lasting a few \nseconds, when during a conversation she will \"zone out\" and \nbecome unresponsive, after which she immediately returns to \nnormal but realizes she was temporarily \"out of it.\" She is \nunsure of when these first started but at least by about ___ years\nago her friend noticed them.\n\nStarting in ___, her boyfriend (who had been living \nwith her for a while previously) started noticing her right arm \nshaking every few days during sleep.\n\nIn terms of her course, she first underwent care at ___ \n___ in ___ about ___ years ago and started \ncarbamazepine (dose unknown) under the care of Dr. ___. \nAccording to the patient, she underwent MRI, which was normal, \nand EEG, which showed some spikes. The carbamazepine caused\nnausea so she switched to Keppra 1000 mg daily in ___. \nFollowing her seizure in ___, she presented to ___ \nwhere her Keppra was increased to 1000 mg BID. Ambulatory EEG \nshowed 3 Hz spike-and-wave pattern, consistent with absence \nseizures, up to 10 per day. She was admitted from ___ for inpatient continuous EEG, during which her Keppra was \nincreased to 750 mg BID and she began taking clobazam 5 mg BID. \nBy discharge, her EEG had improved and showed no electrographic \nor clinical seizures. In ___, she noticed absence seizures \nagain and her clobazam was increased to 5mg qam + 10 mg qhs, \nwith subsequent improvement. By ___, she had an increase \nin absence seizures again and her clobazam was increased to 10 \nmg qam + 15 mg qhs.\n\nCurrently, she says she experiences severe fatigue, sleepiness, \nand difficulty concentrating when taking the clobazam, so she \noften only takes the nighttime dose. She feels that when she \ntakes both the am and nighttime dose, her absence seizures \ndecrease to 3-5/day compared to ___. However, she is unable\nto work when on the clobazam. She reports recent poor sleep of \nabout 4h/day compared to a baseline of 7h/day, with increased \ntime required to fall asleep and having to wake up for her job \nat 6 am. She does sleep through the night. She feels tired \nduring the day but does not fall asleep unintentionally. She \nwould like to adjust her medications as she feels the fatigue \nwith clobazam is unbearable. She also wants to reduce the \nfrequency of absence seizures. Lastly, she currently has an IUD \nbut is planning to get pregnant within ___ years and would like to \nhave a plan for medications.\n\nShe denies headache, dizziness, vision changes, hearing changes, \ndouble vision, or incontinence, either currently or during her \nseizures. \n \nPast Medical History:\nprior diagnosis of idiopathic generalized epilepsy\nacne\n \nSocial History:\n___\nFamily History:\nno family history of seizures or neurological conditions\n \nPhysical Exam:\nADMISSION EXAM\n==============\nVitals: ___ 1550 Temp: 97.8 PO BP: 105/72 L Sitting HR: 68\nRR: 16 O2 sat: 100% O2 delivery: Ra \nGeneral: NAD\nHEENT: NCAT, red reflex intact, normal optic disc and vessels\nbilaterally on fundoscopic exam, no oropharyngeal lesions, neck\nsupple\n___: RRR, no M/R/G\nPulmonary: CTAB, no crackles or wheezes\nAbdomen: Soft, NT, ND, no guarding\nExtremities: Warm, no edema\n\nNeurologic:\n\n- Mental Status: Awake, alert, oriented to self, place, and\nplace. Able to relate history without difficulty. Attentive to\nconversation, no observed episodes of zoning out. However, had\ndifficulty with serial 7's with frequent errors in calculation.\nAble to spell WORLD backwards without difficulty. ___ immediate\nrepetition and 5-minute recall. Language is fluent with intact\nrepetition and comprehension. Normal prosody. There were no\nparaphasic errors. Speech was not dysarthric. Able to follow \nboth\nmidline and appendicular commands. There was no evidence of\napraxia or neglect.\n\n-Cranial Nerves:\nI: Olfaction not tested.\nII, III, IV, VI: PERRL 5 to 3mm and brisk. Pupils reactive to\naccommodation bilaterally. EOMi without nystagmus. Normal\nsaccades. \nV: Facial sensation intact to light touch.\nVII: No facial droop, facial musculature symmetric. Able to\nsmile, raise eyebrows, and puff out cheeks symmetrically.\nVIII: Hearing intact to finger-rub bilaterally.\nIX, X: Uvula deviated slightly to right. Able to swallow water\nnormally.\nXI: ___ strength in trapezii and SCM bilaterally.\nXII: Tongue protrudes in midline and moves side-to-side without\ndifficulty.\n\n-Motor: Normal bulk, tone throughout. No adventitious movements,\nsuch as tremor, noted. No pronator drift or asterixis noted.\n Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc \nL 5 ___ 5 ___ 5 5 5 5 \nR 5 ___ 5 ___ 5 5 5 5 \n\n-Sensory: No deficits to light touch throughout.\n\n-DTRs:\n Bi Tri ___ Pat Ach\nL 2 2 2 2 2\nR 2 2 2 2 2\n\n-Coordination and Gait: Normal base width, step length, and\nbalance walking normally, on heels, on toes, or heel-to-toe.\n\nDISCHARGE EXAM\n==============\nGeneral: NAD\nHEENT: NCAT, no oropharyngeal lesions, neck supple\n___: warm and well perfused\nPulmonary: breathing comfortably on room air\nAbdomen: Soft, ND\nExtremities: no edema\n\nNeurologic:\n\n- Mental Status: Awake, alert, oriented to self, place, and\nplace. Able to relate history without difficulty. Attentive to\nconversation, no observed episodes of zoning out. However, had\ndifficulty with serial 7's with frequent errors in calculation.\nAble to spell WORLD backwards without difficulty. ___ immediate\nrepetition and 5-minute recall. Language is fluent with intact\nrepetition and comprehension. Normal prosody. There were no\nparaphasic errors. Speech was not dysarthric. Able to follow \nboth\nmidline and appendicular commands. There was no evidence of\napraxia or neglect.\n\n-Cranial Nerves:\nI: Olfaction not tested.\nII, III, IV, VI: PERRL 5 to 3mm and brisk. Pupils reactive to\naccommodation bilaterally. EOMi without nystagmus. Normal\nsaccades. \nV: Facial sensation intact to light touch.\nVII: No facial droop, facial musculature symmetric. Able to\nsmile, raise eyebrows, and puff out cheeks symmetrically.\nVIII: Hearing intact to finger-rub bilaterally.\nIX, X: Uvula deviated slightly to right. Able to swallow water\nnormally.\nXI: ___ strength in trapezii and SCM bilaterally.\nXII: Tongue protrudes in midline and moves side-to-side without\ndifficulty.\n\n-Motor: Normal bulk, tone throughout. No adventitious movements,\nsuch as tremor, noted. No pronator drift or asterixis noted.\n Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc \nL 5 ___ 5 ___ 5 5 5 5 \nR 5 ___ 5 ___ 5 5 5 5 \n\n-Sensory: No deficits to light touch throughout.\n\n-DTRs:\n Bi Tri ___ Pat Ach\nL 2 2 2 2 2\nR 2 2 2 2 2\n\n-Coordination and Gait: Normal base width, step length, and\nbalance walking normally, on heels, on toes, or heel-to-toe.\n\n \nPertinent Results:\nRELEVANT LABS\n=============\n___ 05:05PM BLOOD WBC-5.1 RBC-3.82* Hgb-11.1* Hct-34.8 \nMCV-91 MCH-29.1 MCHC-31.9* RDW-14.2 RDWSD-47.8* Plt ___\n___ 05:05PM BLOOD Glucose-86 UreaN-11 Creat-0.8 Na-142 \nK-4.0 Cl-104 HCO3-26 AnGap-12\n___ 05:05PM BLOOD ALT-10 AST-13 LD(LDH)-143 AlkPhos-60 \nTotBili-0.2\n___ 05:05PM BLOOD Albumin-3.7 Calcium-9.3 Phos-4.1 Mg-1.8\n\nEEG\n===\nFinal reads pending after ___.\n\n___ \nIMPRESSION: This telemetry captured no pushbutton activations. \nIt showed a \nnormal background in wakefulness and in sleep. There were \nfrequent generalized epileptiform discharges, as described \nabove, suggestive of absence epilepsy. There were no repetitive \ndischarges for longer than a second or so. There were no \nelectrographic seizures. No focal abnormalities were evident. \n\n___\nThis telemetry captured 2 pushbutton activations for a single \nepisode, without showing evidence of epileptiform activity or \nelectrographic seizure on EEG. The background showed normal \nwaking and sleep patterns, interrupted by several generalized \nspike and slow wave discharges, sometimes recurring with a \nfrequency of up to 3 Hz. There were no focal abnormalities or \nelectrographic seizures. \n\n___\nIMPRESSION: This telemetry captured 2 push button activations \nthat appeared accidental. There were no changes on EEG and no \nabnormal behavior on video at those times. Otherwise, the \nbackground showed a normal record in wakefulness and in sleep, \ninterrupted occasionally by generalized spike and slow wave \ndischarges, sometimes occurring at about 3.5 Hz. Nevertheless, \nthere were no electrographic seizures, and there were no focal \nabnormalities. \n\n \nBrief Hospital Course:\n___ is a ___ right-handed woman with a history of \nEEG-confirmed generalized epilepsy who presented for inpatient \nEEG monitoring and medication management.\n\n#Absence epilepsy:\nDowntitrated home levetiracetam (1500 mg BID home dose --> \ndiscontinued), clobazam (10 mg QAM, 15mg QPM home dose --> \ndiscontinued AM dose, reduced ___ dose to 10 mg), and sleep \ndeprived x2. With these adjustments, EEG showed frequent \ngeneralized single or 3 Hz spike and slow wave discharges \ncharacteristic of absence epilepsy. She had no obvious spells \nbesides some hand shaking not captured on video. Her neurologic \nexam remained nonfocal throughout admission. Her medications \nwere reloaded prior to discharge, ultimately discharged with \nlevetiracetam 1500 mg QAM, ___ mg QPM and clobazam 15 mg QHS.\n\nTRANSITIONAL ISSUES:\n====================\n[] initiated folic acid repletion, patient will attempt to \nconceive soon\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Clobazam 10 mg PO QAM \n2. Clobazam 15 mg PO QPM \n3. Doxycycline Hyclate 100 mg PO Q12H acne \n4. LevETIRAcetam 1500 mg PO BID \n5. Mirena (levonorgestrel) 20 mcg/24 hr ___ years) intrauterine ___ \nyears \n6. Ferrous Sulfate\n7. Thiamine\n8. Atralin (tretinoin) 0.05 % topical DAILY \n\n \nDischarge Medications:\n1. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*6 \n2. Ferrous Sulfate 325 mg PO DAILY \n3. LevETIRAcetam 1500 mg PO QAM \nRX *levetiracetam 500 mg 4 tablet(s) by mouth twice a day Disp \n#*240 Tablet Refills:*6 \n4. LevETIRAcetam ___ mg PO QPM \n5. Atralin (tretinoin) 0.05 % topical DAILY \n6. Clobazam 15 mg PO QPM \n7. Doxycycline Hyclate 100 mg PO Q12H acne \n8. Mirena (levonorgestrel) 20 mcg/24 hr ___ years) intrauterine \n___ years \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAbsence epilepsy\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\n\nIt was a pleasure to care for you at the ___ ___ \n___.\n\nYou came to the hospital for seizure monitoring. We found that \nyou had many seizures and optimized your home medications.\n\nPlease take your medications (levetiracetam 1500 mg every \nmorning, ___ mg every night; clobazam 15 mg every night) and \nfollow-up with your doctors as ___. You were counseled \nabout how much medication to take prior to your discharge.\n\nWe wish you all the best,\nYour ___ care team\n\n \nFollowup Instructions:\n___\n" ]

[ "G40409", "T424X6A", "Z91128", "Y92009" ]

[ "G40409: Other generalized epilepsy and epileptic syndromes, not intractable, without status epilepticus", "T424X6A: Underdosing of benzodiazepines, initial encounter", "Z91128: Patient's intentional underdosing of medication regimen for other reason", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nlatex / Codeine / Neurontin\n \nAttending: ___.\n \nChief Complaint:\npresyncope\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\n___ yo M with AS (valve index 0.5 on recent cath, increased\ngradients on recent TTE), HTN, T2DM, OSA on BiPap, obesity, and\nremote DLBCL in remission s/p chemo (c/b Vincristine-induced\nneuropathy & vertigo)and radiation, sinus tachycardia on\nmetoprolol, RBBB and LAFB who presented with pre-syncope. \nPatient\nwas recently discharged from ___ 3 days ago after presenting\nwith syncope and had a pacemaker placed since that time has been\ndoing well but at 7 ___ tonight while sitting on the couch he had\nsudden onset of lightheadedness and feeling like he was falling.\nThis was associated with palpitations. He denied chest pain,\nfevers, chills, nausea, vomiting, abdominal pain change of bowel\nor bladder habits. He went to ___ where\nthey called his cardiologist at ___ who advised him to be\ntransported here.\n\nUpon arrival to the ED, initial VS were HR 70 BP 134/84 RR 20 O2\n98% RA. Labs showed Trop T of 0.02 stable CBC and BMP. Bedside\nultrasound showed no pericardial effusion. Both cardiology and \nEP\nwere consulted in the ED. \n\nPer cardiology, no clear why pre-syncope still occurring despite\nPPM. Ddx includes AS, vasovagal vs medication-induced vs poor\nvenous return in setting of obesity. \n\nPer EP, the pacer is functioning normally with acceptable lead\nmeasurements and battery status. No events on interrogation.\nCurrent symptoms are similar to those he had prior, though his\nPPM is functioning well. They plan to have the ___\nrep come by to discuss the patient's trouble transmitting. \n\nUpon arrival to the floor, the patient was feeling fine. He\nstates that he had 1 episode of lightheadedness since his\ndischarge on ___, which was associated with fluttering in his\nchest. No falls. He states he has been drinking plenty of water\nto try to stay hydrated. He had 2 loose stools yesterday which\nwere nonbloody.\n\nHe was recently hospitalized at ___ from ___ with \nrecurrent\nsyncope, was observed to have a syncopal event with transient\ncomplete heart block and delayed ventricular escape and\nultimately underwent PPM implantation on ___. He was discharged\non ___. Interrogated on ___ showed normal function.\n\n \nPast Medical History:\n1. Cardiac Risk Factors \n- Dyslipidemia\n- Morbid obesity\n2. Cardiac History \n- Tachycardia/arrhythmia\n- Mild Aortic Stenosis (orifice area of 0.4 cm2 due to body \nhabitus)\n- AAA\n3. Other PMH \n1. Hypogammaglobulinemia, first noted in childhood following \nrecurrent bacterial pulmonary infections and treated with \nmonthly\ninfusions of IgG until the age of ___. \n2. Asthma/COPD.\n3. Morbid obesity.\n4. Bacterial (colonic) overgrowth.\n5. ADD.\n6. ___ esophagus.\n7. Hypogonadism.\n8. Diabetes mellitus type 2, on oral hypoglycemics, complicated\nby diabetic neuropathy.\n9. Sleep apnea on BiPAP machine.\n10. Recurrent lower extremity cellulitis in the setting of \nvenous insufficiency/severe chronic lymphedema \n11. Onychomycoses of the feet\n12. Anxiety\n13. DLBCL in remission\n14. Gastrointestinal bleed thought due to gastritis, had massive \n\nhematemesis\n\n \nSocial History:\n___\nFamily History:\nFather died in his early ___ of interstitial\npulmonary fibrosis. He had an MI in his ___. Mother died of\nemphysema in her ___. He has one sister who died at age ___ of\nsystemic lupus erythematosus. He has one son with ADHD. No\nfamily history of stroke, hypertension, hyperlipidemia, diabetes\nmellitus, early coronary artery disease or sudden cardiac death.\n\n \nPhysical Exam:\nAdmission Physical Exam: \n==============\nVITALS: ___ 2323 Temp: 97.6 BP: 168/95 R Sitting HR: 86\nRR: 16 O2 sat: 98% O2 delivery: Ra \n___: Well developed, well nourished in NAD. Oriented x3.\nMood, affect appropriate. \nHEENT: Normocephalic, atraumatic. Sclera anicteric. Poor\ndentition. \nNECK: No JVD. \nCARDIAC: Normal rate, regular rhythm. Systolic ejection murmur\nbest heard at the RUSB.\nLUNGS: Clear to auscultation bilaterally\nABDOMEN: Soft, non-tender, obese. No organomegaly appreciated\nEXTREMITIES: Warm, well perfused. bilateral erythema to mid shin\nbilaterally. \nSKIN: Chronic venous stasis changes. \n\nDischarge physical exam:\n=========================\nVitals: 97.4 124/71 75 18 97 Ra \n___: Comfortable, NAD \nHEENT: Sclera anicteric. Poor dentition. \nNECK: Supple\nCARDIAC: RRR Systolic ejection murmur best heard at the RUSB.\nLUNGS: Clear to auscultation bilaterally\nABDOMEN: Soft, non-tender, obese. No organomegaly appreciated\nEXTREMITIES: Warm, well perfused. Bilateral erythema to mid shin\nbilaterally. \nSKIN: Chronic venous stasis changes. \n \nPertinent Results:\nadmission labs:\n================\n\n___ 06:55AM cTropnT-0.02*\n___ 12:10AM ___ PTT-46.9* ___\n___ 12:01AM GLUCOSE-84 UREA N-17 CREAT-1.0 SODIUM-145 \nPOTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-31 ANION GAP-13\n___ 12:01AM estGFR-Using this\n___ 12:01AM cTropnT-0.02*\n___ 12:01AM WBC-7.5 RBC-4.54* HGB-13.3* HCT-42.3 MCV-93 \nMCH-29.3 MCHC-31.4* RDW-15.2 RDWSD-52.3*\n___ 12:01AM NEUTS-78.3* LYMPHS-9.2* MONOS-10.0 EOS-1.7 \nBASOS-0.4 IM ___ AbsNeut-5.88 AbsLymp-0.69* AbsMono-0.75 \nAbsEos-0.13 AbsBaso-0.03\n___ 12:01AM PLT COUNT-244\n___ 11:11PM URINE HOURS-RANDOM\n___ 11:11PM URINE UHOLD-HOLD\n___ 11:11PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 11:11PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30* \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.5* \nLEUK-NEG\n___ 11:11PM URINE RBC-<1 WBC-0 BACTERIA-NONE YEAST-NONE \nEPI-0\n\nnotable labs during admission: \nTELEMETRY: No events this hospital stay \n \nECG: Known conduction system disease, RBBB w/ LAFB. \n\nECHO ___ \n-Aortic valve: 3.5 peak velocity, 49 peak gradient, area 1.1cm2\n-Mild symmetric left ventricular hypertrophy with normal cavity\nsize and global systolic function (LVEF>55%). \n\nCardiac cath ___\n-No obstructive coronary disease \n-Aortic valve area 1.67 cm2, gradient of 28 mm Hg\n\nSTRESS TEST - Very limited exercise tolerance secondary to\nearly-onset shortness of breath. No anginal symptoms or ischemic\nST segment changes. Lightheadedness reported during exercise in\nthe absence of a drop in systolic blood pressure. Blunted\nhemodynamic response to the limited amount of exercise \ncompleted,\nthough he did increase his blood pressure at peak exertion. \n\ndischarge labs:\n=========================\n___ 07:25AM BLOOD WBC-5.3 RBC-4.66 Hgb-13.8 Hct-41.8 MCV-90 \nMCH-29.6 MCHC-33.0 RDW-14.9 RDWSD-48.5* Plt ___\n___ 09:50AM BLOOD ___ PTT-45.1* ___\n___ 07:25AM BLOOD Glucose-180* UreaN-23* Creat-1.2 Na-142 \nK-4.6 Cl-100 HCO3-28 AnGap-14\n___ 07:25AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.___ with a history of AS ___ 1.1, gradient 49), HTN, T2DM, OSA \non BiPap, remote DLBCL in remission s/p chemo (c/b \nVincristine-induced neuropathy & vertigo) and radiation, RBBB \nand LAFB with recent hospitalization for syncopal event with CHB \nPPM placement ___ who presents with pre-syncope thought \nvasovagal in nature. Stress test, echo, PPM interrogation \nreassuring and patient discharged to rehab.\n\nInvestigations/Interventions:\n1. Pre-syncope: patient had extensive workup including PPM \ninterrogation (recently placed by EP), stress test, \nechocardiogram, orthostatics. PPM interrogation unremarkable \nthough EP did turn on sudden brady response. Patient monitored \non tele without events. Stress test notable only for poor \nexercise tolerance. Echocardiogram with aortic stenosis \nfindings, known as patient is under consideration for TAVR. \nUltimately given pre-syncope is related to meal time, we believe \nthis is vaso-vagal in nature. We placed compression stockings \nand encouraged leg elevation when able. Patient worked with ___ \nand was recommended for rehab upon discharge. He has follow up \nwith his cardiology team. \n\n2. Aortic stenosis: echo obtained ___ showed ___ 1.1 with \ngradient 49. Patient undergoing consideration of TAVR; will \nfollow up with cardiology.\n\n3. HTN: home lisinopril held while hospitalized in setting of \npre-syncope. Can restart as outpatient if patient stable from \npre-syncope standpoint and develops hypertension.\n\n4. ADHD: we uptitrated patient's home methylphenidate. PCP \nfollow up on discharge from rehab.\n\nTRANSITIONAL ISSUES:\n[]Lisinopril held on discharge d/t pre-syncope; patient \nnormotensive in house, restart as outpatient for HTN\n[]Methylphenidate uptitrated as above\n[]Discharge weight 178.4 kg\n\n#Contact: ___, wife: ___ \n#Code: Full (confirmed)\n=============\nGreater than 30 minutes was spent on discharge planning and \ncoordination\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 20 mg PO DAILY \n3. BusPIRone 15 mg PO BID \n4. Cetirizine 10 mg PO QHS \n5. Fenofibrate 134 mg PO DAILY \n6. Fish Oil (Omega 3) ___ mg PO BID \n7. Simethicone 160 mg PO TID \n8. Metoprolol Tartrate 25 mg PO BID \n9. Nortriptyline 25 mg PO QHS \n10. FLUoxetine 40 mg PO DAILY \n11. TraZODone 50 mg PO QHS \n12. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n13. Senna 8.6 mg PO BID:PRN constipation \n14. Acyclovir 400 mg PO Q8H \n15. glimepiride 4 mg oral BID \n16. MetFORMIN (Glucophage) 1000 mg PO BID \n17. peppermint oil 1 capsule oral TID \n18. Perphenazine 2 mg PO QHS \n19. Lisinopril 10 mg PO DAILY \n20. Zolpidem Tartrate 20 mg PO QHS \n21. MethylPHENIDATE (Ritalin) 20 mg PO QAM \n22. MethylPHENIDATE (Ritalin) 10 mg PO QPM \n\n \nDischarge Medications:\n1. Methylphenidate SR 40 mg PO DAILY \nRX *methylphenidate HCl 20 mg 2 tablet(s) by mouth daily Disp \n#*60 Tablet Refills:*0 \n2. Methylphenidate SR 20 mg PO QAM \nRX *methylphenidate HCl 20 mg 1 tablet(s) by mouth qam Disp #*30 \nTablet Refills:*0 \n3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n4. Acyclovir 400 mg PO Q8H \n5. Aspirin 81 mg PO DAILY \n6. Atorvastatin 20 mg PO DAILY \n7. BusPIRone 15 mg PO BID \n8. Cetirizine 10 mg PO QHS \n9. Fenofibrate 134 mg PO DAILY \n10. Fish Oil (Omega 3) ___ mg PO BID \n11. FLUoxetine 40 mg PO DAILY \n12. glimepiride 4 mg oral BID \n13. MetFORMIN (Glucophage) 1000 mg PO BID \n14. MethylPHENIDATE (Ritalin) 20 mg PO QAM \n15. Metoprolol Tartrate 25 mg PO BID \n16. Nortriptyline 25 mg PO QHS \n17. peppermint oil 1 capsule oral TID \n18. Perphenazine 2 mg PO QHS \n19. Senna 8.6 mg PO BID:PRN constipation \n20. Simethicone 160 mg PO TID \n21. TraZODone 50 mg PO QHS \n22. Zolpidem Tartrate 20 mg PO QHS \n23. HELD- Lisinopril 10 mg PO DAILY This medication was held. \nDo not restart Lisinopril until cardiology follow up\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnosis: Vasovagal presyncope, severe aortic stenosis\n\nSecondary diagnoses: Complete heart block status post pacemaker, \nmorbid obesity, hypertension, type 2 diabetes, obstructive sleep \napnea on BiPAP, remote history of diffuse large cell B cell \nlymphoma in remission, sinus tachycardia on metoprolol, right \nbundle branch block.\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you at the ___ \n___. You were admitted because of \npresyncope. During his hospital stay we investigated you for \nvarious causes of presyncope. First, we checked your pacemaker \nand found that you did not have any abnormal rhythm which could \nexplain your symptoms. Second, we asked the cardiology team to \ncome and evaluate you. You underwent a stress test which showed \nthat you were severely deconditioned from not exercising. \nHowever, the exercise stress test did not show us any cause that \ncould explain your presyncope. You had 2 episodes of presyncope \nduring the hospital stay both of which happened under close \nmonitoring. The most likely cause of your presyncope is a \ncondition called vasovagal presyncope. In this condition your \nvagal tone increases leading to pooling of blood in your legs. \nYou should wear compression stockings to help this.\n\nThe cardiologists also evaluated you for the need of replacing \nyour aortic valve located in your heart. Your exercise stress \ntest did not show a significant indicator of doing this during \nthis hospital stay. You have to follow-up with your \ncardiologist and monitor your symptoms of shortness of breath \nwith time.\n\nIt was a pleasure taking care of you at the ___ \n___. We wish you all the best.\n\nYour team\n \nFollowup Instructions:\n___\n" ]

[ "R55", "E1140", "J449", "I452", "Z6843", "I10", "G4733", "R000", "I350", "Z45018", "E785", "E6601", "K2270", "F901", "Z8572", "G4700", "F419" ]

[ "R55: Syncope and collapse", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "I452: Bifascicular block", "Z6843: Body mass index [BMI] 50.0-59.9, adult", "I10: Essential (primary) hypertension", "G4733: Obstructive sleep apnea (adult) (pediatric)", "R000: Tachycardia, unspecified", "I350: Nonrheumatic aortic (valve) stenosis", "Z45018: Encounter for adjustment and management of other part of cardiac pacemaker", "E785: Hyperlipidemia, unspecified", "E6601: Morbid (severe) obesity due to excess calories", "K2270: Barrett's esophagus without dysplasia", "F901: Attention-deficit hyperactivity disorder, predominantly hyperactive type", "Z8572: Personal history of non-Hodgkin lymphomas", "G4700: Insomnia, unspecified", "F419: Anxiety disorder, unspecified" ]

[ "J449", "I10", "G4733", "E785", "G4700", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nLipitor / lisinopril\n \nAttending: ___.\n \nChief Complaint:\nNon-healing left toe ulcer and toe pain with walking short \ndistances \n \nMajor Surgical or Invasive Procedure:\n___ Bilateral lower extremity angiogram:\nLeft lower extremity: The left CIA stent was widely patent. The \nCFA had no significant disease. The SFA was occluded ostially \nwith a PFA that had origin 40% stenosis and this was new \ncompared with angiography in ___. The SFA reconstituted via \nPFA collaterals mid thight. The popliteal artery had no \nsignificant disease. There was three vessel run off to the \nfoot. \n\nRight lower extremity: The CIA had mild disease. There was \nmild disease in the IIA and EIA. The CFA and PFA hasd mild \ndisease. The SFA proximally had 70% diffuse disease.\n\nImpressions:\n1. Occluded SFA with collaterals from PFA.\n\n \nHistory of Present Illness:\nMr. ___ is a ___ yr old male with a history coronary artery \ndisease, s/p MI in ___, peripheral vascular disease, s/p \natherectomy of the left SFA and stenting of the LCIA in ___ \nwho was recently been evaluated by Dr. ___ podiatry for \nc/o marked left foot pain from interdigital lesions due to \nhallux vulgus and a hammertoe deformity. Because of his known \nPAD and recent decline in his ABI's, he was referred for a \nbilateral lower extremity angiogram for possible \nrevascularization prior to any surgical intervention of his \nfoot. In the meantime, he has developed an ulcer on his left \nthird toe. X-rays have been concerning for osteomyelitis. He \nhas since seen Dr. ___\npodiatry who reported that the likelihood of healing of the \nwound was poor and that he would most likely require amputation. \n He is was referred for LLE angiogram on ___ followed by toe \namputation on ___.\n\n \nPast Medical History:\n1. Coronary artery disease status post-acute MI with RCA\nstenting, ___ at ___.\n2. Peripheral vascular disease status post atherectomy of the\nleft SFA and stenting of the ___ in ___. \n3. Emphysema.\n4. Nodular scarring in his right lung\n5. Superficial thrombophlebitis, s/p completed course of\nwarfarin.\n6. Hyperlipidemia\n7. Hypertension\n8. AAA\n9. ___: Possible osteomyelitis of left third toe\n11. Left hallux vulgus, hammertoe deformity\n12. Congenital hip/arthritis of the hip\n13. Positive for Factor V Leiden\n \nSocial History:\n___\nFamily History:\nn/c\n \nPhysical Exam:\nDISCHARGE PHYSICAL EXAM:\nPhysical Exam: \nVitals- 97.7, 140/61, 54, 16, 97% RA\nGeneral- Alert, oriented, no acute distress \nHEENT- Sclera anicteric, MMM, oropharynx clear, poor dentition \nNeck- supple, JVP not elevated, no LAD \nLungs- diffuse mild end-inspiratory wheezes, no crackles\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 \nGU- no foley \nExt- warm, well perfused, non-palpable pulses, no edema \nNeuro- CNs2-12 intact, motor function grossly normal \n \nPertinent Results:\nLAB RESULTS:\n___ 06:50AM BLOOD WBC-7.8 RBC-4.29* Hgb-12.4* Hct-38.2* \nMCV-89 MCH-28.9 MCHC-32.5 RDW-14.6 RDWSD-47.0* Plt ___\n___ 06:50AM BLOOD Glucose-98 UreaN-12 Creat-0.9 Na-138 \nK-4.0 Cl-99 HCO3-28 AnGap-15\n___ 06:45AM BLOOD UreaN-16 Creat-0.9 K-4.3\n___ 06:50AM BLOOD Calcium-9.7 Phos-3.8 Mg-1.9\n\nIMAGING / STUDIES:\n\n___ AP,LAT & OBL LEFT \nFINDINGS: \nThere is diffuse osteopenia which limits evaluation for \nnondisplaced\nfractures. There has been interval surgical amputation of the \nthird toe at\nthe level of the base of the third proximal phalanx. \nPostsurgical changes are\nseen in the overlying soft tissues. Again noted is a severe \nhallux valgus\ndeformity.There is suggestion of hammertoe deformities of the \n___, and\n___ toes, although this is not a weightbearing radiograph. No \nacute fracture\nor dislocation.\nIMPRESSION: \nPostsurgical changes noted from surgical amputation of the third \ntoe with\nexpected postsurgical changes in the overlying soft tissues.\n\n___ DUP EXTEXT BIL (MAP \nFINDINGS: \nDuplex was performed of bilateral lower extremity veins. On the \nright the\ngreat saphenous vein is patent from the groin to the ankle with \ndiameters\nranging from 2.4-5.3 mm. The right small saphenous is patent \nwith diameters\nless than 2 mm throughout. On the left the great saphenous vein \nis patent\nfrom the groin to the ankle with diameters ranging from 2.1-4.3 \nmm. The left\nsmall spur saphenous is patent with diameters ranging from \n1.5-3.3 mm. See\nthe scanned worksheet for detailed locations.\nIMPRESSION:\nPatent bilateral great saphenous failure. Patent but small \nbilateral small\nsaphenous veins. See the scanned worksheet for detailed \ndiameter locations.\n\n___ DUP UPPER EXT BI \nFINDINGS: \nDuplex was performed of bilateral upper extremity veins. The \nright cephalic\nvein is patent from the wrist to the shoulder with diameters \nranging from\n2.3-3.5 mm. An IV is present in the antecubital fossa. The \nbone is patent\nwith diameters ranging from 1.4-4.0 mm. On the left the \ncephalic vein is\npatent with diameters ranging from 1.6-2.7 mm. The left basilic \nis patent\nwith diameters ranging from 1.3-2.5 mm. See the scanned \nworksheet for\ndetailed diameter locations.\nIMPRESSION:\nPatent bilateral cephalic and basilic veins. See the scanned \nworksheet for\ndetailed diameters.\n\n___: TOES, AMPUTATION, NON-TRAUMATIC\nPATHOLOGIC DIAGNOSIS:\nThird toe, left foot, amputation:\n- Mild degenerative changes of the subcutaneous soft tissue; no \nacute osteomyelitis identified.\n- Bone and soft tissue at the resection margin appears viable \nand free of inflammation.\n\n___ \nSinus rhythm. Leftward axis. Low limb lead voltage. Compared to \nthe previous\ntracing of ___ the inferior ST-T wave changes persist. The \nright precordial\nT waves are tall and peaked. These findings suggest \ninferoposterior ischemia.\nClinical correlation is suggested.\n Intervals ___\nRatePRQRSQTQTc (___) ___ ___-___\n\n___ Physician ___\nThe distal aorta had mild diffuse disease.\nLeft lower extremity: The left CIA stent was widely patent. The \nCFA had no significant disease. The SFAwas occluded distally \nwith a PFA that had origin 40% stenosis and this was new \ncompared with angiography in ___. The SFA reconstituted via PFA \ncollaterals mid thight. The popliteal artery had no significant \ndisease. There was three vessel run off to the foot.\nRight lower extremity: The CIA had mild disease. There was mild \ndisease in the IIA and EIA. The CFA and PFA hasd mild disease. \nThe SFA proximally had 70% diffuse disease.\nImpressions:\n1. Occluded SFA with collaterals from PFA.\n \nBrief Hospital Course:\nA ___ yr old male with a history of CAD, HTN, HLD, PVD s/p LCIA \nstenting (___) and a chronic non healing left lateral ___ toe \nulcer concerning for osteomyelitis. \n\n# Osteomyelitis\nPatient notes that he has had this ulcer for many years now, \nprimary managed in the outpatient setting by his podiatrist. He \nis status post a LLE diagnostic angiogram on ___ \n(cardiology) which showed a left SFA occlusion with adequate \ncollateral circulation. He was taken to the OR by podiatry and \nunderwent an uncomplicated L ___ toe amputation on ___. He \nwas treated with IV vancomycin and ciprofloxacin for 24 hours \nafter his procedure then trasitioned to PO Bactrim DS 2 tabs BID \nuntil ___ to complete a 10 day course. He was scheduled for \nfollow up with podiatry for dressing change and post-procedure \nfollow up. Physical therapy worked with him prior to discharge \nand recommended rolling walker for ambulation in addition to \nhome ___ and ___.\n\n# PVD\nPatient with know history of PVD s/p atherectomy of the left SFA \nand stenting of the LCIA in ___. He had angiography done by \ncardiology and will follow up with them in their clinic on \ndischarge.\n\n# CAD / HTN / HLD\nPatient with know history of CAD s/p RCA stenting, ___ at \n___. He was continued on his home ASA 81, \ncrestor 10, amlodipine 10 and metoprolol 25 XL daily. \n\nTRANSITIONAL ISSUES:\n- Patient discharged on Bactrim oral suspension 40mL BID \n(equivalent to 2 DS tabs BID), for treatment of osteomyelitis \nuntil wound is healing. Last dose on evening of ___.\n- Patient's LLE dressing should remain intact for 7 days per \npodiatry until follow up appointment.\n- Please follow up pending micro data on amputated ___ toe, \npending on discharge.\n- Patient evaluated by ___ prior to discharge and sent with a \nscript for a rolling walker to be used until foot heals. Weight \nbearing as tolerated.\n- Patient discharged with home ___ for dressing changes and home \nphysical therapy. \n#Code: full code\n#Communication: ___, WIFE, Phone number: \n___\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Succinate XL 25 mg PO DAILY \n2. amLODIPine 10 mg PO DAILY \n3. Rosuvastatin Calcium 40 mg PO QPM \n4. Aspirin 81 mg PO DAILY \n5. Loratadine 10 mg PO DAILY \n6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n\n \nDischarge Medications:\n1. Loratadine 10 mg PO DAILY \n2. amLODIPine 10 mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Metoprolol Succinate XL 25 mg PO DAILY \n5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n6. Rosuvastatin Calcium 40 mg PO QPM \n7. Sulfameth/Trimethoprim Suspension 40 mL PO BID \nRX *sulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL 40 mL by \nmouth twice a day Disp #*800 Milliliter Refills:*0\n8. Rolling Walker\nRolling walker, to be used daily for ambulation.\nQuantity: 1\nPrognosis: good\nDx: Left toe amputation (___)\nDuration: 13 months\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY\nOsteomyelitis, Chronic\nPeripheral Vascular Disease\n\nSECONDARY\nCoronary Artery Disease\nHypertension\nHyperlipidemia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nYou were admitted to the ___ \nfor evaluation of your left toe osteomyelitis and peripheral \nvascular disease. You an angiogram done of the left leg that \nshowed a blockage in one of your major arteries. Luckily, since \nthis blockage happened over a long period of time there was \nenough blood flow around the blockage to supply adequate blood \nto your leg and foot so you did not need a stent in this artery. \n\n\nDue to concern for toe infection you went to the OR on ___ \nfor a toe amputation. The procedure went well and you had \nminimal to no pain afterwards. \n\nYou worked with physical therapy who recommended using a walker \nwhile your foot heals. \n\nYou were given IV antibiotics while you were admitted and were \ndischarged with oral Bactrim 40 mL twice daily to be continued \nfor a total of 10 days. You should start it on the evening of \ndischarge and your last dose will be on the evening of ___. \n\nYou were discharged with follow up appointments with both \npodiatry and interventional cardiology.\n\nPlease do not change the dressing on your foot until your follow \nup appointment with podiatry in ___ days.\n\nIt was a pleasure participating in your care and we wish you the \nbest moving forward.\nSincerely, \nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "M86672", "L97529", "I70202", "I2510", "F17210", "I10", "E785", "I252" ]

[ "M86672: Other chronic osteomyelitis, left ankle and foot", "L97529: Non-pressure chronic ulcer of other part of left foot with unspecified severity", "I70202: Unspecified atherosclerosis of native arteries of extremities, left leg", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "F17210: Nicotine dependence, cigarettes, uncomplicated", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "I252: Old myocardial infarction" ]

[ "I2510", "F17210", "I10", "E785", "I252" ]

[]

[ " \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:\nSore throat and fever\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nHealthy ___ presents with sore throat and fever. Patient was in \nhis usual state of health until last ___ at midnight, when he \nnoticed that the right side of his throat was sore. ___ \nmorning he woke up with subjective fever and chills, and \nworsening sore throat. He did not have nasal congestion. He \nmanaged his symptoms at home with increased fluids, Emergen-C, \nDayquil/Nyquil, but without sufficient relief. He went to ___ \n___ ___ morning where he is followed. Per patient, he had \na rapid strep test that was negative and a fever to 102. Thought \nto be a viral URI and was sent home. Re-presented to ___ \n___ the following morning, where per patient, doctor felt \nthat \"R tonsil was very swollen, and there was c/f peritonsillar \nabscess.\" Repeat rapid strep at that time was negative. \n Patient says that over the course of the last 48 hours he has \npain and difficulty swallowing, and that it is tender when he \ntouches his R neck. Does not feel that he has had muffled voice \nor difficulty breathing. Denies specific sick contacts. \n On arrival to the floor he is feeling much better than at the \ntime of presentation. He still has some right neck soreness but \nit is much improved. States that this has never happened before. \n \n ROS: positive per HPI. Otherwise no n/v, diarrhea, \nconstipation. No urinary frequency or dysuria. No chest pain or \ndyspnea. Denies fatigue, unintentional weight loss. \n In the ED, initial vitals were: 101.0, 92, 117/70, 18, 100% RA \n\n - Exam notable for: R tonsillar erythema and swelling. No uvula \ndeviation. No soft tissue mass. \n - Labs notable for: WBC count 14 \n - Imaging: Right palatine tonsillitis with phlegmon/early \nabscess formation and associated right deep neck space edema and \nswelling causing moderate narrowing of the right oropharynx and \nmild narrowing of the hypopharynx. \n - He was given. \n ___ 17:21 PO Acetaminophen 1000 mg \n ___ 20:14 PO/NG Dexamethasone 8 mg \n ___ 23:27 IV Ampicillin-Sulbactam 3 g \n ENT was consulted and recommended: clears after midnight and IV \nunasyn, admit to medicine. \n Tranfer vitals: 99.1, 78, 112/70, 16, 100% RA \n\n \nPast Medical History:\n- right knee meniscal tear s/p repair \n - eye surgery for strabismus \n\n \nSocial History:\n___\nFamily History:\nMother with spine? CA currently in remission \n Grandfather and grandmother with lung CA, both smokers \n No h/o cardiovascular disease. autoimmune disease or frequent \ninfections. \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n===========================\n VITAL SIGNS - 98.9PO, 97/64, 60, 16, 98%RA \n GENERAL - well appearing thin man in NAD \n HEENT - PERRL, EOMI, sclera anicteric, MMM with right tonsilar \nswelling to midline, no exudates or lesions \n NECK - Bilateral LAD greater on the right than the left \n CARDIAC - RRR normal S1/S2 no S3/S4 murmurs or rubs \n LUNGS - CTAB no wheezing \n ABDOMEN - soft ,flat non-tender to palpation, non distended, no \nHSM \n EXTREMITIES - WWP, pulses +2, no edema \n NEUROLOGIC - CN II-XII grossly intact \n SKIN - no rash \n\nDISCHARGE PHYSICAL EXAM\n========================\n\n \nPertinent Results:\nADMISSION LABS\n================\n___ 08:15PM WBC-14.0* RBC-4.77 HGB-13.9 HCT-42.0 MCV-88 \nMCH-29.1 MCHC-33.1 RDW-12.7 RDWSD-41.3\n___ 08:15PM NEUTS-67.8 ___ MONOS-12.0 EOS-0.1* \nBASOS-0.3 IM ___ AbsNeut-9.47* AbsLymp-2.70 AbsMono-1.67* \nAbsEos-0.01* AbsBaso-0.04\n___ 08:15PM GLUCOSE-118* UREA N-7 CREAT-0.6 SODIUM-139 \nPOTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-28 ANION GAP-20\n\nCT NECK W/ CONTRAST\n===================\n1. Right palatine tonsillitis with phlegmon/early abscess \nformation and\nassociated right deep neck space edema and swelling from the \nlevel of the\neustachian tubes to just below the epiglottis causing moderate \nnarrowing of\nthe right oropharynx and mild narrowing of the hypopharynx. No \nsoft tissue gas\nor discrete fluid collection to suggest a drainable collection \nor organized\nabscess.\n2. Patent neck vessels.\n3. Mild left paranasal sinus disease.\n\nDISCHARGE LABS\n==================\n___ 06:15AM BLOOD WBC-11.1* RBC-4.73 Hgb-14.0 Hct-41.7 \nMCV-88 MCH-29.6 MCHC-33.6 RDW-12.5 RDWSD-41.0 Plt ___\n___ 06:15AM BLOOD Glucose-128* UreaN-12 Creat-0.5 Na-139 \nK-4.8 Cl-96 HCO3-26 AnGap-22*\n \nBrief Hospital Course:\nMr. ___ is a ___ year old healthy male who was admitted for a \nperitonsillar abscess/phlegmon. There was not a distinct \ndrainable pocket on imaging. ENT was consulted, but ultimately \nhe was discharged on Augmentin to complete a 10 day course.\n\n# Right tonsillitis with phlegmon - Evalauted by CT and ENT, no \nabscess. Improved greatly with 2 doses of unasyn, IV Tylenol, \nand ketorolac. Able to swallow and take PO at discharge. No \nindication for steroids per ENT. ENT scoped and the airway \nlooked patent with no concern for compromise. Discharged on a 10 \nday course of augmentin as above. \n\n# CODE: full code \n# CONTACT: \n Next of Kin: ___ \n Relationship: friend (former partner) \n Phone: ___ \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. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \n2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days \n\nRX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by \nmouth twice a day Disp #*19 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis: \nTonsillitis with phlegmon\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 hospital with concern for an abscess \n(bad infection) in the back of your throat by your tonsil. This \nwas able to be treated with antibiotics alone rather than \nneeding to be drained. You were discharged on oral antibiotics. \nAt home, it is very important that you look out for signs of an \nabscess developing which includes difficulty with swallowing, \nchange in your voice, worsening neck pain or if you continue to \nhave high fevers. If you have any of these symptoms, please call \nyour primary care doctors office as ___ may need drainage of an \nabscess. \n\nIt was a pleasure taking care of you,\nYour ___ Care Team.\n \nFollowup Instructions:\n___\n" ]

[ "J0390", "Z87891" ]

[ "J0390: Acute tonsillitis, unspecified", "Z87891: Personal history of nicotine dependence" ]

[ "Z87891" ]

[]

[ " \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:\nDyspnea\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ with metastatic thyroid cancer to lung c/b bilateral pleural \neffusions on ___ NC home oxygen & on hospice, pAF with \npacemaker, CAD, CHF who p/w SOB. \n\nPatient reports progressive SOB over the course of the past \nseveral weeks. He has a history of thyroid cancer with \nmetastases to the lung, complicated by malignant effusions. He \nwas initially started on home oxygen with little improvement in \nsymptoms, which were primarily dyspnea on exertion. Patient had \nbilateral Pleurx catheters placed on ___ by IP and has \nsince had ___ care to drain the effusions every other day. \nPatient notes that, for the past several weeks, he has had \nincreased drainage from his Pleurx catheters. He has had \napproximately 1.5L out every other day. In this setting, he had \nnoticed increased DOE, to the extent that he can only walk 2 \nsteps before becoming very short of breath. Patient's oxygen was \nincreased from 2.5L to 3L 4 days ago. Patient also notes that he \nhas had dysphagia, and frequently coughs after eating a large \nmeal. In addition, he has had decreased appetite and has only \nhad 1 cup of coffee yesterday and some yogurt this morning. Of \nnote, patient has continued to take his home Lasix. ROS is \notherwise notable for decreased UOP today. Patient also notes \n35lb weight loss over the past ___ months, which has been \naccelerating recently. Patient denies any chest pain, orthopnea, \n___ swelling, cough in the absence of eating, fevers, other pain. \nHe notably takes no pain medications at home. Patient presented \nto the ED today because of increased SOB. \n\nWith regards to his GOC, patient is currently on home hospice. \nHe reports that he is DNR/DNI, but would otherwise like \nadditional procedures if needed.\n\nIn ED initial VS: 96.6, 102, 106/69, 24, 87%/RA \n\nExam: Not documented\n\nPatient was given: \n1) ___ 12:40 IVF NS, stopped ___ 13:37 \n2) ___ 14:10 IV CefePIME 2 g \n3) ___ 15:12 IV Vancomycin (1000 mg ordered) \n4) /___ 16:10 IV Albumin 5% (25g / 500mL) \n\nImaging notable for: CXR with b/l chest tubes in place with \nsmall effusions. Persistent innumerable bilateral pulmonary \nnodules. \n\nLabs notable for: \n1) WBC 10 w/ 87% PMN\n2) PTT 29/INR 1\n3) Troponin 0.02\n4) VBG ___, lactate 3.4, peripheral ___ BNP 1630\n6) Albumin 2.9, \n7) Na 128, K 5.3, BUN/Cr 32/1.0\n8) Flu PCR negative\n9) Lactate 3.4\n\nConsults: None\n\nVS prior to transfer: 89-104, 91/58, 18, 97%/NC\n \nREVIEW OF SYSTEMS: \n(+) Per HPI \n(-) Denies fever, chills, night sweats, recent weight loss or \ngain. Denies headache, sinus tenderness, rhinorrhea or \ncongestion. Denies cough, shortness of breath, or wheezing. \nDenies chest pain, chest pressure, palpitations, or weakness. \nDenies nausea, vomiting, diarrhea, constipation, abdominal pain, \nor changes in bowel habits. Denies dysuria, frequency, or \nurgency. Denies arthralgias or myalgias. Denies rashes or skin \nchanges. \n \nPast Medical History:\n-METASTATIC THYROID CANCER \n-ADULT ONSET DIABETES MELLITUS \n-BLADDER CANCER \n-COLON POLYPS \n-CORONARY ARTERY DISEASE \n-PAROXYSMAL ATRIAL FIBRILLATION \n-HYPERLIPIDEMIA \n-diastolic CHF\n-PROSTATE CANCER \n-RENAL MASS \n-SYSTOLIC HYPERTENSION \n-OSTEOARTHRITIS \n-BACK PAIN \n-PERIPHERAL VASCULAR DISEASE \n \nSocial History:\n___\nFamily History:\nNon-contributory \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nVITALS: 97.7; 102; 98/65; 20; 88% 3___\nGENERAL: Alert, oriented, no acute distress. Cachectic. \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP not elevated, no LAD. Ultrasound showed very \neasily compressible Left IJ.\nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi. Bilateral Pleurx catheters in place. \nCV: Irregular, normal S1 S2, no murmurs, rubs, gallops. ICD in \nplace on Left chest wall.\nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSKIN: Numerous waxy brown plaques on back and chest with stuck \non appearance.\n\nDISCHARGE PHYSICAL EXAM\n=======================\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 12:13PM BLOOD WBC-10.0 RBC-5.32 Hgb-15.3 Hct-46.5 \nMCV-87 MCH-28.8 MCHC-32.9 RDW-16.1* RDWSD-49.9* Plt ___\n___ 12:13PM BLOOD Neuts-86.3* Lymphs-5.5* Monos-6.2 \nEos-0.8* Baso-0.4 Im ___ AbsNeut-8.61* AbsLymp-0.55* \nAbsMono-0.62 AbsEos-0.08 AbsBaso-0.04\n___ 12:13PM BLOOD ___ PTT-28.9 ___\n___ 12:13PM BLOOD Plt ___\n___ 02:04PM BLOOD Glucose-136* UreaN-32* Creat-1.0 Na-128* \nK-5.2* Cl-95* HCO3-23 AnGap-15\n___ 02:04PM BLOOD ALT-7 AST-15 AlkPhos-123 TotBili-0.5\n___ 12:13PM BLOOD cTropnT-0.02*\n___ 02:04PM BLOOD proBNP-1630*\n___ 07:59PM BLOOD cTropnT-<0.01\n___ 02:04PM BLOOD Albumin-2.9*\n___ 07:59PM BLOOD TSH-0.05*\n___ 03:22AM BLOOD Free T4-1.2\n___ 03:22AM BLOOD Cortsol-18.1\n___ 12:16PM BLOOD ___ pO2-20* pCO2-48* pH-7.33* \ncalTCO2-26 Base XS--2 Intubat-NOT INTUBA\n___ 12:16PM BLOOD Lactate-3.4*\n___ 12:16PM BLOOD O2 Sat-20\n\nIMAGES\n======\nCXR (___): Bilateral chest tubes with small persistent \nbilateral pleural effusions.\n\nCXR (___): Bilateral chest tubes in place with small \neffusions. Persistent innumerable bilateral pulmonary nodules. \n\nTTE (___): LVEF 50-55%. LA/RA mildly dilated. Suboptimal \nimage- cannot exclude WMA. RV cavity dilated. Abnormal systolic \nseptal motion c/f RV pressure overload. Moderate pulmonary \nartery systolic HTN. Significant pulmonic regurgitation. \n\nEKG: Atrial fibrillation, normal axis, no ischemic ST changes, \nearly R repolarization\n\nMICRO\n=====\nFlu PCR (___): negative\nBlood culture (___): pending \n\n \nBrief Hospital Course:\n___ metastatic thyroid cancer to lung c/b pleural effusions on \n\n___ NC home oxygen, pAF with pacemaker, CAD, CHF who p/w SOB \nafter pleurx drainage found to be mildly hypotensive upon \nadmission due to worsening metastatic cancer. The patient was \nalready on hospice but during this admission wanted to \ntransition to comfort focused care. HIs main symptoms is \nshortness of breath. Palliative care was consulted and he was \nstarted on low dose morphine. We also increased the frequency of \ndraining his pleurx catheters. He is being discharged to ___ \n___ where he can transition to inpatient hospice if needed. \n\n \n================= \nACTIVE ISSUES \n================= \n\n# Hypotension: Likely hypovolemic given history and exam from \nyesterday evening. Not significantly improved with 500cc NS, but \nhe likely needs additional IVF. We will also check ULytes (see \nbelow). Otherwise, TSH was low and AM cortisol was WNL. \nOtherwise, trops are downtrending, and low index of suspicion \nfor cardiac etiology. Metoprolol/lasix were stopped during this \nadmission. He was started on midorine and his blood pressures \nremained low in the ___. \n\n# Shortness of breath: Symptomatically, likely related to \nprogression of thyroid metastases given lack of significant \nimprovement now despite pleural fluid drainage. Palliative care \nwas consulted and he was started on low dose moprhine. With this \nhe felt his symptoms were improved. \n\n# Hyponatremia: Most likely dehydration given concurrent \nhemoconcentration, hypotension with fluid responsiveness. \nUnlikely due to adrenal insufficiency given normal AM cortisol, \nunlikely due to SIADH given improvement with IVF. Unlikely ___ \nCHF. \n\n# Hyperkalemia. Likely ___ dehydration. Unlikely adrenal \ninsufficiency and SIADH as discussed above. \n\n# Hypoxemia: Likely related to underlying pulmonary metastases \nand possible to pleural effusions. However, given that his \nhypoxemia has not improved significantly despite drainage, there \nis concern that his hypoxemia is related to worsening lung \nmetastases. \n\n# Bilateral pleural effusions. B/l malignant pleural effusions \ns/p pleurX placement ___. Pt requires 3L home O2. As above, \nthere is concern that patient's pleural drainage may have \ncontributed to his hypotension. Pt was continued on QOD pleural \neffusion b/l drainage. Home Lasix stopped\n\n# Dysphagia: Likely related to underlying thyroid cancer, and \nthere is certainly concern that his disease is progressing. \nNutrition to comfort\n\n# Thyroid Cancer. Dx ___. Aborted right hemithyroidectomy ___ \niso local extension. Metastatic papillary thyroid carcinoma with \nknown lung metastases c/b pleural effusions. Seen by Dr. ___ \n___ from ___ endocrinology. No candidate for further \ntherapies, transitioned to hospice care. TSH low, and FT4 is \nwnl. \n\n================= \nCHRONIC ISSUES \n================= \n\n# CAD. S/p MI ___. Troponins negative.\n\n# Afib. S/p ___ placement. ___ ADx XL SR 5156, Mode \nVVI. Not on anticoagulation. Metoprolol was stopped during \nadmission in light of hypotension.\n\n# BPH: Not on any home medications\n\n# T2DM: No home medications per prior ___ discussions\n\n==================\nTRANSITIONAL ISSUES\n==================\n\n# CODE: DNR/DNI\n# CONTACT: son as emergency contact ___, ___ \n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Levothyroxine Sodium 200 mcg PO DAILY \n2. Metoprolol Succinate XL 25 mg PO DAILY \n3. Furosemide 80 mg PO DAILY \n4. Furosemide 40 mg PO QPM \n5. Docusate Sodium 100 mg PO BID \n6. LORazepam 0.5 mg PO QHS:PRN sleep/anxiety \n\n \nDischarge Medications:\n1. Midodrine 5 mg PO TID \nRX *midodrine 5 mg 1 tablet(s) by mouth three times a day Disp \n#*90 Tablet Refills:*0 \n2. Morphine Sulfate ___ 15 mg PO Q4H:PRN RR>20 or SOB \nRX *morphine 10 mg/5 mL ___ ml by mouth every four (4) hours \nRefills:*0 \n3. Polyethylene Glycol 17 g PO DAILY \nRX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 1 powder(s) \nby mouth once a day Refills:*0 \n4. Docusate Sodium 100 mg PO BID \n5. Levothyroxine Sodium 200 mcg PO DAILY \n6. LORazepam 0.5 mg PO QHS:PRN sleep/anxiety \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nMetastatic thyroid Cancer \nMalignant Pleural Effusions \nHypotension \nAtrial FIbrillation\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n \nDischarge Instructions:\nDear Mr. ___, \n\nYou were admitted to the hospital when you began to have low \nblood pressure and shortness of breath at home. Initially you \nwere in the ICU. You were treated with several liters of \nintravenous fluids and your metoprolol was stopped. Several \nchest X-ray were done to determine why you were feeling short of \nbreath. These were remarkable for worsening of your metastatic \nlung disease. We increased the frequency of draining your \npleurex catheters to every other day. Given you were still \nhaving symptoms you were also started on low dose morphine to \nrelieve your shortness of breath. With this you improved. You \nhave been followed by hospice and they will help you increase \nthe morphine as needed, and drain your pleural catheters, to \ncontrol your shortness of breath. \n\nIt was a pleasure caring for you, \nYour ___ Doctors \n \n___ Instructions:\n___\n" ]

[ "J9611", "J910", "C7802", "C7801", "I110", "R1310", "I5030", "E871", "I959", "C73", "Z9981", "Z66", "Z515", "I480", "Z950", "E861", "E875", "Z905", "Z85528", "Z8551", "Z8546", "N401", "R338", "R634", "I2510", "E1151" ]

[ "J9611: Chronic respiratory failure with hypoxia", "J910: Malignant pleural effusion", "C7802: Secondary malignant neoplasm of left lung", "C7801: Secondary malignant neoplasm of right lung", "I110: Hypertensive heart disease with heart failure", "R1310: Dysphagia, unspecified", "I5030: Unspecified diastolic (congestive) heart failure", "E871: Hypo-osmolality and hyponatremia", "I959: Hypotension, unspecified", "C73: Malignant neoplasm of thyroid gland", "Z9981: Dependence on supplemental oxygen", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "I480: Paroxysmal atrial fibrillation", "Z950: Presence of cardiac pacemaker", "E861: Hypovolemia", "E875: Hyperkalemia", "Z905: Acquired absence of kidney", "Z85528: Personal history of other malignant neoplasm of kidney", "Z8551: Personal history of malignant neoplasm of bladder", "Z8546: Personal history of malignant neoplasm of prostate", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "R338: Other retention of urine", "R634: Abnormal weight loss", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene" ]

[ "I110", "E871", "Z66", "Z515", "I480", "I2510" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nIncision hernia \n \nMajor Surgical or Invasive Procedure:\n___: Repair of incisional hernia with mesh.\n\n \nHistory of Present Illness:\nMs. ___ is a ___ yo woman with a PMH of ampullary cancer s/p \nWhipple ___ with a hospital course complicated by sepsis, PEA \narrest, multiple intraabdominal collections, candidiasis, and \nStrep infections which have now resolved. The cause of her \ncardiac arrest was unclear, and she suffered respiratory \nfailure.\nShe did not receive adjuvant chemotherapy due to her prolonged \npostoperative recovery. She represented for evaluation of her \nincisional hernia and was found to have three defects along the \nincision on CT scan. She opted to have this corrected and is now \ns/p repair with mesh.\n \nPast Medical History:\nOther allergic rhinitis \nAnemia of chronic renal failure \nAddison anemia \nMixed anxiety depressive disorder \nChronic kidney disease, stage III (moderate) \nUnilateral hearing loss \nDizziness \nHyperlipidemia \nHypoactive thyroid \nOsteoporosis, post-menopausal \nSeizure disorder \nShoulder pain \nTremor \nVesicoureteral reflux \nUnspecified vitamin D deficiency \ns/p cholecystectomy in ___\n \nSocial History:\n___\nFamily History:\nReviewed and found to be not relevant to this illness/reason for \nhospitalization.\n \nPhysical Exam:\nPrior To Discharge:\nVS: 98.4, 87, 152/73, 18, 96% RA\nGEN: Somewhat confused with NAD\nHEENT: PERRL, EOMI, no scleral icterus, no JVD, neck supple \nCV: RRR\nPULM: Diminished BS bilaterally on bases\nABD: Soft, NT/ND. Subcostal incision open to air with steri \nstrips and c/d/I, abdominal binder on.\nEXTR: Warm, no c/c/e\n \nPertinent Results:\nRECENT LABS:\n\n___ 07:12AM BLOOD ___.3* RBC-3.37* Hgb-10.6* Hct-34.3 \nMCV-102* MCH-31.5 MCHC-30.9* RDW-13.8 RDWSD-51.4* Plt ___\n___ 05:06AM BLOOD WBC-9.5 RBC-2.92* Hgb-9.1* Hct-29.0* \nMCV-99* MCH-31.2 MCHC-31.4* RDW-13.7 RDWSD-50.3* Plt ___\n___ 05:06AM BLOOD Glucose-117* UreaN-15 Creat-1.0 Na-144 \nK-4.0 Cl-104 HCO3-24 AnGap-16\n___ 05:06AM BLOOD Calcium-9.0 Phos-3.0 Mg-1.8\n\nRADIOLOGY:\n___ CXR:\nIMPRESSION: \n1. Multiple ill-defined subtle opacities noted in the right \nlung. \n2. Central pulmonary vascular congestion and mild pulmonary \nedema. \n3. Small left pleural effusion. \n\n___ CTA CHEST:\nIMPRESSION: \nNo evidence of pulmonary embolism or aortic abnormality. \nScattered diffuse mild ground-glass opacities could represent \neither mild \nedema or an infectious process. \n\n \nBrief Hospital Course:\nThe patient well know from previous admission was admitted to \nthe General Surgical Service for elective incisional hernia \nrepair. On ___, the patient underwent incisional hernia \nwith mesh, which went well without complication (please see the \nOperative Note for details). After a brief, uneventful stay in \nthe PACU, the patient arrived on the floor NPO, on IV fluids, \nand epidural catheter for pain control. The patient was \nhemodynamically stable.\nNeuro: The patient received epidural analgesia with good effect \nand adequate pain control. When tolerating oral intake, the \npatient was transitioned to oral pain medications.\nPhych: On POD 1, patient developed acute delirium with visual \nhallucinations. Knowing patient past psychiatric history, \nPsychiatry service was consulted. Psychiatry recommended to \ndiscontinue patient's Clonazepam and started her on Ramelteon. \nAlso, the recommended to minimize opioids. During \nhospitalization patient's mental status was waxing and waning, \nand returned close to her baseline prior to discharge. \nClonazepam was held on discharge. \nCV: Patient cardiovascular status was monitored with telemetry \nduring admission. She had a few episodes of tachycardia. ECG was \nobtained and revealed sinus tachycardia. She underwent CTA chest \nto rule out PE, which was negative. HR returned back to regular \nprior to discharge. \nPulmonary: On POD 3, patient desaturated, she required 7L over \nn/c to maintain normal O2 sats. CXR revealed pulmonary edema vs. \ninfectious process. CTA chest was obtained to rule out PE as \npatient was also tachycardic. CTA was negative for PE, revealed \nmild pulmonary edema. Patient was diuresed with 10 mg Lasix x 1. \nPost Lasix patient's respiratory status improved. She was weaned \noff supplemental O2 and remained on RA prior to discharge. \nGI/GU/FEN: Post-operatively, the patient was made NPO with IV \nfluids. Diet was advanced when appropriate, which was well \ntolerated. Patient's intake and output were closely monitored, \nand IV fluid was adjusted when necessary. She developed severe \ndiarrhea and was restarted on Creon. Imodium was provided to \ncontrol diarrhea as well, diarrhea subsided prior to discharge. \nPatient at home takes Colestipol to prevent diarrhea, which \nunfortunately not formulary. \nID: The patient's white blood count and fever curves were \nclosely watched for signs of infection. Wound was evaluated \ndaily and no signs of infection wer e noticed. JP drain was \ndiscontinued on POD 3 as output was low. \nEndocrine: No issues.\nHematology: The patient's complete blood count was examined \nroutinely; no transfusions were required.\nProphylaxis: The patient received subcutaneous heparin and \nvenodyne boots were used during this stay; was encouraged to get \nup and ambulate as early as possible.\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating a regular \ndiet, ambulating with rolling walker, voiding without \nassistance, and pain was well controlled. The patient received \ndischarge teaching and follow-up instructions with understanding \nverbalized and agreement with the discharge plan.\n\n \nMedications on Admission:\nabilify 2', klonopin 0.5', colestipol 4g qHS, prolia inj q6mo, \nhycosamine sulfate 0.125'PRNspasm, lamictal 100\", Synthroid ___ \n(50 on ___, creon ___ - 2 ___, prilosec 40', sertraline \n250', simvastatin 40', asa 81', vit D3 1000', vit B12 1500? \n2500? SL', vit B6 100', ferrous sulfate 325', folic acid 0.8', \nimodium PRN\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever \n2. colestipol 1 gram oral QHS \n3. Ramelteon 8 mg PO QHS:PRN insomnia \n4. ARIPiprazole 2 mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. ClonazePAM 0.25 mg PO QHS \n7. Creon 12 2 CAP PO TID W/MEALS \n8. Cyanocobalamin 1500 mcg PO DAILY \n9. FoLIC Acid 1 mg PO DAILY \n10. LamoTRIgine 100 mg PO BID \n11. Levothyroxine Sodium 100 mcg PO 6X/WEEK (___) \n \n12. Levothyroxine Sodium 150 mcg PO 1X/WEEK (WE) \n13. LOPERamide 2 mg PO QID:PRN diarrhea \n14. Omeprazole 40 mg PO DAILY \n15. Pyridoxine 100 mg PO DAILY \n16. Sertraline 250 mg PO DAILY \n17. Simvastatin 40 mg PO QPM \n18. Vitamin D 1000 UNIT PO DAILY \n19. Ferrous Sulfate 325 mg daily \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n1. Incisional hernia\n2. Post operative delirium \n3. Pulmonary edema \n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid \n(___).\n\n \nDischarge Instructions:\nMs. ___,\nYou were admitted to the surgery service at ___ for elective \nincisional hernia repair. You recovery was complicated by post \noperative delirium and mild pulmonary edema. You are now safe to \nbe discharge into rehabilitation facility to complete your \nrecovery with the following instructions:\n.\nPlease call Dr. ___ office at ___ if you have any \nquestions or concerns. During Off hours: Call Operator at \n___ and ask to ___ team. \n.\nPlease call your doctor or nurse practitioner if you experience \nthe following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain is not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n.\nGeneral Discharge Instructions:\nPlease resume all regular home medications , unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon, who will instruct you further regarding activity \nrestrictions.\nAvoid driving or operating heavy machinery while taking pain \nmedications.\nPlease follow-up with your surgeon and Primary Care Provider \n(PCP) as advised.\n.\nIncision Care:\n*Please wear abdominal binder until your follow up with the \nsurgeon. You can shower without the binder. \n*Please call your doctor or nurse practitioner if you have \nincreased pain, swelling, redness, or drainage from the incision \nsite.\n*Avoid swimming and baths until your follow-up appointment.\n*You may shower, and wash surgical incisions with a mild soap \nand warm water. Gently pat the area dry.\n*If you have staples, they will be removed at your follow-up \nappointment.\n\n \nFollowup Instructions:\n___\n" ]

[ "K432", "J810", "F05", "K660", "Z90411", "Z9049", "Z8674", "I4510", "E785", "N183", "D631", "F418", "J302", "M810", "E039", "G250", "I69398", "G9389", "R000", "E559", "H9110", "N1370", "Z8507", "D510", "G40909" ]

[ "K432: Incisional hernia without obstruction or gangrene", "J810: Acute pulmonary edema", "F05: Delirium due to known physiological condition", "K660: Peritoneal adhesions (postprocedural) (postinfection)", "Z90411: Acquired partial absence of pancreas", "Z9049: Acquired absence of other specified parts of digestive tract", "Z8674: Personal history of sudden cardiac arrest", "I4510: Unspecified right bundle-branch block", "E785: Hyperlipidemia, unspecified", "N183: Chronic kidney disease, stage 3 (moderate)", "D631: Anemia in chronic kidney disease", "F418: Other specified anxiety disorders", "J302: Other seasonal allergic rhinitis", "M810: Age-related osteoporosis without current pathological fracture", "E039: Hypothyroidism, unspecified", "G250: Essential tremor", "I69398: Other sequelae of cerebral infarction", "G9389: Other specified disorders of brain", "R000: Tachycardia, unspecified", "E559: Vitamin D deficiency, unspecified", "H9110: Presbycusis, unspecified ear", "N1370: Vesicoureteral-reflux, unspecified", "Z8507: Personal history of malignant neoplasm of pancreas", "D510: Vitamin B12 deficiency anemia due to intrinsic factor deficiency", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus" ]

[ "E785", "E039" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ngabapentin\n \nAttending: ___.\n \nChief Complaint:\nHeadache\n \nMajor Surgical or Invasive Procedure:\nNone.\n\n \nHistory of Present Illness:\n___ with PMH of TBI, Factor V Leiden w/ prior DVT and venous\nsinus thrombosis (VST) on coumdin and IVF filter, who presented\nwith three days of worsening head pain. She was treated with a\nmigraine cocktail in the ED (IV acetaminophen, Benadryl, fluids,\nand Reglan). Neurology was consulted given c/f thrombosis. VST\nruled out on MR head W & W/O contrast with ___ negative for DVT\nand CTA negative for PE. Started on lovenox bridge to Coumadin\nand originally planned for discharge home but concerns for trops\nuptrending (-Trop 0.08 --> 0.09 --> 0.11, MB 14 --> 16 --> \n15)and\nreportedly 1 month history of chest pain. EKG with new TWI's in\nV1-V3. Recent stress echo was wnl. \n\nUpon interview, patient endorsed continued headache worse than\nprior, says headaches are responsive to topamax. Per patient, \nshe\nhas experienced several months of chest pain, worse in the last\nmonth. The pain is located near the lower chest\nwall/mid-epigastrium, sharp, pleuritic, and intermittent,\nworsened with exertion and improved by rest. Each chest pain\nepisodes last < 5 minutes. Once the pain radiated to ___ L jaw\nbut no radiation to arms. Endorses chronic shortness of breath\nwith worsening dyspnea on exertion. Denies history of MI or \nheart\nfailure.\n\nAlso says she has chronic constipation requiring frequently self\nmanual extraction. Last BM was 5 days ago. Denies bloody stool\nunless after manual extraction. Recalls some nausea in ED but no\nvomiting. No dysuria or hematuria but says she suffers chronic\nUTIs. Endorses chronic for several months with sensation of dry\nthroat and productive copious phlegm initially dark but now\nwhite.\n\nSo far patient has received IV fluids, IV Tylenol, IV benedryl,\nIV reglan, IV toradol, IV heparin, PO topiramate 50mg x 2,\nescitalopram 20mg, pantoprazole 40mg, clonazepam 0.5mg,\nfamotidine 20mg, prochlorperazine 5mg, enoxaparin 70mg, warfarin\n5mg\n\n \nPast Medical History:\nfactor V Leiden (heterozygous)\n- cerebral venous thrombosis (___) with involvement of the\nsuperior sagittal sinus, right transverse sinus, right sigmoid\nand straight dural venous sinus\n- DVT s/p IVC filter placement\ntraumatic brain injury TBI (hx of being on Coumadin and\nsustaining IPH)\ntransient ischemic attacks\ndepression/anxiety\nmigraines\nR patella removal\nL ___ toe surgery \nshingles involving likely R T10 area. \nfactor V Leiden (heterozygous)\n- cerebral venous thrombosis (___) with involvement of the\nsuperior sagittal sinus, right transverse sinus, right sigmoid\nand straight dural venous sinus\n- DVT s/p IVC filter placement\ntraumatic brain injury TBI (hx of being on Coumadin and\nsustaining IPH)\ntransient ischemic attacks\ndepression/anxiety\nmigraines\nR patella removal\nL ___ toe surgery \nshingles involving likely R T10 area. \n \nSocial History:\n___\nFamily History:\nfather and brother died of blood clots ___ Factor\nV Leiden deficiency \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVITALS: T 98.1, BP 99/65, HR 62, O2 97 on RA\nGENERAL: Alert and interactive. In no acute distress.\nHEENT: NCAT. Sclera anicteric and without injection.\nNECK: Supple\nCARDIAC: RRR Audible S1 and S2. No murmurs/rubs/gallops.\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing.\nABDOMEN: Soft, non distended, diffusely tender to deep palpation\nespecially in lower abdomen, no organomegaly\nEXTREMITIES: No clubbing, cyanosis, non-pitting edema in\nbilateral ___. good distal pulses\nSKIN: WWP. No rash.\nNEUROLOGIC: Alert, answers questions appropriately, moves all\nextremities\nPsych: Affect is anxious and somewhat depressed appearing\n\n==============================\nDISCHARGE PHYSICAL EXAM:\n24 HR Data (last updated ___ @ 710)\n Temp: 97.8 (Tm 98.3), BP: 132/78 (104-132/62-78), HR: 57\n(52-68), RR: 18 (___), O2 sat: 97% (96-97), O2 delivery: Ra \n\nGENERAL: Alert and interactive. In no acute distress.\nCARDIAC: RRR Audible S1 and S2. No murmurs/rubs/gallops.\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing.\nABDOMEN: Soft, non distended, non-tender.\nEXTREMITIES: No clubbing, cyanosis, non-pitting edema in\nbilateral ___. good distal pulses\nSKIN: WWP. No rash.\nNEUROLOGIC: Alert, answers questions appropriately, moves all\nextremities\n \nPertinent Results:\nADMISSION LABS:\n___ 05:00PM BLOOD WBC-5.3 RBC-4.13 Hgb-12.2 Hct-38.1 MCV-92 \nMCH-29.5 MCHC-32.0 RDW-15.2 RDWSD-51.7* Plt ___\n___ 05:00PM BLOOD Neuts-44.8 ___ Monos-7.2 Eos-0.2* \nBaso-0.6 Im ___ AbsNeut-2.36 AbsLymp-2.46 AbsMono-0.38 \nAbsEos-0.01* AbsBaso-0.03\n___ 05:00PM BLOOD ___ PTT-31.7 ___\n___ 05:00PM BLOOD Glucose-87 UreaN-16 Creat-0.8 Na-139 \nK-7.3* Cl-105 HCO3-21* AnGap-13\n___ 05:00PM BLOOD Albumin-4.4 Calcium-9.4 Phos-3.6 Mg-2.1\n___ 05:00PM BLOOD ALT-22 AST-72* AlkPhos-36 TotBili-0.4\n___ 06:00AM BLOOD %HbA1c-5.2 eAG-103\n___ 06:00AM BLOOD Triglyc-103 HDL-59 CHOL/HD-3.0 LDLcalc-97\n___ 09:43PM BLOOD ___ pO2-206* pCO2-32* pH-7.38 \ncalTCO2-20* Base XS--4\n\nTROPONINS/CK:\n___ 12:30AM BLOOD CK(CPK)-329*\n___ 12:00PM BLOOD CK(CPK)-300*\n___ 05:00PM BLOOD CK-MB-14* cTropnT-0.08*\n___ 12:30AM BLOOD CK-MB-16* MB Indx-4.9\n___ 12:30AM BLOOD cTropnT-0.09*\n___ 12:00PM BLOOD CK-MB-15* MB Indx-5.0 cTropnT-0.11*\n___ 09:38PM BLOOD CK-MB-10 cTropnT-0.17*\n___ 02:52AM BLOOD CK-MB-10 cTropnT-0.14*\n___ 06:00AM BLOOD CK-MB-10 cTropnT-0.13*\n___ 12:54PM BLOOD cTropnT-0.10*\n\nINR:\n___ 05:00PM BLOOD ___ PTT-31.7 ___\n___ 12:00PM BLOOD ___ PTT-150* ___\n___ 06:00AM BLOOD ___ PTT-60.9* ___\n___ 06:35AM BLOOD ___\n___ 06:40AM BLOOD ___ PTT-37.6* ___\n___ 06:15AM BLOOD ___\n___ 06:03AM BLOOD ___\n\nDISCHARGE LABS: \n___ 06:03AM BLOOD WBC-5.5 RBC-3.33* Hgb-9.9* Hct-31.2* \nMCV-94 MCH-29.7 MCHC-31.7* RDW-15.5 RDWSD-53.3* Plt ___\n___ 06:03AM BLOOD Plt ___\n___ 06:03AM BLOOD ___\n___ 06:03AM BLOOD Glucose-92 UreaN-13 Creat-0.6 Na-146 \nK-3.9 Cl-110* HCO3-23 AnGap-13\n___ 06:03AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.0\n\nMICROBIOLOGY:\n___ 4:44 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: < 10,000 CFU/mL. \n==========================================================\n \n___ 3:49 pm URINE Source: ___. \n **FINAL REPORT ___\n URINE CULTURE (Final ___: \n ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE \nIDENTIFICATION. \n Cefazolin interpretative criteria are based on a dosage \nregimen of\n 2g every 8h. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | \nAMIKACIN-------------- <=2 S\nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- =>32 R\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ =>16 R\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ 8 I\nTRIMETHOPRIM/SULFA---- =>16 R\n\nIMAGING: \n___ CTA CHEST: \n1. No pulmonary embolus or acute aortic abnormality. \n2. New bilateral lower lobe opacification may reflect mild \ninterstitial edema. \n3. Large hiatal hernia. \n \n___ CORONARY CTA:\n \nIMPRESSION:\n1. CAD-RADS 0- No plaque or stenosis. \n2. Moderate to large hiatal hernia. \n3. Mild bibasilar ground-glass opacities and mild bronchial wall \nthickening \nmay be secondary to aspiration, atelectasis and/or mild \ninterstitial edema. \n \n\n \nBrief Hospital Course:\nMs. ___ is a ___ with PMH of TBI, Factor V Leiden w/ \nprior DVT and venous sinus thrombosis (VST) on coumdin and IVF \nfilter, who presented with three days of worsening head pain, \nVST ruled out on MR. ___ hospital course has been complicated by \nE. coli UTI and chest pain for which a coronary CTA was \nperformed. The final read was still pending at the time of \ndischarge.\n\nACUTE ISSUES:\n=============\n#Atypical, intermittent chest pain\n#Elevated troponins\n#Concern for NSTEMI\nPatient reports intermittent chest pain for the past few months \nthat is positional in nature; she reports she experiences the \npain when she is at rest, lying on ___ side and shrugging. Of \nnote, she never experiences the chest pain with exertion. She \nwas found to have elevated troponins that peaked at 0.17 at \nadmission and downtrended thereafter. Reassuringly, EKGs \nappeared similar to prior EKGs (V1-V3 TWIs); also, recent \n___ stress echo was neg for ischemic changes. She was \nhypotensive at admission, so it is possible ___ troponin leak \nmay have been ___ Type 2 NSTEMI. Alternatively, given ___ pain \nis located near ___ mid-epigastrium, it was felt ___ chest pain \nmay have been related to ___ hiatal hernia/GERD vs. h/o anxiety \nc/b panic disorder. ___ CTA was neg for PE. ___ coronary CTA \nprelim read showed no e/o clinically significant coronary artery \ncalcifications or severe coronary artery stenosis. Per the \nradiologist, it would take ___ days for the final report. Given \n___ low cardiac risk, the patient was discharged and ___ \ncardiologist (Dr. ___ was emailed for close follow-up. \nShe was started on statin 20mg qhs (per Cardiology), with a plan \nto add b-blocker if she began to have more concerning sx. \nAspirin was held, as she was already being anticoagulated with \nwarfarin. \n\n#Hypotension\nPatient triggered for Doppler BP of 69 which improved to ___ \non ___. Patient was mentating well without lightheadedness and \nother acute complaints. Unclear etiology, though may have been \n___ poor po intake given pt's history of frequent \nnausea/vomiting. CTA ruled out PE, and patient was afebrile \nwithout infectious symptoms, lowering the concern for sepsis. \n___ BCx showed NGTD. Lactate initially elevated at 2.6, but \ndowntrended on ___ to nml limits. She received 1L LR on ___ \nand BPs improved to 110-130s systolic thereafter. \n\n#Nausea, Vomiting\n#Hiatal hernia\n#Tortuous esophagus\nReports progressive inability to tolerate solid foods over the \npast few months. Also reports ~20% weight loss in past 6 months, \nper Nutrition. ___ EGD notable for hiatal hernia, tortuous \nesophagus which is likely causing ___ inability to swallow foods \n(reports food gets stuck in ___ chest). No e/o malignancy on \nprior EGD. She was continued on Famotidine 40 mg PO BID, \nPantoprazole 40 mg PO Q12H, and IV Compazine initially. She was \nswitched to PO home Compazine when she was able to tolerate po \nintake. We recommend she contact ___ PCP to schedule ___ GI \nappointment. She has seen a GI doctor in the past, but would \nprefer to see another GI doctor. \n\n#Constipation\nReports having to manually disimpact herself at times due to \nhard stool. Likely causing diffuse abdominal pain. Has BM \nusually every other day and uses OTC laxatives. Last BM ~5 days \nprior to admission, but had multiple BMs on ___. She was given \nSenna bid standing, Miralax bid standing, Milk of Magnesia. \n\n#Headache: \nEtiology is likely migraine vs tension headache vs TBI. VST was \nruled out on ___ MR. ___ discussed with Dr. ___ \noutpatient ___ and increased ___ home topiramate from \n75mg qd > 100mg qd. She was continued on PO Tylenol, as well as \nCompazine.\n\n#Factor V Leiden\n#Prior DVT and venous sinus thrombosis (VST) \nPatient was subtherapeutic with INR 1.3 on presentation. During \nthis admission, she was bridged from lovenox to warfarin. No PE \nseen on CTA and ___ without DVT. ___ ___ clinic \nwas contacted and will contact patient for an INR recheck within \n___ days of discharge. \n\n#Severe chronic malnutrition\nReports unintentional weight loss (~20% in past 6 months), \nlikely due to frequent vomiting ___ episodes of emesis \nthroughout the week). Nutrition was consulted and she was \nstarted on MVI with minerals. \n\n#Acute E. Coli UTI\n#Chronic UTI\n___ UCx was negative at admission and home Keflex ___ qd for \nppx UTI was subsequently held. We initiated ___ on Keflex and \npyridium, as she began to experience dysuria, urinary \nincontinence. ___ UCx was notable for E. Coli UTI, sensitive \nto Keflex. She was increased from 250mg qd to Keflex ___ bid.\n\n#Hypernatremia\nShe was briefly hypernatremia, but this resolved after we \nencouraged increased po fluid intake. \n\nCHRONIC ISSUES:\n=============== \n#Urinary incontinence: \nContinued Oxybutynin 5 mg PO TID \n\n#Depression/Anxiety: \nContinued Escitalopram Oxalate 20 mg PO DAILY and Clonazepam 0.5 \nmg PO/NG BID:PRN anxiety. \n\n======================\nMEDICATION CHANGES\n======================\n[]Increased home topiramate from 75mg once daily to 100mg once \ndaily. \n[]Started atorvastatin 20mg qhs for intermittent chest pain. ASA \n81mg was not started as she was already being AC with warfarin. \n___ home Keflex ___ daily was increased to 500mg bid x3 days \ndue to ___ UCx notable for E. coli. Antibiotic course \n(___). \n[]Started multivitamin with minerals for malnutrition. \n[]Held Strattera during admission, as pt said she did not like \nthe side effects of Straterra. She plans on following up with \n___ outpatient Psychiatrist to discuss switching Straterra > \nAdderall. \n\n======================\nTRANSITIONAL ISSUES\n======================\n[] Re-check INR in 3 days (___). Modify warfarin dosing as \nneeded. \n[] Monitor headache symptoms. \n[] Monitor for UTI symptoms. \n[] Follow-up with neurology, cardiology.\n\n#CODE: DNR/DNI (confirmed with patient and daughter on \n___\n#CONTACT: ___ (___), phone: ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Cephalexin 250 mg PO DAILY \n2. ClonazePAM 0.5 mg PO BID:PRN anxiety \n3. Escitalopram Oxalate 20 mg PO DAILY \n4. Famotidine 40 mg PO BID \n5. Oxybutynin 5 mg PO TID \n6. Pantoprazole 40 mg PO Q12H \n7. Topiramate (Topamax) 50-75 mg PO DAILY \n8. Warfarin 5 mg PO DAILY16 \n9. Ferrous Sulfate 325 mg PO DAILY \n10. Prochlorperazine 5 mg PO Q8H:PRN nausea \n11. atomoxetine 40 mg oral DAILY \n\n \nDischarge Medications:\n1. Atorvastatin 20 mg PO QPM \nTake one tablet (20mg) every night. \nRX *atorvastatin 20 mg one tablet(s) by mouth every evening Disp \n#*30 Tablet Refills:*0 \n2. Cephalexin 500 mg PO Q12H Duration: 3 Days \nDon't take your cephalexin 250 mg daily while taking this. \nResume it after completing this regimen. \nRX *cephalexin 500 mg one capsule(s) by mouth every 12 hours \nDisp #*4 Capsule Refills:*0 \n3. Multivitamins W/minerals Chewable 1 TAB PO DAILY \n4. Phenazopyridine 200 mg PO TID Duration: 3 Days \nRX *phenazopyridine 200 mg one tablet(s) by mouth three times \ndaily Disp #*6 Tablet Refills:*0 \n5. Polyethylene Glycol 17 g PO BID \nRX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth \ntwice daily as needed for constipation Refills:*0 \n6. Senna 8.6 mg PO BID \nRX *sennosides [senna] 8.6 mg one tablet by mouth twice daily as \nneeded for constipation Disp #*30 Tablet Refills:*0 \n7. Topiramate (Topamax) 100 mg PO DAILY \n8. atomoxetine 40 mg oral DAILY \n9. Cephalexin 250 mg PO DAILY \n10. ClonazePAM 0.5 mg PO BID:PRN anxiety \n11. Escitalopram Oxalate 20 mg PO DAILY \n12. Famotidine 40 mg PO BID \n13. Ferrous Sulfate 325 mg PO DAILY \n14. Oxybutynin 5 mg PO TID \n15. Pantoprazole 40 mg PO Q12H \n16. Prochlorperazine 5 mg PO Q8H:PRN nausea \n17. Warfarin 5 mg PO DAILY16 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nHeadache\nAtypical chest pain\nHypotension\nNausea\nVomiting\nHiatal Hernia \nConstipation \nFactor V Leidin\nDVT \nVenous ___ thrombosis \nSevere chronic malnutrition \nHypernatremia\nAcute on chronic urinary tract infection \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n====================== \nDISCHARGE INSTRUCTIONS \n====================== \nDear Ms. ___, \n\nIt was a privilege caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n- You came to the hospital for 3 days of worsening head pain. \n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- We increased your Topamax from 75mg once daily to 100mg once \ndaily. We discussed this with your Neurologist, who agreed with \nthis change. \n- We obtained imaging of your heart vessels. The final report \nwas still pending at the time of your discharge. We started you \non a new medication, called atorvastatin to help reduce the risk \nof heart disease. \n- We increased your Keflex dose from 250mg once daily to 500mg \ntwice daily for a urinary tract infection that grew a type of \nbacteria called E. coli. Take the 500mg twice daily dose until \n___. Thereafter, you can resume your daily 250mg dose. \n- We gave you additional medications to help with your \nconstipation. \n- We continued you on your home warfarin. \n- We started you on a multivitamin, as this will help with your \nnutrition. \n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n- Continue to take all your medicines and keep your \nappointments. \n- The ___ clinic will contact you about \nchecking your INR within ___ days of leaving the hospital. \n- Ask your primary care doctor to refer you to a ___ \nVanguard GI doctor for your hiatal hernia. \n\nWe wish you the best! \n\nSincerely, \nYour ___ Team \n\n \nFollowup Instructions:\n___\n" ]

[ "G43909", "E43", "D6851", "E870", "N390", "G44209", "R0789", "I959", "K449", "R112", "K5900", "Z86718", "Z7901", "Z6827", "B9620", "R32", "F329", "F419", "Z66", "Z8673", "Z23" ]

[ "G43909: Migraine, unspecified, not intractable, without status migrainosus", "E43: Unspecified severe protein-calorie malnutrition", "D6851: Activated protein C resistance", "E870: Hyperosmolality and hypernatremia", "N390: Urinary tract infection, site not specified", "G44209: Tension-type headache, unspecified, not intractable", "R0789: Other chest pain", "I959: Hypotension, unspecified", "K449: Diaphragmatic hernia without obstruction or gangrene", "R112: Nausea with vomiting, unspecified", "K5900: Constipation, unspecified", "Z86718: Personal history of other venous thrombosis and embolism", "Z7901: Long term (current) use of anticoagulants", "Z6827: Body mass index [BMI] 27.0-27.9, adult", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "R32: Unspecified urinary incontinence", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "Z66: Do not resuscitate", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z23: Encounter for immunization" ]

[ "N390", "K5900", "Z86718", "Z7901", "F329", "F419", "Z66", "Z8673" ]

[]

[ " \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:\nDehydration, Hyperkalemia, Acute Kidney Injury\n \nMajor Surgical or Invasive Procedure:\n___ - Placement of a 16 ___ MIC Gastrostomy Tube\n___ - LUE PICC placed by ___\n\n \nHistory of Present Illness:\n___ is a ___ yo man with metastatic head and neck SCC \non palliative RT, s/p dobhoff for dehydration, electrolyte \nabnormalities and ___ noted on labs.\n\nMr. ___ was initially diagnosed with well differentiated \npapillary SCC involving the right gumline in ___. In \n___, he was seen by Dr ___ at ___ and the lesion \nwas noted to have grown 2.8 x 1.8 cm -> 3.2 x 2 cm. He was \nrecommended for surgery +/- RT, but he elected to pursue \nalternative medicine. In ___, his lesion began eroding \nthrough his check. He was referred to Dr ___ ENT but prior \nhis initial visit, he presented to ___ ED ___. CT \ndemonstrated an large ill-defined fungating lesion lateral to \nthe right mandible, several necrotic cervical nodes, and \nnumerous pulmonary nodules. A dobhoff tube was placed in light \nof poor PO intake ___ trismus with 40 lb weight loss over the \nlast year. He was referred for palliative RT and received the \nfirst of 3 planned fx (1480 cGy / 4400 cGy) on ___.\n\nHe established care with Dr ___ day prior to admission. \nThey discussed various options for chemotherapy. Routine \nbloodwork was obtained, which returned today demonstrating \nmultiple electrolyte derangements (including Na 156) and ___ (Cr \n2.0, from prior baseline 1.1), concerning for dehydration. He \nwas recommended to present to the ED.\n\nOf note, he did have a BUN/Cr checked ___ as part of routine \nmonitoring for IV antibiotics (on CTX/Flagyl started ___ for \npossible superimposed bacterial infection of oral mass), which \ndemonstrated ___: 44/1.5 from ___ on ___. Other \nelectrolytes were not checked at that time.\n\nIn the ED: T 97.9 F | 129 (baseline 110s) | 123/82 | 99% RA. He \nreceived CTX/flagyl, 1L NS, and 40 mEq KCl.\n\nWhen seen at bedside, Mrs. ___ reports that she has been \ntrying to keep up with free water flushes through Dobhoff and \nestimates she can get about ___ fluid oz in a day (approx. \n700-900 cc) since discharge from hospital. However, because his \nTF cycle for 16 hours a day, her ability to flush water through \nthe tube has been limited.\n\nMr. ___ noted increased dry mouth and thirst, but has been \nunable to tolerate anything by mouth apart from small sips due \nto his trismus and large facial tumor. Mr ___ states he \nnoticed worsening fatigue, some slight palpitations, and perhaps \ndarker urine, but felt well otherwise. He denies any \nnausea/vomiting apart from a couple episodes of emesis on ___ \nwhen his dobhoff\nbecame clogged and dislodged (replaced in ___ ED). He has not \nhad fevers. He denies any lightheadedness/dizziness including \nwhen he stands. Both Mr and Mrs ___ deny any confusion or \nchange in mental status.\n \nPast Medical History:\nMr. ___ and his wife ___ reports that he first noticed a \nlesion of his right gumline in ___. On ___ \nhe had a biopsy of the area with his oral surgeon Dr. ___ \n___ in ___ which showed papillary squamous cell \ncarcinoma, well-differentiated, extending to the tissue edges. \nIt appears in ___ and ___ he saw Dr. ___ at \n___ and the lesion was noted to grow from 2.8 \ncm x 1.8 cm to 3.2 x 2 cm. He was strongly urged to have surgery \nfollowed by possible radiation. Apparently around this time he \nwas also seeing several alternative medicine practitioners \nincluding ___ ___ clinic in ___, a clinic in ___ \n___ and ultimately a ___ in ___. He \nreceived a number of treatments including vitamin C, \nglutathione, sodium bicarbonate, raw juice diet. Over the next \nseveral months he felt that his tumor was actually improving and \nhis wife describes pieces of it sloughing off periodically. \nSometime around ___ though the lesion eroded through \nhis cheek and a fungating lesion began to enlarge. Ultimately he \nwas referred to Dr. ___ in ENT here but prior to that \noutpatient appointment ended up in the emergency room on \n___. CT scans demonstrated a large ill-defined \nfungating soft tissue lesion predominantly lateral to the right \nmandible extending superiorly to the coronoid process of the \nmandible and inferiorly to the superior aspect of the thyroid \ncartilage, invading the right masticator space and oral cavity \nand eroding into the right anterior mandibular body. Several \nnecrotic cervical lymph nodes were noted. A CT of the chest \nshowed numerous round solid pulmonary nodules consistent with \ndiffuse pulmonary metastases. He was started on antibiotics for \npossible superinfection. He was noted to have hypercalcemia to \n12.2 which improved with IV fluids. He had lost about 40 pounds \nover the last year due to a combination of being unable to eat \nsecondary to trismus and only consuming a raw juice vegan diet. \nA Dobbhoff tube was placed and he was started on tube feeds. He \nwas not felt to be a surgical candidate and was seen by medical \nand radiation oncology with a plan to continue treatment \nplanning after discharge. Shortly after discharge his wife noted \ncontinued rapid tumor growth and he was started on palliative \nradiotherapy on ___.\n \nSocial History:\n___\nFamily History:\nNo family history of head or neck cancer.\n \nPhysical Exam:\nVS: T98.4 F | 126/74 | 92 | 98% RA.\nGeneral: Thin cachectic man, lying in bed in no acute distress.\nNeuro: PERRL, alert, oriented, answers questions appropriately\nHEENT: Large fungating tumor extending from the right jaw, \nunable to open mouth fully, dried yellow-white mucus seen inside \nthe mouth and over the tumor site, dry mucus membranes.\nCardiovascular: RRR no murmurs. \nChest/Pulmonary: Crackles at the right base. \nAbdomen: Cachectic abdomen, soft, nontender. PEg tube in place. \nSite c/d/i\nExtr/MSK: WWP. Moderate soft pitting edema of the LUE. PICC site \nis c/d/i.\nSkin: No significant rashes seen\n \nPertinent Results:\n===============\nPertinent Labs: \n===============\n___ 05:16AM BLOOD WBC-7.8 RBC-2.45* Hgb-7.4* Hct-22.9* \nMCV-94 MCH-30.2 MCHC-32.3 RDW-14.6 RDWSD-49.4* Plt ___\n___ 05:16AM BLOOD Glucose-101* UreaN-15 Creat-0.6 Na-141 \nK-3.5 Cl-105 HCO3-27 AnGap-9*\n___ 05:27AM BLOOD ALT-12 AST-12 LD(LDH)-195 AlkPhos-78 \nTotBili-0.3\n___ 05:16AM BLOOD Calcium-6.9* Phos-2.2* Mg-1.7\n___ 04:58AM BLOOD 25VitD-20*\n\n=============\nMicrobiology:\n=============\n___ Blood Culture Pending\n___ Blood Culture Pending\n\n========\nImaging:\n========\nCXR ___\nThe left pleural effusion has minimally decreased. The \npulmonary nodules documented on the CT examination from ___ are only partially visible on the chest \nradiograph. There currently is no evidence for the presence of \npneumonia. Normal size of the heart. Normal position of the \nleft PICC line. \n\nLUE Doppler ___\nDeep venous thrombosis around the left upper extremity PICC \nextending from the left axillary vein into a left brachial vein. \n Additional partially occlusive thrombus seen in the left \ncephalic vein. \n \nBrief Hospital Course:\n___ is a ___ yo man with metastatic oral SCC s/p \npalliative RT and severe\nmalnutrition s/p dobhoff for TF who was initially admitted on \n___ with hypernatremia, ___, and hypercalcemia. He received PEG \ntube placement to assist with correction of metabolic \nabnormalities and malnutrition. During this admission, he was \nalso started on chemotherapy with ___ on \n___. \n\nHis hospital course by issue: \n\n# Dehydration, hypernatremia\n# Severe protein-calorie malnutrition\n# Hypomagnesemia, Hypokalemia, Hypophosphatemia\n\nHe presented with electrolyte abnormalities and ___ due to \ninability to keep up with nutrition and hydration through \ndobhoff tube at home. A PEG tube was placed ___. It was \nreplaced ___ with ___ due to clogging. His free water deficit \nwas corrected and he was started on bolus tube feeds through his \nnew PEG tube. \n\nHe will be discharged with PO magnesium and neutraphos \nsupplementation for ongoing hypomagnesemia and phosphoatemia.\n\n[ ] follow up BMP, Ca/Mg/Phos and adjust electrolyte repletions \nand free water flushes accordingly\n\n# Concern for Mass Infection: \nHad been on CTX/flagyl since last admission. He was recommended \nby ID for ___ wks of therapy, and he completed initial 4-week \ncourse on ___. However developed\npossible AIN with CTX. Also with recurrent sepsis on ___, \npresumably from oral source in the setting of his fungating neck \nmass. Now resolved and on suppressive augmentin. On ___, he \nhad fever to 100.9F and was briefly broadened to \nvanc/cefepime/flagyl. However, his fever was felt to be more \nlikely from tumor and so he was narrowed back to suppressive \naugmentin on ___. \n\n[ ] continue augmentin suppressive therapy indefinitely per ID\n[ ] follow up finalized blood cultures (drawn ___ and ___\n\n# Metastatic Oral Cavity SCC:\n# Secondary Neoplasm of Lung: \nDiagnosed ___ with isolated right gumline lesion. Deferred \nconventional treatment. Presented again ___ with significant \ntumor growth and found to have\nimaging concerning for metastatic disease ___. S/p ___ fx of \npalliative RT on ___. Established care with Dr. ___ ___. \nUrgently started inpatient ___ on \n___. Receive day 8 cetuximab ___.\n\nHe is planned to continue with XRT on ___. Dr ___ discussed \nwith patient and family that they would likely skip D15 \ncetuximab and his next treatment will be with C2D1. \n\n# LUE PICC associated DVT\n\nHis course was complicated by PICC-associated DVT. He had poor \naccess options and declined PORT placement while inpatient. \nAccordingly, he is being treated with lovenox BID while his LUE \nPICC remains in place. \n\n[ ] readdress need for more stable central access\n\n# Acute on Chronic Hypercalcemia: \n# Secondary hypocalcemia: \nHypercalcemia of malignancy with acute worsening due to \ndehydration. Received\npamidronate 60mg IV x 1 on ___ and IVF but then developed \nsecondary hypocalcemia. Continued on calcium 1250 TID on \ndischarge and required intermittent IV calcium gluconate while \nhospitalized for persistent total Ca <7.5\n\n[ ] f/u Ca level on discharge and discontinue calcium \nsupplementation when normalizes\n \n# Difficulty Clearing Secretions \n# Concern for Airway Obstruction \nENT evaluated his airway on this admission and noted he is at \nrisk of airway obstruction. He declined prophylactic trach but \nagreed to intubation in emergent situation, including \n___ and tracheostomy. He has remained stable \nthroughout his hospitalization.\n\nHe is strictly NPO given aspiration risk and recommended to \navoid lying flat.\n\n# Anemia: Secondary to malignancy and possible nutritional \ndeficiencies. B12 and folate normal. Hapto elevated.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. CefTRIAXone 1 gm IV Q24H \n2. MetroNIDAZOLE 500 mg PO Q8H \n3. Bisacodyl 10 mg PR QHS:PRN constipation \n4. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n\n \nDischarge Medications:\n1. Acetaminophen (Liquid) 500 mg PO Q6H:PRN Pain - Mild \nRX *acetaminophen 500 mg/15 mL 15 mL by mouth q6 hours Disp \n#*300 Milliliter Refills:*0 \n2. Amoxicillin-Clavulanate Susp. 500 mg PO Q8H \nRX *amoxicillin-pot clavulanate [Augmentin] 250 mg-62.5 mg/5 mL \n10 mL by mouth three times a day Refills:*5 \n3. Calcium Carbonate Suspension 1250 mg PO TID \nRX *calcium carbonate 500 mg/5 mL calcium (1,250 mg/5 mL) 5 mL \nby mouth three times a day Refills:*0 \n4. Docusate Sodium (Liquid) 100 mg PO BID \n5. Enoxaparin Sodium 60 mg SC Q12H \nRX *enoxaparin 60 mg/0.6 mL 60 mg SC q12 hours Disp #*60 Syringe \nRefills:*0 \n6. Glycopyrrolate 1 mg PO Q6H:PRN secretions \nRX *glycopyrrolate 1 mg 1 tablet(s) by mouth q6 hours Disp #*120 \nTablet Refills:*0 \n7. Magnesium Oxide 400 mg PO BID \nOpen capsule and mix with 400 cc free water flush to prevent \nclogging tube \nRX *magnesium oxide 200 mg magnesium 2 tablet(s) by mouth twice \na day Disp #*120 Tablet Refills:*0 \n8. Neutra-Phos 1 PKT PO TID Duration: 2 Days \nRX *potassium, sodium phosphates 280 mg-160 mg-250 mg 1 \npowder(s) by mouth three times a day Disp #*6 Packet Refills:*0 \n9. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line \n\nRX *ondansetron 8 mg 1 tablet(s) by mouth q8 hours Disp #*90 \nTablet Refills:*0 \n10. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second \nLine \nRX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth q6 hours \nDisp #*90 Tablet Refills:*0 \n11. Senna 8.6 mg NG BID:PRN Constipation - First Line \nRX *sennosides [senna] 8.8 mg/5 mL 5 mL by mouth twice a day \nDisp #*237 Milliliter Milliliter Refills:*0 \n12. Thiamine 100 mg PO DAILY \nRX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily \nDisp #*30 Tablet Refills:*0 \n13. Vitamin D ___ UNIT PO DAILY \n14. Polyethylene Glycol 17 g PO DAILY:PRN constipation \nRX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s) \nby mouth daily Refills:*0 \n15.Bolus Tube Feeding\nJevity 1.5; Full strength via Percutaneous gastrostomy (PEG). # \nof mL per feeding: 480 ml; # of feedings/day: 3. Residual Check: \nBefore each feeding, Hold feeding for residual >=200 ml. Flush \nw/ 30 mL water Per standard. Free water amount: 400 mL Q8H\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nmetastatic oral SCC s/p dobhoff for tube feeds, admitted with \nhypernatremia, ___, hypercalcemia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \n ___ MD ___\n \nCompleted by: ___\n" ]

[ "N170", "E43", "A419", "E870", "C7800", "I82622", "Z681", "D689", "K9423", "C490", "C7989", "E860", "E8342", "E876", "E8339", "D539", "E8352", "E8351", "C031", "D630", "C0689", "K5900", "D72829", "Z87891" ]

[ "N170: Acute kidney failure with tubular necrosis", "E43: Unspecified severe protein-calorie malnutrition", "A419: Sepsis, unspecified organism", "E870: Hyperosmolality and hypernatremia", "C7800: Secondary malignant neoplasm of unspecified lung", "I82622: Acute embolism and thrombosis of deep veins of left upper extremity", "Z681: Body mass index [BMI] 19.9 or less, adult", "D689: Coagulation defect, unspecified", "K9423: Gastrostomy malfunction", "C490: Malignant neoplasm of connective and soft tissue of head, face and neck", "C7989: Secondary malignant neoplasm of other specified sites", "E860: Dehydration", "E8342: Hypomagnesemia", "E876: Hypokalemia", "E8339: Other disorders of phosphorus metabolism", "D539: Nutritional anemia, unspecified", "E8352: Hypercalcemia", "E8351: Hypocalcemia", "C031: Malignant neoplasm of lower gum", "D630: Anemia in neoplastic disease", "C0689: Malignant neoplasm of overlapping sites of other parts of mouth", "K5900: Constipation, unspecified", "D72829: Elevated white blood cell count, unspecified", "Z87891: Personal history of nicotine dependence" ]

[ "K5900", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: UROLOGY\n \nAllergies: \nlevofloxacin\n \nAttending: ___.\n \nChief Complaint:\nscrotal pain\n \nMajor Surgical or Invasive Procedure:\nPROCEDURES PERFORMED: Scrotal exploration, evacuation of\nscrotal hematoma and scrotal washout.\n\n \nHistory of Present Illness:\n___ year old male with history of right epididymal head cyst who \nhad this surgically excised on ___. He was doing well \npost-operatively until a\nfew days ago when he developed right scrotal swelling, firmness \nand pain. He has been doing some lifting that he feels could \nhave contributed to this change. He denies any trauma, fevers, \nchills, or infectious symptoms.\n \nPast Medical History:\nhypertension, fatigue and a fall. He also has a history of some \nerectile dysfunction.\n\nHernia repair in ___, tonsillectomy and appendectomy. \n \n\nRight epididymal cyst excsision \n\n \nSocial History:\n___\nFamily History:\nUnremarkable for any prostate cancer. Positive for hypertension \nand thyroid cancer and liver cancer.\n \nPhysical Exam:\nWdWn male, NAD, AVSS\nInteractive, cooperative\nAbdomen soft, Nt/Nd\nHemiscrotum Incision c/d/i w/out evidence hematoma or infection\nEcchymosis at penile shaft/scrotum noted but without induration\nLower extremities w/out edema or pitting and no report of calf \npain\n\n \nBrief Hospital Course:\nMr. ___ was admitted to Dr. ___ service with \nscrotal pain, swelling. He was taken the operative theatre for \nscrotal exploration, evacuation of\nscrotal hematoma and scrotal washout. No concerning \nintraoperative events occurred; please see dictated operative \nnote for details. Perioperative antibiotics were administered \nfor infection prophylaxis and Mr. ___ tolerated the \nprocedure well. He was recovered in the PACU before transfer to \nthe general surgical floor. The post-op course was \nuncomplicated. He was voiding without difficulty. ___ drain \nwas left in place and he was discharged to home with ___ \nservices. At discharge, his pain was well controlled with oral \npain medications, tolerating regular diet, ambulating without \nassistance, and voiding without difficulty. He will follow-up \nwith his urologist as directed and complete a one week course of \nantibiotics.\n\n \nMedications on Admission:\nSEE H&P\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg ONE capsule(s) by mouth \ntwice a day Disp #*60 Capsule Refills:*0 \n3. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 10 Days \nRX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg ONE \ntab-cap by mouth twice a day Disp #*20 Tablet Refills:*0 \n4. Fish Oil (Omega 3) 1000 mg PO DAILY \n5. Lisinopril 10 mg PO DAILY \n6. Multivitamins W/minerals 1 TAB PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n Postoperative scrotal hematoma.\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n-You will be discharged home with Visiting Nurse (___) services \nto further assist your transition. \n\n-For your safety and the safety of others; PLEASE DO NOT drive, \noperate dangerous machinery, or consume alcohol while taking \nnarcotic pain medications. \n\n-ALWAYS call to inform, review and discuss any medication \nchanges and your post-operative course with your primary care \ndoctor.\n\n-___ scrotum/phallus supported/elevated. Use a \njock-supporter/strap or jockey-type briefs or tight, \ntighty-whities to facilitate this; Change the fluffs for \nsaturation/soiling. Do not pull on the ___ drain.\" You may \nshower but do not tub bathe/immerse.\n\n-Do NOT use penis for intercourse/sex until explicitly advised \nby your urologist that is may be ok to do so.\n\n-You may want to coordinate your showers with your ___ provider \nand the planned dressing changes.\n\n-Shower DAILY and PRN; do NOT bathe, swim or otherwise immerse \nyour incision.\n\n-Tylenol/Acetmainophen should be your first line pain medication\n\n-Resume your home medications, except as noted.\n\n-If you have fevers > ___, vomiting, or increased redness, \nswelling, or discharge from your incision, call your doctor or \ngo to the nearest emergency room.\n \nFollowup Instructions:\n___\n" ]

[ "N99840", "N451" ]

[ "N99840: Postprocedural hematoma of a genitourinary system organ or structure following a genitourinary system procedure", "N451: Epididymitis" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nlisinopril / metronidazole / levofloxacin\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nERCP ___\n\nattach\n \nPertinent Results:\nADMISSION LABS:\n\n___ 10:13AM BLOOD WBC-8.8 RBC-5.04 Hgb-15.3 Hct-45.1 MCV-90 \nMCH-30.4 MCHC-33.9 RDW-13.3 RDWSD-43.2 Plt ___\n___ 10:13AM BLOOD Neuts-89.9* Lymphs-5.3* Monos-2.8* \nEos-0.1* Baso-0.3 Im ___ AbsNeut-7.91* AbsLymp-0.47* \nAbsMono-0.25 AbsEos-0.01* AbsBaso-0.03\n___ 07:43AM BLOOD ___ PTT-25.8 ___\n___ 05:46AM BLOOD ___\n___ 10:13AM BLOOD Glucose-218* UreaN-14 Creat-1.3* Na-136 \nK-5.2 Cl-98 HCO3-23 AnGap-15\n___ 10:13AM BLOOD ALT-48* AST-34 AlkPhos-111 TotBili-1.9* \nDirBili-0.7* IndBili-1.2\n___ 07:43AM BLOOD ALT-91* AST-98* LD(LDH)-303* AlkPhos-92 \nTotBili-4.7* DirBili-3.7* IndBili-1.0\n___ 07:43AM BLOOD Albumin-3.1* Calcium-7.3* Phos-4.1 \nMg-0.8*\n___ 11:25PM BLOOD Lactate-2.6*\n\nDISCHARGE LABS:\n\n___ 05:46AM BLOOD WBC-5.3 RBC-3.82* Hgb-11.6* Hct-34.1* \nMCV-89 MCH-30.4 MCHC-34.0 RDW-13.4 RDWSD-43.7 Plt ___\n___ 05:46AM BLOOD Glucose-174* UreaN-12 Creat-0.7 Na-138 \nK-3.7 Cl-100 HCO3-24 AnGap-14\n___ 05:46AM BLOOD ALT-53* AST-29 AlkPhos-106 TotBili-1.4\n___ 05:46AM BLOOD Calcium-7.9* Phos-1.9* Mg-1.7\n\nMRCP:\n\n1. Motion limited examination. \n2. Heterogeneous right hepatic lobe enhancement is similar to \nprior, likely inflammatory fibrosis. \n3. Cirrhosis with evidence of portal hypertension including \nsplenomegaly and trace perihepatic ascites. \n4. Cystic pancreatic lesions measuring up to 1.3 cm, likely \nreflecting side branch intraductal papillary mucinous neoplasms, \nare not appreciably changed. For management of pancreatic \ncyst(s) between 6-15 mm in patients less than ___ years at \npresentation, recommend annual non-contrast MRCP follow-up for ___ \nyears, then every other year up to a total of ___ years. \n \nBLOOD CULTURES:\n\n KLEBSIELLA PNEUMONIAE\n | \nAMPICILLIN/SULBACTAM-- 4 S\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN---------<=0.25 S\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nPIPERACILLIN/TAZO----- <=4 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- <=1 S\n\n \nBrief Hospital Course:\nOn admission, Mr. ___ was started on \npiperacillin-tazobactam to cover gram negative organisms, as \nwell as bolused lactated ringers for his tachycardia and sepsis. \nBlood cultures grew pan-sensitive Klebsiella pneumonia, and he \nwas switched to oral ciprofloxacin. Because of his elevated \nLFTs, the advanced endoscopy team was consulted, who performed \nan ERCP on ___. A full cholangiogram could not be performed \nbecause of ongoing sepsis; however, during the balloon sweep \nthere was resistance felt, which could be consistent with \nampullary stenosis. He also had an MRCP, which again showed \nright hepatic lobe enhancement consistent with inflammatory \nfibrosis, similar to before, as well as cystic pancreatic \nlesions most consistent with intraductal papillary mucinous \nneoplasms. It again showed splenomegaly. Ultimately, he markedly \nimproved on ciprofloxacin, and will finish a course of two weeks \nof antibiotics (13 additional days, from first day of negative \nblood cultures). He will follow up with the ERCP team for repeat \nERCP and possible dilation of the ampulla. \n\nHOSPITAL COURSE BY PROBLEM:\n\n1. Klebsiella pneumonia bacteremia\n2. Cholangitis, possibly due to ampullary stenosis\n- finish 13 days of ciprofloxacin 13 mg BID\n- outpatient ERCP follow up\n\n3. Cirrhosis\n4. Thrombocytopenia\n- outpatient follow up with liver team\n- patient was unable to afford Ursodiol with his insurance. \n\n5. ___. Resolved with IVF.\n\n6. DM2. Restarting home metformin on discharge.\n\n7. HTN. Restarting home antihypertensives on discharge. \n\nTRANSITIONAL ISSUES:\n\n[ ] follow up with ERCP for possible dilation -- ampullary \nstensosis could potentially explain the reason for recurrent \ninfections\n[ ] MRCP again showed cysts in the pancreas. For management of \npancreatic cyst(s) between 6-15 mm in patients less than ___ \nyears at presentation, recommend annual non-contrast MRCP \nfollow-up for ___ years, then every other year up to a total of ___ \nyears. \n\n> 35 minutes spent on discharge activities. Patient examined on \nday of discharge.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 10 mg PO DAILY \n2. Losartan Potassium 100 mg PO DAILY \n3. MetFORMIN (Glucophage) 500 mg PO BID \n4. Ursodiol 1000 mg PO QAM \n5. Ursodiol 500 mg PO QPM \n\n \nDischarge Medications:\n1. Ciprofloxacin HCl 500 mg PO BID \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day \nDisp #*26 Tablet Refills:*0 \n2. amLODIPine 10 mg PO DAILY \n3. Losartan Potassium 100 mg PO DAILY \n4. MetFORMIN (Glucophage) 500 mg PO BID \n5. Ursodiol 1000 mg PO QAM \n6. Ursodiol 500 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nKlebsiella bacteremia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted to the hospital with bacteria in blood \n(Klebsiella pneumoniae bacteremia) and signs of an infection of \nyour biliary system (cholangitis). You were treated with IV and \nthen oral antibiotics with much improvement. You had a repeat \nERCP, which showed a possible narrowing of your bile duct. An \nMRI was performed, which was unchanged.\n\nYou will need to finish two weeks of antibiotics for your \ninfection (ciprofloxacin). When you are feeling better, the ERCP \nteam will contact you for a planned repeat ERCP to try and \ndilate the bile duct. Otherwise, you will follow up with your \nhepatologist and primary care doctor.\n \nFollowup Instructions:\n___\n" ]

[ "A4159", "K831", "K8309", "N179", "Z6842", "R6520", "I10", "M109", "E119", "Z7984", "E669", "D6959", "E039", "K219", "K7460", "T50996A", "Z91120", "K5730", "R1011", "D136", "R0902", "F1010", "F40240" ]

[ "A4159: Other Gram-negative sepsis", "K831: Obstruction of bile duct", "K8309: Other cholangitis", "N179: Acute kidney failure, unspecified", "Z6842: Body mass index [BMI] 45.0-49.9, adult", "R6520: Severe sepsis without septic shock", "I10: Essential (primary) hypertension", "M109: Gout, unspecified", "E119: Type 2 diabetes mellitus without complications", "Z7984: Long term (current) use of oral hypoglycemic drugs", "E669: Obesity, unspecified", "D6959: Other secondary thrombocytopenia", "E039: Hypothyroidism, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "K7460: Unspecified cirrhosis of liver", "T50996A: Underdosing of other drugs, medicaments and biological substances, initial encounter", "Z91120: Patient's intentional underdosing of medication regimen due to financial hardship", "K5730: Diverticulosis of large intestine without perforation or abscess without bleeding", "R1011: Right upper quadrant pain", "D136: Benign neoplasm of pancreas", "R0902: Hypoxemia", "F1010: Alcohol abuse, uncomplicated", "F40240: Claustrophobia" ]

[ "N179", "I10", "M109", "E119", "E669", "E039", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nlisinopril\n \nAttending: ___\n \nChief Complaint:\nPlanned Admission for TAVR\n \nMajor Surgical or Invasive Procedure:\nTAVR ___\nPPM placement ___\n\n \nHistory of Present Illness:\nMs. ___ is an ___ year old woman with a history of aortic \nstenosis, chronic kidney disease, diabetes mellitus type II, \nhyperlipidemia, hypertension, and pulmonary hypertension who is \npre-op for TAVR scheduled for ___. Patient has been followed \nclosely by her cardiologist to monitor her known CAD and aortic \nstenosis. She expressed initially that she did not want to be \naggressive with treatment but in the setting of progression of \nAS the patient agreed to undergo workup for TAVR. Her most \nrecent echocardiogram in ___ demonstrated an aortic valve \narea of 0.7 cm2, depressed ejection fraction (40-45%), and mild \nmitral regurgitation. Given the progression of her aortic \nstenosis, she was referred to Dr. ___ surgical \nconsideration vs. TAVR. She was determined to be moderate \nsurgical risk so she was referred for TAVR. \n\nOf note, patient had diagnostic cath ___ showing significant \ndisease in the LAD, RCA, and LCx. She subsequently underwent PCI \nin ___. A 90% focal stenosis in mid LAD was treated using a \n2.5mm x 16mm Promus Premier (drug eluting) stent. \n\nOn the floor, the patient reports that she feels well. She \ncurrently denies chest pain but she has recently reported some \nmild exertional anginal symptoms that are short in duration and \nreside with rest. \n\nREVIEW OF SYSTEMS: \nCardiac review of systems is notable for absence of chest pain \nat rest, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, \npalpitations, syncope, or presyncope. \n\nOn further review of systems, denies any prior history of \nstroke, TIA, deep venous thrombosis, pulmonary embolism, \nbleeding at the time of surgery, myalgias, joint pains, cough, \nhemoptysis, black stools or red stools. Denies exertional \nbuttock or calf pain. Denies recent fevers, chills or rigors. \nAll of the other review of systems were negative. \n \nPast Medical History:\n1. CARDIAC RISK FACTORS \n- Diabetes type II \n- Hypertension \n- Dyslipidemia \n2. CARDIAC HISTORY \n- CABG: None \n- PERCUTANEOUS CORONARY INTERVENTIONS: DES ___ \n- PACING/ICD: None \n3. OTHER PAST MEDICAL HISTORY \nSevere aortic stenosis \nPulmonary HTN \nCAD s/p ___ to the LAD ___ \nCholangitis s/p laparoscopic cholecystectomy ___ ___\nCervical cancer \nTAH\nCataracts.\nGoiter.\nGout.\nAnemia \n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n======================\nVS: T=97.3 BP=143/85 HR=81 RR=18 O2 SAT=94%RA \nGENERAL: ___ woman in NAD. Oriented x3. Mood, affect \nappropriate. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa. No xanthelasma. \n\nNECK: Supple \nCARDIAC: RRR, normal S1, S2. crescendo decrescendo murmur heard \nbest at the upper sternal border. No thrills, lifts. \nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp \nwere unlabored, no accessory muscle use. No crackles, wheezes or \nrhonchi. \nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: No c/c/e. No femoral bruits. Mild erythema over \nlower ankles b/l. \nSKIN: No ulcers, scars, or xanthomas. \nPULSES: Distal pulses palpable and symmetric \n\nDISCHARGE PHYSICAL EXAM:\n========================\nGENERAL: ___ woman in NAD. Oriented x3. Mood, affect \nappropriate. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa. No xanthelasma. \n\nNECK: Supple, no JVD\nCARDIAC: RRR, normal S1, S2. Soft ___ systolic murmur heard at \nsternal border. No thrills, lifts. L chest wall with bandage, \nhand in sling\nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp \nwere unlabored, no accessory muscle use. No crackles, wheezes or \nrhonchi. \nABDOMEN: Soft, TTP in RUQ and RLQ without rebound or guarding. \nNo HSM or tenderness. \nEXTREMITIES: No c/c/e. No femoral bruits. Mild erythema over \nlower ankles b/l. 1+ ___ edema. \nSKIN: No ulcers, scars, or xanthomas. \nPULSES: Distal pulses palpable and symmetric \n\n \nPertinent Results:\nADMISSION LABS: \n==============\n___ 07:02PM BLOOD WBC-5.1 RBC-3.00* Hgb-8.2* Hct-27.2* \nMCV-91 MCH-27.3 MCHC-30.1* RDW-15.5 RDWSD-50.8* Plt ___\n___ 06:35AM BLOOD WBC-5.3 RBC-2.85* Hgb-7.9* Hct-26.0* \nMCV-91 MCH-27.7 MCHC-30.4* RDW-15.8* RDWSD-52.0* Plt ___\n___ 06:35AM BLOOD Glucose-127* UreaN-19 Creat-1.2* Na-145 \nK-3.8 Cl-105 HCO3-21* AnGap-23*\n___ 07:02PM BLOOD Glucose-145* UreaN-30* Creat-1.3* Na-136 \nK-4.0 Cl-98 HCO3-24 AnGap-18\n___ 07:02PM BLOOD proBNP-2838*\n___ 07:02PM BLOOD ALT-19 AST-11 CK(CPK)-16* AlkPhos-130* \nTotBili-0.2\n___ 07:02PM BLOOD Albumin-3.3* Iron-28*\n___ 07:02PM BLOOD calTIBC-203* Ferritn-578* TRF-156*\n___ 08:30PM URINE Color-Yellow Appear-Clear Sp ___\n___ 08:30PM URINE Blood-NEG Nitrite-NEG Protein-TR \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD\n\n================\nMICROBIOLOGY:\n================\n___ 8:30 pm URINE Source: ___. \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___ 5:33 pm Staph aureus Screen Source: Nasal swab. \n\n **FINAL REPORT ___\n\n Staph aureus Screen (Final ___: \n NO STAPHYLOCOCCUS AUREUS ISOLATED. \n\n==================\nIMAGING/STUDIES: \n==================\n___ AND TORSO CTA\n1. Consider CT-guided biopsy of the right lower quadrant mass.\n2. Chest CT in 12 months.\n\n___ (PRE-OP PA & LAT)\nTrace pleural effusions.\n\n___\nThe left atrium is mildly dilated. No mass/thrombus is seen in \nthe left atrium or left atrial appendage. No thrombus is seen in \nthe left atrial appendage. There is mild symmetric left \nventricular hypertrophy. The left ventricular cavity size is \nnormal. Right ventricular chamber size and free wall motion are \nnormal. There are complex (>4mm) atheroma in the aortic arch. \nThere are complex (>4mm) atheroma in the descending thoracic \naorta. There are three aortic valve leaflets. There is severe \naortic valve stenosis (valve area <1.0cm2). Mild (1+) aortic \nregurgitation is seen. Mild to moderate (___) mitral \nregurgitation is seen. There is a trivial/small pericardial \neffusion. \nAfter ___ 3 deployment, there is trace perivalvular leak near \nthe aortomitral curtian and intial trace AI. The central AI \nresolved over time and the trace perivavular leak was \nundetectable at the end of the case. Peak AV gradient ___, mean \n3 mm Hg after deployment. Aortic contours and pericardium \nunchanged. \nRemaining exam unchanged. All findings discussed with procedural \nteam at the time of the exam.\n\nCXR ___\n------------\nLung volumes have improved. No pneumothorax, pleural effusion \nor mediastinal widening. However in place. Transvenous right \natrial right ventricular pacer leads in standard placements. \n\nPPM INTERROGATION ___\nDate of Implant: ___\nIndication: Episodes of high degree AV block\nDevice brand/name: ___ ___ MRI A2DR01\nA lead brand/model/implant date: ___ / 4076 / ___\nRV lead brand/model/implant date: ___ / 4076 / ___\n\nSince last check: 1day\n\nInterrogation:\nBattery voltage/time to ERI: Initializing\nPresenting rhythm: AS/VP\nUnderlying rhythm: AS/VS\nMode,base and upper track rate: DDD / 60bpm / 130bpm\n\nLead Testing\nP waves: 1.0mv A thresh: [email protected] A imp: 380ohms\nR waves: 6.3mv RV thresh:[email protected] RV imp: 475ohms\n\nDiagnostics:\nAP: 1.4%\nVP: 99%\nEvents: None\n\n================\nDISCHARGE LABS: \n================\n___:15AM BLOOD WBC-5.4 RBC-2.57* Hgb-7.2* Hct-23.8* \nMCV-93 MCH-28.0 MCHC-30.3* RDW-15.9* RDWSD-52.9* Plt ___\n___ 06:15AM BLOOD ___ PTT-29.6 ___\n___ 06:15AM BLOOD Glucose-147* UreaN-20 Creat-1.1 Na-140 \nK-4.0 Cl-101 HCO3-23 AnGap-20\n___ 06:15AM BLOOD Calcium-9.2 Phos-3.7 Mg-1.8\n___ 07:02PM BLOOD calTIBC-203* Ferritn-578* TRF-156*\n \nBrief Hospital Course:\n___ year old lady with past medical history most notable for \nsevere aortic stenosis , CAD s/p PCI, cardiomyopathy with \nsystolic and diastolic CHF, CKD, who presented for elective TAVR \n___. Course complicated by acute on chronic anemia and \nAV-dissociation, now s/p pacemaker ___. \n\n# Aortic stenosis: Patient with known severe aortic stenosis \n___ TTE with peak transvalvular velocity 4.1 m/sec, \npeak/mean pressure gradients of 67/38 mmHg, and calculated ___ \nby continuity equation of 0.72 cm2), presenting for elective \nTAVR. \nShe underwent successful TAVR on ___ with a 26 ___ 3. \nintraoperative TEE showed good placement and function with trace \nAI. She was continued on ASA and Plavix. Her carvedilol was \ninitially discontinued during hospitalization in the setting of \nthe procedure that is high-risk for AV nodal block, however \nrestarted at low dose of metoprolol succinate 12.5 mg daily \nafter placement of pacemaker (switched to metoprolol from \ncarvedilol given SBP 90-110s). \n\n# AV disassociation: Post procedure telemetry revealed Mobitz I \nAV conduction at rates in ___ as well as episodes of AV \ndissociation with junctional escape, LBBB, and no clear sinus \ncaptured beats suggesting higher grade AV block. Patient had no \nepisodes of syncope, near syncope, or pauses, however given \nconcern for AV dissociation, EP was consulted for consideration \nof pacemaker placement. Upon review of her outpatient EKGs by \nEP, it was found that she has had recent outpt ECGs with PR \nintervals in the 400ms range and others with long cycle \nwenckebach. QRS duration is 125-130ms with IVCD/LBBB and left \naxis deviation. It was thought by EP that her AV conduction \ndisease has been progressive over the last ___ years with \nprogressive prolongation of the PR interval and now ECGs with \nMobitz I; suspicious for progressive deterioration of AV node. \nAt this time, the abnormality is thought to be localized to the \nAV node, but she does have an IVCD so may have some His-Purkinje \nsystem disease as well. After discussion in patient and family, \npacemaker was placed on ___, as normalizing AV synchrony with a \npacemaker may potentially help her feel better. His lead and CS \nlead attempted but unable to be placed.\n\nDevice brand/name: ___ ___ MRI A2DR01\nA lead brand/model/implant date: ___ / ___ / ___\nRV lead brand/model/implant date: ___ / ___ / ___\nPPM was interrogated ___, AP: 1.4%, VP: 99%. \nPresenting rhythm: AS/VP\nUnderlying rhythm: AS/VS\nMode,base and upper track rate: DDD / 60bpm / 130bpm with normal \npacer function. \n\n# Acute-on-chronic anemia: Patient was found on daily CBC to \nhave a drop in her HGB from 8 to 7 one day post-TAVR. Patient \nwas asymptomatic. Patient was transfused 1u PRBCs with \nappropriate response. There was no evidence of femoral TAVR \naccess site hematoma or retroperitoneal bleeding on exam. \nPatient's HGB stabilized at 7.2 prior to discharge. \n\n# Heart failure with reduced ejection fraction: Home furosemide \n40 mg (documented as 60 mg, patient states that she takes 40 mg \ndaily) switched to torsemide 20 mg daily. Discharge weight 78.3 \nkg. Patient discharged on metoprolol succinate 12.5 mg daily \n(switched from carvedilol given SBP of 90-110s). Losartan held \nat discharge.\n\n# CAD s/p LAD stent: Continued aspirin, clopidogrel, and \natorvastatin. Clopidogrel should be continued for 12 months (to \n___ unless discussed with outpatient cardiologist. \nCarvedilol switched to metoprolol succinate 12.5 mg on discharge \ngiven SBP of 90-110s. \n\n# RLQ abdominal mass: Incidentally seen on prior ___ CT \nimaging is a 56 x 52 x 46 mm heterogeneous mass, either \nmesenteric or colonic in origin. Differential considerations \ninclude gastrointestinal stromal tumor (GIST), other mesenchymal \nneoplasm, or less likely a desmoid tumor. This would be amenable \nto biopsy under CT guidance, however would need to discuss with \ncardiologist given DAPT.\n\n# HTN: Patient was normotensive during hospitalization. \n\n# DM: Patient given SSI while in house.\n\n# Gout: Continued home probanacid\n\n# GERD: Continued home pantoprazole\n\n==================\nTRANSITIONAL ISSUES: \n==================\nAORTIC STENOSIS\n- S/P TAVR ___\n\nHEART FAILURE WITH REDUCED EJECTION FRACTION\n- Discharge weight 78.3 kg\n- Home furosemide 40 mg switched to torsemide 20 mg daily\n- Carvedilol switched to metoprolol succinate 12.5 mg daily on \ndischarge\n- Home losartan held at discharge given SBP 90-110s, please \nrestart as tolerated. \n\nAV-DISSOCIATION\n- S/P pacemaker placement ___ ___ /Advisa ___ MRI \nA2DR01)\n- Abx x 5 days ending ___ (vancomycin while in house, cephalexin \non discharge)\n- Follow up with Dr. ___ 1 week of discharge\n\nMISCELLANEOUS:\n- Patient with 56 x 52 x 46 mm heterogeneous right lower \nquadrant mass with plan to biopsy in the future. Please discuss \ntiming of biopsy and holding DAPT with cardiologist if needed \nfor biopsy as DES to LAD was placed ___ (and should be \ncontinued for minimum of 12 months)\n\nCONTACT: HCP: ___: Daughter\nPhone number: ___\nCODE: Full-Code \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Clotrimazole Cream 1 Appl TP BID \n2. Carvedilol 6.25 mg PO BID \n3. MetFORMIN XR (Glucophage XR) 1000 mg PO BID \n4. Ferrous GLUCONATE 324 mg PO DAILY \n5. Furosemide 60 mg PO DAILY \n6. Clopidogrel 75 mg PO DAILY \n7. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE QHS \n8. Pantoprazole 20 mg PO Q24H \n9. Aspirin 81 mg PO DAILY \n10. Probenecid ___ mg PO DAILY \n11. FoLIC Acid 0.4 mg PO DAILY \n12. vit B comp-min-hops-berberine 100-100 mg oral DAILY \n13. Atorvastatin 40 mg PO QPM \n14. Losartan Potassium 12.5 mg PO DAILY \n\n \nDischarge Medications:\n1. Cephalexin 500 mg PO Q8H Duration: 4 Days \nRX *cephalexin 500 mg 1 capsule(s) by mouth three times a day \nDisp #*12 Capsule Refills:*0 \n2. Metoprolol Succinate XL 12.5 mg PO DAILY \nRX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*0 \n3. Torsemide 20 mg PO DAILY \nRX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n4. Aspirin 81 mg PO DAILY \n5. Atorvastatin 40 mg PO QPM \n6. Clopidogrel 75 mg PO DAILY \n7. Clotrimazole Cream 1 Appl TP BID \n8. Ferrous GLUCONATE 324 mg PO DAILY \n9. FoLIC Acid 0.4 mg PO DAILY \n10. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE QHS \n11. MetFORMIN XR (Glucophage XR) 1000 mg PO BID \n12. Pantoprazole 20 mg PO Q24H \n13. Probenecid ___ mg PO DAILY \n14. vit B comp-min-hops-berberine 100-100 mg oral DAILY \n15. HELD- Losartan Potassium 12.5 mg PO DAILY This medication \nwas held. Do not restart Losartan Potassium until your doctor \ntells you to do so\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS: \nAortic Stenosis s/p TAVR\nAV dissociation\n\nSECONDARY DIAGNOSIS: \nAcute-on-chronic anemia \nCAD \nDiabetes Mellitus II \nGout \nGERD \n\n \nDischarge Condition:\n \nDischarge Instructions:\nDear Ms. ___ \n\n___ was a pleasure taking care of you at the ___ \n___! \n\nWhy was I admitted to the hospital? \n-You were admitted because you had a condition called \"aortic \nstenosis\" and underwent a procedure called \"transcatheter aortic \nvalve replacement\" or \"TAVR\" for short. \n\nWhat happened while I was in the hospital? \n- You underwent a procedure where your aortic valve was \nreplaced. \n- After your procedure, we noticed on your telemetry monitoring \nthat you had \"AV dissociation\". That is, the electrical signal \nfrom the heart's upper chambers (atria) to lower chambers \n(ventricles) was impaired. You were seen by the EP doctors \n___ doctors that ___ in the conduction system of the \nheart), who think that your heart has likely had progressive \ndifficulty transmitting signals from the AV node to the lower \nchambers of your heart, perhaps over the past ___ years. After \ndiscussion of risks and benefits, it was decided to place a \npacemaker to see if this could help the transmission of signals \nbetween your atria and ventricles, in an attempt to make you \nfeel better. \n\nWhat should I do after leaving the hospital? \n- It is very important that you continue to take your aspirin \nand plavix. It is also very important that you take all the \nmedications that you were prescribed when you left the hospital. \n\n- You will also need to take antibiotics for a total of 5 days \nending ___ and follow up with your heart doctors.\n\n___ you for allowing us to be involved in your care, we wish \nyou all the best! \n\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "I350", "I130", "I442", "N184", "I5042", "I441", "D62", "Z006", "I272", "M109", "K219", "E785", "E1121", "R197", "I2510", "Z955", "I447", "Z8541", "E1136", "R1903" ]

[ "I350: Nonrheumatic aortic (valve) stenosis", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I442: Atrioventricular block, complete", "N184: Chronic kidney disease, stage 4 (severe)", "I5042: Chronic combined systolic (congestive) and diastolic (congestive) heart failure", "I441: Atrioventricular block, second degree", "D62: Acute posthemorrhagic anemia", "Z006: Encounter for examination for normal comparison and control in clinical research program", "I272: Other secondary pulmonary hypertension", "M109: Gout, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "R197: Diarrhea, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "I447: Left bundle-branch block, unspecified", "Z8541: Personal history of malignant neoplasm of cervix uteri", "E1136: Type 2 diabetes mellitus with diabetic cataract", "R1903: Right lower quadrant abdominal swelling, mass and lump" ]

[ "I130", "D62", "M109", "K219", "E785", "I2510", "Z955" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \namoxicillin / ciprofloxacin / lorazepam / Penicillins / \nphenobarbital / phenytoin / Sulfa (Sulfonamide Antibiotics) / \npropranolol\n \nAttending: ___\n \nChief Complaint:\nSeizure\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ M h/o seizure disorder, HTN, asthma, prior R stroke with L \narm and leg weakness, transferred from ___ for \n?nonconvulsive seizure because he became \"unresponsive\".\n\nHe was taken to ___ last ___ for gastroparesis \nflare/vomiting. En route to the hospital, he had a seizure, was \ngiven Versed and was confused for the next two days. He \nreportedly had a normal MRI and EEG at ___. He claims he is \naware of an old left PCA occlusion. He was discharged ___ \n(on Erythromycin for gastroparesis), but then spiked a fever \n___ night at home. He was seen by his home ___ and referred \nto ___. There he was diagnosed with a UTI. He reportedly \nbecame unresponsive and was given 2mg of Ativan, 2000mg of \nKeppra, and Ceftriaxone for treatment of a UTI. He was then \ntransferred to ___. He was initially very somnolent in the ED \nat ___, although he had received several doses of Ativan. \n\nHis typical seizure frequency is a few per year, but when \ninfected he will have many. Aura is usually nosebleed, left \nsided headache. Ictally he has generalized tonic clonic seizures \nlasting ___ minutes. Postictally has prolonged left sided \nweakness, confusion that often lasts for a day or two.\n\nHad a work-up at ___ last year due to concerns of asymmetric \nlung motion, with concern for neuromuscular disease. Reportedly, \nhe was evaluated for ALS and other neuromuscular disease, and \nall of this was negative. He was also evaluated for \nmitochondrial disease, and although there are some tests yet to \nbe run (unsure what these are), he did not receive a diagnosis. \nWe do not have the results of this work-up available to us.\n \nPast Medical History:\nPrior stroke with residual left hemibody numbness and weakness\nSeizure disorder\nHypertension\nAsthma\n \nSocial History:\n___\nFamily History:\nUnknown\n \nPhysical Exam:\nON ADMISSION\n============\nVitals: afebrile, HR ___, BP 140s/80s, RR ___, 96RA\nGeneral: somnolent, only arousable to noxious stimuli\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx\nNeck: Supple, no carotid bruits appreciated. No nuchal rigidity\nPulmonary: Lungs CTA bilaterally without R/R/W\nCardiac: RRR, nl. S1S2, no M/R/G noted\nAbdomen: soft, NT/ND, normoactive bowel sounds, no masses or\norganomegaly noted.\nExtremities: No ___ edema.\nSkin: no rashes or lesions noted.\n\nNeurologic:\n-Mental Status: Somnulent, grimaces to deep noxious \nsymmetrically\n(no grimace to nasal swab)\n-Cranial Nerves: PERRL 5>3, gaze is midline, no blink to threat,\n+ corneals bilaterally, no VOR, + spont cough\n-Motor: Normal bulk, paratonia. No resting tremor. Adventitious\nmovements as described in episode above, but none since.\nRight upper and lower extremity is anti-gravity. Left upper\nextremity withdraws to noxious. Left lower extremity without\nwithdrawal to noxious (but right lower extremity may be\nattempting to localize to noxious on left by lifting off of bed)\n-Sensory: No deficits to noxious stimuli. \n-DTRs: ___ response was flexor bilaterally.\n-Coordination: Unable to attain\n-Gait: Unable to attain\n\nON DISCHARGE\n============\n24 HR Data \n Temp: 98.6 (Tm 98.6), BP: 112/70 (112-146/70-87), HR: 80\n(76-87), RR: 18 (___), O2 sat: 92% (92-95), O2 delivery: RA \n\nGeneral: awake, in chair, no acute distress\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx\nNeck: Supple, no carotid bruits appreciated. No nuchal rigidity\nPulmonary: Lungs CTA bilaterally without R/R/W\nCardiac: RRR, nl. S1S2, no M/R/G noted\nAbdomen: soft, NT/ND, normoactive bowel sounds, no masses or\norganomegaly noted.\nExtremities: No ___ edema.\nSkin: no rashes or lesions noted.\n\nNeurologic:\n-Mental Status: Awake, alert, attentive to examiner. Oriented to\ndate, location. Slow to respond. Language is halting, but with\nintact naming. \n-Cranial Nerves: PERRL 5>3, gaze is midline, blink to threat\npresent b/l, visual field testing notable for subjectively \nabsent\nvision in entire visual field of left eye. On extraocular\nmovement testing, his gaze appears restricted in all directions,\nhowever, during other parts of the exam he is able to look in \nall\ndirections. Face symmetric. Speech is slightly dysarthric.\n-Motor: Normal bulk, paratonia. No resting tremor. He is able to\nmove the left arm with ___ strength in an upper motor neuron\npattern, with superimposed giveway weakness. The left leg has\n___ strength in an upper motor neuron pattern, again with\ngiveway weakness.\n-Sensory: reports absent light touch sensation throughout the\nleft arm and leg. Extinguished to DSS on left\n-DTRs: ___ response was flexor bilaterally.\n-Coordination: Within limits of weakness, appears intact on\nfinger nose finger\n-Gait: Able to stand from sitting by propping himself up. Walks\nby satelliting around the room, with circumduction of the left\nleg.\n \nPertinent Results:\n___ 06:00AM BLOOD %HbA1c-8.3* eAG-192*\n___ 05:00AM BLOOD Triglyc-153* HDL-20* CHOL/HD-6.8 \nLDLcalc-85\n___ 06:07AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n___ 08:28AM OTHER BODY FLUID FluAPCR-NEGATIVE \nFluBPCR-NEGATIVE\n___ 05:20AM URINE Color-Straw Appear-Clear Sp ___\n___ 05:20AM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 \nLeuks-NEG\n___ 05:20AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG \ncocaine-NEG amphetm-NEG oxycodn-POS* mthdone-NEG\n\nCT/CTA HEAD/NECK ___:\n1. Evidence occlusion the left PCA P1 segment. There is also\natherosclerotic disease involving the right PCA. \n2. No large territorial infarct. \n3. No dissection, aneurysm or occlusion of the neck. No\nsignificant ICA stenosis by NASCET criteria. \n4. Mild-to-moderate chronic inflammatory changes of the \nmaxillary\nsinuses with evidence superimposed acute sinusitis in the right\nmaxillary sinus. \n5. Multidimensional goiter. Correlate with any available \noutside\nthyroid ultrasound. \n\nMRI ___. No acute intracranial abnormality.\n2. Evidence of a prominent right temporal developmental venous\nanomaly.\n3. Mild inflammatory changes of the bilateral maxillary sinuses\nwith evidence superimposed acute on chronic right maxillary \nsinusitis.\n\nEEG read pending, but preliminarily showed only generalized \ntheta activity (___) with occasional bursts of generalized \ndelta activity; no seizures or epileptiform discharges.\n \nBrief Hospital Course:\nMr ___ is a ___ year old man with a history of prior right \nsided stroke with residual left sided weakness and numbness, \nseizure disorder, diabetes, and hypertension, who presents as a \ntransfer from ___ after a seizure. He was recently \ndischarged from ___ after presenting with symptoms of \na gastroparesis flare, and having a seizure while en route. His \nKeppra was increased to 1500mg BID from 1000mg BID during that \nadmission. However, on the day after discharge, he had a fever \nand so returned to ___. There he had another seizure, \nthe semiology of which is unclear, but may have started with \nright head and eye deviation and then generalized. He was given \n2mg of Ativan, 2000mg of Keppra, and Ceftriaxone for treatment \nof a UTI. He was then transferred to ___. He was initially \nvery somnolent in the ED at ___, although he had received \nseveral doses of Ativan. His level of alertness subsequently \nimproved over the next ___ hours. His partner states this is a \ntypical post-ictal phenomenon for him, and that it can last for \ndays. He was monitored on EEG for 24 hours, which showed only \ngeneralized theta activity (___) with occasional bursts of \ngeneralized delta activity; no seizures or epileptiform \ndischarges. He was continued on his home AEDs. His mental status \nimproved to baseline prior to discharge. \n\nThe cause of his breakthrough seizure is most likely a urinary \ntract infection. Although his UA and urine culture were \nunremarkable at ___, he did have a positive UA at ___ \n(+bacteria, WBCs, Leuk esterase). He was treated with \nCeftriaxone for 3 days. \n\nIn the ED a CT head and CTA were also obtained, and he was found \nto have an occluded left PCA, the chronicity of which was \nunclear. An MRI was obtained and showed a prominent right \ntemporal developmental venous anomaly, but no acute stroke. \nStroke risk factors were notable for an A1c of 8.3%, with LDL \n85. \n\nOf note, he underwent a NEGATIVE workup for mitochondrial \ndisorder at ___ - there are several genetic tests pending but \notherwise negative - no \"ragged red fibers\" per his wife.\n\nTRANSITIONAL ISSUES:\n-Consider switching to long-acting AED, given his history of \nrecurrent episodes of vomiting which may prevent medication \nabsorption.\n-Optimization of glucose control\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. LevETIRAcetam 1500 mg PO BID \n2. Sertraline 200 mg PO QHS \n3. amLODIPine 10 mg PO DAILY \n4. Atorvastatin 20 mg PO QPM \n5. Losartan Potassium 50 mg PO DAILY \n6. Dabigatran Etexilate 150 mg PO BID \n7. Docusate Sodium 100 mg PO DAILY *AST Approval Required*\n8. Gabapentin 900 mg PO BID \n9. Hydrochlorothiazide 25 mg PO DAILY \n10. Glargine 30 Units Breakfast\nGlargine 30 Units Bedtime\nInsulin SC Sliding Scale using Novolog Insulin\n11. MetFORMIN (Glucophage) 500 mg PO BID \n12. Omeprazole 40 mg PO DAILY \n13. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN BREAKTHROUGH \nPAIN \n14. LACOSamide 100 mg PO BID \n15. Ondansetron 4 mg PO Q8H:PRN nausea \n16. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia \n\n \nDischarge Medications:\n1. amLODIPine 10 mg PO DAILY \n2. Atorvastatin 20 mg PO QPM \n3. Dabigatran Etexilate 150 mg PO BID \n4. Docusate Sodium 100 mg PO DAILY \n5. Gabapentin 900 mg PO BID \n6. Hydrochlorothiazide 25 mg PO DAILY \n7. Glargine 30 Units Breakfast\nGlargine 30 Units Bedtime \n8. LACOSamide 100 mg PO BID \n9. LevETIRAcetam 1500 mg PO BID *AST Approval Required* \n10. Losartan Potassium 50 mg PO DAILY \n11. MetFORMIN (Glucophage) 500 mg PO BID \n12. Omeprazole 40 mg PO DAILY \n13. Ondansetron 4 mg PO Q8H:PRN nausea \n14. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN BREAKTHROUGH \nPAIN \n15. Sertraline 200 mg PO QHS \n16. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nSeizure\nUrinary tract infection\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr ___,\n\nIt was a pleasure taking care of you at ___ \n___.\n\nYou were admitted to the hospital after you had a seizure in the \nEmergency Room.\n\nIn the hospital, we monitored you on EEG. You did not have any \nmore seizures. We also treated you for a urinary tract \ninfection. It is likely that the urinary tract infection caused \nyou to have a seizure. Finally, we performed an MRI of your \nbrain. This was normal.\n\nWhen you leave the hospital, you should continue to take your \nsame medications. \n\nBest wishes,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "G40419", "I663", "K3184", "I69354", "E1143", "E1165", "N390", "I10", "G4700", "Z7902", "Z794" ]

[ "G40419: Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus", "I663: Occlusion and stenosis of cerebellar arteries", "K3184: Gastroparesis", "I69354: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side", "E1143: Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy", "E1165: Type 2 diabetes mellitus with hyperglycemia", "N390: Urinary tract infection, site not specified", "I10: Essential (primary) hypertension", "G4700: Insomnia, unspecified", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z794: Long term (current) use of insulin" ]

[ "E1165", "N390", "I10", "G4700", "Z7902", "Z794" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nPenicillins / Protonix / adhesive tape / Metallic Poisoning, \nAgents To Treat / Effexor / PROTONIX / PAPER TAPE / METALS / \nBactrim / diazepam / Pravastatin / clonidine / metoprolol / \nhydrochlorothiazide / PLASTICS / red dye / WELLBURTIN / \namlodipine / lorazepam\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain, back pain\n \nMajor Surgical or Invasive Procedure:\n___ Surgery #1\n1. Ultrasound-guided access to bilateral common femoral\n arteries.\n2. Abdominal aortogram.\n4. Coil embolization of the right internal iliac artery.\n3. Bilateral extension of previously placed EVAR iliac\n limbs with 2 additional limbs into the iliac arteries on\n both sides.\n\n___ Surgery #2\n1. Right groin exploration.\n2. Right femoral patch angioplasty with Dacron graft.\n3. Right femoral endarterectomy.\n4. Selective catheterization of right external iliac\n artery, ___ order vessel.\n5. Angiogram of right lower extremity.\n\n \nHistory of Present Illness:\n___ PMH DMII, COPD, ruptured AAA s/p EVAR c/b failure L fem\nperclose req patch angioplasty, ex-lap for evac RP\n___, PAD s/p L fem-peroneal bypass, presenting now\n___/ ___ abdominal and back pain which started overnight. She\nbecame concerned given her previous history of ruptured \naneurysm,\nand decided to come to the ___ ED. She was initially found to\nbe hypertensive to a SBP of 220s, and an esmolol gtt was \nstarted.\nA CTA was performed, which showed what appears to be contained\nrupture without active extravasation of contrast. Vascular\nsurgery was consulted for assessment of surgical repair of\nruptured AAA. \n\nUpon initial assessment by vascular surgery, Ms. ___ reports\ncontinued abdominal pain that has improved mildly with dilaudid.\nShe denies chest fevers, chills, nausea, vomiting, chest pain,\nshortness of breath, dysuria, or pain or weakness in her legs.\nShe expresses intense anxiety and concern over her condition. \n\nROS:\n(+) per HPI\n(-) \n \nPast Medical History:\nPast Medical History:\n-DMII\n-COPD\n-L adrenal adenoma\n-primary hyperparathyroidism\n-HTN\n-fibromyalgia\n-Hx TIAs\n-Hx CVA\n-osteopenia\n-neuropathy,\n-spinal stenosis\n-PVD w/claudication\n-vitD deficiency\n-diverticulosis\n-hemorrhoids\n-hx GI bleed \n\nPast Surgical History:\n-tonsillectomy\n-rectal prolapse reconstruction (___),\n-oophorectomy\n-CCY\n-R CEA (___)\n-parathyroidectomy w re-implantation of one parathyroid gland\n(___) -L thyroid lobectomy (___)\n-EVAR for ruptured infrarenal AAA w L groin exploration for\nrepair aortotomy w thrombectomy and patch angioplasty\n(___), -exlap for decompression RP hematoma\n(___)\n-takeback for abdominal closure (___)\n-R short trochanteric femoral ___\n-L groin exploration\n-redo L femoral to peroneal artery bypass graft w composite\nreverse and non-reverse saphenous vein (___)\n \nSocial History:\n___\nFamily History:\nHer father died of lung cancer. Her mother died of tuberculosis. \nHer fraternal twin sister died of lung cancer. Her paternal \ngrandfather died of cancer.\n\n \nPhysical Exam:\nDISCHARGE PHYSICAL EXAM:\n==========================\nVitals: T 98.7, BP 143/72, HR 81, RR 20, O2 94% 2L NC \nGEN: A&O x3, NAD, tearful when speaks about all that she has \nbeen through\nHEENT: No scleral icterus, EOMI, mucus membranes moist\nCV: RRR \nPULM: No respiratory distress, on 2L NC\nABD: Non-tender. Non-distended. \nGROIN: Staples to right groin, incision site clean/dry/intact \nwith mild surrounding erythema, no drainage. Dermabond to left \ngroin. \nExt: warm, dry, no lesions or erythema, no edema. \n\n \nPertinent Results:\nADMISSION LABS:\n================\n___ 08:23AM NEUTS-84.5* LYMPHS-11.1* MONOS-3.3* EOS-0.2* \nBASOS-0.4 IM ___ AbsNeut-10.41*# AbsLymp-1.37 AbsMono-0.41 \nAbsEos-0.02* AbsBaso-0.05\n___ 08:23AM WBC-12.3*# RBC-5.12 HGB-15.5 HCT-49.3* MCV-96 \nMCH-30.3 MCHC-31.4* RDW-14.3 RDWSD-51.0*\n___ 08:23AM CALCIUM-9.4 MAGNESIUM-2.3\n___ 08:23AM GLUCOSE-157* UREA N-31* CREAT-1.0 SODIUM-141 \nPOTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-24 ANION GAP-20\n___ 08:45AM LACTATE-2.2*\n___ 09:40AM ___ PTT-29.4 ___\n___ 10:12AM URINE MUCOUS-RARE\n___ 10:12AM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE \nEPI-0\n___ 10:12AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-NEG\n___ 10:12AM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 11:07AM ___\n___ 11:07AM ___ PTT-30.2 ___\n___ 11:07AM NEUTS-88.8* LYMPHS-7.1* MONOS-3.2* EOS-0.1* \nBASOS-0.3 IM ___ AbsNeut-12.07* AbsLymp-0.96* AbsMono-0.44 \nAbsEos-0.01* AbsBaso-0.04\n___ 11:07AM WBC-13.6* RBC-4.41 HGB-13.4 HCT-42.0 MCV-95 \nMCH-30.4 MCHC-31.9* RDW-14.2 RDWSD-49.2*\n___ 11:09AM freeCa-1.09*\n___ 11:09AM HGB-13.2 calcHCT-40\n___ 11:09AM GLUCOSE-124* LACTATE-1.4 NA+-141 K+-4.1 \nCL--106\n___ 11:09AM TYPE-ART PO2-227* PCO2-49* PH-7.31* TOTAL \nCO2-26 BASE XS--2 INTUBATED-INTUBATED VENT-CONTROLLED\n___ 12:41PM freeCa-1.01*\n___ 12:41PM HGB-12.1 calcHCT-36\n___ 12:41PM GLUCOSE-127* LACTATE-1.2 NA+-139 K+-3.9 \nCL--109*\n___ 12:41PM TYPE-ART PO2-228* PCO2-48* PH-7.26* TOTAL \nCO2-23 BASE XS--5\n___ 01:18PM freeCa-0.97*\n___ 01:18PM HGB-11.5* calcHCT-35\n___ 01:18PM GLUCOSE-122* LACTATE-1.2 NA+-139 K+-3.9 \nCL--111*\n___ 01:18PM TYPE-ART PO2-224* PCO2-40 PH-7.30* TOTAL \nCO2-20* BASE XS--5\n___ 10:11PM ___ PTT-29.1 ___\n___ 10:11PM WBC-11.9* RBC-3.39* HGB-10.4* HCT-32.6* \nMCV-96 MCH-30.7 MCHC-31.9* RDW-14.8 RDWSD-52.2*\n___ 10:11PM CALCIUM-7.3* PHOSPHATE-4.0 MAGNESIUM-1.8\n___ 10:11PM GLUCOSE-134* UREA N-23* CREAT-0.9 SODIUM-138 \nPOTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-21* ANION GAP-15\n___ 10:24PM TYPE-ART PO2-73* PCO2-37 PH-7.39 TOTAL CO2-23 \nBASE XS--1\n\nDISCHARGE LABS:\n===============\n___ 07:45AM BLOOD WBC-10.4* RBC-3.30* Hgb-10.0* Hct-31.9* \nMCV-97 MCH-30.3 MCHC-31.3* RDW-14.6 RDWSD-51.4* Plt ___\n___ 07:45AM BLOOD ___ PTT-24.9* ___\n___ 07:45AM BLOOD Glucose-115* UreaN-24* Creat-0.7 Na-139 \nK-4.1 Cl-102 HCO3-27 AnGap-14\n___ 07:45AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.1\n\nPERTINENT RESULTS:\n===================\n ___ CHEST (PORTABLE AP): \nFINDINGS: \nInterval increase in heart size, dilatation of the azygos vein, \nwidened \nvascular pedicle and cephalization of upper lobe pulmonary blood \nvessels. \nMild indistinctness of the blood vessels. No large effusion. No \nairspace \nconsolidation. Subsegmental atelectasis in the left lung base. \n \nIMPRESSION: \nFindings in keeping with pulmonary edema. \n\n ___ ___ DUP EXTEXT BIL (MAP \nFINDINGS: \nRIGHT: \nThe great saphenous vein is patent and ranges in diameter from \n0.31 to 0.70 cm. The small saphenous vein is patent and ranges \nin diameter from 0.22 to 0.36 cm. \n \nLEFT: \nThe great saphenous vein has been surgically removed. The left \nsmall \nsaphenous vein is patent and ranges in diameter from 0.24 to \n0.30 cm. \n \nIMPRESSION: \nThe right great saphenous and small saphenous veins are patent \nwith diameters above. \n \nThe left great saphenous vein has been surgically removed. The \nsmall \nsaphenous vein is patent with diameters above. \n\n ___ VENOUS DUP UPPER EXT UN \nFINDINGS: \nRIGHT: \nExamination was not performed as the patient had multiple IVs in \nthe right arm veins. \n \nLEFT: \nThe cephalic vein is not visualized in the upper arm. In the \nforearm, the \ncephalic vein is patent and measures 0.18 cm. The basilic vein \nis patent and ranges in diameter from 0.13 to 0.33 cm. \n \nIMPRESSION: \nThe cephalic vein is not visualized in the left upper arm. In \nthe left \nforearm, the cephalic vein is patent with diameters above. The \nleft basilic vein is patent with diameters above. \n \nExamination of the right arm was not performed as the patient \nhad multiple IVs in the right arm veins. \n\n ___ ART DUP EXT LO UNI;F/U \nFINDINGS: \nThe right common femoral artery is patent with a peak systolic \nvelocity of 120 cm/sec. The deep femoral artery is patent with \na peak systolic velocity 104 cm/sec. There is occlusive \nthrombus within the right proximal SFA. Flow is reconstituted \nin the distal SFA however there are very low velocities of 24 \ncm/sec. The right popliteal artery is patent with a low peak \nsystolic velocity of 12 cm/sec. There is no flow seen in the \nright posterior tibial or dorsalis pedis arteries. The peroneal \nartery is not visualized. \n \nIMPRESSION: \nOcclusive thrombus within the right proximal SFA. \n \nFlow reconstitutes in the distal SFA however there are very low \nvelocities in the distal SFA and popliteal artery. \n \nNo flow seen in the right posterior tibial or dorsalis pedis \narteries. The \nperoneal artery is not visualized. \n\n ___ CTA ABD & PELVIS \nFINDINGS: \nVASCULAR: \nAs before, the patient is status post endovascular repair of an \nabdominal \naortic aneurysm with a suprarenal aortobi-iliac stent. There is \nhigh density fluid draping outside the confines of the partially \ncalcified aneurysm, consistent with aneurysmal rupture. There \nis high density fluid within the excluded aneurysmal sac (for \nexample, ___ and ___). Notably, the iliac portions of the stent \nare above the bifurcation, concerning for type 1B endoleak. The \nexcluded aneurysmal sac measures 6.8 x 7.1 cm (___), minimally \ndecreased compared to ___, when it measured 8.4 x 6.7 \ncm. No significant change in near complete occlusion of the \nleft common iliac artery (___), with distal reconstitution. \nThere is a 1.4 cm left common femoral artery aneurysm, new \ncompared to ___. (___). \n \nThere is a very focal high density along the small bowel, just \nanterior to \ninfrarenal aorta, which is not well seen on pre-contrast images \n(___). \nFistulous connection cannot be excluded. No additional evidence \nto suggest an aorto-enteric fistula. \n \nLOWER CHEST: Again seen is scarring and atelectasis in the lung \nbases. There is no pleural or pericardial effusion. There are \ncoronary artery \ncalcifications. \n \nABDOMEN: \n \nHEPATOBILIARY: There is focal fatty infiltration near the \nfalciform ligament. There is a punctate calcification in the \nright hepatic lobe, likely a calcified granuloma. The liver \notherwise demonstrates homogenous attenuation throughout. There \nis no evidence of focal lesions. There is no evidence of \nintrahepatic biliary dilatation. There is mild dilatation of \nthe central intrahepatic bilary tree and common bile duct, \nmeasuring up to 0.8 cm, likely secondary to cholecystectomy. \n \nPANCREAS: The pancreas has normal attenuation throughout, \nwithout evidence of focal lesions. The pancreatic duct is \nprominent, though unchanged and \nnon-enlarged. There is no peripancreatic stranding. \n \nSPLEEN: The spleen shows normal size and attenuation throughout, \nwithout \nevidence of focal lesions. \n \nADRENALS: The right adrenal gland is normal in size and shape. \nThere is an unchanged heterogeneous left adrenal gland nodule, \nconsistent with an adrenal adenoma as characterized on MRI from \n___. \n \nURINARY: There multiple unchanged hypodense lesions throughout \nthe kidneys, some are simple cysts and others are too small to \ncharacterize. There is a right lower pole hypodense lesion, \nwhich measures slightly above expected for a simple cyst and may \nrepresent a hemorrhagic cyst. It is minimally increased in size \ncompared to ___. There is bilateral cortical thinning, \nconsistent with remote scarring. The kidneys are of normal and \nsymmetric size with normal nephrogram. There is no evidence of \nstones or hydronephrosis. There are no urothelial lesions in the \nkidneys or ureters. There is no perinephric abnormality. \n \nGASTROINTESTINAL: Small bowel loops demonstrate normal caliber, \nwall thickness and enhancement throughout. Diverticulosis \nwithout evidence diverticulitis. Colon and rectum are otherwise \nwithin normal limits. Appendix contains air, has normal caliber \nwithout evidence of fat stranding. There is no evidence of \nmesenteric lymphadenopathy. \n \nRETROPERITONEUM: There is no evidence of retroperitoneal \nlymphadenopathy. \n \nPELVIS: The urinary bladder and distal ureters are unremarkable. \n There is no evidence of pelvic or inguinal lymphadenopathy. \nThere is high density fluid in the pelvis, likely representing \nblood from AAA rupture. \n \nREPRODUCTIVE ORGANS: The reproductive organs are atrophic. \n \nBONES: There is no evidence of worrisome osseous lesions or \nacute fracture. As before the patient is status post ORIF of \nthe right femur. There are moderate degenerative changes with \nfacet arthropathy, disc space narrowing and osteophytosis. \n \nSOFT TISSUES: There is a small fat containing umbilical hernia \nand two small fat containing ventral hernias (___, 106). The \nabdominal and pelvic wall is otherwise within normal limits. \n \nIMPRESSION: \n1. Acute rupture of an infrarenal abdominal aneurysm. The \npatient is status post suprarenal aorto bi-iliac stent with the \niliac portions of the stent located superiorly to the aortic \nbifurcation, concerning for endoleak type 1B. High-density \nmaterial is visualized in the excluded aneurysm sac. \n2. There is a very focal high density along the small bowel, \njust anterior to infrarenal aorta, which is not well seen on \npre-contrast images (___). Fistulous connection cannot be \nexcluded. No additional evidence to suggest an aorto-enteric \nfistula. \n3. 1.4 cm left common femoral artery aneurysm, new compared to \n___. \n\n ___ Cardiovascular ECHO \nConclusions \nExam done during vascular procedure; \n\n LVEF >55% no wall motion abnormalities. Grade I diastolic \ndysfunction with lateral mitral e' < 5cm/sec. The left atrium is \nnormal in size. There is moderate symmetric left ventricular \nhypertrophy. Right ventricular chamber size and free wall motion \nare normal. There are complex (>4mm) atheroma in the descending \nthoracic aorta. There are three aortic valve leaflets. The \naortic valve leaflets are moderately thickened. There is no \naortic valve stenosis. No aortic regurgitation is seen. The \nmitral valve appears structurally normal with trivial mitral \nregurgitation. There is no pericardial effusion. Normal coronary \nsinus. Possible PFO. \n\nOPERATIVE REPORTS:\n====================\n___ Operation #1\n--------------------\nSurgeon: ___, ___\nFIRST ASSISTANT: Dr. ___.\nSECOND ASSISTANT: ___.\n\nPREOPERATIVE DIAGNOSIS: Ruptured abdominal aortic aneurysm.\nPOSTOPERATIVE DIAGNOSIS: Ruptured abdominal aortic aneurysm.\n\nPROCEDURES PERFORMED:\n1. Ultrasound-guided access to bilateral common femoral\n arteries.\n2. Abdominal aortogram.\n4. Coil embolization of the right internal iliac artery.\n3. Bilateral extension of previously placed EVAR iliac\n limbs with 2 additional limbs into the iliac arteries on\n both sides.\n\nCONTRAST USED: 60 mL Visipaque.\n\nFLUORO DOSE: 337 mGy.\n\nFLUORO TIME: 30.3 minutes.\n\nINDICATIONS FOR PROCEDURE: An ___ woman who\npreviously underwent an EVAR for ruptured abdominal aortic\naneurysm ___ years ago presents with new rupture, which appears\nto have been contained. The imaging was suggestive of loss\nof distal seal of the iliac limbs, therefore, she presents\nfor angiogram and repair of ruptured aneurysm.\n\nDESCRIPTION OF PROCEDURE: The patient was brought to the\noperating room and placed in the supine position. Both\ngroins were prepped and draped in the standard fashion and a\ntime-out was performed. The patient was kept awake at this\ntime as we used ultrasound to interrogate both common femoral\narteries. These were both found to be patent and free of\nsignificant calcification. Therefore, under direct\nultrasound visualization, the right common femoral artery was\naccessed with a micropuncture needle and the left proximal\nbypass graft was accessed with a micropuncture needle. Two\nPerclose devices were placed in each groin in the pre-close\ntechnique and ___ sheaths were placed. We then used a\nwire to cannulate the iliac limbs from their respective\nsides. We then turned our attention to coil embolization of\nthe right hypogastric artery from the right groin. We were\nable to advance a wire into the right hypogastric artery and\nthen an 0.035 catheter tracked easily into it. We placed a\nnumber of Tornado embolization coils and an Interlock coil\ninto the hypogastric artery. When this was completely\ncoiled, we removed the catheter from the hypogastric and shot\nan aortogram. This revealed good type 1A seal and good flow\nthrough the graft. There was no obvious evidence of any leak\ninto the aneurysm sac, although the limbs were clearly not\nsealed in the iliac arteries. At this point, we decided to\nproceed with treating the left limb. Therefore, we performed\na retrograde left groin hand injection and sized our pieces.\nWe placed first a 16 mm to 16 mm Endurant limb, which\nextended the limb into the proximal left common iliac. We\nthen placed an additional 16 mm to 8 mm Gore limb, which\nbrought the seal down even further to the very distal common\niliac just above the hypogastric artery. These 2 limbs were\nthen ballooned with a Reliant balloon. We then turned our\nattention to the right groin. We performed a retrograde\nright sheath injection and similarly extended the graft with\na 16 mm to 16 mm right iliac Endurant limb, and then extended\nfurther with a 16 mm to 10 mm Endurant limb into the external\niliac on the right. After deployment, it was determined that\nthe limb on the right was not fully expanded, so we performed\na balloon angioplasty with a 10 x 40 balloon with a good\nresult. We then used a Reliant balloon to mold all the areas\nof overlap on the right. A catheter was advanced up the\naorta and an angiogram was performed. This showed good flow\nthrough both limbs and no evidence of any 1B leak on either\nside. The left hypogastric filled and the right was occluded\nby the embolization coils. We then decided to complete the\nprocedure, so the wires and catheters were removed, the\nsheaths were removed, and the arteriotomies were closed with\nPerclose devices Protamine 30 mg was given and 5 minutes of\nmanual groin pressure was held. At the completion of this,\nthe patient had soft groins without any evidence of hematoma\nand was transferred to the PACU for recovery. There was some\nconcern initially for right leg ischemia, but the ultrasound\nshowed that there was some flow in the superficial femoral\nartery distal to the puncture site, so we transferred her to\nthe ICU for recovery.\n\nDr. ___ was present for the entire duration of the\noperation.\n\n ___, MD ___\n\nI was physically present during all critical and key portions of\nthe procedure and immediately available to furnish services \nduring\nthe entire procedure, in compliance with CMS regulations.\n \nDictated By: ___, Fellow\nEdited By: ___ MD\n\n___ Operation #2\nSurgeon: ___, MD ___\n\nASSISTANTS: Dr. ___, vascular fellow, and Dr. ___, PGY-5.\n\nPREOPERATIVE DIAGNOSIS: Right lower leg critical limb\nischemia status post ruptured abdominal aortic aneurysm.\n\nPOSTOPERATIVE DIAGNOSIS: Right lower leg critical limb\nischemia status post ruptured abdominal aortic aneurysm.\n\nPROCEDURES PERFORMED:\n1. Right groin exploration.\n2. Right femoral patch angioplasty with Dacron graft.\n3. Right femoral endarterectomy.\n4. Selective catheterization of right external iliac\n artery, ___ order vessel.\n5. Angiogram of right lower extremity.\n\nANESTHESIA: General endotracheal anesthesia.\n\nINDICATIONS: Briefly, this is an ___ woman with a\nhistory of a ruptured AAA status post EVAR, who presented\nthis morning with acute abdominal pain and back pain. She\nwas found to have extravasation concerning for repeat\nruptured AAA. As such, earlier in the day she had undergone\nemergent endovascular assessment with bilateral common iliac\nartery stent placement for presumed type 1B bar graft leak.\nPostoperatively, she had initially been doing well, but was\nnoted to have a cooler right foot over the course of the\nsubsequent hours and loss of her posterior tibial Doppler\nsignal. Arterial duplex confirmed occlusion of the right\nlower extremity lower leg arteries, prompting concern for\nproximal occlusion. As such, the patient was prepped for\nimmediate right groin exploration.\n\nOPERATIVE DESCRIPTION: After informed consent was obtained,\nthe patient was brought to the operating room and placed\nsupine on the operating table. The patient's right lower\nextremity and right groin were prepped and draped in the\nusual sterile fashion. General endotracheal anesthesia was\ninduced, which the patient tolerated well. A time-out was\nperformed confirming the patient's identity and planned\noperation. 5000 units of IV heparin was given prior to our\narteriotomy. A vertical incision was made overlying the\nright femoral artery including the percutaneous site where\nthe EVAR had been performed earlier in the day. The soft\ntissue was divided down to the level of the femoral artery\nusing a combination of sharp dissection and ___\nelectrocautery. The proximal common femoral artery was\nidentified, and we identified the location of the arteriotomy\nfrom the EVAR with Perclose sutures attached. We carefully\ndissected out the common femoral artery and worked our way\ndown towards this takeoff of the superficial femoral artery\nand the profunda femoris artery. We obtained control of\nthese vessels using silastic vessel loops. On examination,\nit was clear that there was a palpable pulse proximal to the\nPerclose closure, but that this was absent distal to the site\nof the Perclose closure. Also of note, the common femoral\nartery was noted to be significantly atherosclerotic and\nhardened, though the SFA and profunda femoris as well as the\nproximal common femoral artery did have some healthy and soft\nand less diseased portions. We thus decided to enter the\nartery. We used 15 blade to create an arteriotomy\nlongitudinally on the anterior aspect of the common femoral\nartery just proximal to the continuation of the profunda\nfemoris artery. We extended this proximally using Potts\nscissors. We identified some atherosclerotic plaque, and an\nendarterectomy was performed. Working our way more\nproximally towards the side of the Perclose closure, we noted\nthat the Perclose closure appeared to have raised a flap of\nplaque from the posterior aspect of the common femoral\nartery. This appeared to be the cause of the occlusion. We\ndid not identify significant amounts of thrombus further\ncorroborating this diagnosis. Once we freed up and excised\nthe plaque that had been raised by the Perclose device, we\nnoted very strong inflow from the common femoral artery.\n\nAt this point, we turned our attention towards performing our\npatch angioplasty. We decided to use a Dacron patch to\nperform the angioplasty. We noted good backbleeding from the\nprofunda femoris artery and some slow backbleeding from a\nsuperficial femoral artery. The Dacron patch was sized to\nour arteriotomy and sutured in place circumferentially with 5-\n0 Prolene suture. After allowing for back-bleeding and\nforward-bleeding, we completed our angioplasty. We then\nperformed an angiogram to further assess the outflow to the\nright lower extremity. We used a micropuncture needle and\npassed a wire retrograde up into the aorta through the\nendovascular stent. Fluoroscopy was utilized to perform an\naortogram, and subsequently the catheter was moved down to\nthe right common iliac artery, and the right lower extremity\nangiogram was performed. We noted good flow into the\nsuperficial femoral artery. The profunda femoris appeared\noccluded at the level of the mid femur. Below the knee,\nthere was 2-vessel runoff into a diffusely diseased posterior\ntibial and peroneal artery. The anterior tibial artery\nappeared occluded. Being satisfied with our\nrevascularization, we turned our attention towards closure of\nthe wound. We removed the introducer catheter and\nguidewires, and closed the defect with a Dacron patch using 6-\n0 Prolene suture. We obtained good hemostasis in the right\ngroin incision, and the incision was closed in multiple\nlayers using ___ Vicryl suture in a running fashion, and a 3-\n0 Vicryl suture in the deep dermal layer, and the skin was\nclosed using skin staples. The needle, sponge, and\ninstrument counts were correct at the end of the case.\nSterile dressings were placed over the top of the incision\nsite. The patient was extubated and brought back to the ICU\nin stable condition.\n\nDr. ___ was present through the entirety of the\noperation. At the end of the operation, the posterior tibial\nartery signal was noted to be strong once again.\n\nEBL: 200 mL.\n\nURINE OUTPUT: 250 mL.\n\nIV FLUIDS: 1500 mL LR.\n\n ___, ___\nI was physically present during all critical and key portions of\nthe procedure and immediately available to furnish services \nduring\nthe entire procedure, in compliance with CMS regulations.\n \n\nDictated By: ___, MD\n\n \nBrief Hospital Course:\nMs. ___ is an ___ year old female with history of type 2 \ndiabetes, ruptured AAA s/p EVAR complicated by failure of left \nfemoral perclose requiring patch angioplasty and ex-lap for \nhematoma evacuation (___), PAD s/p L fem-peroneal bypass, who \npresented with abdominal and back pain, found to have re-rupture \nof her AAA.\n\nShe was initially found to be hypertensive to a SBP of 220s, and \nan esmolol gtt was started. A CTA was performed, which showed \nwhat appeared to be contained rupture without active \nextravasation of contrast. Vascular surgery was consulted for \nassessment of surgical repair of ruptured AAA. \n\nShe was emergently taken to the operating room for re-rupture of \nher AAA, and type 1B bar graft leak. She underwent coil \nembolization of the right internal iliac artery, as well as \nbilateral extension of previously placed EVAR iliac limbs with \ntwo additional limbs into the iliac arteries on both sides to \nreseal her previous EVAR graft. Upon transfer to the PACU, there \nwas some concern initially for right leg ischemia, but the \nultrasound showed that there was some flow in the superficial \nfemoral artery distal to the puncture site, and she was \ntransferred to the ICU for recovery.\n\nPostoperatively, she had initially been doing well, but was \nnoted to have a cooler right foot over the course of the \nsubsequent hours and loss of her posterior tibial Doppler \nsignal. Arterial duplex confirmed occlusion of the right lower \nextremity lower leg arteries, prompting concern for proximal \nocclusion. As such, the patient was prepped for immediate right \ngroin exploration. Intraoperatively it was noted that the \nPerclose closure appeared to have raised a flap of plaque from \nthe posterior aspect of the common femoral artery. This \nappeared to be the cause of her occlusion. She then underwent \nright femoral patch angioplasty with Dacron graft, right femoral \nendarterectomy, selective catheterization of right external \niliac artery, second order vessel, and angiogram of the right \nlower extremity. It was determined that revascularization had \nbeen successful, as her posterior tibial\nartery signal was noted to be strong again intraoperatively and \npostoperatively. The patient was transferred to the PACU in \nstable condition. \n\nPost-operatively she continued to experience intermittent pain \nand anxiety. Her home medications were restarted and she \nreceived medications as needed for adequate pain control. She \nwas also seen by social work and spoke with her outpatient \npsychiatrist, which helped to alleviate her anxiety.\n\nShe was discharged to rehab. She should continue frequent \nincentive spirometer use daily. Anticipate rehab stay less to be \nthan 30 days. \n\nShe should follow up with Dr. ___ at her scheduled \noutpatient appointment. She should continue taking aspirin 81mg \ndaily as well as her other medications as prescribed. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. ammonium lactate 12 % topical apply to legs BID PRN dryness \n2. LORazepam 0.5 mg PO BID \n3. OxyCODONE (Immediate Release) 5 mg PO Q4H with acetaminophen \n500 mg \n4. Acetaminophen 500 mg PO Q4H with oxycodone \n5. Aspirin 81 mg PO DAILY \n6. Vitamin D 1000 UNIT PO DAILY \n7. magnesium hydroxide unknown strength oral DAILY \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \nDo not take if loose stools \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n2. Polyethylene Glycol 17 g PO DAILY:PRN constipation \nHold if loose stools \nRX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by \nmouth daily Disp #*30 Packet Refills:*3 \n3. Senna 8.6 mg PO BID \nRX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n4. Acetaminophen 1000 mg PO Q6H \nRX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6) \nhours Disp #*240 Tablet Refills:*0 \n5. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - \nSevere \nDo not take if sedated \nRX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn pain Disp #*30 \nTablet Refills:*0 \n6. ammonium lactate 12 % topical apply to legs BID PRN dryness \n\n7. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*3 \n8. LORazepam 0.5 mg PO BID \nRX *lorazepam 0.5 mg 1 tablet by mouth twice a day Disp #*30 \nTablet Refills:*0 \n9. magnesium hydroxide unknown oral DAILY \n10. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___ \n \nDischarge Diagnosis:\nRuptured abdominal aortic aneurysm\nRight lower leg critical limb ischemia status post ruptured \nabdominal aortic aneurysm\nType II Diabetes Mellitus\nChronic Obstructive Pulmonary Disease\nHypertension\nFibromyalgia\n\n \nDischarge Condition:\nMental Status: Clear and coherent, intermittently anxious.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nYou were admitted to ___ for a \nruptured abdominal aortic aneurysm. You underwent an \nendovascular repair to fix this major blood vessel in your \nabdomen. \n\nWHAT TO EXPECT:\n1. It is normal to feel weak and tired, this will last for ___\nweeks\n• You should get up out of bed every day and gradually increase \nyour activity each day\n• You may walk and you may go up and down stairs\n• Increase your activities as you can tolerate, do not do too \nmuch right away!\n2. It is normal to have incisional and leg swelling:\n• Wear loose fitting pants/clothing (this will be less \nirritating to incision)\n• Elevate your legs above the level of your heart with ___\npillows every ___ hours throughout the day and at night\n• Avoid prolonged periods of standing or sitting without your \nlegs elevated\n3. It is normal to have a decreased appetite, your appetite will \nreturn with time\n• You will probably lose your taste for food and lose some \nweight\n• Eat small frequent meals\n• It is important to eat nutritious food options (high fiber, \nlean meats, vegetables/fruits, low fat, low cholesterol) to \nmaintain your strength and assist in wound healing\n• To avoid constipation: eat a high fiber diet and use stool \nsoftener while taking pain medication\n• Take all the medications you were taking before surgery, \nunless otherwise directed\n• Take one aspirin daily, unless otherwise directed\n\nACTIVITIES:\n• No driving until postop\nvisit and you are no longer taking pain medications\n• You should get up every day, get dressed and walk, gradually \nincreasing your activity\n• You may up and down stairs, go outside and/or ride in a car\n• Increase your activities as you can tolerate, do not do too \nmuch right away!\n• No heavy lifting, pushing or pulling (greater than 5 pounds) \nuntil your post op visit\n• You may shower (let the soapy water run over incision, rinse \nand pat dry)\n• Your incision may be left uncovered, unless you have small \namounts of drainage from the wound, then place a dry dressing \nover the area\nCALL THE OFFICE FOR : ___\n• Redness that extends away from your incision\n• Purulent or foul smelling drainage from your incision\n\nWe wish you the best in your health,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "I713", "T82330A", "J449", "T81718A", "F17210", "Y832", "Y929", "I70291", "E119", "I10", "Z8673", "I771", "E210", "E861", "Y834", "Y92239", "M797" ]

[ "I713: Abdominal aortic aneurysm, ruptured", "T82330A: Leakage of aortic (bifurcation) graft (replacement), initial encounter", "J449: Chronic obstructive pulmonary disease, unspecified", "T81718A: Complication of other artery following a procedure, not elsewhere classified, initial encounter", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Y832: Surgical operation with anastomosis, bypass or graft as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "I70291: Other atherosclerosis of native arteries of extremities, right leg", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "I771: Stricture of artery", "E210: Primary hyperparathyroidism", "E861: Hypovolemia", "Y834: Other reconstructive surgery as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "M797: Fibromyalgia" ]

[ "J449", "F17210", "Y929", "E119", "I10", "Z8673" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROSURGERY\n \nAllergies: \nPenicillins\n \nAttending: ___.\n \nChief Complaint:\nDizziness and unsteady gate\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old female from ___\nwho presents to the ED with dizziness and falls. The patient is \nunfortunately a poor historian. History obtained from the \npatient and ___ interpreter via phone. She has been in \n___ x 2 days. The patient reports dizziness and\nunsteadiness for approximately ___ years; she characterizes the \ndizziness as \"lightheadedness.\" She denies any syncopal events, \nbut her daughter noted that her gait was unsteady and she had \nseveral falls. She states she was evaluated for dizziness in \n___ and symptoms were attributed to menopause. She has no \nprior brain imaging. NCHCT reveals a left petrous apex mass \nconcerning for meningioma.\n\n \nPast Medical History:\nUnknown\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nON ADMISSION: \n\nPHYSICAL EXAM:\n**With ___ interpreter via phone\nO: T: 98.3 BP: 167/83 HR: 90 R: 18 O2Sats: 100% RA\nGen: WD/WN, comfortable, NAD.\nHEENT: Pupils: PERRL EOMs Full\nNeck: Supple.\nLungs: No resp distress\nExtrem: Warm and well-perfused.\nNeuro:\nMental status: Awake and alert, cooperative with exam, normal\naffect.\nOrientation: Oriented to person, place, and date.\nLanguage: Speech fluent with good comprehension. No dysarthria \nor\nparaphasic errors.\n\nCranial Nerves:\nI: Not tested\nII: Pupils equally round and reactive to light, 4mm to\n3mm bilaterally. \nIII, IV, VI: Extraocular movements intact bilaterally without\nnystagmus.\nV, VII: Slight R facial asymmetry. \nVIII: Hearing intact to voice.\nIX, X: Palatal elevation symmetrical.\nXI: Sternocleidomastoid and trapezius normal bilaterally.\nXII: Tongue midline without fasciculations.\n\nMotor: Normal bulk and tone bilaterally. No abnormal movements,\ntremors. Strength full power ___ throughout. No pronator drift\n\nSensation: Intact to light touch\n\n==================================================\n\nON DISCHARGE:\n\nExam:\nOpens eyes: [x]spontaneous [ ]to voice [ ]to noxious\nOrientation: [x]Person [x]Place [x]Time\nFollows commands: [ ]Simple [x]Complex [ ]None\nPupils: PERRL 3-2mm\nEOM: [x]Full [ ]Restricted\nFace Symmetric: [x]Yes [ ]No\nTongue Midline: [ ]Yes [x]No - deviates to R \nPronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No\nComprehension intact [x]Yes [ ]No\n\nMotor:\nTrapDeltoidBicepTricepGrip\n___\n\nIPQuadHamATEHLGast\nRight55___\nLeft5 5 5 5 5 5\n\n[x]Sensation intact to light touch\n\n \nPertinent Results:\nPlease refer to ___ for pertinent imaging and lab results. \n \nBrief Hospital Course:\n___ is a ___ year old female, from ___, \nwho presents with symptoms of dizziness and unsteady gait. \nImaging demonstrated a petrous apex brain lesion with mass \neffect, concerning for meningioma. \n\n#Petrous Brain Lesion\n___ was admitted to the neurosurgery service \non ___ with imaging concerning for meningioma. An MRI was \nobtained for further details. Both ENT and ophthalmology were \nconsulted. The patient underwent visual field testing, per \nophthalmology the testing was unreliable and has evidence of \nnon-specific defects. MRA brain revealed patent intracranial \nvasculature however the mass encases several vessels without \nsignificant stenosis. Patient was seen by ___ for vestibular \ntesting and it was recommended she be discharged home with \noutpatient vestibular ___. Upon re-examination on ___, physical \ntherapy compiled home exercises for patient, and educated the \npatient and her daughter with an interpreter present. \nRadiation oncology was consulted and feels patient will benefit \nfrom radiation after surgical decompression of the brainstem. \nPatient was added to Brain Tumor Conference list for \ninterdisciplinary discussion. It was determined that the patient \nwould be discharged home and follow up in clinic in 4 weeks to \ndiscuss surgical resection options.\n\n#Pituitary work-up\nStrict I&Os were ordered. Labs were collected to check for \npituitary function which showed elevated FSH and Prolactin \nlevels. \n\n#ENT/Audiology\nAudiology was consulted at the request of ENT for hearing and \nauditory brainstem response testing. The audiology testing \nrevealed a low-to-mid frequency conductive hearing loss in the \nright ear, but normal hearing in the left ear. The auditory \nbrainstem response testing was deferred to outpatient workup. \nThe patient was provided with the appropriate numbers to contact \nfor her Audiogram work up and an order was placed in ___ for \nclinic purposes. \n\n#Dysphagia\nSLP was consulted and recommended soft texture foods with thin \nliquids. On ___, SLP was re-consulted and stated that soft foods \nwere at the patient's discretion because she had the sensation \nof \"food being caught\", if patient not longer has these symptoms \nthen she is able to progress to solid foods. \n\n#Dispo planning\nPatient will need to have follow-up in 4 weeks for surgical \nplanning. Pt will need Audiogram prior to this appointment. All \nappropriate information and numbers for appointments were \nrelayed to patient and daughter with interpreter present. \n\n \nMedications on Admission:\nUnknown\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Docusate Sodium 100 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPetrous Meningioma \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDiet: Regular diet as tolerated. Speech Therapy is having you \neat \na soft diet because of the sensation of \"food being stuck in \nyour throat\". If this sensation resolves, you may progress to a \nregular diet. \nSpeech Therapy recommends: \nSitting upright 90 degrees for all intake and for at least 30 \nmin following\nSolid foods should be well-moistened - use extra sauces/gravies\nDo not use straws\nPlease take small bites/sips\nPlease alternate liquids and solids \n\nActivity:\nOpen mouth to sneeze and cough (do not stifle sneeze or cough)\nWalk as tolerated \nPlease follow instructions given by the Physical Therapists and \ntheir exercises. \n\nCall or Return with:\nEye pain or redness\nVision changes\nIncreasing headache\nNeck stiffness\nLight sensitivity (e.g. headache with light or discomfort with \nexposure to light)\nWorsening of dizziness or vertigo symptoms\nHearing loss\nTinnitis or ringing in your ears\n\nMedications:\nYou may resume all regular medications\nYou may take acetaminophen for headaches. \n \nFollowup Instructions:\n___\n" ]

[ "D320", "G935", "R42", "H9011", "H5340", "R1310", "I10", "R947" ]

[ "D320: Benign neoplasm of cerebral meninges", "G935: Compression of brain", "R42: Dizziness and giddiness", "H9011: Conductive hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side", "H5340: Unspecified visual field defects", "R1310: Dysphagia, unspecified", "I10: Essential (primary) hypertension", "R947: Abnormal results of other endocrine function studies" ]

[ "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nBactrim\n \nAttending: ___\n \nChief Complaint:\nleukocytosis/abd pain \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ woman w/ alcoholic cirrhosis (c/b HE, ascites, jaundice, ETOH \ndilated cardiomyopathy, Grade I varices), COPD, recently \nadmitted from ___ - ___ with alcoholic hepatitis now w/ C. \ndifficile, who presents from ___ for abdominal pain \nand leukocytosis. \n During admission from ___ she had an ongoing O2 \nrequirement likely related to COPD and volume overload, tx w/ \ndiuresis, and tube feeding was started. She was also restarted \non prednisone 40mg daily on ___ with atovaquone as \nprophylaxis for a planned total of 4weeks with follow-up with \nDr. ___ in clinic ___. \n \n Her WBC increased to 28 from 17 per report; abdominal pain is \nstable. Reports that she has been taking her PO vancomcyin, \nhowever she continues to have up to 10 stools per day while on \nlactulose. She was sent for diagnostic paracentesis. Reports \nthat her temperature was ___ at rehab. Denies chest pain, \nshortness of breath, nausea, vomiting, dysuria, or hematuria. \n In the ED, initial vitals were: 97.8 90 118/52 20 98% RA \n - Exam notable for: Profoundly jaundiced, icteric sclerae, RRR, \nno MRGs, scant wheezes bilaterally, abdomen soft, distended, \n+fluid wave, NABS, 1+ edema bilaterally. No asterixis PICC line \npresent in RUE. \n - Labs notable for: Na 132, K 4.9, Cr 0.9, BUN 30 UA w/ trace \nleuks, neg nitrites, INR: 1.5, ALT: 215 AP: 249 Tbili: 14.9 Alb: \n3.6, AST: 184 Dbili: 8.8, Lip: 59, WBC 27.4 w/ 90.4% N \n - Imaging was notable for: unable to identify an accessible \npocket for bedside paracentesis. \n - Patient was given: Flagyl, PO vancomycin, Lasix 40 PO, \nlactulose, citalopram, oxy, tramadol \n Liver was consulted and rec : Repeat infectious w/u w/ CXR, UA, \nblood cx. Cont PO vanc, could add IV flagyl for now. RUQUS w/ \ndopplers. Diag para if anything to tap. \n Vitals on transfer- 98.6 73 99/68 20 96% RA \n Upon arrival to the floor, patient reports mild abd pain at \nrest, unchanged over the last week. She denies any diarrhea X 1 \nweek, and says her stools have been solid for a week now. Denies \nany CP, SOB, nausea, vomiting. Denies dysuria. Says she was sent \nhere from ___ because they think she has an infection and \nare concerned it's in her belly. \n\n \nPast Medical History:\nETOH Cirrhosis c/b HE \n ETOH Abuse \n ETOH withdrawal, complicated (required intubation, +DT history) \n \n ETOH Dilated cardiomyopathy \n CKD III \n GERD \n Lung mass \n Hypothyroidism \n COPD - not on home O2 \n OSA on CPAP \n Depression \n Benign right ovarian tumor s/p resection and tubal ligation \n Obesity \n\n \nSocial History:\n___\nFamily History:\nFather had diabetes, CAD, pancreatic cancer. Mother had COPD. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVITAL SIGNS: 99.0 117/74 98 18 94 RA \n GENERAL - jaundiced but NAD, comfortably laying in bed, talking \non phone \n HEENT - Icteric sclera, PERRL, EOMI \n NECK - Supple, no LAD, JVD obscured by habitus \n CARDIAC - RRR, normal S1S2, no M/R/G \n LUNGS - mildly decreased bibasilar BS, no wheeze or rales \n ABDOMEN - obese, distended, tympanitic, +caput medusa, \n mild TTP RUQ > RLQ, no rebound/guarding, NABS, \n+hepatosplenomegaly \n EXTREMITIES - WWP, no ___, RUE ___ c/d/I w/out TTP, palmar \nerythema \n NEUROLOGIC - A&O to self and place and year, could not tell me \nmonth, knew it was still winter, CN II-XII intact grossly, mild \nasterixis, \n ___ strength in upper and lower extremity flexors/extensors \n SKIN - jaundiced, palmar erythema, telangiectasias, ecchymoses \n\n\nDISCHARGE PHYSICAL EXAM:\n=========================\nVS - 97.8 ___ 18 93 RA \nGENERAL - jaundiced but NAD, comfortably laying in bed, talking \non phone \nHEENT - Icteric sclera, PERRL, EOMI \nNECK - Supple, no LAD, JVD obscured by habitus \nCARDIAC - RRR, normal S1S2, no M/R/G \nLUNGS - mildly decreased bibasilar BS, no wheeze or rales \nABDOMEN - obese, distended, tympanitic, +caput medusa, mild TTP \nRUQ > RLQ, no rebound/guarding, NABS, +hepatosplenomegaly \nEXTREMITIES - WWP, no ___, RUE ___ c/d/I w/out TTP, palmar \nerythema \nNEUROLOGIC - A&O to self and place and year, could not tell me \nmonth, knew it was still winter, CN II-XII intact grossly, mild \nasterixis, \n___ strength in upper and lower extremity flexors/extensors \nSKIN - jaundiced, palmar erythema, telangiectasias, ecchymoses \n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 01:30AM BLOOD WBC-27.4* RBC-2.86* Hgb-11.3 Hct-33.2* \nMCV-116* MCH-39.5* MCHC-34.0 RDW-16.4* RDWSD-70.7* Plt Ct-69*\n___ 01:30AM BLOOD Neuts-90.4* Lymphs-2.2* Monos-5.1 \nEos-0.4* Baso-0.1 Im ___ AbsNeut-24.77* AbsLymp-0.59* \nAbsMono-1.41* AbsEos-0.12 AbsBaso-0.04\n___ 01:30AM BLOOD ___ PTT-26.6 ___\n___ 01:30AM BLOOD Glucose-113* UreaN-30* Creat-0.9 Na-132* \nK-4.9 Cl-97 HCO3-19* AnGap-21*\n___ 01:30AM BLOOD ALT-215* AST-184* AlkPhos-249* \nTotBili-14.9* DirBili-8.8* IndBili-6.1\n___ 01:30AM BLOOD Lipase-59\n___ 01:30AM BLOOD Albumin-3.6 Calcium-8.9 Phos-3.8 Mg-1.9\n\nDISCHARGE LABS:\n================\n___ 06:00AM BLOOD WBC-19.9* RBC-2.62* Hgb-10.1* Hct-30.5* \nMCV-116* MCH-38.5* MCHC-33.1 RDW-15.5 RDWSD-66.7* Plt Ct-51*\n___ 06:00AM BLOOD ___ PTT-26.0 ___\n___ 06:00AM BLOOD Glucose-97 UreaN-30* Creat-1.0 Na-135 \nK-3.8 Cl-98 HCO3-21* AnGap-20\n___ 06:00AM BLOOD ALT-245* AST-271* LD(LDH)-281* \nAlkPhos-195* TotBili-13.8*\n___ 06:00AM BLOOD Albumin-3.1* Calcium-8.5 Phos-4.5 Mg-1.6\n\nMICRO:\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___ BLOOD CULTURE PENDING\n\nIMAGING:\n=========\nCXR ___: \nRight-sided PICC terminates in the low SVC without evidence of \npneumothorax. \nAgain seen is suggestion of left-sided pulmonary nodule, with \nleft midlung \nnodular opacity measuring approximately 1.9 x 1.2 cm. Recommend \nfurther \nassessment with non emergent chest CT. Findings are concerning \nfor pulmonary \nneoplasm, although if there is concern for infection, could \nrepresent \nenlarging focal consolidation. \n\nABDOMINAL US ___: \n1. Patent hepatic vasculature with appropriate direction of \nflow. The \nanterior right portal vein is not interrogated/seen on today's \nexam. \n2. Nodular and coarsened hepatic architecture, compatible with \nknown \nalcoholic cirrhosis. \n3. Small amount of perihepatic ascites. \n4. Splenomegaly, measuring up to 17.3 cm. \n\n \nBrief Hospital Course:\n___ woman w/ alcoholic cirrhosis (c/b HE, ascites, jaundice, ETOH \ndilated cardiomyopathy), COPD, recently admitted from ___ - ___ \nwith alcoholic hepatitis now w/ C. difficile, who presents from \n___ Rehab for abdominal pain and leukocytosis. \n\n#Leukocytosis\n#C. Difficile\nLeukocytosis to 27 on presentation, but on repeat check \nleukocytosis downtrended to 19 prior to receiving antibiotics. \nLeukocytosis likely secondary to C. Diff infection although \npatient has been receiving treatment with PO Vancomycin since \n___. Toxic megacolon less likely given unremarkable KUB. \nPatient did have right upper quadrant abdominal pain that has \nbeen stable for the last month. Abdominal US with no ascities \nonly trace fluid surrounding liver, thus diagnostic paracentesis \nwas not able to be obtained. Chest x-ray w/ known nodule but no \nacute infectious process.Urine culture with no growth. Patient \nwas treated with Ceftriaxone x1 overnight, now discontinued give \nno obvious infection. She also received IV Flagyl x1 on \npresentation, but this was discontinued given clinical \nstability. Plan to treat with PO Vancomycin for 2 week course \n(___). \n\n# Alcoholic hepatitis c/b cirrhosis\nPatient with Alcoholic hepatitis c/b cirrhosis. She has Childs \n___ score is C, MELD is 23, discriminant function is 37 on \nadmission, which is similar to when she was discharged on ___. \nShe is on a 4 week course of prednisone and was on Atovaquone \nfor prophylaxis. Discontinued Atovaquone, given patient only \nrequires Prednisone for one month and she is not on additional \nimmunosuppressive therapy. Her feeding tube was removed when she \nwas at ___ about a week ago and she reports she has been \neating well. She was continued on Furosemide 40mg and \nSpironlactone 100mg. \n\n#Hepatic encephalopathy\nPatient with asterixis on exam, however she is A&O x3. Having \n___ bowel movements per day on Lactulose. Will initiate \nRifaximin. \n\n#Grade 1 varices- Plan for yearly EGD, hold off on Nadolol for \nnow. \n\n# COPD- Was discharged on oxygen, however she is no longer \nrequiring O2. Continued on home tiotropium inhaler. \n \n# CODE: Confirmed full \n# CONTACT: Name of health care proxy: ___, \nRelationship: daughter, Phone number: ___ \n\nTRANSITIONAL ISSUES:\n=====================\n- Plan to treat C. Diff with PO Vancomycin for 2 week course \n(___). \n- Atovaquone was discontinued given she only requires Prednisone \nfor one month and she is not on additional immunosuppressive \ntherapy.\n- Please ensure patient follows up with hepatology. She was \ncontinued on Prednisone 40mg until her appointment on ___. \n- Patient with asterixis during admission. She was initiated on \nRifaximin. Please ensure Lactulose is titrated to ___ bowel \nmovements per day. \n- Please clarify patient's pain regimen. Per patient she was \npreviously taking Buprenorphine-Naloxone for pain which she \ncannot take because of her cirrhosis. She was taking Oxycodone \nand Tramadol at her nursing facility. She was not discharged \nwith no narcotic pain medications.\n- Consider initiation of Acamprosate for medication assistance \nwith alcohol cessation.\n- Please link patient with therapy for additional support for \nher alcohol cessation.\n- Outpatient follow up for left lung nodule, was prev f/b pulm \nin setting of smoking hx. \n- Ensure patient gets a yearly EGD to monitor varices (grade I). \nShe is not on nadolol because of hypotension. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Citalopram 40 mg PO DAILY \n2. Furosemide 40 mg PO DAILY \n3. Lactulose 20 mL PO BID \n4. Multivitamins 1 TAB PO DAILY \n5. Omeprazole 40 mg PO DAILY \n6. Atovaquone Suspension 1500 mg PO DAILY \n7. PredniSONE 40 mg PO DAILY \n8. Spironolactone 100 mg PO DAILY \n9. TraMADol 50 mg PO Q12H:PRN Pain - Moderate \n10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe \n11. Nystatin Cream 1 Appl TP BID \n12. Vancomycin Oral Liquid ___ mg PO Q6H \n13. Nicotine Patch 14 mg TD DAILY \n14. LORazepam 0.5 mg PO QHS:PRN insomni and anxiety \n15. Cepacol (Sore Throat Lozenge) 1 LOZ PO PRN sore throat \n16. Famotidine 40 mg PO DAILY \n17. FoLIC Acid 1 mg PO DAILY \n18. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY \n\n \nDischarge Medications:\n1. Rifaximin 550 mg PO BID \nRX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0 \n2. Thiamine 100 mg PO DAILY \nRX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily \nDisp #*30 Tablet Refills:*0 \n3. Tiotropium Bromide 1 CAP IH DAILY \nRX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 puff \nINH daily Disp #*1 Capsule Refills:*0 \n4. Lactulose 30 mL PO TID \nRX *lactulose 20 gram/30 mL 30 mL by mouth three times a day \nRefills:*0 \n5. Citalopram 40 mg PO DAILY \nRX *citalopram 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n6. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n7. Furosemide 40 mg PO DAILY \nRX *furosemide 40 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet \nRefills:*0 \n8. Multivitamins 1 TAB PO DAILY \nRX *multivitamin [Daily Multiple] 1 tablet(s) by mouth daily \nDisp #*30 Tablet Refills:*0 \n9. Nicotine Patch 14 mg TD DAILY \nRX *nicotine 14 mg/24 hour one patch to upper arm daily Disp #*1 \nPackage Refills:*0 \n10. Omeprazole 40 mg PO DAILY \nRX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30 \nCapsule Refills:*0 \n11. PredniSONE 40 mg PO DAILY \nRX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*5 Tablet \nRefills:*0 \n12. Spironolactone 100 mg PO DAILY \nRX *spironolactone 100 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0 \n13. Vancomycin Oral Liquid ___ mg PO Q6H \nRX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp \n#*20 Capsule Refills:*0 \n14. HELD- OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nSevere This medication was held. Do not restart OxyCODONE \n(Immediate Release) until Please discuss with your primary \ndoctor what medicine you should be on for pain. \n15. HELD- TraMADol 50 mg PO Q12H:PRN Pain - Moderate This \nmedication was held. Do not restart TraMADol until you discuss \nwith your primary doctor\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary: Clostridium difficile \n\nSecondary: Leukocytosis, Alcoholic hepatitis, Cirrhosis, Hepatic \nencephalopathy, grade 1 esophageal varices. \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. ___,\nIt was a pleasure taking care of you at ___.\n\nWhy was I here?\n- You had a high level of white blood cells that make us worry \nabout infection. \n\nWhat was done while I was here?\n- We made sure you did not have any infections other than your \nC. Diff infection in your colon causing you to have diarrhea.\n- You were given antibiotics for your C. diff infection.\n\nWhat should I do when I get home?\n- Take all your medicines as prescribed. You will need to take \nthe antibiotic, Vancomycin, 4 times a day until ___. \n- Make sure you have ___ bowel movements a day and adjust your \nlactulose. \n- Continue to avoid all alcohol. It is very dangerous if you \ndrink alcohol with your severe liver disease. \n- Please schedule an appointment with your primary care \nphysician ___ ___ days. \n- Please follow up with Dr. ___ at the ___ on \n___.\n- You make take acetaminophen (no more than 2 g/day) for pain, \nplease avoid naproxen/ibuprofen/advil/motrin\n \nFollowup Instructions:\n___\n" ]

[ "A047", "D72829", "K7031", "F1010", "K7030", "K7040", "I8510", "I426", "R911", "K219", "E039", "J449", "G4733", "F329", "E669", "Z6841", "F17210" ]

[ "A047: Enterocolitis due to Clostridium difficile", "D72829: Elevated white blood cell count, unspecified", "K7031: Alcoholic cirrhosis of liver with ascites", "F1010: Alcohol abuse, uncomplicated", "K7030: Alcoholic cirrhosis of liver without ascites", "K7040: Alcoholic hepatic failure without coma", "I8510: Secondary esophageal varices without bleeding", "I426: Alcoholic cardiomyopathy", "R911: Solitary pulmonary nodule", "K219: Gastro-esophageal reflux disease without esophagitis", "E039: Hypothyroidism, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "F329: Major depressive disorder, single episode, unspecified", "E669: Obesity, unspecified", "Z6841: Body mass index [BMI]40.0-44.9, adult", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]

[ "K219", "E039", "J449", "G4733", "F329", "E669", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Prochlorperazine / Chlorpromazine\n \nAttending: ___.\n \nChief Complaint:\nSuicidal Ideation\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ w/ myasthenia ___, sarcoidosis, osteoporosis presents w/\nSI.\n\nPatient states that her neighbor called ___ because she \nexpressed\nsuicidal ideation. Patient states that she is having thoughts of\nhurting herself and plans to use a gun. She does not have a gun\nbut was planning on obtaining done. Denies HI. On arrival to the\nemergency department, patient made multiple attempts to leave.\nPatient made multiple about how we should not be allowed to keep\nher here in the hospital and how it is only because she is in\n___ that she is kept against her will. She is\nperseverating on the fact that if she were in ___, she be\nallowed to leave. She denies any complaints. She says she does\nnot take any medication since every day except for Synthroid. \nShe\nwas in the ED for 3 days prior to transfer to the floor.\n\nIn the ED, initial vitals: T 97.5 HR 114 BP 110/71 RR 18 98% RA \n-Exam notable for: agitated, aggressive, non-linear thoughts\n-Labs notable for: wbc 6, hgb 12.7, plt 148, Cr 0.6, S/U tox \nneg,\nUA neg.\n-Imaging notable for: NCCTH w/o acute process. CXR no acp. EKG \nw/\nHR 100, NS NI NA QTc 452.\n-Pt given: Ativan 2 mg IM x2, Haldol 5 mg IM x 2, levothyroxine\n100 mcg, donepezil 5 mg.\n-Psych was consulted and said no more ___, continue 1:1\nsitter, BEST bed search cancelled, Recommend Medical Admission\nfor Safe discharge planning, Recommend ___, OT, and social work\nconsult, for acute agitation, Haldol 2/Ativan 1 PO or IM; \nmonitor\nECG. Essentially, unsafe to go home, but no indication for a\npsych facility.\n-Vitals prior to transfer: T 97.8 HR 85 BP 100/68 RR 16 96% RA \n\nUpon arrival to the floor, the patient is a poor historian. She\nis alert, but thoughts are non-linear. She states that if she\ntook all of her medications she would have been dead by now\n(trazodone specifically). She states that she has chronic foot \nan\nback pain. She takes her levothyroxine daily. She ambulates with\na cane or walker at home. She is A+Ox3 currently and states that\nshe has a lot of distrust about the emergency room and why she \nis\nhere. She does not remember taking her other medications or what\nthey are. She cries when talking about her memory impairment and\nhow she no longer can read ___ (she was a previous\n___). She states that her mother passed away from\nAlzheimer's as well ___ years old). Denies CP, SOB, DOE,\nswelling.\n \nPast Medical History:\nMYASTHENIA ___ \nOSTEOPOROSIS \nARTHRITIS \nCATARACTS \nCHEST PAIN \nEPISODIC R FACIAL DROOP \nFATIGUE \nGASTRITIS \nHEALTH MAINTENANCE \nHEMATURIA \nHERPES ZOSTER \nHYPOTHYROIDISM \nLEFT SHOULDER PAIN \nMIGRAINES \nNARCOTICS AGREEMENT \nPALPITATIONS \nPOSITIVE PPD \nRECLAST \nSARCOIDOSIS \nSPINAL STENOSIS \nWEIGHT LOSS \nDEPRESSION \nPANCREATITIS \nGASTROINTESTINAL BLEEDING \nTHYROID CANCER \nPERIPHERAL NEUROPATHY \nMICROSCOPIC HEMATURIA \nHYPERTENSION \nMILD COGNITIVE IMPAIRMENT \nPULMONARY NODULE \nOSTEOPENIA \nTHYROIDECTOMY ___ \nSHOULDER SURGERY \nHAND SURGERY \nCATARACT SURGERY \nTONSILLECTOMY \nELBOW SURGERY \n \nSocial History:\nCountry of Origin: ___ \nMarital status: Divorced \nChildren: No \nLives with: Alone \nLives in: Apartment \nWork: ___\nTobacco use: Former smoker \n Year Quit: ___ \n Years Since Quit: 57 \n # Packs/Day: 1 \n # Years Smoked: 10 \n Pack Years: 10 \nDepression: Over the past two weeks, the patient expresses \nlittle\ninterest or pleasure in activity \nPositive PHQ-2 Screen Actions: Complete PHQ-9 evaluation \n \nComments: Moved frequently as she grew up in an ___ family\nDivorced twice (both husbands were ___). Lived in ___\nmany years; studied ___ Culture at ___ and\nworked as a ___ ___ literature.\n___ degree from ___, completed some course work \ntowards\n___ PhD but never finished. Formerly played the bass___. No\nchildren. Has home health aid. One paternal cousin in ___\nand no other family.\n \nFamily History:\nMother ALZHEIMER'S DISEASE \nFather ALCOHOL ABUSE \n ATRIAL FIBRILLATION \n CLUSTER HEADACHES\nMGM MIGRAINE HEADACHES \nPGM MIGRAINE HEADACHES\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n========================\n___ Temp: 97.8 PO BP: 119/78 R Sitting HR: 84 RR: 18 \nO2\nsat: 96% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ \nGeneral: Alert, oriented x3 (knows the year and that she is in\nfar in the hospital), no acute distress \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,\nneck supple, JVP not elevated, no LAD \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops \nLungs: Clear to auscultation bilaterally, no wheezes, rales,\nrhonchi \nAbdomen: Soft, non-tender, non-distended, bowel sounds present,\nno organomegaly, no rebound or guarding \nGU: No foley \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema. No signs of inflammatory arthritis.\nSkin: Warm, dry, no rashes or notable lesions. \nNeuro: CNII-XII intact, ___ strength upper/lower extremities,\ngrossly normal sensation, 2+ reflexes bilaterally. A+Ox3.\n\nDISCHARGE PHYSICAL EXAM\n=======================\n___ 0405 Temp: 98.4 PO BP: 96/65 HR: 85 RR: 20 O2 sat: 96%\nO2 delivery: Ra \nGeneral: WDWN older woman in NAD\nHEENT: NCAT, sclerae anicteric, normal conjunctivae, PERRL, \nEOMI,\noropharynx clear, MMM\nCV: RRR, normal S1/S2, no m/r/g\nLungs: CTAB, no increased work of breathing\nAbdomen: Soft, non-tender, non-distended, normoactive BS\nExt: Warm, DP pulses 2+ bilaterally, mild non-pitting edema of\nlower extremities (baseline per patient)\nNeuro: A&Ox3, CNII-XII intact, strength ___ in upper and lower\nextremities bilaterally throughout, sensation intact throughout.\nAble to say days of week backwards.\n \nPertinent Results:\nED LABS\n========\n___ 04:30PM BLOOD WBC-6.0 RBC-4.19 Hgb-12.7 Hct-39.5 MCV-94 \nMCH-30.3 MCHC-32.2 RDW-13.0 RDWSD-44.7 Plt ___\n___ 04:30PM BLOOD Neuts-62.2 ___ Monos-11.1 \nEos-0.7* Baso-0.2 Im ___ AbsNeut-3.71 AbsLymp-1.51 \nAbsMono-0.66 AbsEos-0.04 AbsBaso-0.01\n___ 04:30PM BLOOD Plt ___\n___ 04:30PM BLOOD Glucose-86 UreaN-12 Creat-0.6 Na-140 \nK-4.4 Cl-107 HCO3-23 AnGap-10\n___ 04:30PM BLOOD ALT-8 AST-18 LD(LDH)-185 AlkPhos-64 \nTotBili-0.8\n___ 04:30PM BLOOD Albumin-4.2 Calcium-9.3 Phos-3.6 Mg-2.1\n___ 04:30PM BLOOD TSH-0.61\n___ 04:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n___ 02:15PM URINE Color-Yellow Appear-Clear Sp ___\n___ 02:15PM URINE Blood-TR* Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG\n___ 02:15PM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE \nEpi-<1\n___ 08:18AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG \ncocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG\n\nDISCHARGE LABS\n==============\n___ 05:15AM BLOOD WBC-4.4 RBC-4.25 Hgb-12.8 Hct-40.3 MCV-95 \nMCH-30.1 MCHC-31.8* RDW-13.0 RDWSD-45.1 Plt ___\n___ 05:15AM BLOOD Plt ___\n___ 05:15AM BLOOD Glucose-96 UreaN-12 Creat-0.7 Na-142 \nK-3.8 Cl-107 HCO3-22 AnGap-13\n___ 05:15AM BLOOD Calcium-9.0 Phos-4.3 Mg-1.9\n\nIMAGING\n========\nCT HEAD (___)\nFINDINGS: \nThere is no evidence of infarction, hemorrhage, edema, or mass \neffect. There\nis prominence of the ventricles and sulci suggestive of \ninvolutional changes.\nPeriventricular and subcortical white matter hypodensities are \nnonspecific but\nlikely sequelae of chronic small vessel ischemic disease.\n \nThere is no evidence of fracture. The visualized portion of the \nparanasal\nsinuses, mastoid air cells, and middle ear cavities are clear. \nStatus post\nbilateral lens replacement.\n \nIMPRESSION: \nNo acute intracranial process.\n\nCXR (___)\nFINDINGS: \nNo focal consolidation, pleural effusion, evidence of \npneumothorax is seen. \nThe cardiac and mediastinal silhouettes are stable. Overall, \nthere has been\nno significant interval change since ___. \nPeribronchovascular\nground-glass opacities seen on prior CT from ___ \nwere better\nassessed on CT.\n \nIMPRESSION: \nNo significant change compared to ___. No new focal \nconsolidation\nidentified.\n\nMICROBIOLOGY\n==============\n___ 8:18 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\n___ 2:15 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 \nBrief Hospital Course:\n___ w/ myasthenia ___, sarcoidosis, osteoporosis presents w/\nSI. Receives all of her care at ___.\n\n#SI:\n#Dementia:\nPatient presented with reported SI with plan. Evaluated by \npsychiatry in the ED, noted impulsivity, mood lability c/w \npossible frontotemporal dementia. Patient otherwise alert and \noriented, cognition grossly linear, no focal neuro deficits. \nMild word-finding difficulties and memory loss. Admitted to \nmedicine for further evaluation. Initially on 1:1 sitter. Per \npsychiatry, patient does not meet ___ criteria. \nDiscontinued 1:1 sitter per psychiatry, who felt that from psych \nperspective patient safe for discharge. Patient evaluated by OT \nwhile inpatient, who assessed patient as independent in upper \nand lower extremity ADLs with independent functional ambulation \nand no errors on executive testing. Corroborating information \nprovided by patient's home PCA, who felt that patient was \nmentating at baseline. OT recommended continuing home PCA for \nADL/IADL support. Patient would likely benefit from further \nneurocognitive evaluation; however, given absence of acute \nchange in neurocognitive status, OT evaluation noted above, \npresence of home PCA to assist with ADLs/IADLs, absence of other \nmedical conditions requiring hospitalization, reasonable to \npursue further testing as outpatient. Patient assessed to have \ncapacity and expressed strong preference for outpatient \nevaluation and discharge home. Medicine team also spoke with \npatient's PCP by email, who felt that if patient cleared by \npsychiatry then safe to discharge home. PCP ___ assist in \ncoordinating further evaluation for additional ___ services \nafter discharge. Continued home donepezil 5MG QHS while patient \nadmitted and on discharge.\n\n#Myasthenia ___:\nHistory questionable, has been off mastinon and cellcept for\nmonths. Follows with neurology at ___. No e/o exacerbation \nduring\nthis hospitalization.\n\n#Hypothroidism:\nTSH WNL. Continued home levothyroxine 200 mcg qd.\n\n#Osteoporosis:\n#Vitamin D deficiency:\nWas recently started on high dose vitamin D weekly and is on\nalendronate weekly as well. Continued home vitamin D while \ninpatient.\n\n#Sarcoidosis:\nFollows pulm at ___. Parenchymal lung abnormalities, but\nminimal symptoms. Was a concern for sarcoid associated arthritis\nand was on MTX. No concerns for active inflammatory arthritis\ncurrently.\n\nTRANSITIONAL ISSUES\n====================\n[ ] Consider brain MRI for further dementia work-up\n[ ] Follow-up with cognitive neurology for further dementia \nwork-up\n[ ] Consider checking B12 level\n[ ] Consider further depression evaluation\n\nNew Medications:\nNone\n\nChanged Medications:\nNone\n\nStopped/Held Medications:\nNone\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Alendronate Sodium 70 mg PO Frequency is Unknown \n2. Donepezil 5 mg PO QHS \n3. Vitamin D ___ UNIT PO 1X/WEEK (MO) \n4. Levothyroxine Sodium 200 mcg PO DAILY \n5. Omeprazole 20 mg PO DAILY \n\n \nDischarge Medications:\n1. Alendronate Sodium 70 mg PO 1X/WEEK (MO) \n2. Donepezil 5 mg PO QHS \n3. Levothyroxine Sodium 200 mcg PO DAILY \n4. Omeprazole 20 mg PO DAILY \n5. Vitamin D ___ UNIT PO 1X/WEEK (MO) \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n==================\nSuicidal Ideation\nDementia\n\nSECONDARY DIAGNOSES\n=====================\nHypothyroidism\nSarcoidosis\nOsteoporosis\nMyasthenia ___\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 \nIt was a pleasure taking part in your care here at ___! \n\nWhy was I admitted to the hospital? \n- You were admitted for thoughts of harming yourself and for \nfunctional assessment.\n \nWhat was done for me while I was in the hospital? \n- You were evaluated by psychiatry, who assessed that it was \nsafe for you to return home.\n- You were evaluated by occupational therapy, who recommended \ncontinuing your home ___ services to assist with daily \nactivities.\n\nWhat should I do when I leave the hospital? \n- Continue to take all of your medications as prescribed.\n- Attend all of your scheduled follow-up appointments.\n\nSincerely, \nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "G3109", "R45851", "F0281", "G7000", "M810", "E559", "Z85850", "I10", "E890", "Z87891", "D860", "Z915" ]

[ "G3109: Other frontotemporal dementia", "R45851: Suicidal ideations", "F0281: Dementia in other diseases classified elsewhere with behavioral disturbance", "G7000: Myasthenia gravis without (acute) exacerbation", "M810: Age-related osteoporosis without current pathological fracture", "E559: Vitamin D deficiency, unspecified", "Z85850: Personal history of malignant neoplasm of thyroid", "I10: Essential (primary) hypertension", "E890: Postprocedural hypothyroidism", "Z87891: Personal history of nicotine dependence", "D860: Sarcoidosis of lung", "Z915: Personal history of self-harm" ]

[ "I10", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: OTOLARYNGOLOGY\n \nAllergies: \n___\n \nAttending: ___.\n \nChief Complaint:\nrecurrent glottis cancer\n \nMajor Surgical or Invasive Procedure:\ntotal laryngectomy (primary closure reinforced with \nconstrictors), left hemithyroidectomy, bilateral neck dissection \n(II-IV) for recurrent left glottic SCCa\n\n \nHistory of Present Illness:\n___ yr old male with hoarseness ___ yrs, last 6 months has not\nimproved with recurrent SCCa of the left glottis s/p total \nlaryngectomy (primary closure\nreinforced with constrictors), left hemithyroidectomy, BLND\n(II-IV) for recurrent left glottic SCCa\n\n \nPast Medical History:\nT2DM, COPD w/ DOE, HTN,\nrecent dx of IgA Vasculitis w/ leg rash & angioedema requiring\nintubation x3d & pT1bN0M0 glottic SCC w/ involvement of \nbilateral\n___ s/p XRT (completed ___, followed by Dr. ___\n \nSocial History:\n___\nFamily History:\nnoncontributory\n \nPhysical Exam:\nPHYSICAL EXAM:\n___ 0734 Temp: 98.7 PO BP: 118/79 L Sitting HR: 82 RR: 18 \nO2\nsat: 97% O2 delivery: Ra \n\nGeneral: No acute distress, comfortable\nHEENT: Neck flat and soft, incision with staples c/d/i. OC/OP\nclear w/o bleeding. Stoma clear w/o crusting, stoma widely \npatent\nCardiac: HDS, WWP\nRespiratory: Normal work of breathing on room air\nNeuro: Alert and oriented x3. CN VII, X, XI, XII intact\nbilaterally\n\n \nPertinent Results:\n___ 07:20AM BLOOD WBC-13.2* RBC-3.76* Hgb-10.7* Hct-33.5* \nMCV-89 MCH-28.5 MCHC-31.9* RDW-16.8* RDWSD-54.2* Plt ___\n___ 06:41AM BLOOD Neuts-76.7* Lymphs-8.0* Monos-11.0 \nEos-2.1 Baso-0.8 Im ___ AbsNeut-9.31* AbsLymp-0.97* \nAbsMono-1.33* AbsEos-0.26 AbsBaso-0.10*\n___ 07:20AM BLOOD Plt ___\n___ 07:20AM BLOOD Glucose-174* UreaN-17 Creat-0.6 Na-142 \nK-4.6 Cl-101 HCO3-27 AnGap-14\n___ 07:20AM BLOOD Albumin-3.5 Calcium-8.5 Phos-4.2 Mg-2.0\n \nBrief Hospital Course:\nThe patient was admitted to the Otolaryngology-Head and Neck \nSurgery Service after s/p total laryngectomy (primary closure\nreinforced with constrictors), left hemithyroidectomy, BLND\n(II-IV) for recurrent left glottic SCCa. Please see the \nseparately dictated operative note for details of procedure. \nThere were no significant intraoperative complications. \nPost-operatively, patient underwent an ___ hospital \ncourse.\n\nENT: The patient was monitored in the ICU and transferred to \nfloor when appropriate. Neck drains were sequentially \ndiscontinued once they met drain criteria. \n\nNeuro: Patient received parenteral and then enteral narcotics as \nneeded for pain control via his NG tube. The patient was at \nbaseline neurologic status. Patient is to continue his pain \nregimen and wean narcotics as tolerated. \n\nCV: Patient was on home medications throughout the hospital \nstay. Vitals were monitored while the patient was hospitalized. \nPatient's vitals were within normal limits on discharge. \n \nPulm: Patient was breathing comfortably on RA at the time of \ndischarge.\n \nGI: Patient must remain NPO and receive all medications and \nnutrition through NG tube until otherwise stated by his surgeon. \n Patient has appointment for a swallow study in 2 weeks post-op. \n\n\nRenal/GU: Patient was on IVF as needed with electrolytes \nrepleted prn. \n\nHeme: Pt was on ___ and compression boots for DVT prophylaxis. \n\nID: The patient was on perioperative antibiotics and remained \nafebrile otherwise. \n\nEndocrine: The patient’s blood glucose was checked and diabetes \nmedications were adjusted throughout the hospital stay.\n\nOverall the patient had an uneventful recovery and is being \ndischarged to home in stable condition.\n\nAt time of discharge, the patient was in stable condition, \nambulating and voiding independently, and with adequate pain \ncontrol. The patient was given instructions to follow-up in \nclinic as scheduled. Pt was given detailed discharge \ninstructions outlining wound care, activity, diet, follow-up and \nthe appropriate medication scripts.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. PredniSONE 5 mg PO TID \n2. MetFORMIN (Glucophage) 500 mg PO BID \n3. Simvastatin 20 mg PO QPM \n4. Atovaquone Suspension 1500 mg PO DAILY \n5. GlipiZIDE 5 mg PO BID \n6. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen (Liquid) 650 mg PO Q4H:PRN Pain - Mild \n Reason for PRN duplicate override: Patient is NPO or unable to \ntolerate PO\nRX *acetaminophen 160 mg/5 mL 650 mg by mouth every six (6) \nhours Refills:*1 \n2. Aspirin 81 mg NG DAILY \n3. Calcium Carbonate 1000 mg PO BID \nRX *calcium carbonate 500 mg/5 mL calcium (1,250 mg/5 mL) 10 ml \nNG twice a day Refills:*1 \n4. Docusate Sodium (Liquid) 100 mg PO BID \nRX *docusate sodium 50 mg/5 mL 100 mg by mouth twice a day \nRefills:*1 \n5. OxyCODONE Liquid ___ mg PO Q3H:PRN Pain - Moderate \nRX *oxycodone 5 mg/5 mL ___ ml by mouth q4-6h Disp #*420 \nMilliliter Refills:*0 \n6. GlipiZIDE 5 mg NG DAILY \nRX *glipizide 5 mg 1 tablet(s) NG once a day Disp #*30 Tablet \nRefills:*2 \n7. MetFORMIN (Glucophage) 1000 mg NG BID \nRX *metformin 1,000 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*2 \n8. Atovaquone Suspension 1500 mg NG DAILY \n9. Lansoprazole Oral Disintegrating Tab 30 mg NG DAILY \n10. PredniSONE 5 mg NG TID \n11. HELD- Simvastatin 20 mg PO QPM This medication was held. Do \nnot restart Simvastatin until you are cleared to take \nmedications by mouth\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nRecurrent left glottis SCCa\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDivision of Otolaryngology – Head and Neck Surgery\nPost-Operative Instructions \nLaryngectomy\n\nACTIVITY\n•Go home and rest today.\n•If you have received general anesthesia, you may feel tired \nand drowsy for a few hours. You should not drink alcoholic \nbeverages, drive a car, operate any machinery, or make legal \ndecision for 24 hours.\n•You need to avoid strenuous activity for 2 weeks\n•Do NOT lift any weight greater than 10 Lbs for 2 weeks.\n•Make sure you exercise your shoulders and arms gently to keep \nthem from getting stiff\n•You should not take in anything by mouth until cleared at your \n___ appointment \n\nMEDICATIONS\n•Take pain medication as prescribed.\n•Resume other medications as prescribed except any aspirin or \naspirin containing products unless cleared by your surgeon.\n\nCARE OF PROCEDURE SITE\n•Your voice box has been removed. The hole in your neck is your \nonly airway, and therefore should be treated with great care\n•Be sure to clean the crusts around the hole in your neck (the \n“stoma”), as often as needed. Keep the humidified air around the \nstoma as often as possible to prevent crusting.\n•You may find you need to suction deep into the stoma to get \nrid of this mucous. Some saline may be dropped into the stoma to \nbreak up some of the mucous if you find it is too thick.\n•Some swelling of the neck incision is expected\n•Apply antibiotic ointment to your incisions twice a day.\n•Keep incisions dry for 3 days. You may be able to take a bath \nfrom your shoulders down as long as the incision stays dry. If \nthere is tape on your incision apply ointment over the tape. \nThis tape will start falling off on its own.\n•If there are any crusts/clots on your wound you may gently \nclean them with a Q-tip and Half strength hydrogen peroxide \n(10cc water + 10cc peroxide) as needed. Do not be too vigorous \nor your stitches or staples may break\n•The staples/stitches will be removed on your first \npost-operative visit\n\nWHEN TO CALL YOUR DOCTOR\n•Excessive redness of your incision site\n•Fever greater than 101 degrees Fahrenheit\n•Sudden excessive swelling of incision site\n\n*You should have a family member or friend call your local \npolice and fire station to alert them you have had a \nlaryngectomy and are limited in the ability to verbally \ncommunicate. This way, if they receive a call from your \nresidence, they will send help immediately.\n\nFor questions or problems, please call ___ to speak \nto the clinic nurse during clinic hours.\n\nAfter hours, or on weekends, dial ___ and ask the \noperator to page the Otolaryngology resident on-call.\n\n \nFollowup Instructions:\n___\n" ]

[ "C320", "C770", "L97329", "L97319", "J449", "I10", "Z930", "Z931", "I776", "E1165", "Z7984", "Z87891", "R110", "D649", "E669", "Z6836" ]

[ "C320: Malignant neoplasm of glottis", "C770: Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck", "L97329: Non-pressure chronic ulcer of left ankle with unspecified severity", "L97319: Non-pressure chronic ulcer of right ankle with unspecified severity", "J449: Chronic obstructive pulmonary disease, unspecified", "I10: Essential (primary) hypertension", "Z930: Tracheostomy status", "Z931: Gastrostomy status", "I776: Arteritis, unspecified", "E1165: Type 2 diabetes mellitus with hyperglycemia", "Z7984: Long term (current) use of oral hypoglycemic drugs", "Z87891: Personal history of nicotine dependence", "R110: Nausea", "D649: Anemia, unspecified", "E669: Obesity, unspecified", "Z6836: Body mass index [BMI] 36.0-36.9, adult" ]

[ "J449", "I10", "E1165", "Z87891", "D649", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: ORTHOPAEDICS\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nright hip pain/infection\n \nMajor Surgical or Invasive Procedure:\n___: stage II revision right THA\n\n \nHistory of Present Illness:\n___ y/o M with history right hip infection and resection \narthroplasty, here for stage II revision right THA with Dr. \n___.\n \nPast Medical History:\nBPH\nGlaucoma\nR hip replacement c/b PJI\n\nPSHx\nS/p hip surgeries as above\n \nSocial History:\n___\nFamily History:\nHis son died from gout and alcoholism. His mother and father had \nstrokes. His mother had +PAD s/p BKA.\n \nPhysical Exam:\nWell appearing in no acute distress \nAfebrile with stable vital signs \nPain well-controlled \nRespiratory: CTAB \nCardiovascular: RRR \nGastrointestinal: NT/ND \nGenitourinary: Voiding independently \nNeurologic: Intact with no focal deficits \nPsychiatric: Pleasant, A&O x3 \nMusculoskeletal Lower Extremity: \n* Aquacel dressing with scant serosanguinous drainage \n* Thigh full but soft \n* No calf tenderness \n* ___ strength \n* SILT, NVI distally \n* Toes warm\n\n \nPertinent Results:\n___ 08:09AM BLOOD WBC-9.5 RBC-2.69* Hgb-7.5* Hct-24.2* \nMCV-90 MCH-27.9 MCHC-31.0* RDW-13.2 RDWSD-43.0 Plt ___\n___ 07:52AM BLOOD WBC-11.0* RBC-3.19* Hgb-8.9* Hct-28.5* \nMCV-89 MCH-27.9 MCHC-31.2* RDW-12.9 RDWSD-41.8 Plt ___\n___ 07:27AM BLOOD WBC-8.6 RBC-3.57* Hgb-9.8* Hct-32.3* \nMCV-91 MCH-27.5 MCHC-30.3* RDW-12.7 RDWSD-41.8 Plt ___\n___ 03:57PM BLOOD WBC-10.4* RBC-4.04* Hgb-11.3* Hct-35.7* \nMCV-88 MCH-28.0 MCHC-31.7* RDW-12.6 RDWSD-40.7 Plt ___\n___ 08:09AM BLOOD Plt ___\n___ 07:52AM BLOOD Plt ___\n___ 07:27AM BLOOD Plt ___\n___ 03:57PM BLOOD Plt ___\n___ 07:27AM BLOOD Glucose-115* UreaN-14 Creat-1.0 Na-141 \nK-4.7 Cl-101 HCO3-26 AnGap-14\n___ 07:27AM BLOOD Calcium-9.1 Phos-4.1 Mg-1.7\n \nBrief Hospital Course:\nThe patient was admitted to the orthopedic surgery service and \nwas taken to the operating room for above described procedure. \nPlease see separately dictated operative report for details. The \nsurgery was uncomplicated and the patient tolerated the \nprocedure well. Patient received perioperative IV antibiotics.\n\nPostoperative course was remarkable for the following:\nPOD#1: Patient was ordered for one dose of radiation treatment \nfor heterotropic ossification. This was not able to be completed \non POD #1 due to major gas leak in the hospital near radiology \noncology site and was rescheduled to POD #2. Infectious disease \nwas consulted for recommendations of PO suppressive antibiotics \npost-op given history of prosthetic joint infection and \nrevisions. They recommended starting IV Ancef.\nPOD#2: Patient received 1 dose of radiation treatment to prevent \n___. Drain was kept in place. A urinalysis was obtained due to \nelevated WBC of 11 from 8.6. Results were negative for a urinary \ntract infection. ID deferred antibiotic regimen to \nOrthopaedics. No antibiotics needed per Dr. ___.\nPOD#3: Patient's drain was pulled. Urine culture was pending at \ntime of discharge. He will be contacted if urine culture comes \nback positive and needs to be treated. He was discharged home.\n\nOtherwise, pain was controlled with a combination of IV and oral \npain medications. The patient received Aspirin 81 mg twice \ndaily for DVT prophylaxis starting on the morning of POD#1. The \nAquacel dressing remained clean and intact without erythema or \nabnormal drainage/saturation. The patient was seen daily by \nphysical therapy. Labs were checked throughout the hospital \ncourse and repleted accordingly. At the time of discharge, the \npatient was tolerating a regular diet and feeling well. The \npatient was afebrile with stable vital signs. The patient's \nhematocrit was acceptable and pain was adequately controlled on \nan oral regimen. The operative extremity was neurovascularly \nintact.\n \nThe patient's weight-bearing status is weight bearing as \ntolerated on the operative extremity. Please use walker or 2 \ncrutches for as long as you need. They physical therapist will \nhelp guide you until you are safe to wean from assistive \ndevices.\n \nMr. ___ is discharged to home with services in stable \ncondition.\n \nMedications on Admission:\n1. Acetaminophen 1000 mg PO Q8H \n2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n3. Senna 8.6 mg PO BID:PRN Constipation - First Line \n4. Multivitamins 1 TAB PO DAILY \n5. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate \n6. Aspirin EC 81 mg PO DAILY \n7. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \n2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain \n3. Pantoprazole 40 mg PO Q24H \nTake daily while on Aspirin x 28 days \n4. Aspirin EC 81 mg PO BID \nResume normal dosing of ASA after 4 weeks course of twice daily \ndosing. \n5. Acetaminophen 1000 mg PO Q8H \n6. Multivitamins 1 TAB PO DAILY \n7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n8. Senna 8.6 mg PO BID:PRN Constipation - First Line \n9. Tamsulosin 0.4 mg PO QHS \n10. HELD- Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate This \nmedication was held. Do not restart Ibuprofen until you've been \ncleared by your surgeon\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nright hip infection\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\n1. Please return to the emergency department or notify your \nphysician if you experience any of the following: severe pain \nnot relieved by medication, increased swelling, decreased \nsensation, difficulty with movement, fevers greater than 101.5, \nshaking chills, increasing redness or drainage from the incision \nsite, chest pain, shortness of breath or any other concerns.\n \n2. Please follow up with your primary physician regarding this \nadmission and any new medications and refills. \n \n3. Resume your home medications unless otherwise instructed.\n \n4. You have been given medications for pain control. Please do \nnot drive, operate heavy machinery, or drink alcohol while \ntaking these medications. As your pain decreases, take fewer \ntablets and increase the time between doses. This medication can \ncause constipation, so you should drink plenty of water daily \nand take a stool softener (such as Colace) as needed to prevent \nthis side effect. Call your surgeons office 3 days before you \nare out of medication so that it can be refilled. These \nmedications cannot be called into your pharmacy and must be \npicked up in the clinic or mailed to your house. Please allow \nan extra 2 days if you would like your medication mailed to your \nhome.\n \n5. You may not drive a car until cleared to do so by your \nsurgeon.\n \n6. Please call your surgeon's office to schedule or confirm your \nfollow-up appointment.\n \n7. SWELLING: Ice the operative joint 20 minutes at a time, \nespecially after activity or physical therapy. Do not place ice \ndirectly on the skin. \n \n8. ANTICOAGULATION: Please continue your Aspirin 81mg twice \ndaily with food for four (4) weeks to help prevent deep vein \nthrombosis (blood clots). Continue Pantoprazole daily while on \nAspirin to prevent GI upset (x 4 weeks). If you were taking \nAspirin prior to your surgery, take it at 81 mg twice daily \nuntil the end of the 4 weeks, then you can go back to your \nnormal dosing. \n \n9. WOUND CARE: Please keep your incision clean and dry. It is \nokay to shower after surgery while wearing your aquacel \ndressing, but no tub baths, swimming, or submerging your \nincision until after your first checkup and cleared by your \nsurgeon. After the aquacel dressing is removed 7 days after your \nsurgery, you may leave the wound open to air. Check the wound \nregularly for signs of infection such as redness or thick yellow \ndrainage and promptly notify your surgeon of any such findings \nimmediately.\n \n10. ___ (once at home): Home ___, Aquacel removal POD#7, and \nwound checks. \n \n11. ACTIVITY: Weight bearing as tolerated with two crutches or \nwalker for as long as you need. The physical therapist will help \nguide you until you are safe to wean from assistive devices. \nPosterior hip precautions. No strenuous exercise or heavy \nlifting until follow up appointment. Mobilize frequently\n\nPhysical Therapy:\nWBAT operative extremity\nPosterior hip precautions \nWean assistive device as able\nMobilize frequently\n\nTreatments Frequency:\nremove aquacel POD#7 after surgery\napply dry sterile dressing daily if needed after aquacel \ndressing is removed\nwound checks daily after aquacel removed\n\n \nFollowup Instructions:\n___\n" ]

[ "Z4732", "N400", "H409", "H548", "K219", "F1021", "M1611" ]

[ "Z4732: Aftercare following explantation of hip joint prosthesis", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "H409: Unspecified glaucoma", "H548: Legal blindness, as defined in USA", "K219: Gastro-esophageal reflux disease without esophagitis", "F1021: Alcohol dependence, in remission", "M1611: Unilateral primary osteoarthritis, right hip" ]

[ "N400", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nabdominal pain \n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ with DM2, GERD and s/p lap converted to open subtotal\ncholecystectomy 2 months ago who is being transferred from ___ for ACS evaluation after presenting with two days of\nabdominal pain, nausea, vomiting, fevers, chills, one episode of\ndiarrhea, w/ imaging findings of increased fluid collection in\nthe gallbladder fossa. At ___, she had a leukocytosis and\notherwise unremarkable workup including unremarkable EKG,\nnegative CXR, troponin/LFTs, RUQ US at ___. CT scan showed \nan\nincrease in size of the known fossa fluid collection. She had a\nsimilar presentation on CT one month ago and fluid collection \nwas\nnoted to be c/w post-op changes, however, this fluid collection\nhas since doubled in size. She received multiple doses of IV \npain\nand nausea medication and was sent here for both ACS evaluation\nand admission. She also endorses chest pain and tightness, two\nepisodes, one on ___ and a second yesterday that were short\nlived, non-exertional and self resolved. \n\n \nPast Medical History:\nDMII, GERD, morbid obesity, depression, LBP, lumbar disk\ndisplacement\n\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nGeneral - comfortable, in NAD\nHEENT - moist mucous membranes, PERRLA, EOMI\nCardiac - RRR, no M/R/G\nChest - CTAB\nAbdomen - soft, nondistended, no rebound or guarding. ___ drain \nin place. Draining scant bilious/serosang.\nExtremities - warm and well-perfused\nNeuro - A&OX3 \n\n \nPertinent Results:\n___ 10:31AM LACTATE-1.5\n___ 10:20AM GLUCOSE-126* UREA N-10 CREAT-0.6 SODIUM-138 \nPOTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-20* ANION GAP-15\n___ 10:20AM ALBUMIN-3.9 CALCIUM-8.9 PHOSPHATE-3.6 \nMAGNESIUM-2.1\n___ 10:20AM NEUTS-58.1 ___ MONOS-8.2 EOS-2.5 \nBASOS-0.4 IM ___ AbsNeut-7.19*# AbsLymp-3.77* AbsMono-1.01* \nAbsEos-0.31 AbsBaso-0.05\n___ 10:20AM NEUTS-58.1 ___ MONOS-8.2 EOS-2.5 \nBASOS-0.4 IM ___ AbsNeut-7.19*# AbsLymp-3.77* AbsMono-1.01* \nAbsEos-0.31 AbsBaso-0.05\n___ 10:20AM PLT COUNT-___ with DM2, GERD and s/p lap converted to open subtotal\ncholecystectomy 2 months ago who is being transferred from ___ for ACS evaluation after presenting with two days of\nabdominal pain, nausea, vomiting, fevers, chills, one episode of\ndiarrhea, w/ imaging findings of increased fluid collection in\nthe gallbladder fossa. This fluid collection was drained on \n___. On ___ the patient had an ERCP to check for retained \nstone. The result was equivocal because it was difficult to \nshoot dye into the cystic duct. An MRCP was done which revealed \nthat the short segment of distal cystic duct appears \nunremarkable. See below for full read: 1. Short segment of \ndistal cystic duct appears unremarkable. Given \nsusceptibility related to drainage catheter/air in gallbladder \nfossa \ncollection, the remainder of the cystic duct is obscured. 2. \nInterval decrease in size of gallbladder fossa fluid collection. \n3. Pancreatic cystic lesions with the largest measuring 7 mm in \nthe uncinate process, for which follow-up MRCP can be obtained \nin ___ year. 4. Severe hepatic steatosis. The patient was \ndischarged home in stable condition with follow up in 1 week. \nShe needs outpatient PCP work up of her hepatic steatosis and \npancreatic cyst. \n\n \nMedications on Admission:\n1. Omeprazole 20'\n2. acetaminophen\n3. gabapentin\n4. metformin 500mg'\n\n \nDischarge Medications:\n1. Omeprazole 20'\n2. acetaminophen\n3. gabapentin\n4. metformin 500mg'\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\ngallbladder fossa fluid collection \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon.\n\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\n \nFollowup Instructions:\n___\n" ]

[ "K9189", "R188", "K862", "K760", "E6601", "Z23", "K2970", "K210", "E119", "Z6839", "F329", "M5126", "Y838", "Y929" ]

[ "K9189: Other postprocedural complications and disorders of digestive system", "R188: Other ascites", "K862: Cyst of pancreas", "K760: Fatty (change of) liver, not elsewhere classified", "E6601: Morbid (severe) obesity due to excess calories", "Z23: Encounter for immunization", "K2970: Gastritis, unspecified, without bleeding", "K210: Gastro-esophageal reflux disease with esophagitis", "E119: Type 2 diabetes mellitus without complications", "Z6839: Body mass index [BMI] 39.0-39.9, adult", "F329: Major depressive disorder, single episode, unspecified", "M5126: Other intervertebral disc displacement, lumbar region", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable" ]

[ "E119", "F329", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins\n \nAttending: ___.\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\nLeft heart catheterization ___\n\n \nHistory of Present Illness:\nMr. ___ is a ___ gentleman with a PMH significant for \nCKD (baseline Cr 2.3), hypertension, and hyperlipidemia who \npresents from his cardiologist's office with chest pain and new \nfocal wall motion abnormalities on TTE. \n\nPer the patient, his symptoms started about a week ago. He was \ndriving and began to feel dizzy, lightheaded, diaphoretic. He \ndrove himself to the ___ ER and was evaluated there. He \nreportedly had two negative troponins and ruled out for ACS. He \nnotes that at that time he also experienced some discomfort that \nradiated to his bilateral shoulders.\n\nThe patient then went to ___ where he and his wife \nwere looking for a new house. He spent three days there. During \nthis time he in general felt more weak than usual and fatigued. \nHe did not have recurrence of the lightheadedness or dizziness \nand he denies having any chest pain or pressure while there. He \ncontinued to feel fatigued and weak at the time he presented to \na scheduled follow up appointment with his Cardiologist Dr. \n___ (___). He had a TTE in the office that \nshowed anteroseptal apical, anterolateral apical and \ninferoapical hypokinesis to akinesis. He was noted to have mild \nsymmetrical LVH. EF estimated to be 60%. Upon seeing these \nfindings, patient was referred to ___ for further work up and \npossible intervention. He took a full ASA prior to arrival.\n\nIn the ED initial vitals were: 97.7 75 148/68 16 99% RA. \n\nEKG: noted by ED staff to be NSR, rate 71, non-specific IVCD, \nLAD, and LVH. \n\nLabs/studies notable for: normal coagulation studies, normal \nCBC, normal chemistries except for BUN/Cr 36/2.3, trop-T <0.01, \nCK-MB 3.\n\nPatient was given: lorazepam 0.25 mg IV x1 and briefly started \non maintenance IVF.\n\nCardiology was consulted and recommended admission for risk \nstratification.\n\nVitals on transfer: 97.6 67 132/72 19 97% RA. \n\nOn the floor patient denies any lightheadedness or dizziness. \nWhen he initially sat up in bed on arrival to the floor, he \nexperienced a sharp epigastric pain that had resolved by time of \ninterview. He notes that this is like his \"duodenal spasms\" that \nhe sometimes gets and is not like the feelings he had when he \ninitially presented to ___. Mr. ___ notes that he always \nsleeps on three pillows at night and that this is not a new \nissue for him. He denies PND. He occasionally snores but has \nnever had a sleep study. He denies any SOB at rest or with \nexertion. He reports what he describes as occasional PVCs.\n\nREVIEW OF SYSTEMS:\nCardiac review of systems is notable for absence of chest pain, \ndyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, \nankle edema, syncope, or presyncope.\n\nOn further review of systems, denies any prior history of \nstroke, TIA, deep venous thrombosis, pulmonary embolism, \nbleeding at the time of surgery, myalgias, joint pains, cough, \nhemoptysis, black stools or red stools. Denies exertional \nbuttock or calf pain. Denies recent fevers, chills or rigors. \nAll of the other review of systems were negative.\n \nPast Medical History:\n1. CARDIAC RISK FACTORS\n- Diabetes\n- Hypertension\n- Dyslipidemia\n2. CARDIAC HISTORY\n- Reported history of LBBB and RBBB\n3. OTHER PAST MEDICAL HISTORY\n- CKD (baseline Cr 2.3)\n- GERD\n- Asthma\n- Diverticulitis\n- BPH\n \nSocial History:\n___\nFamily History:\nFather with MI and CABG at age ___, longstanding type 1 DM and \npassed away at age ___. Mother with CHF at age ___, deceased at \nage ___. No siblings.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION:\nVS: T afebrile BP 148/79 HR 71 RR 18 O2 SAT 99%RA Wt. 92.7kg\nGENERAL: WDWN male in NAD. Oriented x3. Mood, affect \nappropriate.\nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, MMM. Significant neck/facial soft tissue.\nNECK: Supple with JVP of 8 cm.\nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. RR, normal S1, S2. No murmurs/rubs/gallops.\nLUNGS: No chest wall deformities. Mildly diminished breath \nsounds at right lung base, otherwise clear bilaterally.\nABDOMEN: Soft, obese, nontender. No HSM or tenderness.\nEXTREMITIES: No c/c/e.\nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\nPULSES: Distal pulses palpable and symmetric.\nNEURO: CN II-XII grossly intact. Moving all extremities \nsymmetrically.\n\nDISCHARGE PHYSICAL EXAMINATION:\nVS: 98.6 ___ ___ 18 95RA\nTele - No events\nWt: 93.1 <- 92.7kg\nYesterday I/Os: not recorded since admission\nGENERAL: well appearing man in NAD. Oriented x3. \nNECK: Supple, no evidence of JVD, large firm parotid glands \nbilaterally\nCARDIAC: regular rhythm. normal S1, S2, no murmur appreciated\nLUNGS: Resp unlabored, no accessory muscle use. CTAB, no wheezes \nor crackles.\nABDOMEN: Soft, NTND. No HSM or tenderness.\nEXTREMITIES: no ___ edema or cyanosis\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 02:53PM ___ PTT-28.9 ___\n___ 02:53PM PLT COUNT-277\n___ 02:53PM NEUTS-64.3 ___ MONOS-8.7 EOS-1.1 \nBASOS-0.6 IM ___ AbsNeut-5.62 AbsLymp-2.16 AbsMono-0.76 \nAbsEos-0.10 AbsBaso-0.05\n___ 02:53PM WBC-8.7 RBC-4.70 HGB-13.2* HCT-40.2 MCV-86 \nMCH-28.1 MCHC-32.8 RDW-14.4 RDWSD-44.0\n___ 02:53PM CALCIUM-9.8 PHOSPHATE-3.1 MAGNESIUM-2.1\n___ 02:53PM CK-MB-3\n___ 02:53PM cTropnT-<0.01\n___ 02:53PM GLUCOSE-84 UREA N-36* CREAT-2.3* SODIUM-141 \nPOTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-27 ANION GAP-16\n\nDISCHARGE LABS\n==============\n___ 07:48AM BLOOD WBC-8.9 RBC-4.73 Hgb-13.3* Hct-40.7 \nMCV-86 MCH-28.1 MCHC-32.7 RDW-14.4 RDWSD-45.2 Plt ___\n___ 07:48AM BLOOD ___ PTT-27.8 ___\n___ 07:48AM BLOOD Glucose-77 UreaN-33* Creat-2.3* Na-137 \nK-4.0 Cl-101 HCO3-25 AnGap-15\n___ 07:48AM BLOOD Calcium-9.8 Phos-3.7 Mg-2.0\n\nPERTINENT LABS\n==============\n___ 02:53PM BLOOD cTropnT-<0.01\n___ 12:05AM BLOOD cTropnT-<0.01\n\nRADIOLOGY\n=========\n___ CXR\nNo acute cardiopulmonary process.\n\nCARDIAC STUDIES\n===============\n___ Heart Cath\nCoronary Anatomy\nDominance: Right\n* Left Main Coronary Artery\nThe LMCA is normal.\n* Left Anterior Descending\nThe LAD has a 50% mid stenosis and diffuse 95% stenosis in its \nvery distal apical segment.\n* Circumflex\nThe ___ Marginal is small with an 80% proximal stenosis and the \nlarge OM2 has a 60% stenosis.\n* Right Coronary Artery\nThe RCA is dominant. The Right PDA has a 60% mid stenosis and \nthe posterolateral has a proximal 60% stenosis.\n\nImpressions:\nBranch disease best ___ for continued med Rx.\nRecommendations\nContinue med Rx.\n \nBrief Hospital Course:\nMr. ___ is a ___ year old male with PMH significant for Type II \nDM, HTN, HLD, CKD who is presenting with new ECHO findings \nconcerning for possible LAD lesion with apical hypokinesis and \none week history of fatigue/weakness after an episode of \ndizziness/lightheadedness, chest pain radiating to his shoulders \nfor which he presented to ___ ER and ruled out for ACS. \n\n# New Apical hypokinesis/akinesis: In setting of one week \nhistory of malaise/fatigue and ___ ED visit for \nlightheadedness/CP one week ago where patient reportedly ruled \nout for ACS with negative troponins. Patient is not having chest \npain on admission here to ___. Troponin negative x2. EKG \nwithout concerning ischemic changes at this time. Patient had a \nheart cath on ___ with a distal LAD lesion that could explain \nthe echo findings but which was not amenable to PCI because of \nhow apical it was, and also a small tight OM2 lesion and non \ncritical lesions in the LCx and RCA not warranting \nrevascularization att this time. Medical management was \nrecommended. . Pravastatin and verapamil stopped and \nAtorvastatin 80 mg daily, metoprolol succinate 25 mg daily, and \nImdur 30 mg daily started for CAD. Patient may also benefit from \noutpt heart monitor to assess for intermittent heart block given \nLBBB on resting ECG and dizziness symptoms while driving. An \noutpatient ___ of hearts was arranged. Patient was given \nappropriate cardiology ___ for continued monitoring.\n\n# HTN: \nChange in home medications as above.\n\n# HLD: given concern for missed MI. Continued Atorvastatin 80mg \ndaily \n\n# CKD: with reported baseline Cr of 2.3. Currently at baseline. \nReceived hydration on admission with 1L LR in anticipation for \ncath. Cr 2.3 at discharge with appropriate PCP ___ for \nmonitoring.\n\n# Type II Diabetes, on insulin: \nContinue home Glargine and Humalog at discharge\n\n# GERD: On Esomeprazole at home \n\n# Gout: continue home Allopurinol \n\n====================\nTRANSITIONAL ISSUES:\n====================\n- Follow up with outpatient Cardiology for further management of \ncoronary artery disease.\n- Pravastatin and verapamil stopped.\n- Atorvastatin 80 mg daily, metoprolol succinate 25 mg daily, \nand Imdur 30 mg daily started for CAD.\n- PCP follow up in ___ weeks after admission for monitoring of \ndiabetes and CKD. Should have blood drawn at that visit for \nmonitoring of Cr function after catheterization/contrast.\n- Patient will come back to ___ to received ___ of Heart \nmonitor to assess for arrhythmia given his complaint of having \nan episode of pre-syncope while driving.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Glargine 36 Units Breakfast\nGlargine 36 Units Bedtime\nHumalog 16 Units Breakfast\nHumalog 16 Units Lunch\nHumalog 16 Units Dinner\nHumalog 12 Units Bedtime\n2. LORazepam 0.5-1 mg PO BID:PRN anxiety \n3. Vitamin D ___ UNIT PO Q 1 MONTH \n4. esomeprazole magnesium 40 mg oral DAILY \n5. Pravastatin 20 mg PO QPM \n6. fosinopril 10 mg oral DAILY \n7. UroxaTRAL (alfuzosin) 10 mg oral DAILY \n8. Zolpidem Tartrate ___ mg PO QHS:PRN insomnia \n9. Allopurinol ___ mg PO DAILY \n10. Hydrochlorothiazide 25 mg PO DAILY \n11. Verapamil SR 180 mg PO DAILY \n12. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Allopurinol ___ mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. LORazepam 0.5-1 mg PO BID:PRN anxiety \n4. esomeprazole magnesium 40 mg oral DAILY \n5. fosinopril 10 mg oral DAILY \n6. Hydrochlorothiazide 25 mg PO DAILY \n7. UroxaTRAL (alfuzosin) 10 mg oral DAILY \n8. Vitamin D ___ UNIT PO Q 1 MONTH \n9. Zolpidem Tartrate ___ mg PO QHS:PRN insomnia \n10. Glargine 36 Units Breakfast\nGlargine 36 Units Bedtime\nHumalog 16 Units Breakfast\nHumalog 16 Units Lunch\nHumalog 16 Units Dinner\nHumalog 12 Units Bedtime\n11. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*1\n12. Metoprolol Succinate XL 25 mg PO DAILY \nRX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*1\n13. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \nRX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*1\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY:\nCAD\n\nSECONDARY:\nCKD\nHLD\nHTN\nDM\nGERD \nGout\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\nIt was a pleasure taking care of you. You were admitted to ___ \nfrom your cardiologist's office for concern of you new symptoms \nof fatigue and changes in the ultrasound of your heart. You had \na catheterization of your heart that showed atherosclerosis or \nplaque build up in the arteries of your heart. However, they \nwere not significant enough to warrant placing a stent. Because \nof this new finding, we are making changes to your medication \nlist.\n\nYou are now ready for discharge home. Please reference the \nmedication list given to you at discharge to see new or changes \nin old medications. You will be contacted to return to ___ to \npick up a wearable monitor to assess for any abnormalities in \nyour heart rhythm. Additionally, you should follow-up with Dr. \n___ in 1 week.\n\nWe wish you the best of health,\n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "I25110", "E1122", "N189", "I129", "E785", "K219", "M109", "Z794", "E780" ]

[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N189: Chronic kidney disease, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "M109: Gout, unspecified", "Z794: Long term (current) use of insulin", "E780: Pure hypercholesterolemia" ]

[ "E1122", "N189", "I129", "E785", "K219", "M109", "Z794" ]

[]

[ " \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:\ncoffee ground emesis and melena x 2 days\n \nMajor Surgical or Invasive Procedure:\n___ EGD, intubation\n___ Extubation \n \nHistory of Present Illness:\nMr. ___ is a ___ y.o. M with EtOH cirrhosis \ndecompensated\nby recurrent variceal bleeds (s/p TIPS ___, history of HCV\ns/p treatment, HTN, insulin-dependent T2DM, COPD, seizure\ndisorder who initially presented on ___ for hematemesis and\nBRBPR, and was admitted to MICU for EGD/intubation. \n\nHe reports a 3 days history of hematemesis with bright red\nbleeding and dark stool associated with abdominal pain and\nvomiting. He was recently discharged from a ___ facility\nfollowing a ___. He reported in triage that 'I just want\nto die', but later denied suicidal ideation.\n\nIn the ED, initial vital signs with T 97.7, HR 116, BP 210/96, \nO2\n89% on RA. He was noted to be altered and did not have any\nfurther episodes of hematemesis. Rectal exam without obvious\nbright red blood. Labs notable for HCO3 20 with AG 24, lactate\n5.6, Cr 1.4, serum EtOH 329. CXR without lobar consolidation.\nHepatology was consulted who recommended admission to ICU for\nEGD. He was given IV octreotide, ceftriaxone and 1 LR. \n\nVS on arrival to MICU: HR 115, BP 185/96, RR 14, 96% O2\n\nMr ___ confirms the above history. Was in rehab until about 2\nweeks ago for 21 days (center in ___, then restarted\ndrinking and drinks about ___ nips of vodka/day, last drink\nthis AM. Has had hx of seizures before when he stops drinking.\nDenies any NSAID/ASA use. Last episode of coffee-ground emesis\nthis AM, last black tarry BM this AM. Feels a little dizzy right\nnow, with headache and feels like he needs something for\nwithdrawal. \n\n \nPast Medical History:\n Hypertension \n DM2 poorly controlled since age ___ \n Migraines \n Depression \n Anxiety \n Cirrhosis, ESLD ___ hepatitis C/ alcohol/ Diabetes. \n Hepatitis C with cirrhosis s/p treatment with negative viral \nload\n Thrombocytopenia \n Seizure disorder (?seizure ___, per patient neurology \n(___) didn't think he needed treatment \n \nSocial History:\n___\nFamily History:\nReports family history of Diabetes. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n======================== \nVS: HR 108 BP 198/98 RR 14 O2 98% RA\nGEN: thin man sitting in bed in NAD, appears anxious\nHEENT: icteric sclera, dry MM, right eye ptosis (since ___ per\npt)\nNECK: supple, no LAD\nCV: tachycardic, reg rhythm no m/r/g\nRESP: CTAB, no crackles/wheezes\nGI: abd soft, NT/ND no rebound or guarding\nMSK: ___ strength in all extremities \nSKIN: tattoos on chest/arms\nNEURO: right eye ptosis, left lower facial droop (since MVA in\n___ per pt); otherwise CN2-12 intact with no gross focal neuro\ndeficits; no asterixis on exam\nPSYCH: no current SI/HI\n\nDISCHARGE PHYSICAL EXAM\n======================\nVITALS: 24 HR Data (last updated ___ @ 1544)\n Temp: 97.5 (Tm 98.2), BP: 156/84 (129-160/77-84), HR: 89\n(84-94), RR: 18, O2 sat: 95% (92-96), O2 delivery: RA, Wt: \n164.02\nlb/74.4 kg \n \nGENERAL: Awake, alert. Answers questions appropriately. NAD.\nHEENT: Normocephalic, atraumatic. Moist mucous membranes, \nmissing\nteeth. Left sided mouth droop.\nNECK: Mildly elevated JVP. \nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. \nSystolic\nmurmur at RUSB and at apex.\nLUNGS: No rhonchi or rales. Decreased bibasilar breath sounds. \nABDOMEN: +BS. Distended, soft. Mild TTP throughout with no\nrebound or guarding. +Hepatomegaly.\nEXTREMITIES: Trace edema b/l. \nSKIN: Warm.\n \nPertinent Results:\nADMISSION LABS:\n===================\n___ 03:15PM BLOOD WBC-10.4* RBC-2.52* Hgb-9.1* Hct-26.1* \nMCV-104* MCH-36.1* MCHC-34.9 RDW-17.2* RDWSD-64.6* Plt Ct-42*\n___ 03:15PM BLOOD Neuts-70.3 Lymphs-14.3* Monos-9.3 Eos-3.8 \nBaso-0.9 Im ___ AbsNeut-7.28* AbsLymp-1.48 AbsMono-0.96* \nAbsEos-0.39 AbsBaso-0.09*\n___ 03:15PM BLOOD Glucose-450* UreaN-17 Creat-1.4* Na-138 \nK-3.8 Cl-94* HCO3-20* AnGap-24*\n___ 03:15PM BLOOD ___ PTT-28.0 ___\n___ 03:15PM BLOOD ALT-25 AST-58* AlkPhos-182* TotBili-2.1*\n___ 03:15PM BLOOD ASA-NEG ___ Acetmnp-NEG \nTricycl-NEG\n___ 03:54PM BLOOD Lactate-5.6*\n___ 11:32PM BLOOD Lactate-3.6*\n\nINTERVAL LABS:\n=============\n___ 03:15PM BLOOD Lipase-75*\n___ 04:02AM BLOOD Beta-OH-0.8*\n___ 07:46PM BLOOD Beta-OH-0.2\n___ 04:21PM BLOOD Beta-OH-<0.2\n___ 11:52AM BLOOD Beta-OH-1.3*\n___ 04:03AM BLOOD Beta-OH-1.4*\n___ 03:15PM BLOOD Beta-OH-2.7*\n\nDISCHARGE LABS:\n==============\n___ 07:13AM BLOOD WBC-3.0* RBC-2.51* Hgb-8.7* Hct-26.1* \nMCV-104* MCH-34.7* MCHC-33.3 RDW-18.9* RDWSD-72.2* Plt Ct-37*\n___ 07:13AM BLOOD ___ PTT-29.7 ___\n___ 07:13AM BLOOD Glucose-240* UreaN-21* Creat-1.4* Na-141 \nK-4.2 Cl-104 HCO3-23 AnGap-14\n___ 07:13AM BLOOD ALT-80* AST-86* LD(LDH)-312* AlkPhos-189* \nTotBili-0.8\n___ 07:13AM BLOOD Albumin-2.9* Calcium-8.0* Phos-2.6* \nMg-1.8\n\nIMAGING:\n=======\n___ (PORTABLE AP)\nFINDINGS: \nLimited exam. There background changes of COPD with a few \nreticulations in\nthe midlung zones, could represent superimposed fibrosis on \nreview of prior\nCT. However, subtle aspiration may have a similar appearance, \nfor clinical\ncorrelation. No lobar consolidation.\n\n___ DOPP ABD/PEL\nIMPRESSION:\n1. Patent TIPS.\n2. Appropriate directional flow in the anterior and posterior \nright portal\nveins. Patent main portal vein. Nonvisualization of flow \nwithin the left\nportal vein, similar to multiple prior ultrasounds most recently \n___.\n3. Small volume ascites.\n\n___ (PORTABLE AP)\nIMPRESSION: \nHeart size and mediastinum are stable. Vascular congestion has \nprogressed in\nthe interim but there is still no overt pulmonary edema. Small \nbilateral\npleural effusions are present. No pneumothorax\n\nPROCEDURES:\n===========\n___\nFindings:\nEsopahgus - Grade B Esophagitis with no bleeding was seen in the \ndistal esophagus\nStomach - diffuse congestion, consistent with portal \nhypertensive gastropathy \n\nMICROBIOLOGY:\n============\n___ 4:07 pm BLOOD CULTURE\n **FINAL REPORT ___\n Blood Culture, Routine (Final ___: NO GROWTH. \n \nBrief Hospital Course:\nTRANSITIONAL ISSUES:\n=====================\n[ ] Patient presented with acute alcohol intoxication, and is \nstill actively drinking despite his diagnosis of alcoholic \ncirrhosis. He was offered resources and rehab, but declined. He \nhad plans to re-engage with AA. Please continue to offer \naddiction resources in the outpatient setting. \n[ ] Patient presented with severe hyperglycemia, and his insulin \nwas titrated by ___ while inpatient. He was discharged with \nan adjustment in his Humalog and NPH doses, with plans for close \n___ with PCP. Consider referral to ___ or endocrinology \nin outpatient setting. \n[ ] Patient had not been taking medications for up to 1 month \nprior to his hospitalization; restarted on his former \nmedications on admission. Will need reinforcement in outpatient \nsetting.\n[ ] Last day of ciprofloxacin ___\n[ ] Restarted spironolactone during admission \n[ ] Discontinued nadolol given no varices on EGD \n[ ] Discharged on BID pantoprazole, given evidence of \nesophagitis on EGD (had been on once daily PPI prior to \nhospitalization). Prior authorization for this medication \npending at time of discharge; please ___ to ensure that \nthis goes through. \n\n[ ] Family safety concerns: patient's wife called medical team \nduring his hospitalization, to express concerns that patient was \nviolent towards her at home, and that he had pulled a knife on \nher in the past. She asked us to section the patient, to avoid \nhim coming home. After discussion with SW, it was decided that \nthis was not a reasonable medical option for the patient, as he \ndid not meet Section 35 criteria. He declined rehab/substance \nuse treatment, but did express desire to engage with AA in \noutpatient setting, and was directed to appropriate resources. \nWe referred patient's wife to crisis resources, and SW was in \nprocess of filing elder abuse report, given concerns that \npatient may have been mistreating his elderly mother-in-law, who \nalso lives in his home. Please ___ with these concerns in \nthe outpatient setting. \n\n----\n\n___ with h/o EtOH cirrhosis decompensated by recurrent variceal\nbleeding s/p TIPS (___), history of HCV, HTN, T2DM on \ninsulin,\nCOPD and seizure disorder who presented with hematemesis and \nBRBPR\nconcerning for variceal bleed. Had EGD that revealed grade B \nesophagitis, but no varices. \n\nACUTE ISSUES \n=============== \n#Hematemesis\n#BRBPR\nPresenting with ___ day history of symptoms i/s/o known \nrecurrent\nvariceal bleeding s/p TIPS ___. Last EGD in ___ with\nnon-bleeding grade 1 varices. S/p colonoscopy in ___ with\npoorly visualized mucosa due to poor prep, without source of\nbleeding identified. Admitted to ICU for close monitoring per \nhepatology\nrecommendations given high risk. Received 2 units PRBCs ___ for \nHgb drop 9.1-->6. EGD ___ revealed grade B esophagitis thought \nto be the cause of UGIB. No evidence of varices. Initially \ntreated with octreotide, IV PPI. Abd U/S revealed patent TIPS. \nStarted on ceftriaxone for infectious prophylaxis iso bleed, \ntransitioned to ciprofloxacin on discharge. \n\n#Anion gap metabolic acidosis\n#Lactic acidosis\nHCO3 20 with AG 24 representing mixed gap and non-gap acidosis.\nVBG with pH 7.35. AG likely ___ elevated lactate with possible\ncontribution from DKA given glucose 420, EtOH given elevated\nserum level of 329. Resolved with treatment of his hyperglycemia \nand GI bleed. \n\n#Hyperglycemia\n#Type II Diabetes \n#Concern for DKA\nGlucose 450 with AGMA concerning for possible DKA despite\nrelatively normal pH. Reportedly with poor compliance with\ninsulin. Last Hgb A1C 7.6% in ___. Difficult blood\nglucose control on prior admission. In ICU, treated with\nDKA protocol with insulin gtt, fluids, beta-hydroxybutyrate \nelevated\nand trended down over 24 hours. ___ managed patient's insulin \nregimen while inpatient, and made adjustments in his home NPH \nand Humalog dosing. He was discharged with plans for close PCP \n___ of his T2DM, and may need further titration of his \ninsulin in the outpatient setting (of note, patient admits to \nnot being compliant with his medication for the month prior to \nhis admission, so likely was not taking insulin as prescribed. \n\n#Hypertensive urgency \nSBP 190s-200s without reported chest pain or visual changes.\nReportedly with poor compliance with home medications. Goal\nSBP<160. Resumed home amlodpine, carvedilol prior to discharge. \n\n# Shortness of Breath\n# Hypoxia (resolved) \nInitially hypoxic, thought to be due to aspiration iso \nhematemesis, as well from alcohol intoxication, and associated \nsomnolence. Pneumonitis more likely than pneumonia as patient \nafebrile with normal to low WBC. Patient successfully weaned off \noxygen with treatment of his hematemesis and intoxaication, as \nabove. \n\n___\nCr peaked at 1.8, from prior baseline of 1.1-1.4. Suspect \npre-renal i/s/o GI bleed, and possible osmotic diuresis from \nhyperglycemia and vomiting. Initially held diuretics \n(spironolactone, furosemide), but both were restarted prior to \ndischarge. He required one day of IV Lasix after he become \nvolume-overloaded from a dose of albumin, but was able to resume \nPO diuresis the following day. Cr was 1.4 on discharge, \nsuspected to be his new baseline\n\n#EtOH Intoxication\n#Alcohol use disorder\nEtOH level 329 on admission. Most recently in rehab 2 weeks ago,\nrelapsed. Given thiamine, MVI, folate, then phenobarb loaded \nprior\nto stepdown given high risk of withdrawal. Patient was seen by \nsocial work and addition psychiatry, and offered various \nresources; rehab was also discussed, but patient declined, \nstated he preferred to go home and re-engage with AA. Please see \ndescription of family safety concerns in above TRANSITIONAL \nISSUES section for more elaboration. \n\n#Decompensated cirrhosis\nMELD-Na 24. Patient has history of esophageal varices s/p TIPS\n___ and hepatic encephalopathy. EtOH use ongoing. \nHEPATIC ENCEPHALOPATHY: \nContinued Lactulose 30mg TID with goal ___ BMs daily (although \npatient refused ___ doses), rifaximin 550mg BID \nGIB/VARICES: history of UGIB with varices in ___. Last EGD \non ___ with grade I varices in distal esophagus. Discontinued \nnadolol as no evidence of varices on EGD from this admission. \nASCITES: h/o TIPS in (___), no evidence of ascites on exam, \nno history of SBP. RUQUS with patent tips. Initially held \nfurosemide and spironolactone in setting of ___, resumed on ___. \n\n\n#Anemia\nHgb drop to 6 on night of admission, received 2 units PRBCs as \nabove. Hgb stabilized and was 8.7 on day of discharge. \n\n#Thrombocytopenia\nIso cirrhosis, stable in ___ range.\n\nCHRONIC ISSUES \n=============== \n# Seizures: continued keppra 500 BID\n\n# Depression: continued Fluoxetine 20 daily\n\n# HCV: Chronic hepatitis C has been treated with Harvoni and\nribavirin, for 12 weeks finished treatment ___ and achieved\nSVR ___. Last hepatitis C viral load ___, not\ndetected.\n\n#Other meds: Held Gabapentin 800 mg PO/NG TID given concern for\nencephalopathy/EToH withdrawal, did not restart as patient was \nnot in pain throughout hospitalization and was intermittently \nsomnolent. Consider resuming in outpatient setting. \n\n#CODE STATUS: FULL CODE confirmed\n#EMERGENCY CONTACT: wife ___ ___\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 10 mg PO DAILY \n2. FLUoxetine 20 mg PO DAILY \n3. FoLIC Acid 1 mg PO DAILY \n4. Lactulose 30 mL PO TID \n5. LevETIRAcetam 500 mg PO Q12H \n6. Multivitamins 1 TAB PO DAILY \n7. Pantoprazole 40 mg PO Q24H \n8. Rifaximin 550 mg PO BID \n9. Artificial Tear Ointment 1 Appl LEFT EYE QHS \n10. Artificial Tears ___ DROP LEFT EYE Q4H \n11. Thiamine 100 mg PO DAILY \n12. Nadolol 40 mg PO DAILY \n13. Gabapentin 400 mg PO TID \n14. CARVedilol 6.25 mg PO BID \n15. Furosemide 20 mg PO DAILY \n16. Humalog 10 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin\n\n \nDischarge Medications:\n1. Albuterol Inhaler 2 PUFF IH Q4H:PRN Cough, shortness of \nbreath \nRX *albuterol sulfate 90 mcg 2 puffs INHL every four (4) hours \nDisp #*1 Inhaler Refills:*0 \n2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Doses \nFirst dose ___ in the evening, last dose ___ in the evening \nRX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice \na day Disp #*3 Tablet Refills:*0 \n3. Spironolactone 100 mg PO DAILY \nRX *spironolactone 100 mg 1 tablet(s) by mouth once daily Disp \n#*30 Tablet Refills:*0 \n4. Humalog 8 Units Breakfast\nHumalog 8 Units Lunch\nHumalog 8 Units Dinner\nNPH 20 Units Breakfast\nNPH 10 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin \n5. Pantoprazole 40 mg PO Q12H \nYou should take twice daily dosing until you follow up with your \nhepatologist in ___. \nRX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n6. amLODIPine 10 mg PO DAILY \nRX *amlodipine 10 mg 1 tablet(s) by mouth once daily Disp #*30 \nTablet Refills:*0 \n7. Artificial Tear Ointment 1 Appl LEFT EYE QHS \n8. Artificial Tears ___ DROP LEFT EYE Q4H \n9. CARVedilol 6.25 mg PO BID \n10. FLUoxetine 20 mg PO DAILY \n11. FoLIC Acid 1 mg PO DAILY \n12. Furosemide 20 mg PO DAILY \nRX *furosemide 20 mg 1 tablet(s) by mouth once daily Disp #*30 \nTablet Refills:*0 \n13. Lactulose 30 mL PO TID \n14. LevETIRAcetam 500 mg PO Q12H \n15. Multivitamins 1 TAB PO DAILY \n16. Rifaximin 550 mg PO BID \n17. Thiamine 100 mg PO DAILY \nRX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once \ndaily Disp #*30 Tablet Refills:*0 \n18. HELD- Gabapentin 400 mg PO TID This medication was held. Do \nnot restart Gabapentin until you see your primary care physician\n\n \n___:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n=================\nUpper GI Bleed\nGrade B esophagitis\nAcute on chronic anemia\nAlcohol use disorder\nDiabetic Ketoacidosis\nDiabetes Mellitus type II\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 \nIt was a pleasure to care for you at the ___ \n___. \n \nWhy did I come to the hospital? \n - You had blood in your vomit and stool.\n \nWhat happened while I was in the hospital? \n- You were admitted to the intensive care unit for close \nmonitoring.\n- You underwent endoscopy to look at your stomach and esophagus, \nwhich revealed esophagitis (inflammation of your esophagus) \nlikely from alcohol use.\n- You were given medications to help prevent alcohol withdrawal.\n- You were treated with antibiotics to reduce you risk of \ninfection, in the setting of your GI bleed. \n- You were restarted on your former home medications, including \nyour blood pressure and diuretic medications. \n- The addiction social work team saw you, and discussed possible \noptions for rehab, but you refused, preferring to instead go \nhome and re-engage with alcoholics anonymous (AA). \n- The ___ diabetes team managed your insulin regimen and made \nsome changes to your home medications. \n \nWhat should I do once I leave the hospital? \n- Stop drinking alcohol, or your liver will continue to get \nworse and you will be at risk for ongoing bleeding from your GI \ntract.\n- Please go to AA meetings, to help you abstain from alcohol. \nOur social work team gave you resources regarding AA during your \nhospitalization. \n- Take medications as prescribed and follow up with your doctor \nappointments below.\n \n We wish you the best! \n Your ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "K208", "J690", "E1110", "K766", "E872", "N179", "D62", "K228", "Z794", "E1142", "K3189", "F418", "I160", "R569", "F17210", "K7290", "D696", "E559", "R29810", "V892XXS", "R0902", "E8770", "F1010", "J449", "K7031" ]

[ "K208: Other esophagitis", "J690: Pneumonitis due to inhalation of food and vomit", "E1110: Type 2 diabetes mellitus with ketoacidosis without coma", "K766: Portal hypertension", "E872: Acidosis", "N179: Acute kidney failure, unspecified", "D62: Acute posthemorrhagic anemia", "K228: Other specified diseases of esophagus", "Z794: Long term (current) use of insulin", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "K3189: Other diseases of stomach and duodenum", "F418: Other specified anxiety disorders", "I160: Hypertensive urgency", "R569: Unspecified convulsions", "F17210: Nicotine dependence, cigarettes, uncomplicated", "K7290: Hepatic failure, unspecified without coma", "D696: Thrombocytopenia, unspecified", "E559: Vitamin D deficiency, unspecified", "R29810: Facial weakness", "V892XXS: Person injured in unspecified motor-vehicle accident, traffic, sequela", "R0902: Hypoxemia", "E8770: Fluid overload, unspecified", "F1010: Alcohol abuse, uncomplicated", "J449: Chronic obstructive pulmonary disease, unspecified", "K7031: Alcoholic cirrhosis of liver with ascites" ]

[ "E872", "N179", "D62", "Z794", "F17210", "D696", "J449" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics)\n \nAttending: ___\n \nChief Complaint:\nRectal pain\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n3 days ago started having severe pain in rectum \"deep\". felt \nlike\n\"she was having a baby\". ___. pain worse with trying to\ndefecate, but did not resolve when she was off commode. there \nall\nthe time. after 3 days felt she had to come in.\n\nWhen I saw her in am, pain had resolved. received morphine in ED\nlast night. slept well and ate breakfast without an issue.\n\nalso associated with bloating feeling and nausea when she eats. \n\nhas not been eating well, lost 5lbs, not drinking. feels very\nweak when she stands up. fell 2x in last week when she lost her\nbalance. no ns, fevers. blood in stool. \n\ncomplains of constant dry mouth\n\nhx of constipation, but never severe or had symptoms similar\n\n12 pt ROS otherwise negative \n\n \nPast Medical History:\nBREAST CANCER \nBreast CA s/p lumpetomy in ___ (invasive tubular adenoCA grade\n___, ER/PR+, Her 2 neu neg, -LVI, - margins), declined XRT,\npreviously taking arimidex. Annual mammogram due in ___. \nCARPAL TUNNEL SYNDROME \nCATARACTS \nDAUGHTER ___ ___ \n___ \nDUODENAL ULCER \nGASTROESOPHAGEAL REFLUX \nHEMORRHOIDS \nHYPERTENSION \nHYPOTHYROIDISM \nLEG EDEMA \nOSTEOARTHRITIS \nSPINAL STENOSIS \nSTROKE ___ -Left sided deficit \nURINARY INCONTINENCE \n VARICOSE VEINS \n VERTIGO AND DISEQUILIBRIUM \nCERVICAL SPONDYLOSIS \nHYPERCHOLESTEROLEMIA \nDIABETES MELLITUS \n \nSocial History:\n___\nFamily History:\nno abd issue\n \nPhysical Exam:\nafeb 132/63 578-77 98-99% RA \nCONS: NAD, comfortable, very anxious \nGeneral- Alert, oriented, no acute distress \n HEENT- Sclera anicteric, MMM, oropharynx clear \n Neck- supple, JVP not elevated, no LAD \n Lungs- Clear to auscultation bilaterally, no wheezes, rales,\nronchi \n CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops \n Abdomen- soft, non-distended, bowel sounds present, no rebound\ntenderness or guarding, mild TTP in epigastrum\n GU- no foley \nno anal fissure, tear, healed hemorrhoids, rectal exam \nreproduced\npain, large amount of stool in rectal vault,\ndisimpacted and removed large amount of stool, no blood\n Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or\nedema \n Neuro- CNs2-12 intact, motor function grossly normal, felt very\nweak when she stood up. unwilling to take a step because she was\nafraid she would fall.\n \nPertinent Results:\nlabs normal except slightly elevated glucose\n\n===========================\nADMISSION ABDOMINAL CT SCAN:\nIMPRESSION: \n1. No acute intra-abdominal process. \n2. Moderate amount of stool is noted in the colon and rectum. \n\n \nBrief Hospital Course:\n___ admitted with rectal pain.\n\n#Based on CT/exam (large amount of stool in vault and pain \nreproduced on exam) Likely due to impacted stool. After \ndisimpaction felt better. Pain recurred and with enema several \nlarge bowel movements. Since that point no recurrence of rectal \npain.\n\nStart miralax. After touching base with PCP stopped ___ of her \nmeds that she was neither taking or intermittently. \nAnti-cholinergic effect of meds for urinary incontinence might \nhave been culprit.\n\nDid have intermittent epigastric/chest pain/bloating. Unclear \nwhether related to constipation. Did check EKG/CXR/troponin. \nImproved with simethicone.\n\nWould recommend also checking TSH in case contributing to \nconstipation. \n\n# HTN - did have elevated BP in morning before taking meds. \nRecommend takes ACE at night and beta blocker in morning. SBP in \n160's but did not increase meds given age and wide pulse \npressure and concern about weakness and falls.\n\n#DM - continue home metformin. glucoses reasonable\n\n#Hyponatremia - mild. with hydration resolved from 132 -> 139\n\n#Weakness - attributed to poor POs for some time and not getting \nout of bed. ___ eval felt unsafe to go home and therefore \ntransfer to rehab.\n\n# Anxiety - during hospital stay, patient became very worried \nabout many issues - BP, headache, abd pain and idea of going to \nrehab. Per family this is baseline. \n\n#TRANSITION\n- check TSH \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Sertraline 25 mg PO DAILY \n2. Omeprazole 20 mg PO DAILY \n3. Levothyroxine Sodium 88 mcg PO DAILY \n4. MetFORMIN (Glucophage) 500 mg PO DAILY \n5. Metoprolol Succinate XL 50 mg PO DAILY \n6. Hydrocortisone Acetate Suppository 1 SUPP PR TID pain \n7. Allopurinol ___ mg PO DAILY \n8. Atorvastatin 10 mg PO QPM \n9. NexIUM (esomeprazole magnesium) 20 mg oral Q24H \n10. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n11. Gabapentin 600 mg PO QHS \n12. Lisinopril 10 mg PO DAILY \n13. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n14. Vesicare (solifenacin) 5 mg oral Q24H \n\n \nDischarge Medications:\n1. Allopurinol ___ mg PO DAILY \n2. Atorvastatin 10 mg PO QPM \n3. Hydrocortisone Acetate Suppository ___ID:PRN \npain/itching \n4. Levothyroxine Sodium 88 mcg PO DAILY \n5. Lisinopril 10 mg PO QHS \nPlease give in evening. \n6. Metoprolol Succinate XL 50 mg PO DAILY \n7. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n8. MetFORMIN (Glucophage) 500 mg PO DAILY \n9. Omeprazole 20 mg PO DAILY \n10. Polyethylene Glycol 17 g PO DAILY \n11. Simethicone 80 mg PO QID:PRN gas/epigastric pain \n12. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nConstipation\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\n___, we believe your severe pain in your rectum was due to \nconstipation. After you were disimpacted and you had the enema \nyou felt better. Stopping some medications and taking a fiber \nevery day will help prevent this from happening in future.\n\nYou were very weak and we have sent you to a rehab to become \nstronger.\n \nFollowup Instructions:\n___\n" ]

[ "K5900", "I10", "E119", "E871", "R531", "F419", "Z853", "R1013", "Z8673" ]

[ "K5900: Constipation, unspecified", "I10: Essential (primary) hypertension", "E119: Type 2 diabetes mellitus without complications", "E871: Hypo-osmolality and hyponatremia", "R531: Weakness", "F419: Anxiety disorder, unspecified", "Z853: Personal history of malignant neoplasm of breast", "R1013: Epigastric pain", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits" ]

[ "K5900", "I10", "E119", "E871", "F419", "Z8673" ]

[]

[ " \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 \nMajor Surgical or Invasive Procedure:\nexlap, LOA, component separation, w/ biologic & synth mesh, \ngastropexy \n\nattach\n \nPertinent Results:\nAdmission Labs:\n=========================\n\n___ 03:45PM BLOOD WBC-13.7* RBC-2.68* Hgb-8.1* Hct-24.3* \nMCV-91 MCH-30.2 MCHC-33.3 RDW-13.5 RDWSD-45.5 Plt ___\n___ 03:45PM BLOOD ___ PTT-33.7 ___\n___ 10:47PM BLOOD Glucose-102* UreaN-83* Creat-2.4* Na-136 \nK-4.3 Cl-103 HCO3-17* AnGap-16\n___ 08:14AM BLOOD cTropnT-0.07*\n___ 03:45PM BLOOD Calcium-7.6* Phos-4.5 Mg-2.0\n___ 04:19AM BLOOD calTIBC-152* Ferritn-220* TRF-117*\n___ 05:20AM BLOOD Ammonia-<10\n___ 04:19AM BLOOD PEP-NO SPECIFI FreeKap-54.4* \nFreeLam-39.6* Fr K/L-1.4\n___ 05:20AM BLOOD Trep Ab-NEG\n___ 07:06PM BLOOD Glucose-90 Lactate-0.6 Na-129* K-3.4* \nCl-100\n\nDischarge labs:\n===========================\n\n___ 04:43AM BLOOD WBC-7.5 RBC-2.85* Hgb-8.4* Hct-26.8* \nMCV-94 MCH-29.5 MCHC-31.3* RDW-14.7 RDWSD-50.4* Plt ___\n___ 02:55PM BLOOD Glucose-112* UreaN-22* Creat-1.3* Na-145 \nK-4.8 Cl-104 HCO3-27 AnGap-14\n___ 02:55PM BLOOD Calcium-8.9 Phos-3.8 Mg-2.1\n___ 12:52AM BLOOD pO2-30* pCO2-32* pH-7.43 calTCO2-22 Base \nXS--2 Comment-GREEN TOP\n\nImaging:\n============================\n___ CTA head/Neck:\n1. No acute intracranial abnormality on noncontrast CT head. \nSpecifically, no evidence of acute large territory infarct or \nintracranial hemorrhage. \n2. Allowing for mild atherosclerotic disease, unremarkable CTA \nof the head. \n3. Allowing for mild atherosclerotic disease, unremarkable CTA \nneck. There is no stenosis of the cervical internal carotid \narteries by NASCET criteria. \n4. Patulous esophagus containing fluid, compatible with severe \nreflux. \n5. There is a 9 mm left upper lobe pulmonary nodule. Small left \npleural \neffusion also identified. \n6. Additional findings as described above. \n\n___ TTE\nEF 50%, Mild symmetric left ventricular hypertrophy with mild \nregional systolicdysfunction suggestive of coronary artery \ndisease (PDA distribution). Mild-moderate aortic\nregurgitation with mildly thickened leaflets. Minimal aortic \nvalve stenosis. Mild pulmonary artery\nsystolic hypertension.\n\n \nBrief Hospital Course:\nMs. ___ is an ___ with history of colon cancer s/p \nhemicolectomy ___ c/b ventral hernia and CAD who initially \npresented as a transfer from ___ with worsening SBO \nsecondary to ventral and paraesophageal hernias, status-post \nurgent repair with ACS, course complicated by Parabacteriodes \nbacteremia, acute hypoxic respiratory failure secondary to \naspiration PNA, intermittent episodes of hypernatremia, and \ntoxic metabolic encephalopathy, ultimately discharged to rehab \nfacility.\n\nACTIVE ISSUES: \n===============\n# Small bowel obstruction secondary to ventral and \nparaesophageal hernias\nAdmitted as transfer after failing non-operative management. \nSeen by ___ on arrival and taken emergently to the \noperating room for exploratory laparotomy and hernia repair. \nRecovered uneventfully post-operatively and discharged on \nTylenol alone for pain control. He abdominal exam remained \nbenign on the day of discharge without concern for infection. \n\n# Parabacterioides bacteremia\nDeveloped as a complication of surgery, as above. Received 2wk \ncourse of IV flagyl for treatment (end date ___.\n\n# Toxic metabolic encephalopathy\nDeveloped waxing/waning mentation with periods of increased \nagitation, specifically overnight. Etiology felt to be \nmultifactorial in the setting of electrolyte disturbances (see \nbelow), delirium from recent surgery, acute illness, and \ninsomnia, and likely underlying cognitive impairment. Patient \ndeveloped acute-onset dysarthria the night of ___, prompting \nCODE STROKE. A CT head was obtained that showed no evidence of \nacute infarct, but patient was started on aspirin empirically. \nNeurology recommended obtaining MRI brain which we were unable \nto get due to mental status despite multiple attempts. However, \ndysarthria improved and vry low concern for stroke. She was \nultimately discharged to rehab for ongoing treatment of delirium \nthough improved on the day of discharge. \n\n# Acute kidney injury\nFelt to be pre-renal in the setting of poor oral intake. \nImproved with IV fluids as needed. Held home ABR in this \nsetting. \n\n# Acute on chronic normocytic anemia\nHgb downtrending from ___ on admission to ___. Etiology \nfelt to be multifactorial in the setting of mild iron deficiency \nanemia and anemia of inflammation. Iron repletion deferred in \nthe setting of active infection. Received 1u pRBC ___ and Hgb \nremained stable thereafter. \n\n# Thrombocytosis\nFelt to be reactive in the setting of acute infection, as above. \nIncrease on day of discharge in the setting of hemoconcentration \nwith all lines increasing without any clinical concern for \ninfection. \n\n# Nutrition\nConcern for malnutrition given limited oral intake and \nintermittent hypernatremia that corrected with free water \nrepletion. Nutrition consulted and recommended pureed solid diet \nwith nectar thickened liquids due to concern for aspiration. \n\nCHRONIC ISSUES:\n================\n# HFpEF \nInitially with some concern for volume overload given CXR with \nevidence of pulmonary edema, prompting diuresis with IV lasix \nboluses. She was discharged on furosemide 40mg daily. \n\n# Hypothryoidism\nContinued home levothyroixine 25mcg daily\n\n# CAD\nContinued home ASA 81mg daily\n\nTRANSITIONAL ISSUES:\n=====================\n[] Please obtain repeat CBC in ___ days, if there is increase in \nthrombocytosis or WBC, consider CT abdomen/pelvis. \n[] Please repeat BMP in 1 week to ensure Cr remains stable on \nfurosemide 20mg \n[] Please obtain outpatient brain MRI w/out contrast for \ncompletion of neurological work up\n[] consider Quetiapine 12.5mg PRN for agitation \n[] Please ensure ongoing discussions regarding code status\n[] Repeat S&S evaluation in outpatient setting; upgrade diet as \nable\n[] Start oral iron repletion pending improvement in mental \nstatus and re-check iron studies ___ months after initiation of \ntherapy \n\n#CONTACT: ___ \n Relationship: SON \n Phone: ___ \n Other Phone: ___ \n#CODE: Full, presumed \n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfurther investigation.\n1. Atorvastatin 80 mg PO QPM \n2. Metoprolol Succinate XL 25 mg PO BID \n3. LORazepam 0.5 mg PO BID:PRN anxiety \n4. Aspirin 81 mg PO DAILY \n5. Furosemide 20 mg PO DAILY \n6. irbesartan 75 mg oral DAILY \n7. Loratadine 10 mg PO DAILY \n8. amLODIPine 10 mg PO DAILY \n9. DULoxetine ___ 40 mg PO DAILY \n10. Levothyroxine Sodium 50 mcg PO DAILY \n11. Lidocaine 5% Patch 1 PTCH TD Frequency is Unknown \n12. Vitamin D ___ UNIT PO DAILY \n13. Senna 8.6 mg PO DAILY:PRN Constipation - First Line \n14. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Calcium Carbonate 500 mg PO QID:PRN Reflux \n2. Pantoprazole (Granules for ___ ___ 40 mg PO BID \n3. Ramelteon 8 mg PO QPM \n4. Metoprolol Succinate XL 50 mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. Atorvastatin 80 mg PO QPM \n7. DULoxetine ___ 40 mg PO DAILY \n8. Furosemide 20 mg PO DAILY \n9. Levothyroxine Sodium 50 mcg PO DAILY \n10. melatonin 3 mg oral QHS \n11. Multivitamins 1 TAB PO DAILY \n12. Senna 8.6 mg PO DAILY:PRN Constipation - First Line \n13. Vitamin D ___ UNIT PO DAILY \n14. HELD- amLODIPine 10 mg PO DAILY This medication was held. \nDo not restart amLODIPine until you have high blood pressure\n15. HELD- irbesartan 75 mg oral DAILY This medication was held. \nDo not restart irbesartan until talking to your doctor\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n===================\nSmall bowel obstruction\nParabacterioides blood stream infection \nAcute hypoxic respiratory failure\nToxic metabolic encephalopathy\nHypernatremia\nAcute kidney injury\nAcute on chronic anemia\nAcute on chronic heart failure with preserved ejection fraction\n\nCHRONIC ISSUES:\n=================\nCoronary artery disease\nHypothyroidism\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMs. ___,\n \nWHY WERE YOU ADMITTED TO THE HOSPITAL?\n- You were admitted to the hospital because you were having \nworsening abdominal pain. \n\nWHAT HAPPENED TO YOU IN THE HOSPITAL?\n- You were seen by the surgeons you took you to the operating \nroom urgently because you had a bowel obstruction, caused by \nyour hernias. \n- Your oxygen level became very low, and you had a breathing \ntube placed for a short period of time.\n- You had issues with high sodium levels and received fluid to \ntreat this.\n- You became confused while in the hospital. You had labs done \nto try and find the cause of your confusion. \n- You developed slurred speech and had trouble finding words. \nYou were taken for an emergent CT scan of your head, that showed \nno evidence of a stroke. The neurologists saw you and \nrecommended that we get an MRI of your brain. We were unable to \nget this during this hospitalization but you can obtain it \noutside\n\nWHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?\n- Avoid heavy lifting for at least 6 weeks - talk to your \nsurgeons before resuming heavy lifting.\n- Do not scrub your incision, or soak/take baths for at least 6 \nweeks after surgery. \n- Notify your surgeon immediately if your incision becomes red, \nswollen, or starts draining fluid.\n- Please continue taking all your medications, as prescribed. \n- Attend all your follow-up appointments (see below for \nappointment details)\n\nIt was a privilege caring for you, and we wish you well!\n\nSincerely,\nYour ___ Care Team \n\n \n\n \nFollowup Instructions:\n___\n" ]

[ "A414", "J690", "R6521", "J9601", "I5033", "G92", "K430", "K440", "N179", "E870", "E46", "E872", "I2510", "E039", "Z85038", "D509", "I252", "Z781", "R471", "Z6825" ]

[ "A414: Sepsis due to anaerobes", "J690: Pneumonitis due to inhalation of food and vomit", "R6521: Severe sepsis with septic shock", "J9601: Acute respiratory failure with hypoxia", "I5033: Acute on chronic diastolic (congestive) heart failure", "G92: Toxic encephalopathy", "K430: Incisional hernia with obstruction, without gangrene", "K440: Diaphragmatic hernia with obstruction, without gangrene", "N179: Acute kidney failure, unspecified", "E870: Hyperosmolality and hypernatremia", "E46: Unspecified protein-calorie malnutrition", "E872: Acidosis", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E039: Hypothyroidism, unspecified", "Z85038: Personal history of other malignant neoplasm of large intestine", "D509: Iron deficiency anemia, unspecified", "I252: Old myocardial infarction", "Z781: Physical restraint status", "R471: Dysarthria and anarthria", "Z6825: Body mass index [BMI] 25.0-25.9, adult" ]

[ "J9601", "N179", "E872", "I2510", "E039", "D509", "I252" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nlisinopril / tetanus and diphtheria toxoids\n \nAttending: ___.\n \nChief Complaint:\nR hip pain\n \nMajor Surgical or Invasive Procedure:\nR hip hemiarthroplasty \n \nHistory of Present Illness:\nHPI: ___ female presents with the above fracture s/p mechanical\nfall. Patient was walking in her bedroom in her apartment when\nher foot was caught in her bedspread on the floor. She\nsubsequently fell onto her right side and had immediate pain and\ninability to stand. She initially presented to ___ where\nshe had plain films of hip and pelvis notable for right femoral\nneck fracture. \n\n \nPast Medical History:\nHTN \nDepression\n \nSocial History:\n___\nFamily History:\n___\n \nPhysical Exam:\nVitals: AVSS\nGEN: A&Ox3, NAD, Pleasant\nRight Lower Extremity\n- Dressing C/D/I\n- Soft, non-tender thigh and leg, moderate tenderness to hip\n- Moderate pain on active and passive ROM of the right hip but\nexam limited ___ to pain. Full, painless ROM of knee, and ankle\n- Fires ___\n- SILT S/S/SP/DP/T distributions\n- 1+ ___ pulses, WWP\n \nPertinent Results:\n___ 03:00PM GLUCOSE-115* UREA N-22* CREAT-1.3* SODIUM-141 \nPOTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-18* ANION GAP-18\n \nBrief Hospital Course:\nThe patient presented to the emergency department and was \nevaluated by the orthopedic surgery team. The patient was found \nto have r femoral neck fracture and was admitted to the \northopedic surgery service. The patient was taken to the \noperating room on ___ for hemi arthroplasty which the patient \ntolerated well. For full details of the procedure please see the \nseparately dictated operative report. The patient was taken from \nthe OR to the PACU in stable condition and after satisfactory \nrecovery from anesthesia was transferred to the floor. The \npatient was initially given IV fluids and IV pain medications, \nand progressed to a regular diet and oral medications by POD#1. \nThe patient was given ___ antibiotics and \nanticoagulation per routine. The patient's home medications were \ncontinued throughout this hospitalization. The patient worked \nwith ___ who determined that discharge to rehab was appropriate. \nThe ___ hospital course was otherwise unremarkable.\n\nShe is being discharged on lovenox for DVT prophylaxis. Please \nsee activity orders regarding ___ instructions. \n \nMedications on Admission:\n7. Citalopram 20 mg PO DAILY \n8. LORazepam 0.5 mg PO Q8H:PRN Anxiety \n9. Omeprazole 20 mg PO DAILY \n10. Pravastatin 20 mg PO QPM \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \nRX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp \n#*100 Tablet Refills:*1 \n2. Heparin 5000 UNIT SC TID \nRX *heparin (porcine) 5,000 unit/mL 5000 Units subc three times \nper day Disp #*85 Vial Refills:*0 \n3. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain \nwean as tolerated \nRX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as \nneeded for pain Disp #*80 Tablet Refills:*0 \n4. Polyethylene Glycol 17 g PO DAILY:PRN constipation \nThis is a new medication to prevent constipation. please hold \nfor loose stools. \nRX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily \nDisp #*30 Packet Refills:*0 \n5. Senna 8.6 mg PO BID \nThis is a new medication to prevent constipation. please hold \nfor loose stools. \nRX *sennosides [senna] 8.6 mg 2 tabs by mouth at bedtime Disp \n#*40 Tablet Refills:*0 \n6. amLODIPine 5 mg PO DAILY \n7. Citalopram 20 mg PO DAILY \n8. LORazepam 0.5 mg PO Q8H:PRN Anxiety \n9. Omeprazole 20 mg PO DAILY \n10. Pravastatin 20 mg PO QPM \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n right femoral neck fracture\n \nDischarge Condition:\naox3\navss \n \nDischarge Instructions:\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n- weight bearing as tolerated \n\nMEDICATIONS:\n- Please take all medications as prescribed by your physicians \nat discharge.\n- Continue all home medications unless specifically instructed \nto stop by your surgeon.\n- Do not drink alcohol, drive a motor vehicle, or operate \nmachinery while taking narcotic pain relievers.\n- Narcotic pain relievers can cause constipation, so you should \ndrink eight 8oz glasses of water daily and take a stool softener \n(colace) to prevent this side effect.\n\nANTICOAGULATION:\n- Please take lovenox daily for 4 weeks\n\nWOUND CARE:\n- You may shower. No baths or swimming for at least 4 weeks.\n- Any stitches or staples that need to be removed will be taken \nout at your 2-week follow up appointment.\n- Please remain in your dressing and do not change unless it is \nvisibly soaked or falling off.\n- Splint must be left on until follow up appointment unless \notherwise instructed\n- Do NOT get splint wet\n\nPhysical Therapy:\nWBAT, ROMAT \nTreatment Frequency:\ndressing changes PRN\n \nFollowup Instructions:\n___\n" ]

[ "S72001A", "I10", "F329", "W010XXA", "Y92032" ]

[ "S72001A: Fracture of unspecified part of neck of right femur, initial encounter for closed fracture", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter", "Y92032: Bedroom in apartment as the place of occurrence of the external cause" ]

[ "I10", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nPenicillins\n \nAttending: ___.\n \nChief Complaint:\nHypertensive emergency in the setting of 5.3 cm thoracic aortic \npseudoaneurysm\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with hx of uncontrolled HTN, recent diagnosis of type B \ndissection, transferred from OSH after being found to have BP \n270/140 at OSH outpatient visit and admitted to the MICU for BP \ncontrol. Per report, about 1 mo ago, was admitted at OSH for \nright basal ganglia bleed and on a CTA found to have \"chronic\" \ntype B dissection. Plan at the time was for control with meds \nand vascular surgery f/u but neither happened. Today at outpt \nappointment found to have BP 270/140 while asymptomatic, and \ntransferred to ED OSH ___. Started on labetalol gtt and \nsubsequently sent to ___. \n\nIn the ED, initial vitals: 98.2 83 103/64 20 97RA. Labs notable \nfor normal CBC, normal UA, Cr 1.2. CTA notable for 5.3cm \noutpouching of descending thoracic aorta, ddx pseudoaneurysm vs \nsecular aneurysm vs descending dissection. Pt seen by vascular. \nPlan for BP control and discussion re: possible stenting in AM. \n \nOn transfer, vitals were: 97.6 63 110/51 14.\nOn arrival to the MICU, patient asymptomatic. Feels absolutely \nat baseline and has no complaints.\n \nReview of systems: \n(+) Per HPI \n(-) Denies fever, chills, night sweats, recent weight loss or \ngain. Denies headache, sinus tenderness, rhinorrhea or \ncongestion. Denies cough, shortness of breath, or wheezing. \nDenies chest pain, chest pressure, palpitations, or weakness. \nDenies nausea, vomiting, diarrhea, constipation, abdominal pain, \nor changes in bowel habits. Denies dysuria, frequency, or \nurgency. Denies arthralgias or myalgias. Denies rashes or skin \nchanges. \n\n \nPast Medical History:\nHTN since age ___\nR basal ganglia infarct ___\nAsthma\nDepression\n \nSocial History:\n___\nFamily History:\nNo hx of HTN on mother's side, does not know father's family hx\n\n \nPhysical Exam:\nOn Admission:\nVitals: T:97.8 BP:112/66 P:69 R: 18 O2:95/2L \nGENERAL: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear, missing multiple \nteeth \nNECK: supple, JVP not elevated, no LAD \nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, ___, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nNEURO: ___ intact, no motor or sensory deficits, normal \nfinger to nose test, some dysarthria(says has had it for \ndecades)\n\nOn Discharge:\nVitals: T:99.8 BP:100/55 P:63 R: 16 O2:97% RA \nGENERAL: A&O x3, in NAD \nHEENT: Sclera anicteric, MMM, oropharynx clear, missing multiple \nteeth \nNECK: supple, JVP not elevated, no LAD \nLUNGS: CTAB, breathing comfortably on RA \nCV: RRR\nABD: soft, NT, ND, no masses palpable\nEXT: No edema b/l, warm, well perfused, no cyanosis \n\nPulse exam: R: p/p/p/p L: p/p/p/p\n \nPertinent Results:\nOn Admission:\n\n___ 04:24PM BLOOD ___ \n___ Plt ___\n___ 04:24PM BLOOD ___ \n___ Im ___ \n___\n___ 04:24PM BLOOD Plt ___\n___ 04:24PM BLOOD ___ \n___\n___ 02:40AM BLOOD ___ LD(LDH)-128 ___ \n___\n___ 02:40AM BLOOD ___ cTropnT-<0.01\n___ 04:24PM BLOOD ___\n\nPertinent Interval:\n\nImaging:\n___ CTA Chest\nFocal 5.3 cm outpouching of the descending thoracic aorta \nbeginning at the \nlevel of the isthmus and extending to its mid descending aorta \nwith linear \ndensities projecting into the lumen along the margins, findings \nfelt to \nrepresent a chronic pseudoaneurysm with disrupted intima. \n\n___ CTA Torso\nIMPRESSION: \n1. Redemonstrated descending thoracic pseudoaneurysm measuring \nup to 5.7 cm \nwith intimal disruption. The aortic vasculature ___ are \ndescribed in \ndetail above. \n2. Mild ectasia of the abdominal aorta and common iliac arteries \nwith minimal \natherosclerotic disease noted throughout the vasculature. \n\n___ ECG\nSinus bradycardia. Voltage criteria for left ventricular \nhypertrophy. Poor \nR wave progression in leads ___ raising the possibility of \nanteroseptal \nmyocardial infarction of indeterminate age. ___ ST \nsegment changes with T wave inversion in the lateral leads may \nbe consistent with \nrepolarization abnormality seen with left ventricular \nhypertrophy, though \ncannot exclude possible myocardial ischemia. Clinical \ncorrelation is \nsuggested. Compared to the previous tracing of ___ the \nsinus rate has \ndecreased by about 10 beats per minute with no other diagnostic \nchange.\n\n___ DUPLEX DOPP ABD/PEL\n\nIMPRESSION: \nNormal renal ultrasound. No evidence of renal artery stenosis. \n\nPertinent lab results/ discharge lab results:\n\n___ 12:40PM BLOOD ___ \n___ Plt ___\n___ 12:40PM BLOOD ___ \n___\n___ 02:40AM BLOOD ___ LD(LDH)-128 ___ \n___\n___ 12:40PM BLOOD ___\n___ 02:48AM BLOOD ___\n___ 11:45AM BLOOD ___\n___ 12:40PM BLOOD ___\n___ 06:00AM BLOOD ___\n___ 11:45AM BLOOD ___\n___ 11:45AM BLOOD RENIN - ___\n\nPsychiatric consultation ___:\n\n \n\n \n___ F ___ ___ \n Note History \n\n \n\nUnsigned notes are not final until signed by the author. \n\nNote Date: ___\nUNSIGNED by ___, MD Affiliation: ___\n \nPSYCHIATRY CONSULTATION SERVICE ATTENDING NOTE\n\nconsult question: is psychiatric issue interfering with ability\nto make decisions. capacity. safety eval, is she suicidal?\n\n___ yo woman with a PMH of poorly controlled hypertension, \nasthma,\nanxiety/PTSD, and recent right basal ganglia CVA and Type B\naortic dissection who was admitted to Vascular Surgery for\nconsideration of dissection repair. Dissection likely due to HTN\nin the setting of medication ___ resulting from lack\nof medical insurance. Vascular surgery feels that she will\nultimately need a thoracic endovascular aortic repair (TEVAR) \nbut\nlikely not during this hospital stay; \nShe is declining surgery after an extensive risk/benefit\ndiscussion with several doctors.\n\ndoesn't care if lives or dies. had a bad experience with prior\nsurgery, fears she will die if she gets surgery. they think she\nunderstands. \nShe says she might reconsider this decision in the future. She\ndoes say that she will follow up with her PCP and will take her\nmedications.\n \n___ years ago she had a hysterectomy and \"died\" during the\nsurgery. Pt fears she will die again if she has another \nsurgery.\nTold SW she 'wished she could go home so that she could avoid\nthinking about her health anymore.'\nShe says her boyfriend and children know about her situation and\nhave told her 'it's my choice'. \n\nI spoke by phone with the patient's mother, ___. I\nexplained the medical situation and she appears to understand\n(she also spoke with the primary team). She indicates ___ has\n'never been good about seeing doctors', she is not surprised \nthat\nshe is refusing the surgery, but hopes 'we can convince her to\nhave it'. She confirms that ___ can stay with her tonight. She\nbelieves that she will follow up with her PCP and will take her\nmedications if they are made available. She does not have any\nsafety concerns. She is unhappy with the boyfriend ('he has his\nproblems') but does not feel ___ is in any danger at home. She\nconfirms ___ does not have any current or recent psychiatric\ntreatment.\n\nPsych hx: Unclear past dx ? anxiety, possible PTSD (chart notes\nh/o childhood sexual abuse); she reports also dx 'ADD'. \nThe patient says she say psychiatrist years ago and was\nprescribed 'depression pills', Lexapro and then Paxil. She says\nthat she cut her wrist ___ years ago but was never hospitalized.\nShe had suicidal thoughts ___ years ago, not more recently.\nShe denies any history of mania. When questioned about psychotic\nsymptoms she does endorse occasional auditory hallucinations,\nalso says she has seen 'spirits' in the past and she explains\nthat she is a 'natural witch'. \n\nPMH:\nHTN\nMIs? \nHyperlipidemia \nright parietal stroke 1 month ago\nMVC at age ___, multiple injuries\nPSH: C section x2, tubal ligation\nPCP, ___ - ___\nAll: PCN\nCurrent meds:\nParoxetine 20 mg PO/NG DAILY \nAtorvastatin 40 mg PO/NG QPM \nCyanocobalamin 500 mcg PO/NG DAILY \nAlbuterol Inhaler ___ PUFF IH Q6H:PRN SOB, wheezing \nAspirin 81 mg PO/NG DAILY \nAmlodipine 10 mg PO/NG DAILY \nClopidogrel 75 mg PO/NG DAILY \nCloniDINE 0.1 mg PO ONCE Duration: 1 Dose \nClonidine Patch 0.3 mg/24 hr 2 PTCH TD QSUN \nHydrochlorothiazide 25 mg PO/NG DAILY \nLisinopril 20 mg PO/NG DAILY \n\nSubstance use:\nSmokes half ppd since age ___\nHistory of alcohol abuse, says she is sober now ___ years.\nFormer marijuana use.\n\nDivorced. Lives with boyfriend in ___.\nShe is close with her mother who lives in ___. \nShe has two children, ages ___ and ___ who live in ___ and\n___. \nShe graduated high school, worked in the past at ___, but has not worked ___ years and has no income;\ncurrently supported by her boyfriend, she has applied for ___. \n\nExam: T 97.7 147/74 50 18 ___\nPatient seated on bed, casually dressed, poor dentition. No abn\nmovt. Speech normal rate/tone/volume. Affect euthymic, reactive,\nmood fine. Thought form linear/nl without LOA. Content without\ndelusions or odd preoccupations, although concrete in discussing\nmedical situation. No SI or HI. +past halluc (see above). \nInsight with regard to her medical condition and recommended \ncare\nis limited, as noted above. Judgment appears fair.\nCogn: oriented to BID, ___, ___, she can tell me New\nYears is in 3 days. attn intact for days of week backwards,\nrefuses MOYB 'I can't'. recalls ___ words at 5' without\ndifficulty. Calc $2=8Q. Names ___, ___.\nLanguage fluent/grossly nl. Apple and Orange 'both rounds', car\nand train 'both have engines'. ___ fair.\n\nImp: ___ year old woman with unclear past psychiatric history-\npossibly past depression, anxiety/PTSD. r/o intellectual\ndisability. \nNo indication of active mood disorder or psychosis. No suicidal\nideation.\nThe patient appears to minimize concerns about risk and this\nseems to reflect some limitation of understanding or insight;\nalso there may be a component of anxiety/fear affecting her\ndecision making. In any case she does demonstrates a basic\nunderstanding of her medical situation, recommended care,\npossible risks associated with the treatment and with refusal of\ntreatment. The history from both the patient and her mother\nsuggests she has a chronic pattern of receiving limited care,\naccepting what might be considered substandard health care; \nthere\nhave also been financial barriers to care in the past, but this\nhas been at least partially alleviated by access to public\nassistance/Medicaid.\n\nRec:\nContinue to encourage patient to participate in recommended \ncare-\naddress her fears with reassurance, simple explanations.\nIf she continues to refuse would discharge home with close\nfollow.\nWould try to maximize supports and supervision- e.g. ___ to see\npatient after she returns home.\nEncourage close f/u with PCP- appt is scheduled for next week,\nwould also urge PCP office to reach out to patient if needed to\nassure f/u.\nSuggest communication with family to share what is known and\nrecommended- the patient refuses contact with her children or\nboyfriend but the team has had contact with the patient's mother\n(with whom she will be staying tonight). Would inform pt's \nmother\nabout the situation, including pt's decision, risks/concerns, \nand\nencourage her to share this information with other family\nmembers.\n\n \n\n \n\n \nBrief Hospital Course:\nMs. ___ is a ___ with a history of uncontrolled HTN, recent \ndiagnosis of type B dissection, transferred from OSH after being \nfound to have BP 270/140 at OSH outpatient visit and admitted to \nthe MICU for BP control.\n\n# Descending aorta pseudoaneurysm: 5.3 cm outpouching of the \ndescending thoracic aorta with findings felt to represent a \nchronic pseudoaneurysm with disrupted intima. Per review of \nprior records and ED report, noted about a month ago during an \nadmission at OSH with plan for cardiothoracic follow up which \nhas not happened yet. Aneurysm likely due to chronic \nhypertension and smoking. Seen by vascular at ED. She was \ninitially admitted to the ICU for strict blood pressure control. \nWith respect to operative intervention, the vascular team \ndecided to perform a TEVAR procedure.\n\nOn ___, nursing, the vascular surgery team members, social \nwork and the chaplain talked to Mrs. ___ about her scheduled \nTEVAR procedure on ___. Unfortunately, she did not want to \nundergo surgery, although the risks and benefits of surgery and \nobservation were explained to her multiple times.\n\nAs per the spiritual care note on ___ by ___ \n___, MS, ___\n: Patient understood that having the surgery might mean that she\nwould live longer remained resolute in not wanting the surgery.\nWhen asked what made life worth living she answered \"my\ngrandchildren.\" She could not acknowledge what it would mean to\nthem should she pass away. Patient felt that deceased father is\nwatching over her. Patient talked about being a \"new witch\"\nsomething she had known about herself for awhile, but did not go\ninto details about what this meant.\n\nDr. ___ talked to the patient on ___, \nbut she continued to decline surgery.\n\nPsychiatry was consulted to ensure the patient was competent in \nmaking decisions.\nOn ___ psychiatry concluded that she us competent in making \ndecisions (see pertinent results for details of psychiatric \nevaluation)\n\n# Hypertensive emergency: Pt found to have BP to 270/140, though \nwas asymptomatic. She has a history of poorly controlled \nhypertension since age ___. She has also not been adherent to her \nantihypertensive regimen at home and seeks care rather \ninfrequently. She was started on a labetalol gtt at the OSH \nprior to transfer and transitioned to nicardipine gtt at ___ \nwith goal BP SBP<120.\nShe was transferred to Vascular surgery for blood pressure \ncontrol and surgical planning for ___ on ___ and was \nswitched from her labetalol gtt to PO labetalol 200 TID. BP was \ncontrolled on labetalol but became bradycardic (< - dose decr \n400-->200. She was cleared by cardiology for TEVAR. Due to \nongoing difficulties in managing her blood pressure and due to \nbradycardia (40s), she was put on Hydralazine 25mg TID and \nAmlodipine 5mg on ___. Cardiology was consulted and \naccording to their suggestions, she was she was switched to \nAmlodipine 10mg, Hydral 10mg PO BID, Clonidine 0.2 BID on \n___ . On ___, she was switched to Captopril 12.5 TID \nadded, BP ___ s/p captopril. On ___, she was started \non captopril 25mg TID. Internal Medicine was consulted on ___ \nfor blood pressure control due to ongoing blood pressure swings \n(>180). As per their suggestions, hydral was d/c'd and clonidine \n0.6 QSUN was initiated), as well as captopril was increased to \n50mg TID. Her blood pressure remained well under control under \nthis regimen started on ___ (BP 130s):\n\nClonidine Patch 0.3 mg/24 hr 2 PTCH \nHydrochlorothiazide 25 mg PO/NG DAILY \nAmlodipine 10 mg PO/NG DAILY \nLisinopril 20 mg PO/NG DAILY \nHydrochlorothiazide 25 mg PO/NG DAILY \n\nInternal medicine further suggested work- up for secondary \nhypertension as an outpatient, which was started as an inpatient \nand for which she will follow up with her PCP.\nA renal Doppler ultrasound was within normal limits. For details \non the US and other lab results, please see pertinent results.\n\n# History of recent basal ganglia stroke: She has a history of R \nbasal ganglia stroke approximately one month prior to admission. \nOn admission there were no focal deficits. She has mild \ndysarthria but states she has had it for a long time. \nAspirin/Plavix on hold on admission given potential for surgical \nintervention. Plavix was restarted on ___.\n\n# HLD: Continued lovastatin\n\n# Depression: Continued paxil\n\nPrior to discharge, ___ mother was called and encouraged to \nensure that ___ both takes her medication and sees her PCP for \n___ follow up visit. The patient did not want her children to be \ncontacted.\n\nTransitional:\n\n- Please ensure tight BLOOD PRESSURE CONTROL (SBP <140)\n- Please continue SECONDARY HYPERTENSION WORKUP (RESULTS in \npertinent results or pending)\n- Smoking and EtOH cessation \n- Please ensure workup for ___ injury from longstanding \nhypertension including outpatient ophthalmology, neurology, and \ncardiology followup\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Paroxetine 20 mg PO DAILY \n2. Clopidogrel 75 mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Cyanocobalamin 500 mcg PO DAILY \n5. Atenolol 50 mg PO DAILY \n6. Lovastatin 20 mg oral QHS \n7. CloniDINE 0.2 mg PO BID \n\n \nDischarge Medications:\n1. Lisinopril 20 mg PO DAILY \nPlease hold for SBP <100\nHR <60 \nRX *lisinopril 20 mg 1 tablet(s) by mouth once a day Disp #*31 \nTablet Refills:*3\n2. Hydrochlorothiazide 25 mg PO DAILY \nPlease hold for SBP <100 and HR <60 \nRX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth once a day \nDisp #*31 Tablet Refills:*3\n3. Amlodipine 10 mg PO DAILY \nPlease hold for SBP <100 and HR <60 \nRX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*31 \nTablet Refills:*3\n4. Aspirin 81 mg PO DAILY \n5. Clopidogrel 75 mg PO DAILY \n6. Cyanocobalamin 500 mcg PO DAILY \n7. Lovastatin 20 mg oral QHS \n8. Paroxetine 20 mg PO DAILY \n9. Clonidine Patch 0.3 mg/24 hr 2 PTCH TD QSUN \nPlease hold for SBP <100 and HR <60 \nRX *clonidine 0.3 mg/24 hour Please change weekly ___ Disp #*8 \nPatch Refills:*3\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n5.3 cm thoracic aortic pseudoaneurysm\n\n \nDischarge Condition:\nMental Status: Clear and coherent (confirmed by psychiatry)\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were diagnosed with a Focal 5.3 cm outpouching of the \ndescending thoracic aorta beginning at the level of the isthmus \nand extending to its mid descending aorta with linear densities \nprojecting into the lumen along the distal margins, findings \nfelt to most likely represent a pseudoaneurysm with disrupted \nintima, differentials \ninclude a focal saccular aneurysm or type B dissection.\nWhen you came to ___, your blood pressure was elevated (>180). \nYou were put on a strong regimen of oral antihypertensive \nmedication (Clonidine, Lisinopril, Hydrochlorothiazide, \nAmlodipine) and your blood pressure was under control (SBP \n130s). We cannot overemphasize how important blood pressure \ncontrol is to prevent rupture of your aneurysm and possible \ndeath.\nPlease follow up with your primary care physician concerning \nblood pressure control (we arranged an appointment for you \n___ at 10AM).\n\nWe also cannot over emphasize how important it would have been \nto undergo TEVAR for the treatment of your thoracic aortic \naneurysm, which was offered to you at ___ by Dr. ___. \nYou were booked for a TEVAR on ___, but you decided you did \nnot want to undergo surgery. Nursing, multiple members of the \nvascular surgery team, social care, chaplain and psychiatry were \nconsulted and explained the risks and benefits of surgery. You \nwere deemed competent to decide that you did not want surgery. \nPlease call ___ to arrange an appointment if you decide \nyou would like to undergo TEVAR in the future.\n\nPLEASE FOLLOW UP WITH YOUR PCP REGARDING \n- BLOOD PRESSURE CONTROL\n- SECONDARY HYPERTENSION WORKUP (RESULTS PENDING AT DISCHARGE)\n- Smoking and EtOH cessation \n- ___ injury from longstanding hypertension including \noutpatient ophthalmology, neurology, and cardiology followup\n\n \nFollowup Instructions:\n___\n" ]

[ "I10", "I712", "E785", "F17200", "Z8673", "F329", "F4310", "Z9114", "J45909" ]

[ "I10: Essential (primary) hypertension", "I712: Thoracic aortic aneurysm, without rupture", "E785: Hyperlipidemia, unspecified", "F17200: Nicotine dependence, unspecified, uncomplicated", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "F329: Major depressive disorder, single episode, unspecified", "F4310: Post-traumatic stress disorder, unspecified", "Z9114: Patient's other noncompliance with medication regimen", "J45909: Unspecified asthma, uncomplicated" ]

[ "I10", "E785", "Z8673", "F329", "J45909" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: UROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nnephrolithiasis\n \nMajor Surgical or Invasive Procedure:\n___: CYSTOSCOPY STENT PLACEMENT LEFT; URETEROSCOPY LEFT \nLASER LITHOTRIPSY\n\n \nHistory of Present Illness:\n___ year old male with history of nephrolithiasis and DM II who \npresents with two days of left flank pain radiating to his left \ngroin. His pain originally started 2 days ago and awoke him from \nsleep. He has been unable to get comfortable and his pain was \noriginally associated with some nausea and emesis. He denies \nfevers/chills, dysuria, gross hematuria. He has received \nmorphine in the ER and reports pain improved but still left \nflank pain. With regard to his previous nephrolithiasis \nhistory, he has never required intervention. He passed a stone \non his own and analysis demonstrates calcium oxalate. \n \n \nPast Medical History:\nPAST MEDICAL HISTORY:\nTYPE II DIABETES MELLITUS\nNEPHROLITHIASIS\nASTHMA\nDIVERTICULITIS\nOBSTRUCTIVE SLEEP APNEA\nOBESITY \n\nPAST SURGICAL HISTORY:\nNo previous GU surgery \n \nSocial History:\n___\nFamily History:\n non-contributory\n \n \n\n \n\n \nPhysical Exam:\nWdWn male, NAD, AVSS\nInteractive, cooperative\nAbdomen soft, Nt/Nd, obese\nFlank pain improved\nLower extremities w/out edema or pitting and no report of calf \npain\n \nPertinent Results:\n___ 05:35AM BLOOD WBC-7.6 RBC-4.24* Hgb-12.3* Hct-37.4* \nMCV-88 MCH-29.0 MCHC-32.9 RDW-13.7 RDWSD-44.2 Plt ___\n___ 01:10PM BLOOD WBC-8.1 RBC-4.98 Hgb-14.5 Hct-43.2 MCV-87 \nMCH-29.1 MCHC-33.6 RDW-13.7 RDWSD-42.5 Plt ___\n___ 01:10PM BLOOD Neuts-73.8* Lymphs-17.4* Monos-8.1 \nEos-0.1* Baso-0.2 Im ___ AbsNeut-5.99 AbsLymp-1.41 \nAbsMono-0.66 AbsEos-0.01* AbsBaso-0.02\n___ 05:35AM BLOOD Glucose-203* UreaN-17 Creat-1.5* Na-137 \nK-4.6 Cl-100 HCO3-24 AnGap-13\n___ 01:10PM BLOOD Glucose-238* UreaN-17 Creat-1.5* Na-136 \nK-4.5 Cl-100 HCO3-22 AnGap-14\n___ 01:10PM BLOOD ALT-17 AST-13 AlkPhos-89 TotBili-0.6\n___ 01:10PM BLOOD Lipase-20\n___ 01:10PM BLOOD Albumin-4.1 Calcium-9.5 Phos-3.1 Mg-1.9\n\n___ 2:42 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: < 10,000 CFU/mL. \n \nBrief Hospital Course:\nMr. ___ was admitted to Dr. ___ from the ED for \nnephrolithiasis management with a known 8mm left proximal \nureteral junction calculus and acute kidney injury. On hospital \nday 2, he underwent urgent cystoscopy, ureteroscopy, laser \nlithotripsy and ureteral stent placement on the left. He \ntolerated the procedure well and recovered in the PACU before \ntransfer to the general surgical floor. See the dictated \noperative note for full details. His diet was advanced and after \nvoiding, he was prepped for discharge home. At discharge Mr. \n___ pain was controlled with oral pain medications, he \nwas tolerating regular diet, ambulating without assistance, and \nvoiding without difficulty. He was explicitly advised to follow \nup as directed as the indwelling ureteral stent must be removed \nand or exchanged.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n2. Repaglinide 2 mg PO TIDAC \n3. Januvia (SITagliptin) 25 mg oral DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg ONE capsule(s) by mouth \ntwice a day Disp #*60 Capsule Refills:*0 \n3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg one tablet(s) by mouth Q4HRS Disp #*15 Tablet \nRefills:*0 \n4. Tamsulosin 0.4 mg PO DAILY \nRX *tamsulosin [Flomax] 0.4 mg ONE capsule(s) by mouth at \nbedtime Disp #*30 Capsule Refills:*0 \n5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n6. Januvia (SITagliptin) 25 mg oral DAILY \n7. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY \n8. Repaglinide 2 mg PO TIDAC \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nFLANK PAIN, LEFT\nNEPHROLITHIASIS, OBSTRUCTING\nACUTE KIDNEY INJURY\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n-You can expect to see occasional blood in your urine and to \npossibly experience some urgency and frequency over the next \nmonth; this may be related to the passage of stone fragments or \nthe indwelling ureteral stent.\n\n-The kidney stone may or may not have been removed AND/or there \nmay fragments/others still in the process of passing.\n\n-You may experience some pain associated with spasm of your \nureter.; This is normal. Take the narcotic pain medication as \nprescribed if additional pain relief is needed.\n\n-Ureteral stents MUST be removed or exchanged and therefore it \nis IMPERATIVE that you follow-up as directed. \n\n-Do not lift anything heavier than a phone book (10 pounds) \n\n-You may continue to periodically see small amounts of blood in \nyour urine--this is normal and will gradually improve\n\n-Resume your pre-admission/home medications EXCEPT as noted. You \nshould ALWAYS call to inform, review and discuss any medication \nchanges and your post-operative course with your primary care \ndoctor. HOLD ASPIRIN and aspirin containing products for one \nweek unless otherwise advised.\n\n-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken \neven though you may also be taking Tylenol/Acetaminophen. You \nmay alternate these medications for pain control. For pain \ncontrol, try TYLENOL FIRST, then ibuprofen, and then take the \nnarcotic pain medication as prescribed if additional pain relief \nis needed.\n\n-Ibuprofen should always be taken with food. Please discontinue \ntaking and notify your doctor should you develop blood in your \nstool (dark, tarry stools)\n\n-You MAY be discharged home with a medication called PYRIDIUM \nthat will help with the \"burning\" pain you may experience when \nvoiding. This medication may turn your urine bright orange.\n\n-You may be given “prescriptions” for a stool softener and/or a \ngentle laxative. These are over-the-counter medications that \nmay be “health care spending account reimbursable.” \n\n-Colace (docusate sodium) may have been prescribed to avoid \npost-surgical constipation or constipation related to use of \nnarcotic pain medications. Discontinue if loose stool or \ndiarrhea develops. Colace is a stool-softener, NOT a laxative.\n\n-Senokot (or any gentle laxative) may have been prescribed to \nfurther minimize your risk of constipation. \n\n-Do not eat constipating foods for ___ weeks, drink plenty of \nfluids to keep hydrated\n \nFollowup Instructions:\n___\n" ]

[ "N132", "N179", "E669", "Z6839", "J45909", "G4733", "E119" ]

[ "N132: Hydronephrosis with renal and ureteral calculous obstruction", "N179: Acute kidney failure, unspecified", "E669: Obesity, unspecified", "Z6839: Body mass index [BMI] 39.0-39.9, adult", "J45909: Unspecified asthma, uncomplicated", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E119: Type 2 diabetes mellitus without complications" ]

[ "N179", "E669", "J45909", "G4733", "E119" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nAmpicillin / Tetracycline / Keflex / Vancomycin / Erythromycin \nBase / adhesive tape / citalopram / Zostavax (PF)\n \nAttending: ___.\n \nChief Complaint:\nRight hip pain\n \nMajor Surgical or Invasive Procedure:\nRight TFN (___)\n\n \nHistory of Present Illness:\n___ female presents presents with right hip pain after a fall\nwhile ambulating to the bathroom.\n\nOn the evening prior to admission the patient was hustling to \nthe\nbathroom to avoid having an accident. She bumped into the door\njam of her bathroom and stumbled backwards onto her right hip. \nNo head strike or loss of consciousness. No presyncopal \nsymptoms\npreceding the fall. The patient denies pain elsewhere. Patient\ndenies denies numbness and tingling and motor dysfunction in the\nright lower extremity. She denies headache, neck pain, back\npain, chest pain, shortness of breath, abdominal pain, nausea,\nand other medical complaints.\n\nOf note she does have a history of breast carcinoma in situ\nstatus post lumpectomy and radiation for which she is followed\nand there is no evidence of local or metastatic recurrence.\n\n \nPast Medical History:\nACTINIC KERATOSIS \nALLERGIC RHINITIS \nHYPERPLASTIC COLON POLYP \nMULTIPLE DRUG ALLERGIES \nMITRAL VALVE PROLAPSE \nVITREOUS DETACHMENT \nMILIUM \nACROCHRODON \nDUCTAL CARCINOMA IN SITU \nTINNITUS \nDIVERTICULAR DISEASE \nOSTEOPOROSIS \nNEUROPATHY \nURINARY TRACT INFECTION \nPALPITATIONS \nLEG EDEMA \nH/O S/P LEFT RADIUS AND ULNA FX \nH/O DEPRESSION \nH/O CERIVCAL DEGENERATIVE DISC AND JT DISEASE \nH/O RUPTURED L TM \nH/O TENSION HEADACHES \nH/O VITAMIN D DEFIC \nPremature atrial beats. \n Moderate mitral regurgitation\n \nSocial History:\nThe patient lives in ___. She is married to a\npathologist at the ___. She does not smoke tobacco use\nrecreational drugs. She drinks a glass of wine on rare social\noccasions. She is a community ambulator who goes to the gym ___\ntimes per week. She does not use assistive devices for\nambulation. Marital status: Married \n \nPhysical Exam:\nGeneral: Well-appearing, NAD\nResp: Normal WOB, symmetric chest rise\nCV: Extremities WWP\nMSK:\nL thigh full but compressible, ecchymosis just posterior to\ndressing. Dressing C/D/I\nSILT distally\nFired ___ GA/TA\n\n \nBrief Hospital Course:\nThe patient presented to the emergency department and was \nevaluated by the orthopedic surgery team. The patient was found \nto have a right intertrochanteric femur fracture and was \nadmitted to the orthopedic surgery service. The patient was \ntaken to the operating room on ___ for a R TFN, which the \npatient tolerated well. For full details of the procedure please \nsee the separately dictated operative report. The patient was \ntaken from the OR to the PACU in stable condition and after \nsatisfactory recovery from anesthesia was transferred to the \nfloor. The patient was initially given IV fluids and IV pain \nmedications, and progressed to a regular diet and oral \nmedications by POD#1. The patient was given ___ \nantibiotics and anticoagulation per routine. The patient's home \nmedications were continued throughout this hospitalization. The \npatient worked with ___ who determined that discharge to rehab \nwas appropriate. The patient had a downtrending hematocrit, \nwhich stabilized by POD#3 after several units of pRBCs. The \npatient required multiple blood transfusions post-operatively, \nlikely secondary to a right thigh hematoma.The patient remained \nasymptomatic for sings of anemia. In total, the patient was \ntransfused 5 units of packed red blood cells during the \nadmission. The ___ hospital course was otherwise \nunremarkable.\n\nAt the time of discharge the patient's pain was well controlled \nwith oral medications, incisions were clean/dry/intact, and the \npatient was voiding/moving bowels spontaneously. The patient is \nweight bearing as tolerated in the right lower extremity \nextremity, and will be discharged on lovenox for DVT \nprophylaxis. The patient will follow up with Dr. ___ in \ntwo weeks per routine. A thorough discussion was had with the \npatient regarding the diagnosis and expected post-discharge \ncourse including reasons to call the office or return to the \nhospital, and all questions were answered. The patient was also \ngiven written instructions concerning precautionary instructions \nand the appropriate follow-up care. The patient expressed \nreadiness for discharge.\n\nAny staples or superficial sutures you have are to remain in \nplace for at least 2 weeks postoperatively. Incision may be \nleft open to air unless actively draining. If draining, you may \napply a gauze dressing secured with paper tape. You may shower \nand allow water to run over the wound, but please refrain from \nbathing for at least 4 weeks postoperatively.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Tartrate 25 mg PO ONCE MR1 palpitations \n2. Gabapentin 100 mg PO BID \n3. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250 \nmg-unit oral DAILY \n4. Vitamin D 1000 UNIT PO DAILY \n5. cranberry conc-ascorbic acid 12,600-20 mg oral DAILY \n6. dextran 70-hypromellose 0.1-0.3 % ophthalmic (eye) DAILY:PRN \n7. Glucosamine Sulf-Chondroitin (glucosamine ___ 2KCl-chondroit) \n500-400 mg oral DAILY \n8. Fish Oil (Omega 3) 1000 mg PO BID \n9. vit A-vit C-vit E-zinc-copper ___ unit-mg-unit oral \nDAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO 5X/DAY \n2. Docusate Sodium 100 mg PO BID \n3. Enoxaparin Sodium 40 mg SC QPM \nRX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneous daily Disp \n#*28 Syringe Refills:*0 \n4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain \nDuration: 7 Days \nPartial fill ok \nRX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours \nDisp #*20 Capsule Refills:*0 \n5. Senna 8.6 mg PO DAILY \n6. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250 \nmg-unit oral DAILY \n7. cranberry conc-ascorbic acid 12,600-20 mg oral DAILY \n8. dextran 70-hypromellose 0.1-0.3 % ophthalmic (eye) DAILY:PRN \n \n9. Fish Oil (Omega 3) 1000 mg PO BID \n10. Gabapentin 100 mg PO BID \n11. Glucosamine Sulf-Chondroitin (glucosamine ___ \n2KCl-chondroit) 500-400 mg oral DAILY \n12. Metoprolol Tartrate 25 mg PO ONCE MR1 palpitations \n13. vit A-vit C-vit E-zinc-copper ___ unit-mg-unit \noral DAILY \n14. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nRight intertrochanteric fracture\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n- Weight bearing as tolerated\n\nMEDICATIONS:\n 1) Take Tylenol ___ every 6 hours around the clock. This is \nan over the counter medication.\n 2) Add oxycodone as needed for increased pain. Aim to wean \noff this medication in 1 week or sooner. This is an example on \nhow to wean down:\nTake 1 tablet every 3 hours as needed x 1 day,\nthen 1 tablet every 4 hours as needed x 1 day,\nthen 1 tablet every 6 hours as needed x 1 day,\nthen 1 tablet every 8 hours as needed x 2 days, \nthen 1 tablet every 12 hours as needed x 1 day,\nthen 1 tablet every before bedtime as needed x 1 day. \nThen continue with Tylenol for pain.\n 3) Do not stop the Tylenol until you are off of the narcotic \nmedication.\n 4) Per state regulations, we are limited in the amount of \nnarcotics we can prescribe. If you require more, you must \ncontact the office to set up an appointment because we cannot \nrefill this type of pain medication over the phone. \n 5) Narcotic pain relievers can cause constipation, so you \nshould drink eight 8oz glasses of water daily and continue \nfollowing the bowel regimen as stated on your medication \nprescription list. These meds (senna, colace, miralax) are over \nthe counter and may be obtained at any pharmacy.\n 6) Do not drink alcohol, drive a motor vehicle, or operate \nmachinery while taking narcotic pain relievers.\n 7) Please take all medications as prescribed by your \nphysicians at discharge.\n 8) Continue all home medications unless specifically \ninstructed to stop by your surgeon.\n \nANTICOAGULATION:\n- Please take lovenox daily for 4 weeks\n\nWOUND CARE:\n- You may shower. No baths or swimming for at least 4 weeks.\n- Any stitches or staples that need to be removed will be taken \nout at your 2-week follow up appointment.\n- Incision may be left open to air unless actively draining. If \ndraining, you may apply a gauze dressing secured with paper \ntape.\n- Splint must be left on until follow up appointment unless \notherwise instructed.\n- Do NOT get splint wet.\n\nDANGER SIGNS:\nPlease call your PCP or surgeon's office and/or return to the \nemergency department if you experience any of the following:\n- Increasing pain that is not controlled with pain medications\n- Increasing redness, swelling, drainage, or other concerning \nchanges in your incision\n- Persistent or increasing numbness, tingling, or loss of \nsensation\n- Fever > 101.4\n- Shaking chills\n- Chest pain\n- Shortness of breath\n- Nausea or vomiting with an inability to keep food, liquid, \nmedications down\n- Any other medical concerns\n\nTHIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB\n\nPhysical Therapy:\nActivity: Activity: Out of bed w/ assist\n Right lower extremity: Full weight bearing\n Left lower extremity: Full weight bearing\nEncourage turning, deep breathing and coughing qhour when awake.\n\nTreatments Frequency:\nSite: R Hip\nDescription: ORIF R Hip, Hematoma present w/ ecchymosis to \nposterior aspect of femur.\nCare: ___ leave OTA, dressing will come down post-op day 3.\n\n \nFollowup Instructions:\n___\n" ]

[ "S72141A", "D62", "W010XXA", "G629" ]

[ "S72141A: Displaced intertrochanteric fracture of right femur, initial encounter for closed fracture", "D62: Acute posthemorrhagic anemia", "W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter", "G629: Polyneuropathy, unspecified" ]

[ "D62" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nEpinephrine\n \nAttending: ___.\n \nChief Complaint:\npain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with the past medical\nhistory of ADD who presents to the ER with abdominal pain and\ndiarrhea. Patient in usual state of health until ___ ___ when \nshe\ndeveloped some abdominal cramping. She went to bed, and the \nnext\nmorning, noted that it was more severe, located in her abdomen\ndiffusely, sharp, up to ___, associated with diarrhea, acute.\nShe had up to 30 loose stools without gross blood, non-tarry. \nThat night, she felt like she \"was going to die.\" The following\nmorning, this persisted, and she was unable to eat or drink\nanything much. She had no fevers or shaking chills. She noted \nno\nsick contacts, eating different foods, uncooked foods, or any\nknown precipitating events. This has never happened before. She\nwould have gone to a doctor, but she was on the ___. On ___, \nshe\nwent to see her PCP who gave her 4 liters of IVF without\nsignificant improvement, so she was sent to the ER. \n\nVitals in the ER: 98.6 110 160/55 24 98% RA\n\nThere, the patient was there for about 20 hours and received: \n4L IVF \nCipro 400mg IV x2\nFlagyl 500mg IV x3\nToradol 15mg IV \n\nShe reports that her diarrhea has improved significantly. The\nafternoon of ___, she had 4 oz of juice, and she developed\nsignificant abdominal pain and cramping after as well as repeat\ndiarrhea. She is very hesitant to take any PO at this time as a\nresult.\n \nPast Medical History:\nADD, s/p adenoidectomy as a child \n\n \nSocial History:\n___\nFamily History:\nReviewed and found to be positive for father and\nbrother with diverticulitis, where the brother had to have a\npartial colectomy. \n \nPhysical Exam:\nADMISSION EXAM:\nVITALS: (see eFlowsheet)\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 rate; normal perfusion, no appreciable JVD\nRESP: Symmetric breathing pattern with no stridor. Breathing is\nnon-labored\nGI: Abdomen soft, non-distended, mild tenderness without rebound\nor guarding. No hepatosplenomegaly appreciated. \nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, normal muscle bulk and tone \nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout\nPSYCH: normal thought content, logical thought process,\nappropriate affect\n\nDISCHARGE EXAM\nVital signs:\n___ ___ Temp: 98.4 PO BP: 157/85 HR: 85 RR: 18 O2 sat: 93%\nO2 delivery: RA \nTele: sinus since ~ 12PM ___\nGENERAL: Alert and in no apparent distress\nCV: RRR no mrg\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, mild TTP bilateral lower\nabdomen. Bowel sounds present\n\n \nPertinent Results:\n====================\n\nPERTINENT DATA\n\nWBC wnl\nHGb ___ mostly\nPlts 130-140s -> 200s\n\nCre 0.3-0.4\n\nALT ___\nAST ___\n\nAlk Phos 100s-120s\nTbili 0.2\n\nLipase neg\n\nIron 18, 30\nTIBC 200, 220\nHapto 209, 226\nFerritin 250s\n\nStool culture from Atrius - Heave salmonella group C ___ to \nlevofloxacin, ampicillin, and bactrim)\n\nBlood cx ngtd\n\nUrine cx neg\n\nCT A/P\n1. Procto-pancolitis, likely infectious or inflammatory in \netiology.\n2. Sigmoid diverticulosis without diverticulitis.\n3. Dilated gonadal veins bilaterally with prominent pelvic \nvarices, findings\nwhich can be seen with pelvic congestion syndrome in the correct \nclinical\nsetting. Clinical correlation however is needed.\n\n====================\nDC LABS:\n\n___ 07:40AM BLOOD WBC-6.4 RBC-3.86* Hgb-10.6* Hct-31.9* \nMCV-83 MCH-27.5 MCHC-33.2 RDW-12.8 RDWSD-38.7 Plt ___\n___ 07:25AM BLOOD Glucose-91 UreaN-4* Creat-0.4 Na-146 \nK-4.1 Cl-110* HCO3-29 AnGap-7*\n___ 07:40AM BLOOD ALT-62* AST-61* AlkPhos-104 TotBili-0.3\n___ 07:25AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.7\n___ 06:10PM BLOOD calTIBC-220* Hapto-226* Ferritn-254* \nTRF-169*\n___ 07:40AM BLOOD TSH-<0.01*\n___ 07:40AM BLOOD PTH-37\n___ 07:40AM BLOOD T4-10.6 T3-143\n \nBrief Hospital Course:\nMs. ___ is a ___ female with ADD who presents to the \nER with abdominal pain and diarrhea, found to have pancolitis on \nCT, improving slowly on Cipro/Flagyl, now found to have \nsalmonella on stool culture without clear exposure source. \n\n#Salmonella enterocolitis, group C\n#Abdominal pain, diarrhea\nPresented with abdominal pain and watery nonbloody diarrhea, \nwithout any upper GI symptoms. Also reports she initially had \nfevers. No obvious high risk exposures. No known sick contacts, \nno recent travel out of the country, no suspect food sources, no\nexposure to classic salmonella carrying animals, although she \ndoes report visiting the petting tank at ___ last ___ \n(four days prior to symptoms onset) with her grandson. She did \nnot herself pet any fish, but she held her grandson's hand after\nhe had. Her improvement in abdominal discomfort and diarrhea, \nespecially the worsening she experienced after taking POs was \nslow and gradual. Once salmonella diagnosed she was changed from \ncipro/flagyl to cipro alone. She will complete a 7 day course \nof treatment through ___. She was counseled on good hand \nhygiene and prevention strategies\n\n# Mild Hepatitis: \nSuspect this is nonspecific elevation in setting of her \nsalmonellosis. No significant concern for enteric fever given \nher clinical features and lack of travel history. \n- Recommend repeat LFTs on follow up\n\n# Paroxysmal AF with RVR:\nOn night of ___ she went into AF with RVR. Trop negative. She \nwas initiated on metoprolol. She felt mildly fatigued. SHe \nconverted back to sinus <24 hrs later. I suspect a \nmultifactorial cause to include subclinical hyperthyroidism, \nstress, held stimulants, and family history.\n- Recommend TTE outpatient, consider cards referral\n- Unclear future stroke risk if solitary event. CHADS2VASC = 1, \nlow risk, can consider aspirin\n\n# Subclinical Hyperthyroidism:\nPreviously evaluated at ___. ___ remained low here. Given \nepisode of AF, recommend follow up with endocrine to consider \nfurther evaluation and possible treatment of this.\n\n# Anemia, mild: likely due to inflammation +/-iron deficiency\n\n# Mild thrombocytopenia: resolved. suspect was due to infection\n\n#CT finding\n\"Dilated gonadal veins bilaterally with prominent pelvic \nvarices, findings which can be seen with pelvic congestion \nsyndrome in the correct clinical setting. Clinical correlation \nhowever is needed\"\n- transitional issue, low suspicion this is related to her acute\nillness\n\n=====================\n___ ISSUES:\n\n- PCP ___ next week\n\n- recheck CBC, CMP, LFT\n\n- if any future concern for pelvic congestion syndrome consider \nspecialty referral given CT findings above \n\n- recommend TTE to evaluate heart function. consider cardiology \nreferral\n=====================\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Methylphenidate SR 20 mg PO BID \n2. MethylPHENIDATE (Ritalin) 10 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \ncan take over the counter, limit to maximum 3 grams per day \n2. Ciprofloxacin HCl 500 mg PO Q12H \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day \nDisp #*5 Tablet Refills:*0 \n3. Ondansetron ODT 4 mg PO Q8H:PRN nausea \nRX *ondansetron [Zofran ODT] 4 mg 1 tablet(s) by mouth three \ntimes a day Disp #*30 Tablet Refills:*0 \n4. MethylPHENIDATE (Ritalin) 10 mg PO DAILY \n5. Methylphenidate SR 20 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nSalmonellosis\nReactive hepatitis, mild\nAnemia\nParoxysmal Afib\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were admitted to the hospital because of diarrhea and \nabdominal pain, which ultimately were found to be due to \nsalmonella. We do not know where you got the infection from, \nalthough it is possible you could have been exposed through the \npetting tank at the ___. It took several days for you to \nimprove enough to tolerate oral intake, and so you were given IV \nfluids and antibiotics during that time. \n\nYou will be discharged to complete a course of antibiotics. \nPlease stay well hydrated and take antibiotics as prescribed.\n\nYou also had a brief episode of atrial fibrillation, possibly \ntriggered by your infection above and your mildly active \nthyroid. You are now back in the Normal Sinus Rhythm. We \nrecommend discussing cardiology referral with your PCP, and we \nrecommend getting an \"Echocardiogram\" in the near future. We \nalso recommend following up again with your endocrinologist to \ndiscuss your thyroid gland.\n \nFollowup Instructions:\n___\n" ]

[ "A020", "D696", "I480", "E8342", "K759", "E876", "E860", "D649", "E0580" ]

[ "A020: Salmonella enteritis", "D696: Thrombocytopenia, unspecified", "I480: Paroxysmal atrial fibrillation", "E8342: Hypomagnesemia", "K759: Inflammatory liver disease, unspecified", "E876: Hypokalemia", "E860: Dehydration", "D649: Anemia, unspecified", "E0580: Other thyrotoxicosis without thyrotoxic crisis or storm" ]

[ "D696", "I480", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nindomethacin / meglumine\n \nAttending: ___\n \nChief Complaint:\nPalpitations\n \nMajor Surgical or Invasive Procedure:\nNone \n\n \nHistory of Present Illness:\nMs. ___ is a ___ year-old female with a past medical history \nof\nrheumatic heart disease with moderate mitral regurgitation and\nmild mitral stenosis, paroxysmal atrial fibrillation, and\nhyperlipidemia. Initially diagnosed with AF w/ RVR in ___ s/p\nTEE DCCV. The patient has had longstanding paroxysmal atrial\nfibrillation and cardioverts on her own. She had an episode of\npalpitations in ___ which lasted for approximately 3\nhours but terminated just prior to her presentation to the ED.\nEarlier this year she reported an increase in palpitations. In\n___ patient was prescribed flecainide 50mg BID per EP but\nnever started taking it. \n\nSince ___ night she had experienced palpitations with a sense\nof intermittent chest discomfort described as a sharp sensation\nand intermittent mild shortness of breath along with a mild\nheadache. Palpitations have been constant since that time. Took\nflecainide yesterday x2 (has not been taking but was prescribed\nin ___ by Dr. ___, this is the first time she has ever\ntaken it) reports that did not help palpitations. Took other\nmeds as scheduled including metoprolol and warfarin. Symptoms\nhave persisted and she had seen her primary cardiologist this \nAM,\nnoted her to be in atrial fibrillation with increased \nventricular\nrates and low normal blood pressure along with her symptoms as\ndescribed above. Given her continuing symptoms, along with \natrial\nfibrillation with increased ventricular rates, the decision was\nmade to pursue cardioversion by the emergency room staff on an\nurgent basis. \n\nShe denies any chest pain, shortness of breath, orthopnea, PND,\n___ edema, or claudication.\n\n[x] cardioversion: 100J, one shock. 10mg etomidate, no\ncomplications.\n\nPost-cardioversion EKG: NSR @ 55, STD in V1-2 CWP\n \nIn the ED, initial vitals were 98.7 145 117/83 22 98% RA \nEKG showed af w/ RVR, and stable t wave inversions in v1,v2,v3\nHR @140. \n\nVitals on transfer: 97.3 69 109/49 24 97% RA. \nLabs notable for 3.3, K 4.2\nPatient was given: \n___ 12:59 IV Metoprolol Tartrate 5 mg \n___ 12:59 PO Metoprolol Tartrate 25 mg \n___ 14:38 IV Prochlorperazine 10 mg \nAtrius cardiology consulted. \n\nREVIEW OF SYSTEMS: \nCardiac review of systems is notable for absence of chest pain,\ndyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,\nankle edema, syncope, or presyncope. \n\n \nPast Medical History:\n1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, -Hypertension\n2. CARDIAC HISTORY:\n-Rheumatic MV disease with mild-mod mitral stenosis and mild \nmitral regurgitation, echo ___\n-Atrial Fibrillation (s/p DCCV ___ \n-PVCs\n3. OTHER PAST MEDICAL HISTORY:\n- hearing loss \n- colonic polyp\n- H/O: hysterectomy\n- Pseudophakia \n- s/p cataract surgery ___\n \nSocial History:\n___\nFamily History:\nMother with DM, HTN, heart disease (pt thinks secondary to \nAvandia). \nFather with \"valve problem\" in his ___, where it \"would not \nshut\" all the way. \nGrandparents lived into their ___.\n \nPhysical Exam:\nADMISSION PHYSICAL\n==================\nVS: 97.4PO, 125 / 66, R Lying 61 16 99 RA \nGENERAL: NAD. Oriented x3. Mood, affect appropriate. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were\npink, no pallor or cyanosis of the oral mucosa. No xanthelasma. \n\nNECK: Supple with JVD at 5-6cm\nCARDIAC: PMI located in ___ intercostal space, midclavicular\nline. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,\nlifts. \nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp\nwere unlabored, no accessory muscle use. No crackles, wheezes or\nrhonchi. \nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: No c/c/e. No femoral bruits. \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \nPULSES: Distal pulses palpable and symmetric \n\nDISCHARGE\n==========\nVS: 97.9 PO 101 / 67 R Lying 61 20 91 RA \nGENERAL: NAD. Oriented x3. Mood, affect appropriate. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were\npink, no pallor or cyanosis of the oral mucosa. No xanthelasma. \n\nNECK: Supple with JVD at 5-6cm\nCARDIAC: PMI located in ___ intercostal space, midclavicular\nline. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,\nlifts. \nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp\nwere unlabored, no accessory muscle use. No crackles, wheezes or\nrhonchi. \nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: No c/c/e. No femoral bruits. \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \nPULSES: Distal pulses palpable and symmetric\n \nPertinent Results:\nADMISSION LABS\n============\n___ 12:45PM BLOOD WBC-7.6 RBC-4.72 Hgb-14.1 Hct-42.4 MCV-90 \nMCH-29.9 MCHC-33.3 RDW-12.6 RDWSD-41.6 Plt ___\n___ 12:45PM BLOOD Neuts-50.1 ___ Monos-7.8 Eos-0.7* \nBaso-0.3 Im ___ AbsNeut-3.82# AbsLymp-3.10 AbsMono-0.59 \nAbsEos-0.05 AbsBaso-0.02\n___ 12:45PM BLOOD Glucose-97 UreaN-13 Creat-0.9 Na-135 \nK-6.5* Cl-98 HCO3-25 AnGap-12\n___ 12:45PM BLOOD CK(CPK)-69\n___ 12:45PM BLOOD CK-MB-1 cTropnT-<0.01\n___ 12:45PM BLOOD Calcium-8.6 Phos-3.9 Mg-2.0\n___ 12:45PM BLOOD TSH-3.2\n___ 12:45PM BLOOD Free T4-1.4\n\nDISCHARGE LABS\n==============\n___ 06:40AM BLOOD WBC-5.1 RBC-4.09 Hgb-12.1 Hct-36.7 MCV-90 \nMCH-29.6 MCHC-33.0 RDW-12.5 RDWSD-40.9 Plt ___\n___ 06:40AM BLOOD Glucose-94 UreaN-14 Creat-0.8 Na-142 \nK-5.3* Cl-105 HCO3-26 AnGap-11\n___ 06:40AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.1\n\nMICRO\n=====\nUCx NGTD\n\nIMAGING\n=======\nCXR ___\nNo acute pathology\n \nBrief Hospital Course:\nMs. ___ is a ___ year-old female with a past medical history \nof rheumatic heart disease with moderate mitral regurgitation \nand mild mitral stenosis, paroxysmal atrial fibrillation, \nhyperlipidemia, AF w/ RVR in ___ s/p TEE DCCV on metop \npresenting with palpitations. \n\n#Afib with RVR: Symptoms of palpitations, intermittent chest \ndiscomfort, mild shortness of breath started ___. Patient \nwent to outpatient cardiologist, was found to be in atrial \nfibrillation with increased ventricular rate, normal-low blood \npressure, therapeutic INR. Patient was sent to ED for better \ncontrol. In ED, patient was cardioverted at 100J, one shock \nfollowed by 10mg etomidate, no complications. She was admitted \nfor observation. EP team consulted for further management and \nrecommended flecainide only after CAD/structural heart disease \nruled out properly. Patient wanted to continue the conversation \nwith her cardiologist and PCP as outpatient before committing \nherself to further imaging or procedures. No medication changes \non discharge. Of note, patient was prescribed flecainide by ___ \nclinic in ___ but never took this medication. Patient \nshould be continued on Coumadin since DOACs not well studied in \npatients with more than mild MS. \n- continued metoprolol 25mg XL daily today, continued on \nCoumadin, daily dose is 2 mg on ___ 3 mg all other days \n\n#Rheumatic heart disease: Mild mitral regurgitation at rest, \nmild to moderate mitral stenosis in the setting of rheumatic \nheart disease seen on Echo in ___. Likely has resulted in \nher afib given the atrial strain associated with prolonged \nmitral stenosis/regurg. No evidence of volume overload.\n\n#Dyslipidemia: Continued pravastatin 10 mg tablet daily\n\n#Osteoporosis: Continued home vitamin D\n\nTRANSITIONAL ISSUE\n=================\n[ ] Will be started on an anti-arhythmic medication as an \noutpatient. CAD must be ruled out prior to starting flecainide.\n\n#CODE STATUS: Full (presumed)\n#CONTACT: Name of health care proxy: ___ \nPhone number: ___ \nComments: Pt would like her ___ to be\ncontacted in emergency ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Succinate XL 25 mg PO DAILY \n2. Pravastatin 10 mg PO QPM \n___ MD to order daily dose PO DAILY16 \n4. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Medications:\n1. Metoprolol Succinate XL 25 mg PO DAILY \n2. Pravastatin 10 mg PO QPM \n3. Vitamin D 1000 UNIT PO DAILY \n4. ___ MD to order daily dose PO DAILY16 \n___ - 2mg\n___- 3mg \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis \n=================\nAtrial fibrillation with rapid ventricular response \nAtrial fibrillation\n\nSecondary diagnosis\n===================\nRheumatic heart disease \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\nIt was a pleasure caring for you here at ___.\n\nWhat happened while you were in the hospital?\n- You presented to the emergency department with worsening \npalpitations.\n- In the emergency department you were found to have atrial \nfibrillation with rapid ventricular response, or AF with RVR. \nThis is when your heart starts to be irregularly and very fast. \nYou were given medication to control your heart rate and you \nwere also cardioverted. Your rhythm returned to normal after the \ncardioversion.\n- The electrophysiology (EP) team was consulted to help guide \nfurther management. They recommended starting the medication \nFlecainide. Prior to doing this, it is important to rule out any \ncoronary artery disease or heart disease or else it can be \ndangerous to take Flecainide. Further management regarding your \nheart rate will be done as an outpatient.\n\nWhat to do on discharge?\n- Continue to take all your medications as prescribed except \nflecainide. Do not take this medication until you meet with your \ncardiologist. Your cardiologist may refer you to an EP doctor.\n- If you experience any chest pain, palpitations, \nlightheadedness, please return to the emergency department. \n- Please follow up with your cardiologist and primary care \ndoctor. \n\nWe are happy to see you feeling better.\n\nSincerely,\nYour ___ team \n \nFollowup Instructions:\n___\n" ]

[ "I480", "Z7901", "I052", "E785", "M810", "Z87891" ]

[ "I480: Paroxysmal atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "I052: Rheumatic mitral stenosis with insufficiency", "E785: Hyperlipidemia, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "Z87891: Personal history of nicotine dependence" ]

[ "I480", "Z7901", "E785", "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:\nAMS, hypoxia\n \nMajor Surgical or Invasive Procedure:\nIntubation and Extubation\nCVL placement and removal\n\n \nHistory of Present Illness:\nThis is a ___ female with a medical history including \nchronic atrial fibrillation, hypertension, mild-moderate mitral \nregurgitation, and spontaneous intracranial bleed in ___ due to \nintracerebral aneurysm.\n\nAt ___ ___ from ___. Found to be \n97.7 121/76 112 20 77%RA at ___, placed on O2 99% on 4LNC HR 86. \nReported decreased PO intake during stay. Home diet cardiac 2gm \nsodium 1.5L fluid. \n \nIn the ED, initial vitals: 98.5 80 110/70 12 97% nonrebreather \n \nShe received cefepime 2g, vancomycin 1000mg. She was intubated \nwith etomidate, succinylcholine, placed on midazolam. She was \nstarted on norepinephrine, phenylephrine. \n\nOn transfer, vitals were: 97.7 79 117/97 20 100% Intubation \n\nOn arrival to the MICU, patient is intubated and sedated.\n\nReview of systems: \nunable to obtain ___ intubated/mental status\n\n \nPast Medical History:\nDiastolic Heart failure\nSevere mitral valve regurgitation\nAtrial fibrillation on Coumadin (last INR 1.8 on Coumadin 2mg \ndaily)\nHtn\nHld\nGI bleed from duodenal ulcer\nMild cognitive impairment (per daughter)\n \nSocial History:\n___\nFamily History:\ndaughter denies any pertinent ___\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\nVitals: T: 100.0 BP: 133/72 P: 75 R: 11 SpO2: 100% on 50%FiO2 \nCMV \nGENERAL: Intubated, sedated \nHEENT: Sclera anicteric, MMM, oropharynx clear, ETT and OG tubes \nin place \nNECK: supple, JVP not elevated, no LAD \nLUNGS: Decreased breath sounds throughout with diffuse wheezing, \nno rhonchi\nCV: irregularly irregular, tachycardic, normal S1 S2, III/VI \nholosystolic murmur loudest at apex \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: Cool, 2+ pulses, no clubbing, 2+ nonpitting pedal edema \nbilaterally\nSKIN: nonstagable decub ulcers\nNEURO: intubated, sedated\n\nDISCHARGE PHYSICAL EXAM:\nVS: Tm 98.9 Tc 98.9 ___ 20 97 RA\nGENERAL: alert, NAD\nHEENT: Sclera anicteric, conjunctivae noninjected \nNECK: supple, JVP not elevated \nLUNGS: Decreased breath sounds in apices, no rhonchi, few \ncrackles, no wheezes\nCV: irregularly irregular, normal S1 S2, III/VI holosystolic \nmurmur loudest at apex \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: WWP, no edema \nNEURO: MAE, grossly nonfocal \n \nPertinent Results:\nADMISSION LABS:\n___ 03:11PM BLOOD WBC-12.6*# RBC-4.52 Hgb-14.1 Hct-47.7* \nMCV-106*# MCH-31.2 MCHC-29.6*# RDW-14.4 RDWSD-54.9* Plt ___\n___ 03:11PM BLOOD Neuts-85.2* Lymphs-4.6* Monos-9.1 \nEos-0.0* Baso-0.5 Im ___ AbsNeut-10.78* AbsLymp-0.58* \nAbsMono-1.15* AbsEos-0.00* AbsBaso-0.06\n___ 03:11PM BLOOD ___ PTT-37.3* ___\n___ 03:11PM BLOOD Glucose-186* UreaN-46* Creat-1.3* Na-141 \nK-5.8* Cl-95* HCO3-35* AnGap-17\n___ 11:12PM BLOOD proBNP-4538*\n___ 03:11PM BLOOD Calcium-8.9 Phos-3.9 Mg-2.3\n___ 03:24PM BLOOD ___ pO2-56* pCO2-101* pH-7.28* \ncalTCO2-50* Base XS-15\n___ 03:16PM BLOOD Lactate-2.4*\n\nOTHER PERTINENT LABS:\n___ 02:27AM BLOOD Ret Man-3.8* Abs Ret-0.14*\n___ 11:12PM BLOOD proBNP-4538*\n___ 02:27AM BLOOD VitB12-1475* Folate-15.4 Hapto-41\n___ 11:00PM BLOOD freeCa-1.01*\n\nDISCHARGE LABS:\n___ 06:17AM BLOOD WBC-5.0 RBC-3.93 Hgb-12.1 Hct-38.5 MCV-98 \nMCH-30.8 MCHC-31.4* RDW-13.9 RDWSD-49.7* Plt ___\n___ 06:17AM BLOOD ___ PTT-30.7 ___\n___ 06:17AM BLOOD Glucose-118* UreaN-18 Creat-0.8 Na-140 \nK-4.1 Cl-101 HCO3-32 AnGap-11\n___ 06:17AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.0\n\nIMAGING:\nCXR ___\nRight basal consolidation concerning for pneumonia. \n\nCXR ___\nNG tube tip is in the stomach but the side hole is at the \ngastroesophageal \njunction and should be advanced. Right internal jugular line \ntip is at the level of mid SVC. \n \nThere is a skin fold most likely projecting over the right upper \nchest and \nattention to this area should be paid on the subsequent study. \nImprovement of \nbibasal consolidations is noted. \n\nCXR ___\nAllowing for differences in technique and projection, there has \nnot been a \nsubstantial change in the appearance of the chest since the \nrecent study from earlier the same date. \n\nCXR ___\nComparison ___. The patient has been extubated and \nthe \nnasogastric tube was removed. Bilateral pleural effusions of \nmoderate extent have developed. Subsequent bilateral areas of \nbasilar atelectasis. Unchanged moderate cardiomegaly. No overt \npulmonary edema. No pneumothorax. \n\nECHO ___\nThe left atrium is moderately dilated. The right atrium is \nmoderately dilated. No atrial septal defect is seen by 2D or \ncolor Doppler. The estimated right atrial pressure is at least \n15 mmHg. Left ventricular wall thickness, cavity size and \nregional/global systolic function are normal (LVEF >55%). The \nright ventricular cavity is mildly dilated with normal free wall \ncontractility. The diameters of aorta at the sinus, ascending \nand arch levels are normal. The aortic valve leaflets (3) are \nmildly thickened but aortic stenosis is not present. No aortic \nregurgitation is seen. The mitral valve leaflets are mildly \nthickened. There is probably partial posterior mitral leaflet \nflail. An eccentric, anteriorly directed jet of moderate to \nsevere (3+) mitral regurgitation is seen. Due to the eccentric \nnature of the regurgitant jet, its severity may be significantly \nunderestimated (Coanda effect). The tricuspid valve leaflets are \nmildly thickened. Moderate [2+] tricuspid regurgitation is seen. \nThere is moderate pulmonary artery systolic hypertension. There \nis a trivial/physiologic pericardial effusion. \n\nCompared with the prior study (images reviewed) of ___, \nthe degree of MR seen has increased (however is was likely \nmoderate on prior). \n\nMICRO:\n___ - Urine -urinary legionella antigen - negative\n___ - MRSA screen - negative\n___ - Blood cultures x2 - negative\n___ - Urine culture - negative\n___ - Strep pneumo antigen (urine) - negative\n\n___ 9:45 pm SPUTUM Source: Endotracheal. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n >25 PMNs and <10 epithelial cells/100X field. \n 2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S). \n\n RESPIRATORY CULTURE (Final ___: \n RARE GROWTH Commensal Respiratory Flora. \n \n\n___ 12:16 pm Rapid Respiratory Viral Screen & Culture\n Source: Nasopharyngeal swab. \n\n **FINAL REPORT ___\n\n Respiratory Viral Culture (Final ___: \n TEST CANCELLED, PATIENT CREDITED. \n Refer to respiratory viral antigen screen and respiratory \nvirus\n identification test results for further information. \n\n Respiratory Viral Antigen Screen (Final ___: \n Positive for Respiratory viral antigens. \n Specimen screened for: Adeno, Parainfluenza 1, 2, 3, \nInfluenza A, B,\n and RSV by immunofluorescence. \n Refer to Respiratory Virus Identification for further \ninformation. \n\n Respiratory Virus Identification (Final ___: \n Reported to and read back by RN. ___ ON \n___ AT 11:17\n AM. \n POSITIVE FOR RESPIRATORY SYNCYTIAL VIRUS (RSV). \n Viral antigen identified by immunofluorescence. \n\n \nBrief Hospital Course:\n___ with a history of dCHF and mitral regurgitation, atrial \nfibrillation (on warfarin), and recent hospitalization for \npneumonia complicated by acute on chronic diastolic heart \nfailure who presented with AMS and hypoxic respiratory failure \nand septic shock requiring brief intubation. She was found to be \nRSV positive but due to the severity of her clinical \npresentation she was also treated for HCAP. Her course was \ncomplicated by afib with RVR.\n\nInvestigations/Interventions:\n1. Healthcare-associated pneumonia/RSV pneumonia: She was found \nto have RLL infiltrate on chest X ray on admission and was \nstarted on vanc/cefepime/azithromycin. After one day in the ICU, \nshe was extubated and was moved to the floor. She was found to \nbe RSV+ but antibiotics were continued because of severity of \nher presentation raised concern for bacterial co-infection. \nHowever, vanc/cefepime/azithromycin were transitioned to \nlevofloxacin to complete an 8 day course (finished on ___. \nShe was successfully weaned off O2. Speech and swallow evaluated \npatient who felt that she could tolerate modified diet, however, \nour suspicion for continued aspiration remains high. \n2. Atrial fibrillation with RVR: Pt has a history of afib on \nwarfarin with rate control via atenolol/diltiazem prior to \nhospitalization. She had multiple episodes of afib with RVR \nwhile hospitalized requiring uptitration of diltiazem. Atenolol \nwas discontinued given ___ on presentation. By time of \ndischarge, pt Hr's controlled on Diltiazem monotherapy (75mg \nq6h). We attempted to switch to Diltiazem 300 mg daily on ___ at \nnoon, but pt was unable to swallow the ER daily capsule, and \nonly received half of the dose. Accordingly, will need continued \nspeech and swallow rehab so that she may be able to accommodate \nlarger pill. Until then will need q6h dosing. INR difficult to \ncontrol while on antibiotics and was subtherapeutic on \ndischarge. She was not bridged due to CHADS3 and her history of \nintraparenchymal hemorrhage.\n3. Diastolic heart failure: Pt had a history HFpEF and mitral \nvalve regurgitation. A ___ done on ___ showed severe MR \n___ showed mild-moderate) but noted that the degree of \nMR may have been underestimated. Home Lasix was held given \nsubstantially decreased PO fluid intake on modified diet. She \nshould be followed for evidence of weight gain/hypervolemia and \nLasix restarted if needed.\n4. Nutrition: Due to concerns for aspiration and possibly \naspiration pneumonia, she was evaluated by speech and swallow \nand recommended to be on a diet of prethickened liquids and \npureed foods. She was discharged on this diet and should be \nre-evaluated in the next few weeks as oropharyngeal muscles \nimprove s/p recovery from extubation.\n\nTransitional issues:\n==============================================\n-Please re-check INR on ___ and adjust warfarin dosing as \nneeded\n-On day of discharge pt given diltiazem 300mg ER, but was unable \nto swallow whole pill and only received half of the dose. If HR \n> 110, should start diltiazem 75mg q6h ___, \notherwise, would start 8am on ___ and continue to uptitrate \nas rates require\n- Please weigh patient daily and restart 40mg Lasix PO daily if \ngreater than 3 lbs in 1 day or 5 lbs in 1 week\n- Due to concern for aspiration, patient underwent speech and \nswallow eval and based on recommendations was started on diet of \nprethickened liquids and pureed foods. Pt will need ongoing \nspeech and swallow rehab\n- Given severity of presentation, and suspicion of future \naspiration events, would consider ongoing goals of care \ndiscussion regarding advance directives\n\n- Contact: ___ (daughter): ___ ___ ___ \n\n- Code: Full\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atenolol 50 mg PO BID \n2. Diltiazem 120 mg PO DAILY \n3. Furosemide 40 mg PO DAILY \n4. Lisinopril 2.5 mg PO BID \n5. Omeprazole 20 mg PO BID \n6. Warfarin 2 mg PO DAILY16 \n\n \nDischarge Medications:\n1. Lisinopril 2.5 mg PO BID \n2. Warfarin 2 mg PO DAILY16 \n3. Omeprazole 20 mg PO BID \n4. Diltiazem 75 mg PO Q6H \n5. Senna 8.6 mg PO BID \n6. Bisacodyl 10 mg PO DAILY \n7. Docusate Sodium (Liquid) 200 mg PO BID \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnoses:\nHealth-care associated pneumonia\nRSV pneumonia\nSeptic shock\nAtrial fibrillation with rapid ventricular rate\nMitral valve regurgitation\nDiastolic heart failure\n\nSecondary diagnoses:\nHypertension\nCognitive impairment\n\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were hospitalized at ___ \nbecause you were having difficulty breathing and low oxygen \nlevels. You were treated in the intensive care unit (ICU) for \none day where you had were placed on a ventilator (a machine to \nhelp you breath by moving air through a tube placed in your \nthroat). Your difficulty breathing was due to a pneumonia. You \nwere treated with antibiotics and were soon able to breath on \nyour own and were moved out of the ICU to a regular floor.\n\nThe cause of your pneumonia is not entirely clear. You had a \nviral infection but you may have also had an bacterial infection \ndue to difficulty swallowing, causing food to go into the lungs \ninstead of the stomach. For this reasons, you should only eat \npureed foods, you should take small bites and chew carefully, \nand you should always sit upright when eating. A swallowing \nspecialist will follow up with you after you leave the hospital.\n\nWhile you were in the hospital you had a test done (called an \necho) to image your heart. This showed that one of the valves in \nyour heart is not closing as well as it should. You should \nfollow up with your cardiologist to discuss these results. \n\nIt was a pleasure participating in your care. We wish you all \nthe best in the future.\n\nSincerely,\n\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "A419", "R6521", "J690", "J9601", "L89319", "N179", "E870", "J121", "L89329", "D6959", "E875", "I5032", "I4891", "Z7901", "R1312", "I340", "I129", "N183", "E785" ]

[ "A419: Sepsis, unspecified organism", "R6521: Severe sepsis with septic shock", "J690: Pneumonitis due to inhalation of food and vomit", "J9601: Acute respiratory failure with hypoxia", "L89319: Pressure ulcer of right buttock, unspecified stage", "N179: Acute kidney failure, unspecified", "E870: Hyperosmolality and hypernatremia", "J121: Respiratory syncytial virus pneumonia", "L89329: Pressure ulcer of left buttock, unspecified stage", "D6959: Other secondary thrombocytopenia", "E875: Hyperkalemia", "I5032: Chronic diastolic (congestive) heart failure", "I4891: Unspecified atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "R1312: Dysphagia, oropharyngeal phase", "I340: Nonrheumatic mitral (valve) insufficiency", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "E785: Hyperlipidemia, unspecified" ]

[ "J9601", "N179", "I5032", "I4891", "Z7901", "I129", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAsymptomatic \n \nMajor Surgical or Invasive Procedure:\n___ - Aortic valve replacement with 23 mm Epic Supra \nvalve\n \nHistory of Present Illness:\nMr. ___ is a very nice ___ year old man with a history of \naortic stenosis, BPH, chronic kidney disease, and hypertension. \nHe has been followed with serial echocardiograms. His most \nrecent echocardiogram on ___ demonstrated marked \nprogression of aortic stenosis with peak and mean gradients of \n82 mmHg and 53 mmHg, respectively. The peak velocity was 4.5 m/s \nwith trace regurgitation and a calculated valve area of 1.0 cm2. \n\n\nUntil approximately 8 months ago he was jogging without \nproblems, stopping primarily because of knee or foot symptoms. \nAt that time, he reported that he was able to walk up to 3 miles \nin about 1 hour with no symptoms of shortness of breath or chest \ndiscomfort. He denies any current symptoms limiting his \nactivity. He does state that he is able to walk up and down 1 \nflight of\nstairs without problems. He has had no awareness of arrhythmia \nand no symptoms of lightheadedness or presyncope. Given he \nprogression of his valvular disease, he was referred to Dr. \n___ surgical consultation. \n\nIn preparation for surgery, he underwent cardiac catheterization \nwhich demonstrated no flow limiting coronary artery disease. A \ncarotid ultrasound was negative for stenosis. Chest CT revealed \nsignificant aortic valve calcifications and a mildly dilated \nascending aorta measuring 4.3 cm. There was also an incidental \nfinding of 1.1 cm and 7 mm ground-glass opacities in the right \nand left upper lobe. Follow-up chest CT in 6 months is \nrecommended.\n\nHe denied changes in his symptoms or medical history since his \nlast visit. He specifically denied syncope, lightheadedness, \ndizziness, shortness of breath, dyspnea on exertion, chest pain, \npalpitations, orthopnea, paroxysmal nocturnal dyspnea, or lower \nextremity edema.\n\n \nPast Medical History:\nAortic Stenosis\nAscending Aortic Aneurysm\nBenign Prostatic Hyperplasia\nCervical Spondylosis\nChronic Kidney Disease, baseline Cre ___\nColonic Adenoma\nDegenerative Disc Disease\nGout\nHypertension\n\n \nSocial History:\n___\nFamily History:\nFather - valve replacement, presumably aortic, in his late ___.\n\n \nPhysical Exam:\nHR: 72 BP: 157/87 RR: 16 O2 Sat: 99% RA\nHeight: 70\" Weight: 156 lb\n\nGeneral: Pleasant man, WDWN, NAD\nSkin: Warm, Dry and intact\nHEENT: NCAT, PERRLA, EOMI, sclera anicteric, OP benign\nNeck: Supple, full ROM, no JVD\nChest: Lungs clear bilaterally \nHeart: Regular rate and rhythm, III-IV/VI SEM heard best at LUSB \nand radiating to apex\nAbdomen: Normal BS, soft, non-tender, non-distended \nExtremities: Warm, well-perfused; No Edema \nVaricosities: None \nNeuro: Grossly intact \nPulses:\nDP Right: 2+ Left: 2+\n___ Right: 2+ Left: 2+\nRadial Right: 2+ Left: 2+\n\nCarotid Bruit: Transmitted murmur\n\nDischarge Exam:\n\nVital Signs and Intake/Output:\n___ 1558 Temp: 98.1 PO BP: 114/75 L Lying HR: 68 RR: 18 O2\nsat: 100% O2 delivery: RA \n___ Total Intake: 700ml PO Amt: 700ml \n___ Total Output: 1280ml Urine Amt: 1100ml CT: 180ml \n\nPhysical Examination:\nGeneral/Neuro: NAD [x] A/O x3 [x] non-focal [x] \nCardiac: RRR [x] Irregular [] Nl S1 S2 [x]\nLungs: CTA [x] No resp distress [x]\nAbd: NBS [x]Soft [x] ND [x] NT [x]\nExtremities: no CCE[x] Pulses doppler [x] palpable [] \nWounds: Sternal: CDI [x] no erythema or drainage [x]\n Sternum stable [x] Prevena []\n Leg: Right [] Left[] CDI [x] no erythema or drainage [x]\n Other:\n \n\n \nPertinent Results:\nTransesophageal Echocardiogram ___\nPre-Bypass Examination\nrhythm: sinus\nInfusions: phenylephrine\n1. The left atrium is normal in size. No spontaneous echo \ncontrast is seen in the body of the left atrium or left atrial \nappendage. \n2. No atrial septal defect is seen by 2D or color Doppler. \n3. There is mild symmetric left ventricular hypertrophy. Overall \nleft ventricular systolic function is normal (LVEF>55%). Doppler \nparameters are most consistent with Grade I (mild) left \nventricular diastolic dysfunction. \n4. Right ventricular chamber size and free wall motion are \nnormal. \n5. The ascending aorta is mildly dilated. There are three aortic \nvalve leaflets. The aortic valve leaflets are severely \nthickened/deformed. There is severe aortic valve stenosis (valve \narea <1.0cm2). Mild (1+) aortic regurgitation is seen. \n6. The mitral valve leaflets are elongated. Mild (1+) mitral \nregurgitation is seen. \n7. There is no pericardial effusion. \n\nPost Bypass\nrhytm: sinus\ninfusions: phenylephrine\n1. Left ventricular function is intact, hyperdynamic, LVEF >65%\n2. Right ventricular function is intact\n3. Aortic valve bioprosthesis is well seated, there is in \nparavalvular regurgitation. Mean gradient is 14mmHg. The \nleaflets move well. \n4. There remains mild mitral regurgitation. \n5. Other valvular function is intact and unchanged\n6. The aorta is intact, no evidence of dissection.\n7. Initially upon coming off of bypass, there were very high \nLVOT gradients secondary to systolic anterior motion of the \nmitral valve and septal contact/dynamic LVOT obstruction, \nassociated with severe mitral regurgitation. The patient was \nvolume loaded, given beta blockers, afterload was increased with \nphenylephrine, pacing was discontinued and the LVOT gradients \nimproved, ___ decreased and MR returned to baseline. There \nremains a residual LVOT gradient.\n\n___ 05:03AM BLOOD WBC-11.7* RBC-3.71* Hgb-12.4* Hct-36.7* \nMCV-99* MCH-33.4* MCHC-33.8 RDW-16.8* RDWSD-60.7* Plt ___\n___ 04:41AM BLOOD WBC-14.6* RBC-3.86* Hgb-12.9* Hct-38.1* \nMCV-99* MCH-33.4* MCHC-33.9 RDW-17.2* RDWSD-62.0* Plt ___\n___ 11:30AM BLOOD Hct-41.3\n___ 04:20AM BLOOD Glucose-119* UreaN-29* Creat-1.7* Na-141 \nK-4.6 Cl-103 HCO3-25 AnGap-13\n___ 05:03AM BLOOD Glucose-117* UreaN-27* Creat-1.6* Na-139 \nK-4.3 Cl-103 HCO3-26 AnGap-10\n___ 04:41AM BLOOD Glucose-130* UreaN-29* Creat-1.7* Na-138 \nK-4.4 Cl-102 HCO3-27 AnGap-9*\n___ 11:30AM BLOOD UreaN-26* Creat-1.6* Na-141 K-4.1\n___ 02:03AM BLOOD Glucose-140* UreaN-32* Creat-1.5* Na-139 \nK-4.6 Cl-108 HCO3-22 AnGap-9*\n \nBrief Hospital Course:\n___ was admitted on ___ and was taken to the \noperating room. He underwent aortic valve replacement with a 23 \nmm ___ Biocor Epic tissue valve. Please see \noperative note for full surgical details. He tolerated the \nprocedure well and transferred to the CVICU in stable condition \nfor recovery and invasive monitoring. \n \nHe weaned from sedation, awoke neurologically intact and was \nextubated on POD 1. He was weaned from inotropic and vasopressor \nsupport. Beta blocker was initiated and he was diuresed toward \nhis preoperative weight. He remained hemodynamically stable and \nwas transferred to the telemetry floor for further recovery. \nLasix was started at low dose due to ___ seen in OR. He was not \ngiven potassium due to baseline renal insufficiency - creatinine \nwas at baseline at the time of discharge. He went into rate \ncontrolled atrial fibrillation and was given Amiodarone and \nLopressor was titrated. He converted to sinus rhythm and heart \nrate in the 70's at the time of discharge. He had to have a \nfoley replaced x 2 for urinary retention and clots. He will be \ndischarged with a foley and a leg bag and follow up with \noutpatient urology was arranged for follow up. He was evaluated \nby the physical therapy service for assistance with strength and \nmobility. By the time of discharge on POD 4 he was ambulating \nfreely, the wound was healing, and pain was controlled with oral \nanalgesics. He was discharged home with visiting nurse services \nin good condition with appropriate follow up instructions.\n \nMedications on Admission:\nALLOPURINOL - allopurinol ___ mg tablet. 1.5 (One and a half)\ntablet(s) by mouth daily\nAMLODIPINE - amlodipine 10 mg tablet. one tablet(s) by mouth\ndaily\nAMOXICILLIN - Dosage uncertain - (Prescribed by Other Provider)\nCALCITRIOL - calcitriol 0.25 mcg capsule. 1 capsule(s) by mouth\ndaily\nIPRATROPIUM BROMIDE - ipratropium bromide 42 mcg (0.06 %) nasal\nspray. 2 sprays nose 3 times daily\nLISINOPRIL - lisinopril 10 mg tablet. one tablet(s) by mouth\ndaily\n \nMedications - OTC\nCHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3) \n1,000\nunit tablet. 1 tablet(s) by mouth Daily - (OTC)\n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild \n2. Amiodarone 400 mg PO BID \nChange to 200 mg BID x 1 month, then 200 mg daily x 1 month then \nas directed by cardiologist \nRX *amiodarone 200 mg 2 tablet(s) by mouth twice a day Disp \n#*100 Tablet Refills:*0 \n3. Aspirin EC 81 mg PO DAILY \nRX *aspirin [Adult Aspirin Regimen] 81 mg 1 tablet(s) by mouth \ndaily Disp #*100 Tablet Refills:*1 \n4. Bisacodyl ___AILY:PRN constipation \n5. Furosemide 20 mg PO DAILY Duration: 5 Days \nRX *furosemide [Lasix] 20 mg 1 tablet(s) by mouth daily Disp #*5 \nTablet Refills:*0 \n6. Metoprolol Tartrate 50 mg PO TID \nRX *metoprolol tartrate 50 mg 1 tablet(s) by mouth three times a \nday Disp #*90 Tablet Refills:*1 \n7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain: \nmoderate/severe \nRX *oxycodone 5 mg ___ capsule(s) by mouth Q 4 hours Disp #*60 \nCapsule Refills:*0 \n8. Ranitidine 150 mg PO DAILY Duration: 30 Days \nRX *ranitidine HCl [Acid Control (ranitidine)] 150 mg 1 \ntablet(s) by mouth daily Disp #*30 Tablet Refills:*0 \n9. Senna 17.2 mg PO DAILY \nRX *sennosides [Senokot] 8.6 mg 1 tab by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n10. Tamsulosin 0.4 mg PO QHS \nRX *tamsulosin 0.4 mg 1 capsule(s) by mouth Q HS Disp #*30 \nCapsule Refills:*0 \n11. Allopurinol ___ mg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAortic Stenosis\nBenign Prostatic Hyperplasia\nCervical Spondylosis\nChronic Kidney Disease, baseline Cre ___\nColonic Adenoma\nDegenerative Disc Disease\nHypertension\nPast Surgical History:\nCurrently receiving oral care for teeth - Posts being placed\nProstatectomy\nArthroscopy of knee\nCataract surgery\nHair transplant\nRight inguinal hernia repair\n\n \nDischarge Condition:\nAlert and oriented x3 nonfocal \nAmbulating with steady gait\nIncisional pain managed with Oxycodone\nIncisions: \nSternal - healing well, no erythema or drainage \n1+ Edema \n\n \nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild \nsoap, no baths or swimming until cleared by surgeon. Look at \nyour incisions daily for redness or drainage\n\nPlease NO lotions, cream, powder, or ointments to incisions \n Each morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart \n\n No driving for approximately one month and while taking \nnarcotics, will be discussed at follow up appointment with \nsurgeon when you will be able to drive \n No lifting more than 10 pounds for 10 weeks\n Please call with any questions or concerns ___\n Females: Please wear bra to reduce pulling on incision, avoid \nrubbing on lower edge\n\n**Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\n \nFollowup Instructions:\n___\n" ]

[ "I350", "N400", "M109", "Z87891", "Z8249", "M47812", "J449", "I129", "N189", "I4891", "Y831", "Y92239", "R338", "R310" ]

[ "I350: Nonrheumatic aortic (valve) stenosis", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "M109: Gout, unspecified", "Z87891: Personal history of nicotine dependence", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "M47812: Spondylosis without myelopathy or radiculopathy, cervical region", "J449: Chronic obstructive pulmonary disease, unspecified", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "I4891: Unspecified atrial fibrillation", "Y831: Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "R338: Other retention of urine", "R310: Gross hematuria" ]

[ "N400", "M109", "Z87891", "J449", "I129", "N189", "I4891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: CARDIOTHORACIC\n \nAllergies: \nPenicillins / Reclast / Sulfa (Sulfonamide Antibiotics)\n \nAttending: ___\n \nChief Complaint:\nDyspnea on exertion\n \nMajor Surgical or Invasive Procedure:\n___ Aortic Valve Replacement\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old female with history of bicuspid \naortic valve with aortic stenosis followed with serial \nechocardiograms. She has long standing history of heart murmur \nsince childhood. She has had dyspnea on exertion for at least \nthe past 6 months. In addition, she has occasional palpitations \nand fluttering her chest after activity. These episodes last for \na few minutes. She denies having any chest pain. She does admit \nto syncopal episode approximately ___ year ago but has had no \nrecurrence since that time. Given her symptoms and most recent \necho findings, she has been referred for surgical consultation.\n \nPast Medical History:\nBicuspid aortic valve with aortic stenosis and insufficiency\nBrachial vein occlusive thrombus \nRight vocal cord thrombus\nHistory Of Breast Cancer, s/p surgery and radiation\nHypercholesterolemia \nHistory of Paroxysmal supraventricular tachycardia \nHypertension \nInsomnia \nGERD, ___ esophagus\nCervical radiculitis \nHistory of Hodgkin's disease, s/p radiation and chemo\nOsteoporosis\nFibroadenoma of breast \nMigraines\nAnxiety \nGlaucoma \nPolyposis of colon, s/p Colectomy\ns/p Excision basal cell \ns/p Laser eye\ns/p Mastectomy, Left for breast CA\ns/p Oophorectomy for ovarian cyst\ns/p esophageal dilitation\n \nSocial History:\n___\nFamily History:\n- Mother died of ALS in her ___\n- Father died of stroke in his ___\n \nPhysical Exam:\nPREOPERATIVE EXAM\nVital Signs sheet entries for ___: \nBP: 140/80. Heart Rate: 86. O2 Saturation%: 99. Temperature:\n97.8. Resp. Rate: 18. Pain Score: 0.\n\nGeneral: WDWN female in no acute distress; looked well\nSkin: Dry [x] intact [x] + chest radiation markers noted along\nwith small chest wall scars\nHEENT: PERRL [x] EOMI [x]\nNeck: Supple [x] Full ROM [x]\nChest: Lungs clear bilaterally [x]\nHeart: RRR [x] Irregular [] Murmur [x] grade ______ \nAbd: Soft [x] non-distended [x] non-tender [x] bowel sounds + \nExtremities: Warm [x], well-perfused [x] \nEdema: None\nVaricosities: None \nNeuro: Grossly intact\nPulses:\nFemoral Right: 1 Left: 1\nDP Right: palp Left: palp\n___ Right: palp Left: palp\nRadial Right: 1 Left: 1\nCarotid Bruit: transmitted murmur bilaterally \n\nDISCHARGE EXAM - \nVitals:98.3 PO 123/79 R Lying 82 16 95 Ra \nWt:59 kg\n \nPertinent Results:\nDischarge Labs:\n___ 05:33AM BLOOD WBC-7.5 RBC-2.43* Hgb-6.6* Hct-21.2* \nMCV-87 MCH-27.2 MCHC-31.1* RDW-17.4* RDWSD-54.5* Plt ___\n___ 05:33AM BLOOD ___\n___ 04:40AM BLOOD ___\n___ 06:37AM BLOOD ___ PTT-32.2 ___\n___ 05:33AM BLOOD Glucose-108* UreaN-24* Creat-0.8 Na-144 \nK-4.5 Cl-103 HCO3-29 AnGap-12\n___ 11:55AM BLOOD ALT-19 AST-45* LD(LDH)-368* AlkPhos-47 \nTotBili-0.5\n___ 05:33AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.1\n.\nCXR PA LAT:\nEXAMINATION: Chest radiographs, PA and lateral. \nINDICATION: Status post mitral and aortic valve replacements \nwith low \noxygenation. \nCOMPARISON: Prior examination from ___. \nFINDINGS: Right internal jugular catheter was removed. Patient \nis status post aortic and mitral valve replacements. Cardiac, \nmediastinal and hilar contours appear stable. There are small \nnew bilateral pleural effusions with associated opacities \nprobably due to atelectasis. Lungs appear otherwise clear. No \nvisible pneumothorax. Bony structures are unremarkable. \nIMPRESSION: New small bilateral pleural effusions. Associated \nopacities at each lung base are not entirely specific but highly \nsuggestive of associated compressive atelectasis. Reduced lung \nvolumes. \n___, MD, PhD electronically signed on ___ 7:42 ___ \n.\nRUE Ultrasound:\nEXAMINATION: ___ DUP UPPER EXT UNILAT (DVT) RIGHT \n \nINDICATION: ___ year old woman with new right sided PICC and new \nright UE \nedema// eval for right sided DVT/clot \n \nTECHNIQUE: Grey scale and Doppler evaluation was performed on \nthe right upper \nextremity veins. \n \nCOMPARISON: Ultrasound carotid series dated ___ \n \nFINDINGS: \n \nThere is normal flow with respiratory variation in the bilateral \nsubclavian \nveins. \n \nNonobstructive thrombus within the distal right internal jugular \nvein. \nOcclusive thrombus within the right brachial vein that contains \nthe PICC line. \n \nThe right axillary, and remaining brachial veins are patent, \nshow normal color \nflow, spectral doppler, and compressibility. The right basilic, \nand cephalic \nveins are patent, compressible and show normal color flow. \n \nIMPRESSION: \n \nNonocclusive thrombus within the distal right internal jugular \nvein. \nOcclusive thrombus within the right brachial vein that contains \nthe PICC line. \n \nNOTIFICATION: The impression above was entered by Dr. ___ \n___ on \n___ at 15:48 into the Department of Radiology critical \ncommunications \nsystem for direct communication to the referring provider. \n \nBY ELECTRONICALLY SIGNING THIS REPORT, I THE ATTENDING PHYSICIAN \nATTEST THAT ___ HAVE REVIEWED THE ABOVE IMAGES FOR THE ABOVE \nEXAMINATION(S) AND AGREE WITH THE FINDINGS AS DOCUMENTED ABOVE. \n \n___, MD \n___, MD, PhD electronically signed on FRI ___ \n6:47 ___ \n.\nENT/Video Swallow:\nSUMMARY:\nPatient presents with mild oral and moderate pharyngeal phase\ndysphagia. Oral stage of the swallow was most notable for mild\nresidue and slowed A-P transfer of solids likely related to\nxerostomia. Pharyngeal phase of the swallow notable for \nsuspected\npharyngeal weakness and reduced vocal fold and laryngeal\nvestibule closure compounded by the curvature of her spine. \nThese\ndeficits resulted in trace-mild diffuse residue with liquids and\nmoderate residue with solids mostly in the valleculae.\nAdditionally, she had intermittent trace penetration of thin and\nnectar thick liquids which did not clear and resulted in silent\ntrace aspiration x1 with nectar thick liquids. A cued throat\nclear was effective to clear material from the airway when this\noccurred.\n\nRecommend the patient consume a diet of soft solids with thin\nliquids with medications given crushed in puree or in liquid\nform. She should follow strict aspiration precautions as listed\nbelow. The patient is scheduled to discharge today. After this\nevaluation, the patient was provided with extensive education\nabout the results, recommendations, and plan moving forward for\nher swallowing. Plan to have her return in 2 weeks to 1 month to\nrepeat this evaluation.\n\nRECOMMENDATIONS:\n1. Diet: Soft foods-Add sauces/gravies as able. Avoid breads\n2. Liquids: Thin liquids\n3. Medications: Crushed in applesauce or in liquid form\n4. Safe Swallowing Strategies:\n-Alternate your bites and sips\n-Go slowly, swallowing multiple times per bite/sip\n-Periodically (every 5 sips or so) clear your throat and \n reswallow\n -Sit fully upright to eat/drink and remain upright for 1\nhour after eating\n4.Frequent oral care, perform oral care prior to meals\n5. Follow-up with ENT as an outpatient given both vocal \nfold\nmovement and irregular UES shape/reduce opening.\n6. Repeat this videoswallow in 2 weeks-1 month as an\noutpatient, sooner if your voice improves spontaneously, or if \nan ENT\nintervention is completed.\n\nThis swallowing pattern correlates to a functional oral intake\nscale rating of level ___. \n\n \nBrief Hospital Course:\nThe patient was brought to the Operating Room on ___ where \nthe patient underwent an aortic valve replacement - see \noperative note for details. Overall the patient tolerated the \nprocedure well and post-operatively was transferred to the CVICU \nin stable condition for recovery and invasive monitoring. \nLater that day found the patient extubated, alert and oriented \nand breathing comfortably. The patient was neurologically \nintact and hemodynamically stable. Beta blocker was initiated \nand the patient was gently diuresed toward the preoperative \nweight. The patient was transferred to the telemetry floor for \nfurther recovery. Chest tubes and pacing wires were \ndiscontinued without complication. ENT was consulted for soft \nvoice post operatively which revealed vocal cord hypomobility. \nThe patient is scheduled for follow up with ENT and repeat video \nswallow. She is discharged on a soft diet with thin liquids. \nCoumadin was initiated for double mechanical valve with heparin \nbridge until INR was therapeutic. The patient's PCP ___ \n___ office ___ follow her INR checks and warfarin dosing. \nRight upper extremity ultrasound revealed occlusive thrombus of \nthe brachial vein for which PICC line was removed and the \npatient remains anticoagulated with warfarin. The patient was \nevaluated by the Physical Therapy service for assistance with \nstrength and mobility. By the time of discharge on POD 6 the \npatient was ambulating freely, the wound was healing and pain \nwas controlled with oral analgesics. The patient was discharged \nhome with ___ services in good condition with appropriate follow \nup instructions.\n \nMedications on Admission:\nALENDRONATE - alendronate 70 mg tablet. 1 tablet(s) by mouth \nonce\na week - (Prescribed by Other Provider)\nAMLODIPINE - amlodipine 5 mg tablet. 1 tablet(s) by mouth daily \n-\n(Prescribed by Other Provider)\nATORVASTATIN - atorvastatin 20 mg tablet. 1 tablet(s) by mouth\ndaily - (Prescribed by Other Provider)\nCOLESTIPOL - colestipol 1 gram tablet. 2 tablet(s) by mouth once\na day - (Prescribed by Other Provider)\nESCITALOPRAM OXALATE - escitalopram 20 mg tablet. 1 tablet(s) by\nmouth daily - (Prescribed by Other Provider)\nFLUTICASONE PROPIONATE - fluticasone propionate 50 mcg/actuation\nnasal spray,suspension. 2 sprays nasal daily - (Prescribed by\nOther Provider)\nLANSOPRAZOLE - lansoprazole 15 mg capsule,delayed release. 1\ncapsule(s) by mouth once a day - (Prescribed by Other Provider)\nLOPERAMIDE - loperamide 2 mg capsule. 2 capsule(s) by mouth once\na day - (Prescribed by Other Provider)\nMETOPROLOL SUCCINATE - metoprolol succinate ER 25 mg\ntablet,extended release 24 hr. 1.5 tablet(s) by mouth once a day\n- (Prescribed by Other Provider)\n \nMedications - OTC\nASPIRIN [ASPIRIN LOW DOSE] - Aspirin Low Dose 81 mg\ntablet,delayed release. 1 tablet(s) by mouth daily - \n(Prescribed\nby Other Provider)\nCHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3) \n1,000\nunit capsule. 1 capsule(s) by mouth daily - (Prescribed by \nOther\nProvider)\nMULTIVITAMIN [DAILY MULTIPLE] - Daily Multiple tablet. 1\ntablet(s) by mouth daily - (OTC)\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H \n2. Furosemide 40 mg PO BID Duration: 7 Days \nRX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*14 \nTablet Refills:*0 \n3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n4. Metoprolol Tartrate 12.5 mg PO BID \nRX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth \ntwice a day Disp #*60 Tablet Refills:*1 \n5. Potassium Chloride 20 mEq PO BID \nto be taken with Lasix \nRX *potassium chloride [Klor-Con] 20 mEq 1 packet(s) by mouth \ntwice a day Disp #*14 Packet Refills:*0 \n6. ___ MD to order daily dose PO DAILY16 \n7. Warfarin 2 mg PO DAILY16 \ndose to be determined after INR check \nRX *warfarin [Coumadin] 2 mg 1 tablet(s) by mouth once a day \nDisp #*60 Tablet Refills:*1 \n8. Alendronate Sodium 70 mg PO QMON \n9. Aspirin EC 81 mg PO DAILY \n10. Atorvastatin 20 mg PO QPM \n11. colestipol 2 g oral DAILY \n12. Escitalopram Oxalate 20 mg PO DAILY \n13. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n14. Lansoprazole Oral Disintegrating Tab 15 mg PO DAILY \n15. LOPERamide 4 mg PO DAILY:PRN diarrhea \n16. Multivitamins 1 TAB PO DAILY \n17. Vitamin D 1000 UNIT PO DAILY \n18. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do \nnot restart amLODIPine until discussion with your \nPCP/Cardiologist\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nBicuspid aortic valve with aortic stenosis and insufficiency \nRight brachial vein occlusive thrombus \nRight vocal cord hypomobility \nHistory Of Breast Cancer, s/p surgery and radiation \nHypercholesterolemia \nHistory of Paroxysmal supraventricular tachycardia \nHypertension \n___ esophagus \nHistory of Hodgkin's disease, s/p radiation and chemo \n\n \nDischarge Condition:\nAlert and oriented x3, non-focal\nAmbulating, gait steady\nSternal pain managed with oral analgesics\nSternal Incision - healing well, no erythema or drainage\nTrace Edema\n\n \nDischarge Instructions:\nPlease shower daily -wash incisions gently with mild soap, no \nbaths or swimming, look at your incisions daily\nPlease - NO lotion, cream, powder or ointment to incisions\nEach morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart\nNo driving for approximately one month and while taking \nnarcotics\nClearance to drive will be discussed at follow up appointment \nwith surgeon\nNo lifting more than 10 pounds for 10 weeks\nEncourage full shoulder range of motion, unless otherwise \nspecified\n**Please call cardiac surgery office with any questions or \nconcerns ___. Answering service will contact on call \nperson during off hours**\nFemales: Please wear bra to reduce pulling on incision, avoid \nrubbing on lower edge\n \nFollowup Instructions:\n___\n" ]

[ "Q231", "J9811", "J9589", "T82868A", "I82C11", "I82621", "F05", "D62", "Z923", "I10", "K219", "Z9221", "Z85828", "E7800", "I340", "M810", "F419", "Z853", "Z8571", "J3801", "Y831", "Y92239", "D6959", "Y718", "Z781" ]

[ "Q231: Congenital insufficiency of aortic valve", "J9811: Atelectasis", "J9589: Other postprocedural complications and disorders of respiratory system, not elsewhere classified", "T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter", "I82C11: Acute embolism and thrombosis of right internal jugular vein", "I82621: Acute embolism and thrombosis of deep veins of right upper extremity", "F05: Delirium due to known physiological condition", "D62: Acute posthemorrhagic anemia", "Z923: Personal history of irradiation", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "Z9221: Personal history of antineoplastic chemotherapy", "Z85828: Personal history of other malignant neoplasm of skin", "E7800: Pure hypercholesterolemia, unspecified", "I340: Nonrheumatic mitral (valve) insufficiency", "M810: Age-related osteoporosis without current pathological fracture", "F419: Anxiety disorder, unspecified", "Z853: Personal history of malignant neoplasm of breast", "Z8571: Personal history of Hodgkin lymphoma", "J3801: Paralysis of vocal cords and larynx, unilateral", "Y831: Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "D6959: Other secondary thrombocytopenia", "Y718: Miscellaneous cardiovascular devices associated with adverse incidents, not elsewhere classified", "Z781: Physical restraint status" ]

[ "D62", "I10", "K219", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\n1. Uterine prolapse (stage III).\n2. Stage II anterior wall prolapse.\n \nMajor Surgical or Invasive Procedure:\nTotal vaginal hysterectomy, right salpingoopherectomy, bilateral \nuterosacral ligament suspension and cystoscopy\n\n \nHistory of Present Illness:\nMs. ___ is a ___ gravida 7, para 1,\nwho was initially referred to me by Dr. ___ in ___ for\nsymptom of pelvic organ prolapse. She initially was scheduled\nfor surgery but changed her mind and returned ___ years later\ncomplaining of worsening prolapse. She was examined and was\nfound to have stage III uterine vaginal prolapse. She had had\na prior urodynamic test that showed some stress incontinence\ncapacity. She declined any anti-incontinent procedure. She\ndeclined any conservative measure and elected to proceed with\nsurgical management. The risks, benefits and alternatives\nwere reviewed, and she elected to proceed.\n \nPast Medical History:\nHTN \ndepression/anxiety: not on medications \n\n \nSocial History:\n___\nFamily History:\nno history of CAD \n \nPhysical Exam:\nPE: Comfortable\nCV: RRR, no m/r/g\nPulm: CTAB, no crackles or wheezes appreciated\nAbd: soft,distended, appropriately tender, w/o rebound or\nguarding\nGU: pad with minimal spotting\nExt: warm, well perfuse, no tenderness or erythema\n \nPertinent Results:\n___ 02:20PM WBC-5.7 RBC-4.25 HGB-12.4 HCT-37.4 MCV-88 \nMCH-29.2 MCHC-33.2 RDW-12.7 RDWSD-40.6\n___ 02:20PM PLT COUNT-255\n \nBrief Hospital Course:\nOn ___, Ms. ___ was admitted to the gynecology service after \nundergoing a total vaginal hysterectomy, right \nsalpingoopherectomy, uterosacral ligament vault suspension and \ncystoscopy for uterine prolapse and cystocele. Please see the \noperative report for full details.\n\nHer post-operative course was uncomplicated. Immediately \npost-op, her pain was controlled with IV morphine and toradol. \nOn post-operative day 1, her urine output was adequate so her \nfoley was removed and she voided spontaneously. Her diet was \nadvanced without difficulty and she was transitioned to \noxycodone, ibuprofen and tramadol. For her OSA, she was \nmonitored with telemetry. By post-operative day 1, she was \ntolerating a regular diet, voiding spontaneously, ambulating \nindependently, and pain was controlled with oral medications. \nShe was then discharged home in stable condition with outpatient \nfollow-up scheduled.\n\n \nMedications on Admission:\n3. ALPRAZolam 0.25 mg PO TID:PRN anxiety \n4. Aspirin 81 mg PO DAILY \n5. Calcium Carbonate 500 mg PO QID:PRN heartburn \n6. Losartan Potassium 25 mg PO DAILY \n7. Metoprolol Tartrate 25 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO TID \nDo not exceed 4000mg in 24 hours. \nRX *acetaminophen 500 mg ___ tablet(s) by mouth q6h prn Disp \n#*60 Tablet Refills:*0 \n2. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\n___ cause drowsiness. Partial fill on request. \nRX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth q4h prn \nDisp #*6 Tablet Refills:*0 \n3. ALPRAZolam 0.25 mg PO TID:PRN anxiety \n4. Aspirin 81 mg PO DAILY \n5. Calcium Carbonate 500 mg PO QID:PRN heartburn \n6. Losartan Potassium 25 mg PO DAILY \n7. Metoprolol Tartrate 25 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nUterine prolapse, cystocele\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 the gynecology service after your \nprocedure. You have recovered well and the team believes you are \nready to be discharged home. Please call Dr. ___ office \nwith any questions or concerns. Please follow the instructions \nbelow.\n\nGeneral instructions:\n * Take your medications as prescribed.\n * Do not drive while taking narcotics.\n * Take a stool softener such as colace while taking narcotics \nto prevent constipation.\n * Do not combine narcotic and sedative medications or alcohol.\n * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.\n * No strenuous activity until your post-op appointment.\n * Nothing in the vagina (no tampons, no douching, no sex) for 3 \nmonths.\n * No heavy lifting of objects >10 lbs for 6 weeks.\n * You may eat a regular diet.\n * You may walk up and down stairs.\n\nCall your doctor for:\n * fever > 100.4F\n * severe abdominal pain\n * difficulty urinating\n * vaginal bleeding requiring >1 pad/hr\n * abnormal vaginal discharge\n * redness or drainage from incision\n * nausea/vomiting where you are unable to keep down fluids/food \nor your medication\n\nTo reach medical records to get the records from this \nhospitalization sent to your doctor at home, call ___.\n\n \nFollowup Instructions:\n___\n" ]

[ "N813", "N393", "I10", "Z85828", "M1990", "B009", "F419" ]

[ "N813: Complete uterovaginal prolapse", "N393: Stress incontinence (female) (male)", "I10: Essential (primary) hypertension", "Z85828: Personal history of other malignant neoplasm of skin", "M1990: Unspecified osteoarthritis, unspecified site", "B009: Herpesviral infection, unspecified", "F419: Anxiety disorder, unspecified" ]

[ "I10", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nCeclor / Sulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\nfever, increased work of breathing\n \nMajor Surgical or Invasive Procedure:\n___ Successful CT-guided placement of an ___ pigtail \ncatheter into the splenic collection. Sample sent for \nmicrobiology evaluation. \n\n___ Successful diagnostic and therapeutic left \nthoracentesis yielding 930 cc of serosanguineous fluid. A \nsample was sent for Gram stain/culture and LDH, per ordering \nphysician. \n\n \nHistory of Present Illness:\n___ with prior drain placement ___ her spleen after presentation \nwith grade 3 splenic abscess after MVC. She underwent distal and \nproximal splenic artery embolization. She was discharged to \nrehab on ___. She was seen ___ follow-up and underwent cat \nscan imaging to evaluate the status of the collection. Cat scan \nimaging showed recurrence of her splenic collection and she \nunderwent ___ placement of an ___ pigtail catheter into the \nsplenic collection. Cultures have grown Gram positive rods and \nshe went home on augmentin. She reports having ___ cc a day \nbut noted yesterday that she had to drain the bulb 5 times. She \nhas no shortness of breath and on imaging has been found to have \na large left pleural effusion and she was found to have \ndislodgement of her splenic drain that is now ___ the \nsubcutaneous tissue. \n\n \nPast Medical History:\nHTN, Afib not on anticoagulation, Burn to torso as child, \nNonegastric bypass, B/L knee replacement surgery, \ncholecystectomy, hand surgery\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nAdmission Physical Exam:\nT 99.7 HR 86 BP 106/52 RR 18 98% RA\nDiscomfort around drains site but otherwise appears comfortable\nno respiratory distress\nregular rate\nabd soft, tender to palpation at drain site, no surrounding\ncellulitis, drain appears loose but not completely out of skin,\nsuction bulb not holding suction\n\nDischarge Physical Exam:\nVS: 98.4 PO 127 / 81 70 18 94 \nHEENT: No deformity. PERRL, EOMI. Mucus membranes moist.\nCV: RRR\nPulm: Clear to auscultation bilaterally\nAbd: Soft, non-tender, non-distended. ___ drain to Left flank \nwith serous drainage.\nExt: Warm and dry. 2+ ___ pulses.\n \nPertinent Results:\n___ 06:20AM BLOOD WBC-8.3 RBC-3.43* Hgb-9.1* Hct-29.8* \nMCV-87 MCH-26.5 MCHC-30.5* RDW-14.3 RDWSD-45.1 Plt ___\n___ 07:25AM BLOOD WBC-7.7 RBC-3.50* Hgb-9.3* Hct-30.5* \nMCV-87 MCH-26.6 MCHC-30.5* RDW-14.6 RDWSD-46.4* Plt ___\n___ 06:44AM BLOOD WBC-10.3* RBC-3.64* Hgb-10.0* Hct-31.2* \nMCV-86 MCH-27.5 MCHC-32.1 RDW-14.8 RDWSD-46.5* Plt ___\n___ 05:34PM BLOOD WBC-13.5*# RBC-3.85* Hgb-10.4* Hct-32.8* \nMCV-85 MCH-27.0 MCHC-31.7* RDW-14.9 RDWSD-46.2 Plt ___\n___ 06:44AM BLOOD ___ PTT-30.4 ___\n___ 09:45PM BLOOD ___ PTT-31.0 ___\n___ 06:20AM BLOOD Glucose-137* UreaN-11 Creat-0.3* Na-132* \nK-3.9 Cl-96 HCO3-25 AnGap-15\n___ 07:25AM BLOOD Glucose-150* UreaN-8 Creat-0.2* Na-133 \nK-4.0 Cl-96 HCO3-23 AnGap-18\n___ 06:44AM BLOOD Glucose-91 UreaN-11 Creat-0.2* Na-135 \nK-3.9 Cl-99 HCO3-23 AnGap-17\n___ 06:20AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.2\n___ 07:25AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.8\n___ 06:44AM BLOOD Calcium-8.0* Phos-2.8 Mg-1.8\n___ 05:46PM BLOOD Lactate-1.5\n___ 06:38PM URINE Color-Yellow Appear-Clear Sp ___\n___ 06:38PM URINE Blood-NEG Nitrite-NEG Protein-30 \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG\n___ 06:38PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1\n\n___ 10:04 am ABSCESS SPLEEN ABSCESS. \n GRAM STAIN (Final ___: \n 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. \n ___ PAIRS AND CHAINS. \n 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). \n Reported to and read back by ___ ___ \nAT 18:40 ON\n ___. \n SMEAR REVIEWED; RESULTS CONFIRMED. \n FLUID CULTURE (Preliminary): NO GROWTH. \n ANAEROBIC CULTURE (Preliminary): NO GROWTH.\n\n___ 10:03 am PLEURAL FLUID PLEURAL FLUID. LEFT. \nGRAM STAIN (Final ___: \n 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \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): NO GROWTH. \n ANAEROBIC CULTURE (Preliminary): NO GROWTH. \n\n___ CXR:\nLarge left pleural effusion with adjacent atelectasis and mass \neffect with \nrightward mediastinal shift. \n\n___ CT Abdomen/Pelvis:\n1. Interval decrease ___ size of the splenic collection. \n2. The left percutaneous drain is now ___ the subcutaneous \ntissues of the left abdominal wall. \n3. Large left pleural effusion causing complete atelectasis of \nthe imaged left lower lobe. New enhancement of the parietal \npleura or raising concern for superimposed infection. \n\n \nBrief Hospital Course:\nMs. ___ is a ___ yo F with prior history of grade 3 splenic \nlaceration with post embolization abscess formation. She had a \ndrain placed on ___ and completed a course of augmentin. She \npresented on ___ with increased drain output. CT abdomen \npelvis shoed the drain was dislodged ___ the subcutaneous tissues \nand large left pleural effusion causing atelectasis of the left \nlower lobe. White blood cell count was elevated at 13.5. She was \nadmitted to the Acute Care Surgery service for further \nmanagement.\n\nOn HD1 she remained hemodynamically stable and given IV \nantibiotics. \nOn HD2 interventional radiology was consulted and drain was \nreplaced ___ abscess. She underwent ultrasound guided \nthoracentesis with 930 cc of serosanguineous fluid removed. Pain \nwas managed with oral oxycodone. She was given a regular diet \nwith good tolerability. \n\nThe patient was alert and oriented throughout \nhospitalization.The patient remained stable from a \ncardiovascular standpoint; vital signs were routinely monitored. \nThe patient remained stable from a pulmonary standpoint. Good \npulmonary toilet, early ambulation and incentive spirometry were \nencouraged throughout hospitalization. Patient's intake and \noutput were closely monitored. Blood glucose was monitored and \ntreated with insulin. The patient's fever curves were closely \nwatched for signs of infection, of which there were none. White \nblood cell count was trended and decreased from 13.5 to 8.3 upon \ndischarge. She was initially given IV antiboitcs and then \ntransitioned to oral Augmentin. Drain cultures were sent and \ngrew 2+ polymorphonuclear leukocytes, 3+ gram positive cocci, \nand 1+ gram positive rods. Pleural and blood cultures were sent \nand negative. The patient's blood counts were closely watched \nfor signs of bleeding, of which there were none. The patient \nreceived subcutaneous heparin and ___ dyne boots were used \nduring this stay and was encouraged to get up and ambulate as \nearly as possible.\n\nAt the time of discharge, the patient was doing well, afebrile \nand hemodynamically stable. The patient was tolerating a diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan.\n \nPatient endorses pain at drain site requiring oxycodone for \nrelief. Patient assessed on PMP and reports she needs new \nprescription at this time; insufficient quantity at home.\n\n \nMedications on Admission:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n 2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H \n 3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n 4. Docusate Sodium 100 mg PO BID \n 5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \n Moderate \n 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n 7. Senna 8.6 mg PO BID:PRN constipation \n ___ MD to order daily dose PO DAILY16 \n daily ___ dosing as per PCP \n 9. Citalopram 20 mg PO DAILY \n 10. Metoprolol Succinate XL 100 mg PO QHS \n 11. Omeprazole 20 mg PO DAILY \n 12. Zolpidem Tartrate 2.5 mg PO QHS \n 13. Methimazole 5mg daily \n 14. Lantus 20 units \n15. Januvia \n\n \nDischarge Medications:\n1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 17 Days \n\nRX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by \nmouth twice a day Disp #*34 Tablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID \nas needed. \n3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nTake Lowest effective dose. \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*10 Tablet Refills:*0 \n4. sodium chloride 0.9 % 10 mL Drain flush DAILY \nRX *sodium chloride 0.9 % 0.9 % 10 mL catheter once a day Disp \n#*20 Syringe Refills:*0 \n5. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild \n6. Citalopram 20 mg PO DAILY \n7. Glargine 20 Units Bedtime \n8. Januvia (SITagliptin) 100 mg oral DAILY \n9. LOPERamide 2 mg PO TID:PRN diarrhea \n10. Methimazole 5 mg PO DAILY \n11. Metoprolol Succinate XL 100 mg PO QHS \n12. Omeprazole 20 mg PO DAILY \n13. Zolpidem Tartrate 5 mg PO QHS \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___:\nlarge left pleural effusion \nSplenic abscess \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear ___,\n\nYou were admitted to the Acute Care Surgery service on ___ \nwith a dislodgment of your splenic abscess drain and a fluid \ncollection ___ your lung space called a pleural effusion. The \nfluid was sent for culture. You were given IV antibiotics and \nthe drain was replaced to help treat the infection. The fluid \nwas drained from your lung and your breathing improved. Cultures \nfrom the drain and from your lung were sent to microbiology to \nhelp select the appropriate antibiotic treatment.\n\nYou are now doing better, afebrile, tolerating a regular diet, \nand breathing is improved. You are now ready to be discharged to \nhome to continue your recovery.\n\nPlease note the following discharge instructions:\n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood ___ your \nurine, or experience a discharge.\n*Your pain ___ not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change ___ your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon.\n\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\n*Please look at the site every day for signs of infection \n(increased redness or pain, swelling, odor, yellow or bloody \ndischarge, warm to touch, fever).\n*Maintain suction of the bulb.\n*Note color, consistency, and amount of fluid ___ the drain. Call \nthe doctor, ___, or ___ nurse if the amount \nincreases significantly or changes ___ character.\n*Be sure to empty the drain frequently. Record the output, if \ninstructed to do so.\n*You may shower; wash the area gently with warm, soapy water.\n*Keep the insertion site clean and dry otherwise.\n*Avoid swimming, baths, hot tubs; do not submerge yourself ___ \nwater.\n\n \nFollowup Instructions:\n___\n" ]

[ "T85628A", "J90", "I4891", "D733", "Z96653", "Z7901", "I10", "Y848", "Y929" ]

[ "T85628A: Displacement of other specified internal prosthetic devices, implants and grafts, initial encounter", "J90: Pleural effusion, not elsewhere classified", "I4891: Unspecified atrial fibrillation", "D733: Abscess of spleen", "Z96653: Presence of artificial knee joint, bilateral", "Z7901: Long term (current) use of anticoagulants", "I10: Essential (primary) hypertension", "Y848: Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable" ]

[ "I4891", "Z7901", "I10", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nfosaprepitant\n \nAttending: ___.\n \nChief Complaint:\nWeakness\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\nMs. ___ is a ___ female with history of\nmetastatic neuroendocrine carcinoma of the gallbladder to the\nliver and periportal nodes s/p cisplatin/etoposide (completed\n___, lymph node and liver segment resection in ___, and\nrecent admission for fever who presents one day after discharge\nwith weakness.\n\nShe was recently admitted for prolonged hospitalization ___ to\n___. Please see recent discharge summary for complete\nhospitalization. In summary, she was admitted for FUO c/b \npartial\nright portal vein thrombosis now on Lovenox, atypical chest pain\nduring ___ infusion s/p successful ___ challenge,\nthrombocytopenia, and hyperbilirubinemia found to have biliary\nstricture s/p ERCP with fully covered metal stent to common\nhepatic duct on ___. She was discharged home without services\non ___. When she arrived home she was very weak and had to\ncrawl up her 12 stairs. She felt she needs to go to rehab. She\ndoes not feel she can function at home due to generalized\ndeconditioning and weakness in her legs. She called her Oncology\nteam who referred her to the ED.\n\nOn arrival to the ED, initial vitals were 99.2 144 90/60 12 94%\nRA. Exam was notable for tachycardia and mild scleral icterus.\nLabs were notable for WBC 43.5, H/H 9.2/26.8, Plt 69, INR 1.6, \nNa\n134, K 4.2, BUN/Cr ___, Tbili 4.0, trop < 0.01, and lactate\n2.1. Blood cultures were drawn. CXR and CT torso was negative \nfor\nacute process. Patient had low-grade fever to 99.7 and was given\nzosyn and vancomycin. Prior to transfer vitals were 97.7 111\n118/64 22 94% RA.\n\nOn arrival to the floor, patient reports feeling very fatigued\nwith difficulty ambulating to the bathroom. She endorses\noccasional, stable fevers since she was in the hospital. She has\nno dyspnea at rest or chest pain. No abdominal pain but notes\noccasional nausea. 1 episode of diarrhea. No dysuria.\n\nREVIEW OF SYSTEMS: A complete 10-point review of systems was\nperformed and was negative unless otherwise noted in the HPI.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \n- ___: Suprainfected pancreatic cyst, incidental 1cm gastric\nGIST\n- ___: Distal pancreatectomy with splenectomy for \npancreatic\ntail lesion, mucinous cystic neoplasm (Dr ___\n- Dysphagia, IBS symptoms, abdominal pain, BRBPR\n- ___: CT showed 4.1 x 3.7cm mass in the fundus of the\ngallbladder with hypodensity in segment 5 of the liver, thought\nto be direct extension vs. metastasis\n- ___: 8 cycles cisplatin/etoposide. Treatment\ncomplicated by tinnitus, syncopal episode, fatigue, moderate\nnausea. Good treatment response.\n- ___: s/p resection of gallbladder and liver segment 5.\nypT2N2 ___ LN) gallbladder adenocarcinoma with negative margins\nat the cystic duct and liver, LVI +, PNI negative. No evidence \nof\nneuroendocrine carcinoma.\n\nPAST MEDICAL HISTORY: \n- Esophagitis\n- GERD\n- GIST\n- Cervical Dysplasia\n- Elevated Prolactin Level\n- s/p distal pancreatectomy in ___\n- s/p splenectomy in ___ \n \nSocial History:\n___\nFamily History:\nMother with inner ear tumor. Father with\n___. Brother with ___, CVA, DM, and hepatitis C.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVITALS:T 98.5 BP 117/75 HR 107 R 24 SpO2 94 RA \nGENERAL: Tired, chronically ill appearing\nHEENT: Dry mucous membranes, no lesions\nEYES: Icteric, PERRL\nNECK: supple\nRESP: no increased WOB except with ambulation. CTAB\n___: RRR no MRG\nGI: Soft, mild, diffuse TTP\nEXT: pitting edema at ankles b/l\nSKIN: warm, jaundice\nNEURO: CN II-XII intact\nACCESS: PIV\n\nDISCHARGE PHYSICAL EXAM: \nVS: ___ 0817 RR: 16 Dyspnea: 0 RASS: 0 Pain Score: ___ \nGENERAL: Tired, ill appearing\nHEENT: Moist mucous membranes, no lesions\nEYES: Icteric, PERRL\nNECK: supple\nRESP: Mild increase in work of breathing. Clear to auscultation\nbilaterally without wheezes, rales, or rhonchi\n___: tachycardic, regular, no MRG\nGI: Soft, distended, diffusely mildly tender\nEXT: 2+ edema to knees b/l\nSKIN: warm, jaundiced\nNEURO: CN II-XII intact grossly. moving all extremities\nACCESS: ___\n\n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 06:10PM BLOOD WBC-43.5* RBC-3.16* Hgb-9.2* Hct-26.8* \nMCV-85 MCH-29.1 MCHC-34.3 RDW-18.9* RDWSD-54.2* Plt Ct-69*\n___ 06:10PM BLOOD Neuts-90* Bands-0 Lymphs-3* Monos-6 Eos-0 \nBaso-0 ___ Metas-1* Myelos-0 NRBC-2* AbsNeut-39.15* \nAbsLymp-1.31 AbsMono-2.61* AbsEos-0.00* AbsBaso-0.00*\n___ 06:10PM BLOOD ___ PTT-33.1 ___\n___ 06:10PM BLOOD Glucose-198* UreaN-30* Creat-1.0 Na-134* \nK-4.2 Cl-96 HCO3-19* AnGap-19*\n___ 06:10PM BLOOD ALT-16 AST-45* AlkPhos-263* TotBili-4.0*\n___ 06:10PM BLOOD Albumin-2.4*\n___ 06:23AM BLOOD Calcium-7.6* Phos-3.0 Mg-2.0\n___ 06:40PM BLOOD Lactate-2.1*\n\nMICRO:\n======\n___ blood cultures - negative\n___ urine culture - yeast\n___ MRSA screen - negative\n\nIMAGING/STUDIES:\n===============\n___ CXR:\nNo acute cardiopulmonary process.\n\n___ CTA chest, CT abdomen and pelvis w/ contrast\n1. No evidence of pulmonary embolism or acute aortic \nabnormality.\n2. Infiltrative mass in the hilum of the liver compatible with \npatient's known\ngallbladder cancer and multiple lesions in the liver are grossly \nunchanged and\nbetter characterized on MRCP ___, when accounting \nfor differences\nin modality. This mass is better characterized on MRCP ___.\n3. Chronic occlusion invasion of the portal venous system is \nunchanged from ___.\n4. Stable perihepatic fluid collections along the falciform \nligament and\nadjacent to the segment V resection site as compared to ___.\n5. Moderate amount of ascites in the abdomen and pelvis.\n6. No evidence of obstruction. The appendix is normal.\n\n___ CXR:\nHeart size and mediastinum are stable. Bibasal atelectasis is \nmore pronounced\nthan on the prior study, concerning in particular on the right 4 \nright lower\nlobe pneumonia. No pleural effusion or pneumothorax identified.\n\n___ abdominal US:\nVery small amount of ascites in the left lower quadrant, not \namenable for\ndrainage.\n\n___ PICC placement:\nThe tip of a new right PICC line projects over the distal SVC. \nNo pneumothorax.\n\n___ CXR:\nNo evidence of pulmonary edema\n\n___ RUQ US:\n1. There is diffuse pneumobilia, status post CBD stent \nplacement, without\nevidence of biliary ductal dilatation.\n2. Known liver lesions are not well evaluated due to artifact \nfrom\npneumobilia.\n3. No flow was demonstrated within the main portal vein, \nconsistent with known\nchronic occlusion.\n4. An ill-defined, hypoechoic mass in the region of the \npancreatic head/neck\nis better evaluated on prior CT and MR.\n\n___ CXR:\nIn comparison with the study of ___, there again are low \nlung volumes\nwith mild basilar atelectasis, more prominent above the mildly \nelevated right\nhemidiaphragmatic contour. Cardiac silhouette is within normal \nlimits and\nthere is no vascular congestion, pleural effusion, or acute \nfocal pneumonia.\nThe tip of the right subclavian PICC line is in the mid SVC.\n\n___ abdominal US:\nSmall amount of ascites, primarily in the left lower quadrant.\n\nDischarge:\n-___: WBC 3.9, Hgb 6.8, Plts 35 (after Plt transfusion)\n \nBrief Hospital Course:\n___ w/ metastatic gallbladder adenocarcinoma treated with ___ \n(___), PMHx of metastatic neuroendocrine carcinoma of the \nGB s/p 8 cycles of cisplatin/etoposide (___) and \nopen resection of gallbladder and liver segment 5 (___), \noriginally admitted for FUO with hospitalization c/b partial R \nportal vein thrombosis and atypical chest pain during ___ \ninfusion, biliary stricture now s/p ERCP with fully covered \nmetal stent to common hepatic duct on ___, who presented with \nweakness, with plan to transition her to rehab, received C2 of \n___ with civ ___ while inpatient (___), course c/b \nthrombocytopenia and hyperbilirubinemia not amenable to \nintervention, without response of malignancy to chemotherapy. \nDue to symptom progression and lack of cancer-directed therapy \noptions, she was transitioned to comfort-focused care on ___ \nand discharged to inpatient hospice.\n\nACTIVE ISSUES:\n=============\n# Metastatic Gallbladder Adenocarcinoma\nShe received C1D1 ___ during last admit complicated by atypical \nchest pain. She presented with rising leukocytosis as below, \nconcerning for reaction to ongoing malignancy. Imaging on this \nadmission did not show significant radiographic change. ___ \nplaced ___ C2D1 ___ with civ ___. Infusion completed \non ___. However, her liver function continued to worsen \ndespite chemotherapy, with rapidly rising bilirubin, with no \nocclusions amenable to stenting seen on RUQ US, consistent with \nprogression of malignancy despite chemotherapy. At ___ \ndiscussion with patient and family on ___, it was decided that \nthe patient will not undergo further chemotherapy given no \nclinical evidence of chemo efficacy despite significant organ \ndamage (particularly hepatic dysfunction). Her cell counts were \nmonitored and she received blood product transfusions as needed. \nPalliative Care was involved during this admission, and was \ninvolved in ___ discussions. The patient expressed her \npreference to transition to ___ care on ___, at which time \nroutine vital sign and lab checks were discontinued. She \nexpressed her preference for discharge to an ___ \nfacility. She was treated symptomatically with viscous lidocaine \nand magic mouthwash for mucositis, Nystatin for possible \noropharyngeal candidiasis, Dilaudid and Ativan for air hunger \nand discomfort, and IV fluids.\n\n# Anemia/Thrombocytopenia\nLikely due to malignancy and chemotherapy, though ITP is also \npossible. No evidence of active bleeding, though she has had \nsome vaginal spotting for several days. CBC was trended daily \nand she was transfused with platelets and RBCs as needed. Her \nLovenox was held in the setting of thrombocytopenia. Initially \nhad planned to monitor platelets until stably >25, but was then \ntransitioned to CMO with discontinuation of lab draws and \ntransfusions.\n\n# Hyperbilirubinemia\nRecently found to have malignancy related biliary stricture s/p \nERCP with stent covered metal stent placement. bili now \nuptrending, most likely d/t advancing malignancy. RUQUS on ___ \nwithout dilatation or evidence of stent blockage. Discussed with \nERCP team on ___, who agreed that there is little utility in \nobtaining MRCP and ERCP is not indicated given no evidence of \nintervenable biliary obstruction. As above, it was decided that \ncancer-directed therapy would not be further pursued.\n\n# Diabetes mellitus\nA1C 6.7, newly diagnosed during last admission. BG was \npersistently in 300s-400s during this admission, in the setting \nof receiving steroids with recent chemo, though BG remained \nafter steroids were stopped.\n\n# Xerostomia\nLikely d/t malnutrition and chemotherapy effect. This was \ntreated with caphesol, oral hydration, lip balm, sugar free gum, \npilocarpine 5 BID.\n\nCHRONIC/RESOLVED ISSUES:\n========================\n# Acute Kidney Injury\nCr 1.0 on admission from recent peak of 1.3, baseline Cr 0.6. \nLasix were administered on several occasions in attempt to \nimprove her edema, which caused her Cr to uptrend. She received \nfluid and albumin as needed throughout the admission. Her renal \nfunction remained stable ~1.2. Medications were really dosed and \nnephrotoxic medications were avoided.\n\n# Coagulopathy\nThought to be due to nutritional deficiency/vitamin K \ndeficiency. No evidence of DIC. Impaired liver synthetic \nfunction may be contributing. Coags were monitored and vitamin K \nwas repleted.\n\n# Malignancy-related fatigue and weakness:\nPatient presents with weakness and difficulty caring for herself \nfollowing a 1 month hospitalization. Likely due to metastatic \ncancer and prolonged hospitalization leading to deconditioning. \nShe is unable to climb stairs to her second-story ___, and was \nnot seen by ___ prior to last discharge. ___ consulted \nevaluated her near beginning of current admission and \nrecommended rehab. However, the patient's functional capacity \ndeteriorated rapidly during this admission in the setting of her \nadvancing malignancy, and following ___ discussion with family \nas above, it was decided that the patient would be transitioned \nto hospice.\n\n# Hospital acquired pneumonia\n# Tachypnea\nCXR demonstrated possible/likely RLL pneumonia. Given her recent \nhospitalization, chemotherapy, tachycardia, she was treated for \nhospital acquired pneumonia. Tachypnea could be related to PNA \nvs\ndeconditioning, pulm edema in setting of low albumin, and air \nhunger in the setting of her malignancy. She was treated for \npneumonia with a 7 day course of Levofloxacin (last day ___. \nAs above, her air hunger was treated with IV opiates as needed.\n\n# Tachycardia\nSinus tachycardia 110s-120s slightly above baseline in 100s. She \nwas monitored for infection and given crystalloids, albumin, and \nblood products as needed.\n\n# Malnutrition\nPatient with poor PO intake. Artificial nutrition discussed \nduring last admit and decided against. Nutrition was consulted. \nShe was given supplements and PRN repletion of electrolytes.\n\n# Leukocytosis\nLeukocytosis thought to be due to leukemoid reaction from \nmalignancy (WBC was depressed due to recent chemotherapy and now \nclose to baseline level prior to chemo of WBC ___. No new \nsymptoms to suggest infection except for weakness, though will \nclosely monitor. UA unremarkable. With worsening ascites, \nperitonitis remains on the differential. CXR on ___ concerning \nfor RLL pneumonia, and she was treated with a 7 day course of \nlevofloxacin.\n\n# Portal Vein Thrombus\nNoted during prior admission. Her enoxaparin was held in the \nsetting of her thrombocytopenia.\n\n# Atypical Chest Pain: Onset during ___ transfusion on ___. \nACS was unlikely given ECG without ischemic changes and trop x3 \nnegative. Isordil 10 mg was started and the patient underwent \nsuccessful ___ challenge. She was discharged on Imdur. During \nthis admission, her Imdur was held in the setting of \nhypotension.\n\n# GERD: Continued home PPI.\n\nTRANSITIONAL ISSUES:\n===================\nCODE: DNR/DNI (confirmed), comfort measures only\nEMERGENCY CONTACT HCP: ___ (___) ___\n\nThis patient was prescribed, or continued on, an opioid pain \nmedication at the time of discharge (please see the attached \nmedication list for details). As part of our safe opioid \nprescribing process, all patients are provided with an opioid \nrisks and treatment resource education sheet and encouraged to \ndiscuss this therapy with their outpatient providers to \ndetermine if opioid pain medication is still indicated.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Omeprazole 20 mg PO DAILY \n2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate \n\n3. Vitamin D 1000 UNIT PO DAILY \n4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n5. Multivitamins 1 TAB PO DAILY \n6. Polyethylene Glycol 17 g PO DAILY \n7. Simethicone 40-80 mg PO QID:PRN gas \n8. Acyclovir 400 mg PO 5X/DAY:PRN Herpes outbreak \n9. Enoxaparin Sodium 70 mg SC Q24H \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \nRX *acetaminophen 650 mg/20.3 mL 650 mg by mouth every six (6) \nhours Disp #*1 Bottle Refills:*5 \n2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea \nRX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 2.5 mg IH every six \n(6) hours Disp #*1 Vial Refills:*3 \n3. Caphosol 30 mL ORAL QID dry mouth \nRX *saliva substitute combo no.2 [Caphosol] 30 mL four times a \nday Refills:*3 \n4. Lidocaine Jelly 2% 1 Appl TP Q12H:PRN mouth pain \nRX *lidocaine-glycerin [Advanced DNA Medicated Collect] 20 mg/mL \n1 application every twelve (12) hours Disp #*1 Kit Refills:*2 \n5. Lidocaine Viscous 2% 15 mL PO TID:PRN mucositis \nRX *lidocaine HCl [Lidocaine Viscous] 2 % 15 mL three times a \nday Disp #*200 Milliliter Milliliter Refills:*3 \n6. LORazepam Oral Solution 0.25 mg PO Q2H:PRN air hunger, \nanxiety \nRX *lorazepam 2 mg/mL 0.25 mg by mouth Q2H Refills:*3 \n7. Maalox/Diphenhydramine/Lidocaine 15 mL PO TID:PRN mucositis \nRX *alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL 15 mL by \nmouth three times a day Disp #*1 Bottle Refills:*3 \n8. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 4 mg \nPO Q2H:PRN pain, dyspnea \nRX *morphine concentrate 100 mg/5 mL (20 mg/mL) 4 mg by mouth \nQ2H PRN Refills:*3 \n9. Nystatin Oral Suspension 5 mL PO TID \nRX *nystatin 100,000 unit/mL 5 mL by mouth three times a day \nRefills:*3 \n10. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First \nLine \nRX *ondansetron 8 mg 1 tablet(s) by mouth q8hrs PRN Disp #*45 \nTablet Refills:*2 \n11. pilocarpine HCl 5 mg oral BID \nRX *pilocarpine HCl 5 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*1 \n12. Omeprazole 20 mg PO DAILY \nRX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30 \nCapsule Refills:*3 \n13. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 capsule(s) by mouth every six (6) hours \nDisp #*60 Capsule Refills:*2 \n14. Polyethylene Glycol 17 g PO DAILY \nRX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by \nmouth daily Disp #*30 Packet Refills:*3 \n15. Simethicone 40-80 mg PO QID:PRN gas \nRX *simethicone [Gas Relief 80] 80 mg 1 tab by mouth four times \na day Disp #*90 Tablet Refills:*3 \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnoses:\nMetastatic gallbladder adenocarcinoma\nThombocytopenia\nNormocytic anemia\nHospital acquired pneumonia\n\nSecondary diagnoses:\nDiabetes mellitus\nXerostomia\nHyperbilirubinemia\nAcute kidney injury\nMalignancy-related fatigue and weakness\nCoagulopathy\nMalnutrition\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure caring for you at ___ \n___.\n\nWHY WAS I IN THE HOSPITAL?\n- You were very weak after leaving the hospital from your last \nadmission.\n\nWHAT HAPPENED TO ME IN THE HOSPITAL?\n- You received cycle 2 of your chemotherapy.\n- Your cell counts were watched closely, and you required \nmultiple transfusions of blood products.\n- Unfortunately your cancer progressed, and chemotherapy caused \nserious and severe side effects. For this reason, it was decided \nthat cancer-directed therapy would no longer be pursued. \nFollowing a discussion with you, your family, and your entire \nteam of doctors, the decision was made to stop cancer \ntreatment-directed care, and to transition to hospice care.\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?\nPlease enjoy time with your loved ones. Continue taking \nmedicines that will make you comfortable and improve the quality \nof your life.\n\nWe wish you the best. \n\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "C23", "J189", "I81", "C787", "C7889", "N179", "D688", "E46", "C772", "R188", "Z8507", "D6481", "T451X5A", "Y92239", "D638", "D6959", "Y95", "K117", "E119", "R530", "I959", "K219", "Z66", "Z515", "Z6831", "R627", "F419", "R0600" ]

[ "C23: Malignant neoplasm of gallbladder", "J189: Pneumonia, unspecified organism", "I81: Portal vein thrombosis", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C7889: Secondary malignant neoplasm of other digestive organs", "N179: Acute kidney failure, unspecified", "D688: Other specified coagulation defects", "E46: Unspecified protein-calorie malnutrition", "C772: Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes", "R188: Other ascites", "Z8507: Personal history of malignant neoplasm of pancreas", "D6481: Anemia due to antineoplastic chemotherapy", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "D638: Anemia in other chronic diseases classified elsewhere", "D6959: Other secondary thrombocytopenia", "Y95: Nosocomial condition", "K117: Disturbances of salivary secretion", "E119: Type 2 diabetes mellitus without complications", "R530: Neoplastic (malignant) related fatigue", "I959: Hypotension, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "Z6831: Body mass index [BMI] 31.0-31.9, adult", "R627: Adult failure to thrive", "F419: Anxiety disorder, unspecified", "R0600: Dyspnea, unspecified" ]

[ "N179", "E119", "K219", "Z66", "Z515", "F419" ]

[]

[ " \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:\nsyncope\n \nMajor Surgical or Invasive Procedure:\n___ EGD with push enteroscopy/colonoscopy/capsule study\n \nHistory of Present Illness:\n___ with hx of gastritis, ___, CKD, HLD, H. Pylori (treated \n___ p/w syncope. \nPt reports he was sitting on the toilet when he started feeling \nsweaty and dizzy. He got up to go back to bed and then \nsyncopized close to the bed. He endorses a LOC. No head strike. \nNo injuries other than a scratch on the right arm. He is unsure \nhow long he was unconscious for. His son was at home and he had \nawoken by the time son arrived at bedside. He does not take \nblood thinners. He has a history of occult GIB for which he has \nbeen worked up with capsule study without a source of bleeding \nidentified. He was just hospitalized, discharged ___ for \ndyspnea and anemia, a EGD was performed during that \nhospitalization showing only mild duodenitis.\n\nHe endorses black stools (on iron), sometimes loose and \nsometimes formed. No red stools. No nausea or vomiting. No \nfevers or chills. No abdominal pain. He had a prior episode of \nsyncope last week prior to the last hospitalization.\n\nHe's had multiple admission for blood loss anemia. \n\nIn the ED, initial vitals: 97.6 93 144/68 18 99% RA \n \n- Exam notable for: rectal w/ black guaiac positive stool and + \northostatics. \n- Labs notable for: H&H of 5.2/17.5\n- Imaging notable for: NA \n- Patient given: 40 IV PPI and 1 unit of pRBC \n\n \nPast Medical History:\n- Severe Gastritis\n- Iron Deficiency Anemia \n- CKD Stage III \n- Hyperlipidemia\n- History of H. pylori infection, treated ___ \n- Obesity \n- History of Adenomatous Polyps of ___ \n- Personal History of Benign Carcinoid Tumor in ___ \n- Pulmonary Asbestosis \n- ___ Syndrome \n- Gout \n \nSocial History:\n___\nFamily History:\nBrother: cerebral aneurysm \nFather: Cancer - ___ \nMother: CAD/PVD \n \nPhysical Exam:\nADMISSION EXAM:\nVitals: 98.3 PO 185 / 70 L Lying 82 20 99 Ra \nGeneral: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP \nnot elevated, no LAD \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \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 \nSkin: Without rashes or lesions \n\nDISCHARGE EXAM:\nVS 97.5\nPO 128 / 70\nR Lying 71 18 98 ra \nGeneral: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP \nnot elevated, no LAD \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \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 \nSkin: Without rashes or lesions \n\n \nPertinent Results:\nADMISSION LABS:\n\n___ 12:25PM BLOOD WBC-9.4 RBC-1.80*# Hgb-5.2*# Hct-17.5*# \nMCV-97 MCH-28.9 MCHC-29.7* RDW-13.9 RDWSD-48.0* Plt ___\n___ 12:25PM BLOOD Neuts-83.9* Lymphs-9.1* Monos-5.8 \nEos-0.1* Baso-0.0 NRBC-0.3* Im ___ AbsNeut-7.85* \nAbsLymp-0.85* AbsMono-0.54 AbsEos-0.01* AbsBaso-0.00*\n___ 12:25PM BLOOD ___ PTT-25.0 ___\n___ 12:25PM BLOOD Glucose-132* UreaN-34* Creat-1.1 Na-139 \nK-4.0 Cl-104 HCO3-22 AnGap-17\n___ 12:25PM BLOOD tTG-IgA-2\n___ 12:25PM BLOOD IgA-110\n\nPERTINENT LABS:\n___ 05:00PM BLOOD VitB12-___* Folate->20\n___ 05:00PM BLOOD TSH-1.6\n___ 12:25PM BLOOD IgA-110\n___ 12:25PM BLOOD tTG-IgA-2\n\nDISCHARGE LABS:\n___ 07:51AM BLOOD WBC-6.4 RBC-2.80* Hgb-7.9* Hct-25.1* \nMCV-90 MCH-28.2 MCHC-31.5* RDW-14.0 RDWSD-45.6 Plt ___\n\nSTUDIES: \n___ EGD with push enteroscopy: \nAngioectasia in the fundus (thermal therapy)\nOtherwise normal EGD to jejunum\n\n___ COLONOSCOPY:Normal mucosa was noted in the whole ___ \nwith no findings to explain anemia. Other Tattoo and scar from \nprevious rectal carcinoid resection noted in the rectum. \n\n___ SMALL CAPSULE STUDY: Findings:\n1. Prolonged gastric passage time\n2. Rapid small bowel transit time\n3. Fair prep\n4. Mild erythema in the proximal duodenum\n\n \nBrief Hospital Course:\n___ with hx of gastritis, ___, CKD, HLD, H. Pylori (treated ___ \n___ p/w syncope likely ___ blood loss anemia from UGIB. \n\n#UGIB\n#Acute blood loss anemia: He returned with syncope and new \nanemia 5 days after admission for GI bleed. EGD at that time \nshowed only mild duodenitis. Repeat ___ study on \nthis admission showed angectasia in the fundus, for which \nreceived thermal therapy. He received 4 u pRBCs with no bloody \nstools once admitted. He will ___ with GI as outpatient. \nHe will continue BID omeprazole. \n\n#Syncope: Likely from acute blood loss anemia. EKG without \nabnormalities. He denied lightheadedness once pRBC transfusion. \nHistory inconsistent with cardiac etiology. \n\nCHRONIC: \n#HLD: He continued atorv 40 mg daily\n#Preventive: continue vitamin D, B12, and multivitamin\n\nTRANSITIONAL ISSUES:\n-Continue PPI BID\n-Check Hgb at GI appointment on ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Atorvastatin 40 mg PO QPM \n3. Cyanocobalamin 1000 mcg PO DAILY \n4. Multivitamins 1 TAB PO DAILY \n5. Vitamin D 1000 UNIT PO DAILY \n6. Cialis (tadalafil) 20 mg oral PRN sexual activity \n7. Ferrous Sulfate 325 mg PO BID \n8. Fish Oil (Omega 3) 1000 mg PO TID \n9. Omeprazole 40 mg PO BID \n10. Colchicine 0.6 mg PO BID gout \n\n \nDischarge Medications:\n1. Allopurinol ___ mg PO DAILY \n2. Atorvastatin 40 mg PO QPM \n3. Cialis (tadalafil) 20 mg oral PRN sexual activity \n4. Colchicine 0.6 mg PO BID gout \n5. Cyanocobalamin 1000 mcg PO DAILY \n6. Ferrous Sulfate 325 mg PO BID \n7. Fish Oil (Omega 3) 1000 mg PO TID \n8. Multivitamins 1 TAB PO DAILY \n9. Omeprazole 40 mg PO BID \n10. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nSyncope\nAcute blood loss anemia\nUpper gastrointestinal bleed\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Mr. ___, \n\nIt was a pleasure taking care of you at the ___ \n___. \n\nWhy were you here?\n-Your fainted, likely from your low blood counts, which we \nsuspect is from bleeding from your GI tract\n\nWhat was done?\n-The GI doctors performed ___ & colonoscopy, which showed an \narea in your stomach that may have been the cause of your \nbleeding. They cauterized the area to prevent further bleeding. \nYou also had a capsule study, which showed no sign of bleeding.\n-You received 4 units of blood\n\nWhat do to next?\n-Take your acid blocking agent twice daily (pantoprazole)\n-Avoid alcohol\n-___ with your PCP and ___\n\n___ wish you all the best,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "K31811", "D62", "N183", "K921", "I951", "I129", "E785", "E611", "M109", "J61", "E804", "Z85040", "Z23" ]

[ "K31811: Angiodysplasia of stomach and duodenum with bleeding", "D62: Acute posthemorrhagic anemia", "N183: Chronic kidney disease, stage 3 (moderate)", "K921: Melena", "I951: Orthostatic hypotension", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E785: Hyperlipidemia, unspecified", "E611: Iron deficiency", "M109: Gout, unspecified", "J61: Pneumoconiosis due to asbestos and other mineral fibers", "E804: Gilbert syndrome", "Z85040: Personal history of malignant carcinoid tumor of rectum", "Z23: Encounter for immunization" ]

[ "D62", "I129", "E785", "M109" ]

[]

[ " \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:\nAltered mental status\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with HTN and dementia transferred from ___ for\nalteration in mental status initially concerning for stroke. \n\nPer patient's family, in the afternoon of ___ patient started\nfeeling weaker. The family was at a retreat in ___ and\nshe decided to head back to the hotel room early. That evening\nshe no longer could recognize her daughter or granddaughter and\nwas confused, attempting to find doors to get out of the hotel\nroom. That night she frequently went back and forth to the\nbathroom to urinate. At another point she has been found\nsplashing toilet water at her vaginal area stating that she was\n\"cleaning\" herself. In the context of these symptoms she also\ndeveloped a facial droop and the family went to ___ \n___\nwhere labs, imaging, and urine studies were all negative. \nPatient was found to be back at baseline, then was sent back to\nthe hotel. The patient then developed recurrence of her \nsymptoms\nwith visual hallucinations, agitation, and restlessness. In the\nmorning of ___ she was trying to go to work at ___ to clean the floors. Family denies fevers, nausea,\nvomiting, pains, or incidence of this episode previously.\n\nFamily ___ drove back to ___ and ___ into ___. At\nthat time, stroke scale was 2. NCHCT negative for intracranial\nabnormality, CXR without PNA. Infectious workup negative with \nUA\nwith trace bacteria and ___ WBC's. She was transferred for\nfurther neurologic workup given lack of MRI availability at\n___ for the next ___ hours.\n\nOn transfer to ___ she was alert and oriented to name. CN\nintact, with possible left nasolabial fold flattening. Labs \nwere\nunremarkable. Neuro was consulted and felt the presentation was\ninconsistent with stroke, but rather may be a manifestation of\nongoing urinary tract infection. She was started on ceftriaxone\nand admitted for further infectious workup. \n\nIn the ED, initial VS were:\nExam notable for:\nAlert, oriented to name only. Cranial nerves II-XII intact.\nPossible left nasolabial fold flattening. Strength ___ in upper\nand lower extremities. Sensation intact to light touch in upper\nand lower extremities. DTRs intact. Finger to nose slowed.\nUnstable gait.\n\nECG: NSR, TWI in aVR, V1, Q waves in aVL.\nLabs showed:\nWBC 6.5, Hgb 11.2, PLT 198\nNa 142, K 4.3, Cl 104, HCO3 24, BUN 22, Cr 1.2\nAST 26, ALT 20, AP 76, Tbili 0.4\nA1c 6.2\n\nImaging showed:\n___ ___\nVentricles are not dilated. No midline shift. No acute\nintraventricular or intracerebral bleed. No extra-axial\ncollection. No effacement of sulci or gyri. Periventricular \nwhite\nmatter changes consistent with small vessel disease and tiny\nbilateral basal ganglia lacune's all unchanged from the prior\nexam.\n\nVisualized sinuses and mastoid air cells clear\n \nIMPRESSION:\n1. No acute intracranial process. No change from the prior CT\n\n___ CXR\nHeart size top normal. Tortuous thoracic aorta no change\nLungs show dependent markings posteriorly but no definite \nconsolidation. No pleural fluid or pneumothorax\n \nIMPRESSION: Compared to the prior exam no acute change. No acute\nconsolidation\n\nConsults: Neurology\n\nPatient received:\nCTX 1 g\n\nTransfer VS were:\n___ 2215 97.7F, 63, 178/856, 15, 98% on RA\n\nOn arrival to the floor, patient is grumbling in response to\nquestions. Appears exhausted. Per patient's family above\nhistory is accurate. Patient restless after not sleeping much \nin\nthe last 48 hours.\n\nREVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as\nper HPI\n\n \nPast Medical History:\nCKD stage III (baseline Cr ~ 1.3)\nHTN\nDementia c/b paranoia\nOsteoarthritis\nHLD\nOpen Angle Glaucoma\nGERD\n\n \nSocial History:\n___\nFamily History:\nBrother had stomach cancer. Sister died unknown type cancer.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n24 HR Data (last updated ___ @ 009)\n Temp: 97.3 (Tm 97.3), BP: 198/108, HR: 77, RR: 22, O2 sat:\n94%, O2 delivery: RA \n\nGENERAL: Exhausted elderly woman grunting in response.\nHEENT: PERRL\nNECK: supple, no LAD\nCV: RRR, S1/S2, Early systolic murmur crescendoing into mid\nsystole, no gallops or rubs\nPULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles\nGI: abdomen soft, nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly\nEXTREMITIES: no cyanosis, clubbing, or edema\nPULSES: 2+ radial pulses bilaterally\nNEURO: Alert, moving all 4 extremities with purpose, face\nsymmetric\nDERM: warm and well perfused, no excoriations or lesions, no\nrashes\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVITALS: 24 HR Data (last updated ___ @ 315)\n Temp: 97.6 (Tm 98.8), BP: 163/88 (163-196/63-98), HR: 57\n(57-68), RR: 16 (___), O2 sat: 96% (95-97), O2 delivery: Ra \n\n\nGeneral: Elderly woman, alert and cooperative, and appears to be\nin no acute distress.\nHEENT: Normocephalic, atraumatic. PERRLA. EOMI. \nCardiac: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is\nregular. \nPulmonary: Clear to auscultation without rales, rhonchi, \nwheezing\nor diminished breath sounds.\nAbdomen: Normoactive bowel sounds. Soft, nondistended,\nnontender. No guarding or rebound. No masses.\nMusculoskeletal: ROM intact in spine and extremities. No joint\nerythema or tenderness. Muscle bulk and tone appropriate for age\nand habitus. Normal gait.\nNeuro: Alert, oriented to self, \"hospital\" is not oriented to\ntime as per her reported baseline by family. No gross focal\ndeficits. \nSkin: Skin type V. Skin normal color, texture and turgor with no\nlesions or eruptions.\n\n \nPertinent Results:\nADMISSION LABS:\n===================\n___ 08:31PM BLOOD WBC-6.5 RBC-3.75* Hgb-11.2 Hct-35.1 \nMCV-94 MCH-29.9 MCHC-31.9* RDW-13.5 RDWSD-45.5 Plt ___\n___ 08:00AM BLOOD WBC-6.6 RBC-4.04 Hgb-12.4 Hct-37.6 MCV-93 \nMCH-30.7 MCHC-33.0 RDW-13.4 RDWSD-45.5 Plt ___\n___ 08:31PM BLOOD Neuts-55.7 ___ Monos-10.9 Eos-3.1 \nBaso-0.3 Im ___ AbsNeut-3.60 AbsLymp-1.90 AbsMono-0.70 \nAbsEos-0.20 AbsBaso-0.02\n___ 08:00AM BLOOD ___ PTT-25.7 ___\n___ 08:00AM BLOOD Plt ___\n___ 08:31PM BLOOD Glucose-98 UreaN-22* Creat-1.2* Na-142 \nK-4.3 Cl-104 HCO3-24 AnGap-14\n___ 08:00AM BLOOD Glucose-101* UreaN-19 Creat-1.2* Na-142 \nK-4.5 Cl-104 HCO3-24 AnGap-14\n___ 08:31PM BLOOD ALT-20 AST-26 AlkPhos-76 TotBili-0.4\n___ 08:00AM BLOOD ALT-19 AST-25 LD(LDH)-216 AlkPhos-87\n___ 08:31PM BLOOD Albumin-3.7 Calcium-9.9 Phos-3.9 Mg-1.9\n___ 08:00AM BLOOD Calcium-10.2 Phos-4.0 Mg-1.9\n___ 08:31PM BLOOD %HbA1c-6.2* eAG-131*\n___ 08:31PM BLOOD TSH-3.2\n\nURINE STUDIES:\n==============\nUrine Color Straw YELLOW N/A \nUrine Appearance Clear CLEAR N/A \nSpecific Gravity 1.015 1.001 - 1.035 \n \nDIPSTICK URINALYSIS \nBlood TR* \nNitrite NEG \nProtein TR* \nGlucose NEG \nKetone NEG \nBilirubin NEG \nUrobilinogen NEG \npH 6.5 \nLeukocytes MOD* \n \nMICROSCOPIC URINE EXAMINATION \nRBC 5* \nWBC 7* \nBacteria FEW* \nYeast NONE \nEpithelial Cells <1 \n\nOTHER URINE FINDINGS \nUrine Mucous RARE* \n\nMICROBIOLOGY:\n==============\n___ 1:55 am URINE Source: ___. \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___ 8:00 am BLOOD CULTURE\n\n Blood Culture, Routine (Pending): No growth to date.\n\nIMAGING:\n==========\n\nOSH IMAGING:\n___ ___\nVentricles are not dilated. No midline shift. No acute\nintraventricular or intracerebral bleed. No extra-axial\ncollection. No effacement of sulci or gyri. Periventricular \nwhite\nmatter changes consistent with small vessel disease and tiny\nbilateral basal ganglia lacune's all unchanged from the prior\nexam.\n\nVisualized sinuses and mastoid air cells clear\n \nIMPRESSION:\n1. No acute intracranial process. No change from the prior CT\n\n___ CXR\nHeart size top normal. Tortuous thoracic aorta no change\nLungs show dependent markings posteriorly but no definite \nconsolidation. No pleural fluid or pneumothorax\n \nIMPRESSION: Compared to the prior exam no acute change. No acute\nconsolidation\n\n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman with dementia and HTN \npresenting with altered mental status likely ___ UTI.\n\nACUTE ISSUES:\n===============\n#Toxic metabolic Ecephalopathy ___ UTI\nPatient with AMS that developed acutely in the last 48 hours. \nStory per family appearing consistent with UTI given urinary \nfrequency, potential for dysuria with attempts to clean. UA at \n___ not overtly consistent with UTI, but still with \ntrace bacteria. Neurology evaluated the patient and believe \nthis is consistent with metabolic process in the setting of poor \nsubstrate rather than stroke. Patient empirically treated with \nceftriaxone 1g q24. Ecephalopathy improved and patient returned \nto baseline. Avoided deliriogenic agents. \n\n#Urinary tract infection \nPatient with increased urinary frequency at home. UA showing \nmoderate leuks, few bacteria, 7 WBCs. \nPatient empirically treatedf with ceftriaxone which was \ntransitioned to TMP-SMX for discharge. \n\n#HTN\nPatient hypertensive to SBP up to 200's occurring in the setting \nof agitation which improved with intitiation of home atenolol. \nHer blood pressures remained elevated with SBP in 160s. \n\nCHRONIC ISSUES:\n===============\n#CKD III (baseline Cr ~ 1.3)\nPatient at baseline. Continued to monitor Cr and avoid \nnephrotoxic agents as able.\n\n#GLAUCOMA\nContinued brimonidine, latanoprost, and dorzolamide eye drops\n\n#DEMENTIA C/B PARANOIA\nContinued home perphenazine. \n\n#GERD\nOmeprazole 20 mg BID at home, unclear as to why twice daily \ndosing. This was reduced to daily dosing for discharge with \ntransitional issue to re-address with PCP. \n\nTRANSITIONAL ISSUES:\n[] Patient on omeprazole 20mg BID ER at home, unclear as to why \nshe is on BID dosing. This was reduced to once daily and should \nbe discussed with PCP.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atenolol 50 mg PO DAILY \n2. Perphenazine 2 mg PO BID \n3. Omeprazole 20 mg PO BID \n4. Centrum Silver \n(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) \n0.4-300-250 mg-mcg-mcg oral DAILY \n5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n6. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID \n7. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H \n\n \nDischarge Medications:\n1. Sulfameth/Trimethoprim DS 1 TAB PO BID \nRX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 \ntablet(s) by mouth twice a day Disp #*6 Tablet Refills:*0 \n2. Omeprazole 20 mg PO DAILY \n3. Atenolol 50 mg PO DAILY \n4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H \n5. Centrum Silver \n(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) \n0.4-300-250 mg-mcg-mcg oral DAILY \n6. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID \n7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n8. Perphenazine 2 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY: \nTOXIC METABOLIC ENCEPHALOPATHY\nUrinary tract infection \n\nSECONDARY:\nCKD stage III (baseline Cr ~ 1.3)\nHTN\nDementia c/b paranoia\nOsteoarthritis\nHLD\nOpen Angle Glaucoma\nGERD\n\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___: \n\nYou were admitted to the hospital because you were experiencing \nconfusion, facial droop, and you were having increased urinary \nfrequency. \n\nAt the hospital you were started on IV medication to treat a \nurinary tract infection. \n\nWhen you leave the hospital, please take all of your medicine as \ndirected. Please follow up with your doctor. \n\nIt was a pleasure caring for you! We wish you the best!\n\nSincerely, \nYour ___ Treatment Team\n \nFollowup Instructions:\n___\n" ]

[ "N390", "G92", "I129", "N183", "E785", "K219", "H4010X0", "F0390" ]

[ "N390: Urinary tract infection, site not specified", "G92: Toxic encephalopathy", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "H4010X0: Unspecified open-angle glaucoma, stage unspecified", "F0390: Unspecified dementia without behavioral disturbance" ]

[ "N390", "I129", "E785", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROLOGY\n \nAllergies: \nDilantin\n \nAttending: ___.\n \nChief Complaint:\nseizure\n \nMajor Surgical or Invasive Procedure:\nlumbar puncture\n \nHistory of Present Illness:\nEU ___ DOB ___ MRN ___ is \na\n___ year old woman with a history of AVM repair in ___ s/p VPS\nmaintained on depakoate 1000mg ER qhs who presents as ED-to-ED\ntransfer for management of reported seizure activity. History\nobtained by husband and per chart review as patient arrived\nintubated. \n\nPer husband, the patient was reportedly in her usual state of\nhealth up until ___ days ago, when she started answering\nquestions in a nonsensical, almost argumentative type of manner.\nThe husband notes that he would have a conversation with the\npatient and she would respond with coherent words that were\nirrelevant to the topic of conversation. She also wasn't able to\nsleep as well as in prior days. She otherise didn't have any\nsigns of sickness, fever, chills, malaise, or nausea and did not\ncomplain of any specific out-of-the ordinary aches or pains. \n\nThis morning, the husband went to wake the patient up at 07:30AM\n(she typically awakens at 7AM) and they went down to have\nbreakfast. During breakfast, he asked her a questin and she\nresponded with clearly uncunciated words that were irrelevant \nand\nnonsensical to the question that he had asked. He asked her if\nshe was ok, and she sort of responded again with nonsensical\nwords and then laughed, almost nervously. He then said, \"should \nI\ncall EMS?\" And she said \"no no no no no, I do not want to go to\nthe hospital.\" She continued to eat her breakfast through this\nevent. He suggested she lie down to rest and when she went to \nlie\ndown he said that she just looked a little \"off and more drowsy\"\nso he decided to call EMS. At that point, she proceeded to have\nwhat he describes as a seizure, with both her arms \"stiffening\nand relaxing and stiffening and relaxing..\" Her head was \ndeviated\nto a side, but he cannot remember which side. Her eyes were\nblinking and her gaze was described as upwards and possibly\nmidline, although unclear if her eyes deviated throughout event.\nNo incontinence was noticed by the husband. EMS arrived and gave\nher 2gm ativan. She reportedly had an additionals eizure on way\nto the OSH and was given an additional 2gm ativan but this event\nis only described by word-of-mouth via EMS/OSH staff and there \nis\nno report of it.\n\nRegarding prior seizure, history, the husband notes that the\npatient has only had \"two small seizures\" prior to VPS and\nnothing since. They manifested as some seconds of shaking that\nself-resolved. She has been maintained on depakote 1000mg ER qPM\nfor ___ years and has been seizure free per his reports.\n\nRegarding prior AVM rupture, the husband notes that she suffered\na large hemorrhage requiring urgent repair. She was out of it \nfor\n___ years after repair, with significt cognitive impairments and\nunable to perform ADLs (she would leave the stove on and throw\nout pots). She received a VPS within ___ years and her mental\nstatus significantly improved and she is now functioning as a\nnormal adult. At baseline she is fully oriented but has some\nshort-term memory loss/word finding deficits that the husband\nattributes to old age.\n\nAt OSH:\n- GCS 3, intubated for airway protection\n- intubated with induction via etomidate/rocuronium\n- Fentanyl 50 mcg IV ___\n- s/p Keppra 2g IV\n\nPertinent Labs at OSH:\n- DKA 80\n- lactate 2.6\n- UA bland\n- Na 131\n- UA bland\n- CBC wnl\n- LFTs, coags wnl\n\nShe arrived to ___ ED on prop 15ucg gtt. \n\nROS notable for above, otherwise non-contributory\n\n \nPast Medical History:\nAVM s/p repair ___, VPS shunt placed ___ by Dr. ___\n\"rheumatoid pain\"\n \nSocial History:\n___\nFamily History:\n? mother with seizure \"at one point\"\nno family history of stroke\n6 siblings in good health\n\n \nPhysical Exam:\nVitals: T:35.2 Intubated APV 350 5 30% HR 60, 124/61\nGeneral: appears older than stated age, thin\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx\nNeck: No obvious nuchal rigidity\nPulmonary: Lungs CTA bilaterally \nCardiac: RRR, nl. S1S\nAbdomen: soft, NT/ND, normoactive bowel sounds, no masses or\norganomegaly noted.\nExtremities: No ___ edema.\nSkin: no rashes or lesions noted.\n\nNeurologic:\n***Examined 15min off prop***\n\nMS: no spont eye opening, no spont movement. moves head and all\nextremities to noxious, weakly localizes to noxious in upper\nextremities \n\nCN: weak corneal bilateral, PERRL 2>1, no VOR, fixed midline\ngaze, no appreciable skew, + cough, + gag, no clear facial\nasymmetry although would not grimace for noxious testing\n\nMotor: in general moves left upper and lower before moving \nright,\nwithdraws proximally to noxious (antigravity to biceps)\nbilaterally and localizes to noxious when testing cough; moves\nright lower extremity spontaneously and withdraws to noxious\nwithin plane of bed, withdraws left lower extremity to noxious\nwithin plane of bed\n\nReflexes 2+ uppers, 3+ patellar, no clonus, left toe is upgoing\n\nDISCHARGE PHYSICAL EXAM:\n========================\nTmax: 37.2 °C (98.9 °F)\nTcurrent: 36.9 °C (98.4 °F)\nHR: 83 (66 - 93) bpm\nBP: 121/72(52) {94/65(52) - 129/88(95)} mmHg\nRR: 19 (11 - 19) insp/min\nSpO2: 99% \nHeart rhythm: SR (Sinus Rhythm)\nWgt (current): 51.1 kg (admission): 50.2 kg\nHeight: 63 Inch\n\nGeneral: appears older than stated age, pale, thin\nHEENT: NCAT, sclera non-icteric, MMM, EEG in place\nCV: warm and well perfused\nLungs: breathing comfortably on RA\nAbdomen: soft NTND\nExt: no edema\nSkin: no rash\n\nNeuro:\nMental Status:\nAlert. Oriented to person, ___, and ___, but \nthinks it is the ___. Aware of upcoming ___ and recent \n___ holidays. She is less perseverative today, and language \nmore fluent. Difficulty with repetition with noted paraphasic \nerrors present but improving. Reading intact. Naming intact. \n\nCN: Pupils 4.5>2mm on R, 4-2mm on L, smile with slight droop at \nleft corner of mouth, EOMI, ___ beats of nystagmus on right \ngaze. ___ beats of nystagmus on left gaze. Vertical nystagmus. \nSlower to activate smile on left side.\n\nMotor: No drift. decreased bulk, normal tone. No tremor\n Del Bi Tri Wrext Fiext IP Qu Ham TA Gas\nL ___ 5 4+ 4+ ___ 5\nR ___ 5 4+ 4+ ___ 5\n\nReflexes:\nBrisk throughout + pec, + jaw jerk + cross adductor on R, 1 beat\nclonus on left upgoing toe on left, mute on right\n\nSensory: no deficits to gross touch\n\nCoordination: FNF without dysmetria bilaterally.\n\nGait: Differed, unsteady upon standing.\n \nPertinent Results:\n___ 03:27PM BLOOD WBC-10.2* RBC-3.57* Hgb-12.1 Hct-35.7 \nMCV-100* MCH-33.9* MCHC-33.9 RDW-11.8 RDWSD-43.0 Plt ___\n___ 03:27PM BLOOD ___ PTT-29.2 ___\n___ 03:27PM BLOOD Glucose-162* UreaN-15 Creat-0.7 Na-130* \nK-6.7* Cl-96 HCO3-24 AnGap-10\n___ 03:27PM BLOOD ALT-14 AST-39 AlkPhos-34* TotBili-0.4\n___ 12:54AM BLOOD Lipase-12\n___ 10:16PM BLOOD cTropnT-<0.01\n___ 03:27PM BLOOD Albumin-4.0 Calcium-9.3 Phos-2.7 Mg-1.9\n___ 04:06AM BLOOD %HbA1c-5.3 eAG-105\n___ 12:54AM BLOOD Triglyc-39 HDL-40* CHOL/HD-2.6 LDLcalc-57\n___ 09:33AM BLOOD Osmolal-277\n___ 12:54AM BLOOD TSH-0.53\n___ 03:27PM BLOOD Valproa-80\n___ 12:54AM BLOOD Valproa-32*\n___ 03:30PM BLOOD Valproa-102*\n___ 03:50AM BLOOD Valproa-74\n___ 02:50AM BLOOD Valproa-84\n___ 03:27PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n___ 03:28PM URINE Color-Straw Appear-Clear Sp ___\n___ 03:28PM URINE Blood-NEG Nitrite-NEG Protein-TR* \nGlucose-150* Ketone-10* Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG\n___ 03:28PM URINE RBC-2 WBC-2 Bacteri-FEW* Yeast-NONE Epi-0\n___ 03:27PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG \ncocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG\n___ 05:53AM URINE Osmolal-676\n___ 05:30PM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-2 Polys-13 \n___ ___ 05:30PM CEREBROSPINAL FLUID (CSF) TotProt-59* \nGlucose-87\n___ 11:28PM OTHER BODY FLUID FluAPCR-NEGATIVE \nFluBPCR-NEGATIVE\n\nMost Recent Lab Work:\n======================\n___ 06:35AM BLOOD WBC-5.8 RBC-3.28* Hgb-11.2 Hct-34.1 \nMCV-104* MCH-34.1* MCHC-32.8 RDW-12.7 RDWSD-47.7* Plt ___\n___ 06:35AM BLOOD ___ PTT-32.5 ___\n___ 06:35AM BLOOD Glucose-88 UreaN-13 Creat-0.6 Na-143 \nK-4.6 Cl-103 HCO3-30 AnGap-10\n\nIMAGING:\n========\nEKG ___: PR interval 156\n\nAll further EEGs pending final read at time of discharge.\n\n___ EEG:\nIMPRESSION: This is an abnormal continuous EMU EEG study due to \ncontinuous\nslowing, sharp discharges, and bursts of faster activities over \nthe left\nhemisphere. These findings suggest diffuse foci of cortical \nhyper excitability over the left hemisphere with high risk for \nseizures. There are periods where the slowing is maximal in the \nleft posterior quadrant suggestive of focal cerebral \ndysfunction. Generalized slowing of background with periods of \nfrontally predominant rhythmic delta activity is indicative of \nmoderate encephalopathy nonspecific as to etiology. Activities \nof higher frequency and amplitude over the left is consistent \nwith history of neurosurgical breach. There are no definite \nelectrographic seizures. Compared to prior day's recording, \nthere is no significant change.\n\n___ EEG:\nIMPRESSION: This continuous EMU EEG study captured no definite \nelectrographic seizures and no pushbutton activations. The \ntelemetry is abnormal due to 1) asymmetric background with \nhigher amplitudes seen over the left hemisphere with sharp \nfaster frequencies, suggestive of breech effect, 2) occasional \nepileptiform discharges in this same region consistent with \ncortical hyperexcitability and potential seizure focus , and 3) \nperiods of generalized delta frequency slowing consistent with \netiologically non specific moderate to severe encephalopathy.\n\n___ EEG:\nIMPRESSION:This continuous EMU EEG study captured multiple \nelectrographic\nseizures as well as continuous slowing and lateralized periodic \ndischarges\nover the left hemisphere. These findings suggest diffuse foci of \ncortical\nhyperexcitability over the left hemisphere with high risk for \nseizures.\nGeneralized slowing of background is indicative of \nmoderate-severe\nencephalopathy nonspecific as to etiology. Compared to prior \nday's recording, seizure frequency is improved.\n\n___ EEG:\nIMPRESSION: This is an abnormal continuous video-EEG monitoring \nstudy due to electrographic seizures arising from the left \nhemisphere broadly, initially occurring ___ times per hour and \nlasting ___ seconds each toward the beginning of the \nrecording, but decreasing to only one every several hours and \nlasting ___ seconds each by the end of the recording. \nLateralized periodic discharges over the left hemisphere were \nseen, often recurring every ___ seconds. These findings indicate \nactive epileptogenesis from the left hemisphere, which also \nshowed signs of focal cerebral dysfunction in that the \nbackground activity was asymmetric.\n\n___ CTH:\nIMPRESSION:\n1. No evidence of hemorrhage or recent infarction.\n2. The left parietal approach shunt terminates in the right \nparietal lobe\nparenchyma.\n3. Left parietal lobe encephalomalacia, unchanged from the prior \nstudy.\n \n \n \nBrief Hospital Course:\nMs. ___ is a ___ yo female with h/o AVM rupture s/p\nembolization and VPS (placed in ___ at ___ by Dr. ___ \ncomplicated by remote seizures over ___ years ago (maintained on \ntherapeutic VPA) who presented at an outside hospital after a \nwitnessed seizure. She had been having a few days of odd \nbehavior described as nonsensical speech and drowsiness. Husband \ncalled EMS for continued drowsiness and upon their arrival, she \nhad a witnessed seizure described as head deviation (unsure \nside) and blinking. She was given 2 mg Ativan by EMS. At outside \nhospital reportedly received and additinaly 2 mg Ativan, 50 mcg \nof fentanyl and a 2gm keppra load. She was reported to have a \nGCS of 3 and was intubated for airway protection (induction with \netomidate/rocuronium) and transferred to ___ for further \nmanagement. Regarding prior seizure, history, she has only had \n\"two small seizures\" prior to VPS and nothing since for many \nyears. They manifested as some seconds of shaking that \nself-resolved. She has been maintained on depakote 1000mg ER qPM \nfor ___ years and has been seizure free. Her outpatient \nneurologist is Dr. ___ in ___.\n\n#Seizures, Epilepsy\nPatient had no further clinical seizures at ___, but cvEEG \ncaptured multiple electrographic seizures as well as continuous \nslowing and lateralized periodic discharges over the left \nhemisphere suggesting diffuse foci of cortical\nhyperexcitability over the left hemisphere with high risk for \nseizures. Her VPA level on arrival was in the ___. Over the next \n___ hours, she was bolused 20 mg/kg VPA, post load level 102. \nTrough next morning 74. As needed doses of Ativan were given as \nwell. Keppra, which had been started in the ED was continued at \n1500 mg BID but then increased to ___. Her \nelectrographic seizures became less frequent after this but \ncontinued, so vimpat was loaded and titrated up to 200 mg BID \nquickly, at which point seizures were occurring around 1-2/hr. \nPR interval was stable and within normal limits. She was then \nstarted on standing Ativan 1 mg q6h. After this only 1 \nelectrographic seizure was noted. She still had epileptiform \ndischarges. Her clinical exam seemed improved the following day \nafter all of these medication changes as she was less \nperseverative and more attentive. Scheduled Ativan was slowly \ntitrated off with last dose of 1mg given ___. Final AED regimen \nat time of discharge is keppra three times a day (1500 mg, 1000 \nmg, 1000mg), vimpat 200 mg twice daily, and Depakote 350 mg \nevery 6 hours.\n \nAt this point, the etiology of her seizures is thought to be the \nleft temperoparietal encephalomalacia from previous AVM rupture \nas seizures arising from this area and no further sources were \nfound. Her VPS shunt is non-working (terminates in ___ but \nthere is no clear mass effect or signs of elevated ICP. She had \nan LP in ED and was on CNS dosing of ceftriaxone, ampicillin, \nvancomycin, acyclovir which were discontinued when CSF studies \nresulted (1 WBC 59 protein 87 glucose, HSV PCR negative). CTA \nh/n from OSH was reviewed and did not show evidence of change in \nAVM. CTH at ___ without acute intracranial abnormalities. MRI \nbrain was unable to be obtained as despite multiple attempts to \nobtain records from ___, we were unable to obtain VPS serial \nnumber (but make and model was obtained and documented in OMR) \nand embolization record. Radiology felt that it was unsafe to \nperform the MRI at this time. No further toxic, metabolic, or \ninfectious source of seizures found during admission.\n\nAEDS ON DISCHARGE:\n- Valrpoate 350 mg q6h\n- Keppra three times a day at 0600, 1400, 2200. Dosing is 1500 \nmg/1000mg /1000mg respectively\n- Vimpat 200 mg BID\n\n#Acute Respiratory Failure, resolved\nThis was likely due to administration of sedating abortive anti \nseizure medications. She was doing well respiratory wise and \nextubated the morning following admission (___). She had no \nfurther respiratory issues.\n\n#Macrocytic Anemia, stable\nStudies performed at ___ were all within normal limits: Iron- \n122, ferritin- 70, TIBC- 308, B12- 488, folate-10. No ___ \nmedications were started.\n\n#Left sided weakness: Patient was noted to have a mild L facial \ndroop, L pronator drift and extensor pattern of weakness in L \nleg upon transfer to the step-down unit from the ICU. This was \n___ in onset during hospitalization but now resolved.\nNow with only very subtle left facial weakness. CTH was done to \nrule out ischemia as the deficits were present for a few days \nand would be seen on CT scan at the time, and it was without \nacute abnormalities. Most likely represented ___ Phenomenon \nas the weakness resolved upon seizure/discharge improvement. \n\n#AVM s/p embolization and VPS\nPatient's VP shunt is a medium pressure EquaflowRadionics shunt \nplaced in ___ at ___, no further details known. Neurosurgery \nwas consulted in the ED. Per assessment, she is not shunt \ndependent as VPS in brain parenchyma and there is no evidence of\nhydrocephalus. A ___ small left M1 aneurysm (3mm) was detected \non imaging and will need\nneurosurgery follow up outpatient.\n\n#Hypovolemic hyponatremia, resolved\nNa 130 on admission which normalized with IVF\n\nTRANSITIONAL ISSUES:\n======================\n- Will follow up with her outpatient neurologist, Dr. ___\n- ___ AEDs started during this admission as above, can be \nadjusted per outpatient neurologist\n- Recommend surveillance MRI as unable to obtain at ___ due to \n___ records of shunt and embolization being unobtainable\n- Will need outpatient follow up with Neurosurgery for \nmonitoring of small left M1 aneurysm detected on CTA 3mm. Please \ncall ___ to schedule an appointment for monitoring \nof this aneurysm. \n- Monitor macrocytic anemia \n\n \nMedications on Admission:\nDepakote ER 1000mg qhs \nibuprofen PRN for rheumatoid pain 6 tablets a day \nvagifem 2x/week \npremarin \nverapamil 120 mg PRN palpitations \nvit D3 \nCalcium \n\n \nDischarge Medications:\n1. LACOSamide 200 mg PO BID \n2. LevETIRAcetam 1500 mg PO DAILY \ngive at 0600 \n3. LevETIRAcetam 1000 mg PO DAILY \ngive at 1400 \n4. LevETIRAcetam 1000 mg PO DAILY \ngive at 2200 \n5. Multivitamins W/minerals 1 TAB PO DAILY \n6. Valproic Acid ___ mg PO Q6H \n7. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3) \n600 mg(1,500mg) -200 unit oral DAILY \n8. Estrogens Conjugated 0.625 mg PO DAILY \n9. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild \n10. Vagifem (estradiol) 10 mcg vaginal 2X/WEEK \n11. Verapamil 120 mg PO PRN PALPITATIONS palpitations \n12. HELD- Divalproex (EXTended Release) 1000 mg PO QHS This \nmedication was held. Do not restart Divalproex (EXTended \nRelease) until your Neurologist tells ___ to start\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___ \n___)\n \nDischarge Diagnosis:\nSeizure\nEpilepsy\nMacrocytic Anemia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear ___,\n\n___ were hospitalized due to seizures. The reason ___ had \nseizures is unclear, but most likely is due to chronic changes \nin the tissue of your brain from your prior AVM rupture. CT of \nyour head and neck did not reveal any acute intracranial \nabnormalities. An MRI is more sensitive to see these changes, \nbut we were unable to obtain and MRI as it is unsafe without \nknown the serial number of your VPS and details of your AVM \nembolization. Your lumbar puncture and lab work did not indicate \nan infectious or metabolic cause of your seizures.\n\nAdditionally ___ were found to have a ___ small aneurysm in your \nleft middle cerebral artery. This is an incidental finding and \nis not associated with your seizures. It will need to be \nmonitored by Neurosurgery as an outpatient.\n\nWe are changing your medications as follows: \n- Valproate 350 mg q6h\n- Keppra three times a day at 0600, 1400, 2200. Dosing is 1500 \nmg/1000mg /1000mg respectively\n- Vimpat 200 mg BID\n\nPlease take your other medications as prescribed. \n\nPlease follow up with Neurology, Neurosurgery, and your primary \ncare physician as listed below. \n\n If ___ experience any of the symptoms below, please seek \nemergency medical attention by calling Emergency Medical \nServices (dialing 911). In particular, since stroke can recur, \nplease pay attention to the sudden onset and persistence of \nthese symptoms: \n - Sudden partial or complete loss of vision \n - Sudden loss of the ability to speak words from your mouth \n - Sudden loss of the ability to understand others speaking to \n___ \n - Sudden weakness of one side of the body \n - Sudden drooping of one side of the face \n - Sudden loss of sensation of one side of the body\n \n Sincerely, \n Your ___ Neurology Team \n\n \nFollowup Instructions:\n___\n" ]

[ "G40909", "E871", "I671", "G9389", "G8384", "E861", "R680", "D72829", "R0689", "D539", "Z982" ]

[ "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "E871: Hypo-osmolality and hyponatremia", "I671: Cerebral aneurysm, nonruptured", "G9389: Other specified disorders of brain", "G8384: Todd's paralysis (postepileptic)", "E861: Hypovolemia", "R680: Hypothermia, not associated with low environmental temperature", "D72829: Elevated white blood cell count, unspecified", "R0689: Other abnormalities of breathing", "D539: Nutritional anemia, unspecified", "Z982: Presence of cerebrospinal fluid drainage device" ]

[ "E871" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nMevacor / Demerol / adhesive tape / Darvocet-N 100 / lidocaine / \nmorphine\n \nAttending: ___.\n \nChief Complaint:\nFever, Hypoxia\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMs. ___ is a ___ with PMH of PCV, DVT, HTN, TIA and recent \nadmission for anemia, thrombocytopenia and hypoxemia who \npresents from rehab with hypoxemia and dyspnea. \n Patient's daughter states that patient was noted to be \nincreasingly dyspneic at her rehab facility in the past 3 days. \nHer symptoms started with onset of sore throat, which progressed \nto cough, productive of green/yellow sputum. She was noted to be \nhypoxemic to ___ at rehab on RA and was brought to ___ for \nfurther evaluation. The patient endorses chills. She denies \nchest pain, NVD, dysuria. \n \n Of note, patient was recently admitted to ___ from \n___ with recurrent hypoxemia. This was suspected to be \nmultifactorial in origin - related to severe kyphosis, pleural \neffusions and anemia due to chronic/burnt out PCV vs. MDS and \ndue to volume overload/pulmonary edema. The patient was \ninitially treated with antibiotics as she was febrile in the ED \non that admission, but CXR was without evidence of definite \nconsolidation and patient with no h/o cough or PNA symptoms so \nantibiotics were discontinued. She was treated with Lasix and \nincentive spirometry with plan to continue O2 supplementation at \nrehab. Patient does have a history of PE and DVT, no longer on \nanticoagulation due to fall risk and thrombocytopenia. \n In terms of her underlying hematologic disease, patient has had \nprogressively worsening anemia and thrombocytopenia since ___. This was evaluated by hematology on prior admissions and \nthought to be secondary to burnt out PCV vs. MDS vs. \ntransformation to acute leukemia. Patient declined bone marrow \nbiopsy for further evaluation as outpatient as she would likely \nnot pursue further treatment regardless of diagnosis. She has \nbeen receiving intermittent transfusions as outpatient. She was \ntreated with a platelet transfusion on her admission in early \n___ which was complicated by suspected transfusion reaction \nwith fevers, but no hemolysis. \n In the ED, initial vitals were: 99.4 101 125/75 22 98% NC \n - Exam notable for: crackles on right \n - Labs showed: Hgb 7.7, Plt 21, HCO3 33, lactate 1.2, UA w/few \nbacteria neg leuks and nitrites, flu negative \n - Imaging showed: CXR w/mild interstitial edema, small b/l \npleural effusions mildly increased, opacity at LL base likely \natelectasis cannot r/o pneumonia \n - Received: IV NS, duonebs x1, zosyn 4.5g, vanc 1g IV \n Transfer VS were: 89 128/42 22 100% Nasal Cannula \n On the floor, the patient reports feeling well. \n Review of systems: (+) Per HPI, all other ROS otherwise \nnegative \n \nPast Medical History:\nDVT, post-thrombotic syndrome\nPE with Right ventricular failure secondary to large bilateral \npulmonary emboli, s/p thrombolysis - ___\nPolycythemia ___ - diagnosed ___, followed by Dr. ___, \n___ to maintain Hct ___, then started on hydroxyurea \n___, d/ced ___, BCR/ABL negative, Jak 2 with one \nmutated allele ___\nAnxiety\nBreast Cyst\nCataracts\nDiverticulitis\nHLD\nHTN\nOA\nOsteoporosis\nPulmonary Hypertension\nSkin Cancer\nTIA - head MRI with small areas of acute infarct in L \nparieto-occipital region\nVertigo\nMigraine\nSubclavian Vein Stenosis\nRecurrent Cellulitis\nR rotator cuff injury\nvenous stasis ulcer\nh/o falls\n\nPSH:\nhemorrhoidectomy\nbreast lumpectomies\n \nSocial History:\n___\nFamily History:\nper OMR:\nMother: CAD, CHF, DM, HTN \nFather: brain CA\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n====================== \nVital Signs: T 99.0, BP 147/49, HR 98, RR 28, 93% 4L \nGeneral: no acute distress \nHEENT: Sclerae anicteric, MMM, oropharynx clear \nCV: RRR, normal S1 S2, soft systolic murmur RUSB, no rubs, \ngallops \nLungs: scattered wheeze in posterior lung fields \nAbdomen: Soft, non-tender, non-distended, bowel sounds present \nGU: No foley \nExt: WWP, 2+ pulses, trace edema \nNeuro: CN2-12 grossly intact, moving all extremities \nspontaneously\n\nDISCHARGE PHYSICAL EXAM:\n=======================\nVitals: T 98.2 BP 127-155/53-71 HR ___ RR ___ O2 95-98% on \n5L\nGeneral: Elderly female laying in bed, tired appearing. Neck \npillow on. Irritated.\nHEENT: Sclerae anicteric\nCV: RRR, normal S1 S2, II/VI SEM best heard at right sternal \nborder, no rubs/gallops.\nLungs: Faint crackles auscultated anteriorly throughout.\nAbdomen: Normoactive bowel sounds. Abdomen is soft, nontender \nto palpation. No rebound or guarding.\nNeuro: Moving all extremities spontaneously. A&O x3.\nPsych: Irritable but cooperative with exam.\n \nPertinent Results:\nADMISSION LABS:\n==============\n___ 04:53PM BLOOD WBC-4.2# RBC-2.87* Hgb-7.7* Hct-27.0* \nMCV-94# MCH-26.8 MCHC-28.5* RDW-19.1* RDWSD-63.7* Plt Ct-21*\n___ 04:53PM BLOOD Neuts-75* Bands-1 Lymphs-13* Monos-2* \nEos-0 Baso-0 Atyps-4* ___ Myelos-1* Blasts-4* NRBC-4* \nOther-0 AbsNeut-3.19 AbsLymp-0.71* AbsMono-0.08* AbsEos-0.00* \nAbsBaso-0.00*\n___ 04:53PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-2+ \nMacrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+ \nStipple-OCCASIONAL Tear ___\n___ 04:53PM BLOOD Glucose-142* UreaN-31* Creat-0.9 Na-144 \nK-4.6 Cl-105 HCO3-33* AnGap-11\n___ 07:09AM BLOOD proBNP-2567*\n___ 07:09AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.3\n___ 05:05PM BLOOD Lactate-1.2\n___ 05:27PM URINE Color-Yellow Appear-Clear Sp ___\n___ 05:27PM URINE Blood-NEG Nitrite-NEG Protein-30 \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG\n___ 05:27PM URINE RBC-0 WBC-2 Bacteri-FEW Yeast-NONE Epi-0\n___ 06:02PM OTHER BODY FLUID FluAPCR-NEGATIVE \nFluBPCR-NEGATIVE\n\nMICRO:\n======\n___: Urine culture negative, blood cultures x 2 negative\n___: MRSA swab positive, Legionalla Ab negative\n\nIMAGES:\n=======\nCXR (___): 1. Mild interstitial edema. 2. Small bilateral \npleural effusions are mildly increased. Increased opacity at \nthe left lung base likely represents atelectasis, however \npneumonia cannot\nbe excluded. 3. Unchanged moderate cardiomegaly.\n\nCXR (___): Interval mild improvement.\n \nCXR (___): Compared to chest radiographs since ___, \nmost recently ___ through ___. There is certainly \ngreater opacification in the perihilar regions of both \nhemithoraces since ___ when patient was in mild \npulmonary edema and a lateral view of each showed moderate \nbilateral pleural effusion and therefore I suspect that much of \nthe change is due to more pleural effusion, however there is \nprobably new perihilar pulmonary edema. Moderate to severe \nenlargement of cardiac silhouette is more pronounced. Left \nlower lobe atelectasis has also worsened, contributing to \nrespiratory insufficiency.\n\nDISCHARGE LABS:\n==============\n___ 11:30AM BLOOD WBC-3.4* RBC-2.57* Hgb-7.1* Hct-23.6* \nMCV-92 MCH-27.6 MCHC-30.1* RDW-18.6* RDWSD-60.5* Plt Ct-16*\n___ 07:49AM BLOOD Glucose-96 UreaN-22* Creat-0.5 Na-143 \nK-4.2 Cl-102 HCO3-31 AnGap-14\n___ 07:49AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.4\n \nBrief Hospital Course:\nMs. ___ is a ___ female with a past medical history \nof polycythemia ___, deep venous thrombosis, hypertension, \ntransient ischemic attack, and recent hospital admission for \nhypoxia (secondary to pleural effusions and kyphosis) and low \nhemoglobin/platelets who presented with increasing O2 \nrequirement, cough, and low blood counts concerning for \npneumonia and volume overload.\n\nShe originally presented from rehab on 4L nasal cannula. She was \npreviously on 2. Her hypoxia was thought to be due to pulmonary \nedema and worsening effusions, community acquired pneumonia, and \natelectasis secondary to kyphosis. She also has a history of \npolycythemia ___ with concern for transformation to AML (she \nhad blasts on her smear). She required ongoing transfusions of \npRBCs and platelets on an almost daily basis. She was diuresed \nwith Lasix 40 mg IV throughout her hospital course and \nespecially when she was receiving blood products. She was \ntreated empirically for a community acquired pneumonia given her \nradiologic findings and worsening hypoxia. She completed a 7 day \ncourse of ceftriaxone as well as a 5 day course of azithromycin. \nShe developed worsening hypoxia with diuresis and PNA treatment \nand eventually got up to 5L NC. Given her worsening respiratory \nstatus, goals of care discussion were held with her and her \nfamily and she decided to be DNR/DNI with no ICU transfer (no \nnon-invasive ventilation - BIPAP). Then, given poor improvement \nand ongoing transfusion requirement, palliative care was \nconsulted. In discussion with care team, patient and family \ndecided to transition to comfort focused care with hospice on \ndischarge. \n\nTRANSITIONAL ISSUES:\n=====================\n- Continue titration of pain medications and consider addition \nof morphine if patient develops respiratory distress\n- Please follow patient's clinical volume exam; would consider \nuptitration of Lasix if needed for comfort to prevent pulmonary \nedema\n- Adjust any other medications as needed for comfort\n\nDETAILED HOSPITAL COURSE:\n\n#Goals of care discussions: \nGiven her worsening respiratory status she decided to be DNR/DNI \nwith no ICU transfer. Since her respiratory status did not \nimprove over several days of diuresis and antibiotics, \npalliative care was consulted for symptom management and hospice \nintroduction. She and her family decided to go home with hospice \ncare.\n\n#Hypoxemia:\n#Community acquired pneumonia:\n#Pulmonary edema:\n#Atelectasis:\nShe presented with worsening hypoxemia, dyspnea, with fevers and \nchills. A CXR (___) showed evidence of atelectasis vs. \npneumonia and mild interstitial edema. Her worsening hypoxia was \nlikely multifactorial with atelectasis (secondary to kyphosis), \nvolume overload (has a history of pulmonary arterial \nhypertension), and possible pneumonia. Less likely pulmonary \nembolism, and she was not a candidate for anticoagulation given \nher low platelets. Treated for community acquired pneumonia with \nceftriaxone and azithromycin. She was also diuresed \nintermittently while receiving blood products. Her sputum and \nlegionella antigen were negative. She was MRSA positive, but her \npresentation was not consistent with a MRSA pneumonia. She had a \nCXR (___) that showed worsening bilateral pleural effusions \nand possible perihilar pulmonary edema. Oxygen requirement \nremained stable at 5L throughout her hospital stay and after \ncompletion of CAP Abx; thought to be possibly due to residual \npleural effusions. She declined further workup or treatment of \nsame, favoring going home with hospice care.\n \n#Polycythemia ___:\n#Anemia, Thrombocytopenia: \nHer hemoglobin and hematocrit were decreased from her last \ndischarge (7.7 from 8.8) with platelets of 17. Per her \noutpatient oncology notes, there is a concern for evolution to \nAML (she has blasts in diff). Her transfusion thresholds were \nHCT < 20 and Plts < 20. She received 2 units of blood and 2 \nunits of platelets; she was diuresed with lasix 40 mg IV while \nreceiving blood products. Her platelets remained stably in the \n10's to 20's, despite transfusions. Pt declined further workup \nof this thrombocytopenia, did not want additional transfusions \nafter leaving the hospital, and elected to go home with hospice \ncare.\n\n#Hyperlipidemia: \nShe was continued on her home statin and fish oil \n\n#Hypertension: \nHer home metoprolol was held due to concern for infection.\n\n#Insomnia: \nHer home Xanax was held while inpatient.\n\n#Constipation: \nShe was continued on her home miralax, Maalox, MoM, and \nbisacodyl.\n\n#Gastroesophageal reflux disease:\nShe was continued on her home omeprazole.\n\n#Nutrition:\nShe was continued on her home vitamin C and vitamin D.\n\n#Gout:\nShe was continued on her home allopurinol.\n \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob \n3. Allopurinol ___ mg PO 6X/WEEK (___) \n4. ALPRAZolam 0.25 mg PO QHS:PRN insomnia \n5. Ascorbic Acid ___ mg PO DAILY \n6. Atorvastatin 20 mg PO QPM \n7. Fish Oil (Omega 3) 1000 mg PO DAILY \n8. Furosemide 20 mg PO DAILY \n9. Metoprolol Tartrate 25 mg PO BID \n10. Multivitamins 1 TAB PO DAILY \n11. Omeprazole 20 mg PO DAILY \n12. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n13. Vitamin D ___ UNIT PO DAILY \n14. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3) \n600 mg(1,500mg) -400 unit oral DAILY \n15. Amoxicillin 250 mg PO Q8H \n16. Daily-Vite (multivitamin) oral DAILY \n17. Lactaid (lactase) 3,000 unit oral QIDACHS \n18. Miconazole Powder 2% 1 Appl TP BID:PRN rash \n19. ___ (guaiFENesin) 100 mg/5 mL oral Q4H:PRN \n20. Aluminum-Magnesium Hydrox.-Simethicone 10 mL PO Q4H:PRN \nindigestion \n21. Milk of Magnesia 30 mL PO DAILY:PRN constipation \n22. Bisacodyl 10 mg PR QHS:PRN constiaption \n23. Fleet Enema ___AILY:PRN constipation \n24. Meclizine 12.5 mg PO Q8H:PRN vertigo \n\n \nDischarge Medications:\n1. Ipratropium-Albuterol Neb 1 NEB NEB Q4H dyspnea \nRX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1 \nampule inhaled every four (4) hours Disp #*30 Ampule Refills:*0 \n2. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN shortness of \nbreath \n3. Allopurinol ___ mg PO DAILY \n4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n5. ALPRAZolam 0.25 mg PO QHS:PRN insomnia \n6. Aluminum-Magnesium Hydrox.-Simethicone 10 mL PO Q4H:PRN \nindigestion \n7. Ascorbic Acid ___ mg PO DAILY \n8. Atorvastatin 20 mg PO QPM \n9. Bisacodyl 10 mg PR QHS:PRN constiaption \n10. Fish Oil (Omega 3) 1000 mg PO DAILY \n11. Furosemide 20 mg PO DAILY \n12. ___ (guaiFENesin) 100 mg/5 mL oral Q4H:PRN \n13. Meclizine 12.5 mg PO Q8H:PRN vertigo \n14. Miconazole Powder 2% 1 Appl TP BID:PRN rash \n15. Milk of Magnesia 30 mL PO DAILY:PRN constipation \n16. Multivitamins 1 TAB PO DAILY \n17. Omeprazole 20 mg PO DAILY \n18. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n19. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnoses:\n===================\nHypoxia\nCommunity acquired pneumonia\nPulmonary edema\nPolycythemia ___ with concern for transformation to acute \nmyelogenous leukemia\n\nSecondary diagnoses:\n=====================\nAnemia\nThrombocytopenia\nHyperlipidemia\nHypertension\nInsomnia\nConstipation\nGastroesophageal reflux disease\nGout\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Bedbound.\n\n \nDischarge Instructions:\nMs. ___,\n\nYou were admitted because you were requiring more oxygen at your \nrehab. You were treated for a pneumonia with antibiotics and you \nwere treated for fluid in your lungs with lasix to help you \nurinate. You were also given numerous blood transfusions. Given \nyour lack of improvement, in discussion with your providers, you \ndecided to transition to comfort-focused care only with home \nhospice. Please follow-up with your primary care physician \n___.\n\nIt was a pleasure caring for you,\n\n-Your ___ care team\n \nFollowup Instructions:\n___\n" ]

[ "J189", "I5033", "D696", "D45", "I272", "J9811", "D649", "E785", "G4700", "K5900", "K219", "M109", "F419", "M1990", "R0902", "Z66", "Z86711", "Z86718", "I110" ]

[ "J189: Pneumonia, unspecified organism", "I5033: Acute on chronic diastolic (congestive) heart failure", "D696: Thrombocytopenia, unspecified", "D45: Polycythemia vera", "I272: Other secondary pulmonary hypertension", "J9811: Atelectasis", "D649: Anemia, unspecified", "E785: Hyperlipidemia, unspecified", "G4700: Insomnia, unspecified", "K5900: Constipation, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "M109: Gout, unspecified", "F419: Anxiety disorder, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "R0902: Hypoxemia", "Z66: Do not resuscitate", "Z86711: Personal history of pulmonary embolism", "Z86718: Personal history of other venous thrombosis and embolism", "I110: Hypertensive heart disease with heart failure" ]

[ "D696", "D649", "E785", "G4700", "K5900", "K219", "M109", "F419", "Z66", "Z86718", "I110" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nCeclor / Ampicillin / Sulfa (Sulfonamide Antibiotics) / \nClarithromycin / Bactrim\n \nAttending: ___.\n \nChief Complaint:\nAbdominal Pain\n \nMajor Surgical or Invasive Procedure:\n___: Successful CT-guided removal of 10 cc of red tinged \nfluid within the left pelvis. Specimen was sent for \nmicrobiology. No drain was placed. Collection probably \nrepresented an ovarian or para-ovarian cyst. \n\n___: ___ line placement\n\n \nHistory of Present Illness:\nMs. ___ is a ___ with past medical history significant \nfor longstanding bronchiectasis s/p bilateral lobectomies as a \nchild on home O2 complicated by pulmonary hypertension and cor \npulmonale physiology, presenting with lower abdominal pain. She \nhas had mild intermittent vague abdominal pain for the past 6 \nmonths. 1 month ago, her abdominal pain become more severe and \nshe was went to her PCP who prescribed her 10 days of \ncipro/flagyl. She has known diverticulosis, noted on colonscopy \n___ years ago. Her abdominal pain had improved with antibioitics, \nbut recurred this past week. She also notes constipation for the \npast couple of days. Denies fever, chills, nausea, or vomiting. \n\n \nPast Medical History:\n1. Bronchiectasis.\n2. COPD.\n3. Pulmonary MAC treated from ___ to ___ which\nsuboptimal regimen. New treatment for MAC started in ___.\n4. Chronic sinusitis.\n5. History of partial lung resection x2 in her youth.\n6. Osteoporosis.\n\n \nSocial History:\n___\nFamily History:\nBrother with bronchiectasis. She says her brother was very sick \nall his life and was told at one point that he had CF. \n \nPhysical Exam:\nAdmission Physical Exam:\nVitals: 97.8 100 120/60 18 95%RA\nGEN: AOx3, NAD\nHEENT: No scleral icterus, mucus membranes moist\nCV: RRR, No M/G/R\nPULM: bibasilar ronchi, wheezing\nABD: Soft, distended, mild tenderness to palpation to suprapubic\narea, no rebound/guarding\nDRE: normal tone, stool in vault, no gross or occult blood\nExt: No ___ edema, ___ warm and well perfused\n\nDischarge Physical Exam:\nVS: 97.6, 107/56, 99, 18, 97%4Lnc\nCV: RRR, No M/G/R\nPULM: bibasilar ronchi, wheezing\nABD: Soft, distended, mild tenderness to palpation to suprapubic\narea, no rebound/guarding\nExt: RUE ___ line\n\n \nPertinent Results:\n___ 06:20AM BLOOD WBC-11.0* RBC-3.27* Hgb-8.6* Hct-29.5* \nMCV-90 MCH-26.3 MCHC-29.2* RDW-14.5 RDWSD-47.0* Plt ___\n___ 04:04AM BLOOD WBC-9.7 RBC-3.42* Hgb-9.1* Hct-30.6* \nMCV-90 MCH-26.6 MCHC-29.7* RDW-14.8 RDWSD-47.8* Plt ___\n___ 10:44AM BLOOD WBC-8.6 RBC-3.53* Hgb-9.4* Hct-31.8* \nMCV-90 MCH-26.6 MCHC-29.6* RDW-14.8 RDWSD-47.9* Plt ___\n___ 06:20AM BLOOD Plt ___\n___ 06:20AM BLOOD ___ PTT-33.5 ___\n___ 06:20AM BLOOD Glucose-94 UreaN-34* Creat-0.6 Na-144 \nK-3.5 Cl-92* HCO3-44* AnGap-12\n___ 04:04AM BLOOD Glucose-105* UreaN-30* Creat-0.6 Na-145 \nK-4.2 Cl-93* HCO3-44* AnGap-12\n___ 07:00AM BLOOD ALT-14 AST-18 AlkPhos-55 Amylase-40 \nTotBili-0.1\n___ 06:20AM BLOOD Calcium-10.3 Phos-3.1 Mg-2.2\n___ 07:00AM BLOOD Albumin-3.2* Calcium-9.8 Phos-4.5 Mg-2.3 \nIron-50 Cholest-205*\n___ 07:00AM BLOOD Albumin-3.2* Calcium-9.8 Phos-4.5 Mg-2.3 \nIron-50 Cholest-205*\n___ 07:00AM BLOOD Ferritn-85\n___ 06:20AM BLOOD TSH-0.25*\n___ 06:20AM BLOOD Free T4-1.4\n\n___ EKG: Sinus tachycardia. Non-specific inferior and right \nprecordial ST-T wave abnormalities. Compared to the previous \ntracing of ___ sinus tachycardia is new. \n\n___ CT Ab/Pelvis: \n1. Acute sigmoid diverticulitis. \n2. 4.0 cm fluid collection which appears separate from the \nsigmoid colon but tracks along its posterior aspect, most \nconsistent with an organizing \npericolonic abscess. \n\n___ CXR:\nPersistent blunting of the bilateral costophrenic angles, left \ngreater than right. \nEvidence of extensive bilateral bronchiectasis with possible \nmucous plugging in the right lower lobe. Stable cardiac, \nmediastinal, and hilar contours. \n\n___: cat scan\n\nSuccessful CT-guided removal of 10 cc of red tinged fluid within \nthe left \npelvis. Specimen was sent for microbiology. No drain was \nplaced. Collection probably represented an ovarian or \npara-ovarian cyst. \n\n___ CT ab/pelvis:\n1. Findings consistent with sigmoid diverticulitis. Surrounding \nfluid is \nsmaller than on comparison CT, status post aspiration which had \nyielded non purulent fluid. No definite new rim enhancing \ncollection is identified. \n2. Chronic dilation of the main pancreatic duct with surrounding \nparenchymal atrophy in the pancreatic tail, without clear \nobstructing mass identified at the point of ductal caliber \ntransition. Although such an appearance always raises concern \nfor obstructing malignancy, stability since ___ suggests that \nthis may be due to ductal stenosis such as from an episode of \nprior pancreatitis. Nonaggressive pancreatic neoplasms (e.g. \nSerotonin secreting neuroendocrine tumor) can also cause similar \nfindings. It appears that a dedicated MRCP to further evaluate \nthis finding was not performed and this could be considered if \nclinically indicated. \n\n___: chest x-ray:\n\nIn comparison with the earlier study of this date, the right \nsubclavian PICC line now extends to the lower portion of the \nSVC. Little change in the appearance of the heart and lungs. \n \n\n___: cat scan of abdomen and pelvis:\n\n1. Persistent sigmoid diverticulitis, minimally improved from \nthe prior exam if at all with a residual adjacent small 5 mm \npocket of fluid without rim enhancement, decreased from the \nprior exam. No drainable or new fluid \ncollections. \n \n2. Persistent dilation of the distal pancreatic duct up to 6 mm \nwith marked atrophy of the pancreatic tail, concerning for \nproximal mass lesion, although not visualized on this exam. The \ndegree of dilation is overall unchanged and this could be \npotentially seen as sequelae of a prior pancreatitis, however, \nnonemergent MRCP is again recommended to further evaluate and \nexclude an underlying mass/malignancy. \n \n3. Persistent severe bronchiectasis in the visualized right \nlower lobe, \nunchanged. \n \nRECOMMENDATION(S): Non-emergent MRCP to exclude underlying \npancreatic mass. \n\n___ 9:40 am URINE Source: ___. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: <10,000 organisms/ml. \n\n \n\n \nBrief Hospital Course:\nMs. ___ is a ___ yo F admitted to the Acute Care Surgery \nService on ___ with abdominal pain. She has a history of \ndiverticulitis with recent 10 day course of ciprofloxacin and \nmetronidazole from her primary care. She has a history \nsignificant for bronchiectasis/COPD with resulting pulmonary HTN \nwith cor pulmonale. She had a CT scan that showed acute sigmoid \ndiverticulitis and a 4.0 cm fluid collection that tracs along \nthe posterior aspect of the sigmoid colon concerning for a \npericolonic abscess. She was admitted to the floor for further \nmanagement. \n\nSince she was not responsive to her previous antibiotic course \nshe was given meropenem. Interventional radiology was consulted \nfor the abscess drainage and aspirated red tinged fluid thought \nto be an ovarian or para-ovarian cyst. The fluid was sent for \nculture and has no growth to date. Her diet was progressively \nadvanced to regular, but she continued to report some \nintermittent left lower quadrant abdominal discomfort despite \nhaving bowel movements, no nausea, and a normal white blood cell \ncount. The patient was made NPO and was started on TPN to \nprovide her with additional calories. A PICC line was placed and \nthe patient completed a 14 day course of meropenum. Because the \npatient was still experiencing pain, an additional 14 day course \nwas recommended. \n\nPhysical therapy evaluated her gait and mobility and recommended \nacute care rehab. She was seen by the pulmonary team to assess \nher respiratory status in the setting of bronchiectasis and \ninfection. Chest physical therapy and her home medication \nregimen were maintained. Her pulmonary status remained stable \nand she continued on a nasal cannula. \n\nThe patient's fever curve was closely watched for signs of \ninfection, of which there were none. The patient's blood cell \ncount normalized. The patient received subcutaneous heparin and \n___ dyne boots were used during this stay and was encouraged to \nget up and ambulate as early as possible.\n\nAt the time of discharge, the patient was doing well, afebrile \nand hemodynamically stable. She continued to have chronic, \nabdominal pain, which had decreased in intensity since her \nadmission to the hospital. She remained NPO on cycled TPN. Her \nelectrolytes were closely monitored. Recommendations were made \nfor an additional 14 day course of meropenum. An appointment \nfor follow-up was made with Dr. ___ in the ___ care clinic. \nThe patient received discharge teaching and follow-up \ninstructions with understanding verbalized and agreement with \nthe discharge plan.\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath \n2. Tiotropium Bromide 1 CAP IH DAILY \n3. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation DAILY \n4. Furosemide 40 mg PO BID \n5. Levothyroxine Sodium 75 mcg PO DAILY \n6. Guaifenesin ER 1200 mg PO DAILY \n7. Montelukast 10 mg PO DAILY \n8. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal DAILY \n9. Potassium Chloride 20 mEq PO DAILY \n\n \nDischarge Medications:\n1. Furosemide 40 mg PO BID \n2. Guaifenesin ER 600 mg PO Q12H \n3. Cepacol (Sore Throat Lozenge) 2 LOZ PO Q2H:PRN sore throat \n4. Docusate Sodium 100 mg PO BID \nhold for loose stool \n5. Montelukast 10 mg PO DAILY \n6. Tiotropium Bromide 1 CAP IH DAILY \n7. Levothyroxine Sodium 75 mcg PO DAILY \n8. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal DAILY \n9. Potassium Chloride 20 mEq PO DAILY \n10. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation DAILY \n11. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath \n12. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing \n13. Calcium Carbonate 500 mg PO QID:PRN indigestion or heartburn \n \n14. Senna 8.6 mg PO BID \n15. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n16. Heparin 5000 UNIT SC BID \n17. Meropenem 1000 mg IV Q8H \n14 day course (last dose ___ \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nSigmoid diverticulitis\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 the Acute Care Surgery Service on ___ \nwith abdominal pain. You had a CT scan that showed sigmoid \ndiverticulitis. You were placed on bowel rest, started on IV \nantibiotics, and IV fluids. Imaging showed a fluid collection in \nyour abdomen which was drained in interventional radiology. \nOnce your abdominal pain improved, your diet was advanced \nslowly. Your abdominal pain continued and you were made NPO, \nhad a PICC line placed in order to provide you with calories via \nthe intravenous and allow your bowel to rest. You were seen by \nphysical therapy and recommendations made for discharge to a \nrehabilitation facility to help you regain your strength and \nmobility. \nPlease note the following discharge instructions:\n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids.\n \nFollowup Instructions:\n___\n" ]

[ "K5732", "I272", "Z9981", "I2781", "K868", "Z681", "J479", "Z902", "N8320", "J449" ]

[ "K5732: Diverticulitis of large intestine without perforation or abscess without bleeding", "I272: Other secondary pulmonary hypertension", "Z9981: Dependence on supplemental oxygen", "I2781: Cor pulmonale (chronic)", "K868: Other specified diseases of pancreas", "Z681: Body mass index [BMI] 19.9 or less, adult", "J479: Bronchiectasis, uncomplicated", "Z902: Acquired absence of lung [part of]", "N8320: Unspecified ovarian cysts", "J449: Chronic obstructive pulmonary disease, unspecified" ]

[ "J449" ]

[]

[ " \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:\nElective admission for desens chemo\n \nMajor Surgical or Invasive Procedure:\nOxaliplatin Desens\n \nHistory of Present Illness:\nMr. ___ is a pleasant ___ w/ stage IIIB (pT3N2a) rectosigmoid\nadenocarcinoma, MMR intact, KRAS wildtype, s/p LAR on ___,\nnow on adjuvant FOLFOX presenting for scheduled admission for\noxaliplatin desensitization. His daughter was present in the \nroom\nand she requested to interpret and he denied any F/C, N/V, \nstated\nhe has been otherwise doing well and moving his bowels well.\n \nPast Medical History:\nONCOLOGIC HISTORY:\n-___: He initially presented with rectal bleeding and 20 lb\nweight loss over a ___ month period. \n-___: Colonoscopy showed a large apple core lesion in \nsigmoid\ncolon, ~15 cm from anal verge. Biopsy showed adenomatous\nepithelium with high-grade dysplasia, likely invasive. CEA was\n3.0. \n-___: CT Torso showed irregular wall thickening of the\ndistal sigmoid and multiple prominent adjacent lymph node and\nright internal iliac lymph nodes. There was no definitive\nevidence of metastatic disease. There was a non-specific 8 mm\nsclerotic lesion in T1 and 12 mm lucency in the left humerus.\nThere were also multiple incidental findings including a 1.5 x\n1.6 cm heterogeneously enhancing right kidney mass concerning \nfor\nprimary renal cell carcinoma, multiple bilateral simple renal\ncysts, hypoattenuating lesions in the pancreatic tail consistent\nwith side-branch IPMNs, hypoattenuating hepatic lesions likely\nbenign based on appearance, markedly enlarged prostate, and\nmultiple thyroid nodules.\n-___: Laparoscopic lower anterior resection. Pathology \nshowed\na pT3N2a adenocarcinoma, involving 5 of 16 lymph nodes, \nlow-grade\n(well or moderately differentiated), +venous invasion, LVI/PNI\nnegative, with negative margins. The tumor had intact MMR\nproteins by IHC and was KRAS wildtype.\n-___: C1D1 adjuvant FOLFOX.\n-___: Bone scan negative for areas concerning for \nmalignancy.\nThyroid ultrasound showed multiple nodules, largest on left\nmeasuring 1.7 x 1.2 x 1.6 cm without associated\nmicrocalcifications.\n- ___ C2D15 FOLFOX\n\nPAST MEDICAL/SURGICAL HISTORY:\n-Colon cancer as above.\n-s/p Laparoscopic cholecystectomy.\n \nSocial History:\n___\nFamily History:\nBrother - liver cancer\n___ other known family history of malignancy.\n \nPhysical Exam:\nVITAL SIGNS: 97.8F 138/80 80 141.8 lbs \nGeneral: NAD, Resting in bed comfortably\nHEENT: MMM, no OP lesions, no cervical/supraclavicular\nadenopathy\nCV: RR, NL S1S2 no S3S4 No MRG\nPULM: CTAB, No C/W/R, No respiratory distress\nABD: BS+, soft, NTND, no palpable masses or HSM, well healed\nsurgical scar\nLIMBS: WWP, no ___, no tremors\nSKIN: No rashes on the extremities\nNEURO: Grossly normal\n \nPertinent Results:\nn/a\n \nBrief Hospital Course:\n___ w/ stage IIIB (pT3N2a) rectosigmoid adenocarcinoma, MMR \nintact, KRAS wildtype, s/p LAR on ___, now on adjuvant \nFOLFOX presenting for oxaliplatin per desens protocol. He \ntolerated the chemotherapy well and was observed overnight and \nhe did not develop any reactions. He was discharged to the \nclinic for the remaining chemotherapy infusion to be set up. \nPlease refer to Dr. ___ for further details regarding the \nchemotherapy plan. Patient's home medications were not changed. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN pain \n2. LOPERamide 4 mg PO QID:PRN diarrhea \n3. Ondansetron 8 mg PO Q8H:PRN nausea \n4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain \n5. Prochlorperazine 10 mg PO Q6H:PRN nausea \n6. Psyllium Powder 1 PKT PO DAILY \n7. Tamsulosin 0.4 mg PO QHS \n8. LORazepam 1 mg PO BID:PRN anxiety \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN pain \n2. LOPERamide 4 mg PO QID:PRN diarrhea \n3. LORazepam 1 mg PO BID:PRN anxiety \n4. Ondansetron 8 mg PO Q8H:PRN nausea \n5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain \n6. Prochlorperazine 10 mg PO Q6H:PRN nausea \n7. Psyllium Powder 1 PKT PO DAILY \n8. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nStage IIIB Colon Cancer\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nMr. ___,\n\nIt was a pleasure taking care of you. You were admitted for \nchemotherapy under desensitization protocol and you tolerated it \nwell. We did not make any changes to your medications. You will \ngo to clinic as usual today for the rest of your chemotherapy.\n\nKeep up the great work!\n\nYour ___ Oncology Team\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C19", "Z888", "F17210", "Z800" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C19: Malignant neoplasm of rectosigmoid junction", "Z888: Allergy status to other drugs, medicaments and biological substances", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z800: Family history of malignant neoplasm of digestive organs" ]

[ "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nDapsone / methotrexate\n \nAttending: ___.\n \nChief Complaint:\nScheduled chemotherapy high dose methotrexate\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ PMH of HIV, CNS Lymphoma, Multinodular goiter causing\ndysphagia (s/p total thyroidectomy) presented for last of his\nyearly methotrexate infusions \n\nOf note patient had last MRI in ___ without e/o disease\nrecurrence so presents for last yearly MTX infusion then will be\nfollowed with observation alone. \n\nPatient is ___ speaking so bilingual nurse assisted for\ntranslation. \n\nPt reports that he is in his USOH without any neurologic\nconcerns/symptoms. He stated that he is eating, drinking,\nvoiding, stooling without difficulty. Noted that he has normal\nenergy levels. Reported that he is slightly anxious during\nadmissions, and is hopeful that he will not have to stay in the\nhospital too long \n \nREVIEW OF SYSTEMS: \nA complete 10-point review of systems was performed and was\nnegative unless otherwise noted in the HPI. \n \nPast Medical History:\n- HIV on HAART (viral load undetectable)\n- CAD\n- HTN\n- MI s/p stent placement x 3 (___)\n- CNS lymphoma (dx ___, on chemotherapy, no neuro deficits)\n\n \nSocial History:\n___\nFamily History:\nHis parents are alive; his mother has pre-diabetes while his \nfather has glaucoma and prostate cancer. He has 6 brothers. He \nhas 3 daughters and they are all healthy. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVitals: 24 HR Data (last updated ___ @ 1137)\n Temp: 98.5 (Tm 98.5), BP: 115/80, HR: 76, RR: 18, O2 sat:\n97%, O2 delivery: RA, Wt: 199.8 lb/90.63 kg \nGENERAL: Sitting in bed, appears comfortable, no acute distress,\npleasant, calm\nEYES: He was equally round reactive to light, anicteric sclera\nHEENT: Oropharynx clear, moist mucous membranes\nNECK: Supple, normal range of motion\nLUNGS: Clear to auscultation bilaterally no wheezes rales or\nrhonchi, no increased work of breathing \nCV: regular rate and rhythm, no murmurs rubs or gallops, normal\ndistal perfusion\nABD: Soft, nondistended, normoactive BS, nontender \nGENITOURINARY:\nno Foley or suprapubic tenderness\nEXT: No deformity, normal muscle bulk, normal strength 5 out of \n5\nall extremities\nSKIN: Warm dry, no rash \nNEURO: Alert and oriented x3, fluent speech, cranial nerves\nintact without focal deficits, strength intact in bilateral\nupper/lower extremities, sensation preserved grossly in all\nextremities.\nACCESS: Peripheral IV\n\nDISCHARGE EXAM:\n119 / 72 66 16 98 RA \nGENERAL: Standing in room, no distress, pleasant. \nEYES: Round reactive to light, anicteric sclera\nHEENT: Oropharynx clear, moist mucous membranes\nNECK: Supple, normal range of motion\nLUNGS: Clear to auscultation bilaterally no wheezes rales or\nrhonchi, no increased work of breathing \nCV: regular rate and rhythm, no murmurs rubs or gallops, normal\ndistal perfusion\nABD: Soft, nondistended, normoactive BS, nontender\nGENITOURINARY: no Foley or suprapubic tenderness\nEXT: No deformity, normal muscle bulk, normal strength 5 out of \n5\nall extremities\nSKIN: Warm dry, no rash \nNEURO: Alert and oriented x3, fluent speech, cranial nerves\nintact without focal deficits, strength intact in bilateral\nupper/lower extremities, sensation preserved grossly in all\nextremities.\n \nPertinent Results:\nADMISSION LABS:\n___ 12:30PM BLOOD WBC-4.2 RBC-4.79 Hgb-14.7 Hct-44.4 MCV-93 \nMCH-30.7 MCHC-33.1 RDW-12.7 RDWSD-43.5 Plt ___\n___ 12:30PM BLOOD Neuts-55.8 ___ Monos-8.9 Eos-2.2 \nBaso-0.7 Im ___ AbsNeut-2.32 AbsLymp-1.34 AbsMono-0.37 \nAbsEos-0.09 AbsBaso-0.03\n___ 12:30PM BLOOD ___ PTT-32.9 ___\n___ 12:30PM BLOOD Glucose-96 UreaN-13 Creat-1.3* Na-140 \nK-4.2 Cl-107 HCO3-23 AnGap-10\n___ 12:30PM BLOOD ALT-31 AST-25 AlkPhos-64 TotBili-0.3\n___ 12:30PM BLOOD Calcium-9.2 Phos-3.0 Mg-2.0\n\nLFT trend:\n___ 12:30PM BLOOD ALT-31 AST-25 AlkPhos-64 TotBili-0.3\n___ 05:48AM BLOOD ALT-26 AST-20 AlkPhos-59 TotBili-0.2\n___ 09:00AM BLOOD ALT-175* AST-116* AlkPhos-71 TotBili-0.4\n___ 09:00AM BLOOD ALT-203* AST-133* AlkPhos-60 TotBili-0.3\n___ 09:00AM BLOOD ALT-281* AST-164* AlkPhos-69 TotBili-0.6\n___ 03:08PM BLOOD ALT-319* AST-192* AlkPhos-71 TotBili-0.5\n___ 05:45AM BLOOD ALT-405* AST-248* AlkPhos-68 TotBili-0.7\n___ 06:00AM BLOOD ALT-332* AST-139* AlkPhos-67 TotBili-0.4\n\nMTX trend:\n___ 09:00AM BLOOD mthotrx-1.8*\n___ 09:00AM BLOOD mthotrx-0.53*\n___ 09:00AM BLOOD mthotrx-0.11\n___ 03:08PM BLOOD mthotrx-0.09\n___ 05:45AM BLOOD mthotrx-0.05\n___ 06:00AM BLOOD mthotrx-<0.04\n\nOTHER DISCHARGE LABS:\n___ 06:00AM BLOOD WBC-3.1* RBC-4.74 Hgb-14.9 Hct-44.7 \nMCV-94 MCH-31.4 MCHC-33.3 RDW-12.2 RDWSD-42.7 Plt ___\n___ 06:00AM BLOOD Neuts-63.7 ___ Monos-2.9* Eos-1.9 \nBaso-0.3 Im ___ AbsNeut-2.00 AbsLymp-0.97* AbsMono-0.09* \nAbsEos-0.06 AbsBaso-0.01\n___ 06:00AM BLOOD ___ PTT-30.2 ___\n___ 06:00AM BLOOD Glucose-91 UreaN-8 Creat-1.3* Na-139 \nK-4.2 Cl-98 HCO3-32 AnGap-9*\n___ 06:00AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.___ PMH of HIV, CNS Lymphoma, Multinodular goiter causing \ndysphagia (s/p total thyroidectomy) presented for last of his \nyearly methotrexate infusions course c/b transaminitis\n\n#CNS Lymphoma\n#Transaminitis ___ liver injury from methotrexate infusion\nLast MRI in ___ without e/o disease recurrence so presented \nfor yearly MTX infusion. Dosing was complicated by transaminitis \nwhich was improving but not resolved by time of discharge. \nPatient was instructed to schedule an appt and repeat lab draw \nfor LFTs with his PCP ___ 1 week to ensure that they have \nnormalized. Pt is to f/u with Dr ___ in ___ year. \n\n#CAD: \nTakes single agent ASA at home. Given interference with MTX, ASA \nreplaced with Plavix during stay\n\n#HTN\nContinued on lisinopril/metoprolol during stay\n\n#HLD\nStatin held during stay and on discharge in view of \ntransaminitis. Patient is to continue to withhold dosing until \nhis LFTs are re-checked by his primary care doctor.\n\n#HIV\nReportedly well controlled, continued on stribild\n\n#Headache/Migraine\nRight sided above eye. Occurred on ___, unresponsive to \nmultiple agents, CTH negative for acute issues, eventually \nresolved with fioricet.\n\nTransitional Issues:\n1. Patient was instructed to schedule an appt and repeat lab \ndraw for LFTs with his PCP ___ 1 week to ensure that they have \nnormalized. \n2.Patient is to continue to withhold pravastatin dosing until \nhis LFTs are re-checked by his primary care doctor\n3.Pt is to f/u with Dr ___ in ___ year\n\nI personally spent 26 minutes preparing discharge paperwork, \neducating patient/family, answering questions, and coordinating \ncare with outpatient providers\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Lisinopril 5 mg PO DAILY \n3. Metoprolol Succinate XL 25 mg PO DAILY \n4. Pravastatin 80 mg PO QPM \n5. Stribild 1 tab Other DAILY \n6. Levothyroxine Sodium 150 mcg PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Levothyroxine Sodium 150 mcg PO DAILY \n3. Lisinopril 5 mg PO DAILY \n4. Metoprolol Succinate XL 25 mg PO DAILY \n5. Stribild 1 tab Other DAILY \n6. HELD- Pravastatin 80 mg PO QPM This medication was held. Do \nnot restart Pravastatin until you have your liver tests \nre-checked by your primary care doctor in 1 weeks time\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nCNS Lymphoma\nHD MTX infusion\nHIV\nTransaminitis\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\nIt was a pleasure taking care of you while you were hospitalized \nat ___. As you know, you were admitted for your annual \nmethotrexate infusion which you tolerated well. You should get \nyour liver tests checked in 1 week by your primary care doctor \nto ensure that they have normalized. \n\nDr ___ will call you with followup appointment details \nfor next year. \n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C8589", "B20", "E785", "E890", "I2510", "I10", "I252", "T451X5A", "R740", "G43909", "E876", "E8339", "R12", "Z955", "Y92239" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C8589: Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites", "B20: Human immunodeficiency virus [HIV] disease", "E785: Hyperlipidemia, unspecified", "E890: Postprocedural hypothyroidism", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I10: Essential (primary) hypertension", "I252: Old myocardial infarction", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "E876: Hypokalemia", "E8339: Other disorders of phosphorus metabolism", "R12: Heartburn", "Z955: Presence of coronary angioplasty implant and graft", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]

[ "E785", "I2510", "I10", "I252", "Z955" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: UROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nLeft renal mass\nAnticoagulation for CAD w/ stents (on Xarelto)\nAtrial Fibrillation\n \nMajor Surgical or Invasive Procedure:\nNEPHRECTOMY RADICAL LAPAROSCOPIC LEFT \n\n \nHistory of Present Illness:\n___ is a ___ male with a history of coronary artery\ndisease status post stents ×3, atrial fibrillation on Xarelto \nand\nbaby aspirin, diabetes, hypertension who was found to have a \nleft\n5.3 cm incidental renal mass on CT scan during a colonoscopy\nworkup. Although he has chronic back pain, he does not have any\nflank pain. He denies any episodes of gross hematuria, urinary\ntract infections. He denies constitutional symptoms including\nfevers, chills, unintentional weight loss. He does endorse\noccasional night sweats.\n\nIn terms of urination, he has no complaints. He has had no\nprevious work on his prostate and takes no medications. His AUA\nsymptom score today is 5.\nAllergies:\nNKDA\n\n \nPast Medical History:\nPast medical history:\nCoronary artery disease s/p stents in ___\nDiabetes\nHypertension\nSquamous cell carcinoma of the ear status post resection\nChronic back problems requiring spinal fusion\nHeart murmur\nDiarrhea\nTracheomalacia\n\nSurgeries:\nCardiac stents ×3 in ___\nGallbladder\nBilateral knee replacements\nRight rotator cuff\nMultiple spinal fusions\nCataract surgery bilaterally\nMohs procedure for his left ear\n\n \nSocial History:\n___\nFamily History:\nAlcoholism\nHeart disease\nBlood clots\nDenies prostate, kidney, bladder cancer\nHis sisters have a history of lung cancer and breast cancer\n\n \nPhysical Exam:\nWdWn, NAD, AVSS\nInteractive, cooperative\nAbdomen soft, appropriately tender along incisions\nIncisions otherwise c/d/i\nExtremities w/out edema or pitting and there is no reported calf \npain to deep palpation\n\n \nPertinent Results:\n___ 04:45AM BLOOD WBC-10.6* RBC-3.65* Hgb-11.3* Hct-34.1* \nMCV-93 MCH-31.0 MCHC-33.1 RDW-13.2 RDWSD-44.8 Plt ___\n___ 06:54AM BLOOD WBC-12.1*# RBC-3.49* Hgb-10.9* Hct-33.2* \nMCV-95 MCH-31.2 MCHC-32.8 RDW-13.5 RDWSD-46.6* Plt ___\n___ 07:06AM BLOOD Glucose-114* UreaN-18 Creat-1.6* Na-142 \nK-4.4 Cl-102 HCO3-25 AnGap-15\n___ 04:45AM BLOOD Glucose-122* UreaN-15 Creat-1.7* Na-144 \nK-4.0 Cl-103 HCO3-25 AnGap-16\n___ 06:54AM BLOOD Glucose-201* UreaN-17 Creat-1.7* Na-143 \nK-4.6 Cl-104 HCO3-25 AnGap-14\n___ 04:45AM BLOOD Calcium-9.0 Phos-2.2* Mg-1.9\n \nBrief Hospital Course:\nMr. ___ was admitted to Urology after undergoing \nlaparoscopic left radical nephrectomy. No concerning \nintraoperative events occurred; please see dictated operative \nnote for details. The patient received perioperative antibiotic \nprophylaxis. The patient was transferred to the floor from the \nPACU in stable condition. On POD0, pain was well controlled on \nPCA, hydrated for urine output >30cc/hour, provided with \npneumoboots and incentive spirometry for prophylaxis, and \nambulated once. On POD1, the patient was restarted on home \nmedications, basic metabolic panel and complete blood count were \nchecked, pain control was transitioned from PCA to oral \nanalgesics, diet was advanced to a clears/toast and crackers \ndiet. On POD2, JP and urethral Foley catheter were removed \nwithout difficulty and diet was advanced as tolerated. The \nremainder of the hospital course was relatively unremarkable. \nThe patient was discharged on POD3 in stable condition, eating \nwell, ambulating independently, voiding without difficulty, and \nwith pain control on oral analgesics. On exam, incision was \nclean, dry, and intact, with no evidence of hematoma collection \nor infection. The patient was given explicit instructions to \nfollow-up in clinic in four weeks.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 10 mg PO DAILY \n2. Metoprolol Succinate XL 25 mg PO DAILY \n3. MetFORMIN XR (Glucophage XR) 1000 mg PO BID \n4. Rivaroxaban 15 mg PO QPM \n5. Rosuvastatin Calcium 20 mg PO QPM \n6. Furosemide 20 mg PO DAILY \n7. Aspirin 81 mg PO DAILY \n8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain; max 3 doses \n9. Multivitamins 1 TAB PO DAILY \n10. Cyanocobalamin 500 mcg PO DAILY \n11. Lantus (insulin glargine) 100 unit/mL subcutaneous QHS \n12. HumaLOG KwikPen (insulin lispro) 100 unit/mL subcutaneous \nQIDACHS \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg ONE capsule(s) by mouth \ntwice a day Disp #*60 Capsule Refills:*0 \n3. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg HALF tab by mouth Q4hrs Disp #*10 Tablet \nRefills:*0 \n4. Senna 17.2 mg PO QHS \n5. Aspirin 81 mg PO DAILY \n6. Cyanocobalamin 500 mcg PO DAILY \n7. Furosemide 20 mg PO DAILY \n8. HumaLOG KwikPen (insulin lispro) 100 unit/mL subcutaneous \nQIDACHS \n9. Lantus (insulin glargine) 100 unit/mL subcutaneous QHS \n10. Lisinopril 10 mg PO DAILY \n11. MetFORMIN XR (Glucophage XR) 1000 mg PO BID \n12. Metoprolol Succinate XL 25 mg PO DAILY \n13. Multivitamins 1 TAB PO DAILY \n14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain; max 3 \ndoses \n15. Rivaroxaban 15 mg PO QPM \n16. Rosuvastatin Calcium 20 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nLeft renal mass.\nHiatal hernia.\nAtrial Fibrillation\nAnticoagulation (Xarelto)\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n-Please also refer to the provided “handout” that details \ninstructions and expectations for your post-operative phase as \nmade available by your urologist. \n\n-Resume your pre-admission/home medications except as noted. \nALWAYS call to inform, review and discuss any medication changes \nand your post-operative course with your primary care doctor.\n\n-___ reduce the strain/pressure on your abdomen and incision \nsites; remember to “log roll” onto your side and then use your \nhands to push yourself upright while taking advantage of the \nmomentum of putting your legs/feet to the ground.\n\n--There may be bandage strips called “steristrips” which have \nbeen applied to reinforce wound closure. Allow these bandage \nstrips to fall off on their own over time but PLEASE REMOVE ANY \nREMAINING GAUZE DRESSINGS WITHIN 2 DAYS OF DISCHARGE. You may \nget the steristrips wet.\n\nFor pain control, try TYLENOL (acetaminophen) FIRST, then take \nthe narcotic pain medication as prescribed if additional pain \nrelief is needed.\n\n-Call your Urologist's office to schedule/confirm your follow-up \nappointment in 4 weeks AND if you have any questions.\n\n-Do not eat constipating foods for ___ weeks, drink plenty of \nfluids to keep hydrated\n\n-No vigorous physical activity or sports for 4 weeks or until \notherwise advised. Light household chores/activity and leisurely \nwalking/activity is OK and should be continued. Do NOT be a \n“couch potato”\n\n-Tylenol should be your first-line pain medication. A narcotic \npain medication has been prescribed for breakthrough pain ___.\n\n-Max daily Tylenol (acetaminophen) dose is THREE grams from ALL \nsources\n\n•AVOID lifting/pushing/pulling items heavier than 10 pounds (or \n3 kilos; about a gallon of milk) or participate in high \nintensity physical activity (which includes intercourse) until \nyou are cleared by your Urologist in follow-up.\n\n-No DRIVING for THREE WEEKS or until you are cleared by your \nUrologist\n\n-You may shower normally but do NOT immerse your incisions or \nbathe\n\n-Do not drive or drink alcohol while taking narcotics and do not \noperate dangerous machinery\n\n-You may be given “prescriptions” for a stool softener and/or a \ngentle laxative. These are over-the-counter medications that \nmay be “health care spending account reimbursable.” \n\n-Colace (docusate sodium) may have been prescribed to avoid \npost-surgical constipation or constipation related to use of \nnarcotic pain medications. Discontinue if loose stool or \ndiarrhea develops. Colace is a stool-softener, NOT a laxative.\n\n-Senokot (or any gentle laxative) may have been prescribed to \nfurther minimize your risk of constipation. \n\n-If you have fevers > 101.5 F, vomiting, or increased redness, \nswelling, or discharge from your incision, call your doctor or \ngo to the nearest emergency room.\n \nFollowup Instructions:\n___\n" ]

[ "C642", "I130", "E1122", "I5032", "I480", "E785", "N189", "G4733", "I259", "K219", "Z96653", "M479", "Z794", "Z85828", "Z86718", "Z955", "Z7902" ]

[ "C642: Malignant neoplasm of left kidney, except renal pelvis", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I5032: Chronic diastolic (congestive) heart failure", "I480: Paroxysmal atrial fibrillation", "E785: Hyperlipidemia, unspecified", "N189: Chronic kidney disease, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "I259: Chronic ischemic heart disease, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z96653: Presence of artificial knee joint, bilateral", "M479: Spondylosis, unspecified", "Z794: Long term (current) use of insulin", "Z85828: Personal history of other malignant neoplasm of skin", "Z86718: Personal history of other venous thrombosis and embolism", "Z955: Presence of coronary angioplasty implant and graft", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]

[ "I130", "E1122", "I5032", "I480", "E785", "N189", "G4733", "K219", "Z794", "Z86718", "Z955", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: UROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nprostate cancer\n \nMajor Surgical or Invasive Procedure:\nrobotic prostatectomy\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old man who was diagnosed with \nprostate cancer and elected to proceed with robotic radical \nprostatectomy and lymph node dissection. \n \nPhysical Exam:\nWDWN, NAD, AVSS\nAbdomen soft, non-distended, appropriately tender along incision \nsites\nIncisions C/D/I \nFoley in place, secured to medial thigh. \nBilateral lower extremities w/out edema, pitting or pain to deep \npalpation of calves\n\n \nBrief Hospital Course:\nMr. ___ was admitted to the Urology Service after \nundergoing robotic assisted laparoscopic prostatectomy. No \nconcerning intra-operative events occurred; please see dictated \noperative note for full details. The patient received \n___ antibiotic prophylaxis. At the end of the \nprocedure the patient was extubated and transported to the PACU \nfor further recovery before being transferred to the floor. He \nwas transferred from the PACU in stable condition. On POD0, pain \nwas well controlled on PCA, hydrated with intravenous fluids for \nurine output >30cc/hour, provided with pneumoboots and incentive \nspirometry for prophylaxis, and he ambulated once. On POD1, the \npatient was restarted on home medications, basic metabolic panel \nand complete blood count were checked, pain control was \ntransitioned from PCA to oral analgesics, diet was advanced to a \nclears/toast and crackers diet for breakfast and lunch. Foley \ncatheter care and leg bag teaching was provided by nursing. The \nremainder of the hospital course was unremarkable. The patient \nwas discharged in stable condition, eating well, ambulating \nindependently, and with pain control on oral analgesics. On \nexam, incision was clean, dry, and intact, with no evidence of \nhematoma collection or infection. The patient was given explicit \ninstructions to follow-up in one week for post-operative \nevaluation and trial of voiding.\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \n2. Bacitracin Ointment 1 Appl TP TID \n3. Docusate Sodium 100 mg PO BID \n4. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - \nModerate\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nprostate cancer\n\n \nDischarge Condition:\nstable\nmental status appropriate\nambulatory\n\n \nDischarge Instructions:\n-Please also reference the additional handout provided by your \nurologist with instructions and information about your surgery \nand post-operative plan of care.\n\n-Please also reference the instructions provided by nursing on \nFoley catheter care, hygiene and waste elimination. \n\n-ALWAYS follow-up with your referring provider ___ your PCP \nto discuss and review your post-operative course and \nmedications. Any NEW medications should also be reviewed with \nyour pharmacist.\n\n-Resume your pre-admission medications except as noted AND you \nnote that you NO longer need to take medications that shrink \nyour prostate (Hytrin, Avodart, Flomax, etc.)\n\n-You may take ibuprofen and the prescribed narcotic together for \npain control. FIRST, use Tylenol and Ibuprofen. Add the \nprescribed narcotic (examples: Oxycodone, Dilaudid, \nHydromorphone) for break through pain that is >4 on the pain \nscale.\n\n-The maximum dose of Tylenol (ACETAMINOPHEN) is 3- 4 grams (from \nALL sources) PER DAY.\n\n-Ibuprofen should always be taken with food. If you develop \nstomach pain or note black stool, stop the Ibuprofen. Ibuprofen \nworks best when taken “around the clock.”\n\n-For your safety and the safety of others; PLEASE DO NOT drive, \noperate dangerous machinery, or consume alcohol while taking \nnarcotic pain medications. \n\n-Do NOT drive while Foley catheter is in place.\n\n-AVOID lifting/pushing/pulling items heavier than 10 pounds (or \n3 kilos; about a gallon of milk) or participate in high \nintensity physical activity (which includes intercourse) until \nyou are cleared by your Urologist in follow-up. Generally about \nFOUR weeks. Light household chores are generally “ok”. Do not \nvacuum. \n\n-No DRIVING for THREE WEEKS or until you are cleared by your \nUrologist\n\n-Do not drive or drink alcohol while taking narcotics and do not \noperate dangerous machinery\n\n-You may be given “prescriptions” for a stool softener ___ a \ngentle laxative. These are over-the-counter medications that \nmay be “health care spending account reimbursable.” \n\n-Colace (docusate sodium) may have been prescribed to avoid \npost-surgical constipation or constipation related to use of \nnarcotic pain medications. Discontinue if loose stool or \ndiarrhea develops. Colace is a stool-softener, NOT a laxative.\n\n-Senokot (or any gentle laxative) may have been prescribed to \nfurther minimize your risk of constipation. \n\n-You may shower 2 days after surgery, but do not tub bathe, \nswim, soak, or scrub incision for 2 weeks\n\n-If you had a drain removed from your abdomen, bandage strips \ncalled “steristrips” have been applied to close the wound. Allow \nthese bandage strips to fall off on their own ___ days). \nPLEASE REMOVE any remaining dressings w/ gauze within 2 days of \ndischarge. You may get the steristrips wet.\n\n-___ medical attention for fevers (temp>101.5), worsening pain, \ndrainage or excessive\nbleeding from incision, chest pain or shortness of breath.\n\n-Your Foley should be secured to the catheter secure on your \nthigh at ALL times until your follow up with the surgeon.\n\n-Follow up in 1 week for wound check and Foley removal. DO NOT \nallow anyone that is outside of the urology team remove your \nFoley for any reason.\n\n-Wear Large Foley bag for majority of time; the leg bag is only \nfor short-term when leaving the house, etc.\n\n-Take prescribed antibiotic for Foley catheter removal as \ndirected\n\n-resume regular home diet and remember to drink plenty of fluids \nto keep hydrated and to minimize risk of constipation. For the \nfirst few days at home, you should eat SMALL PORTIONS. Avoid \nhigh fat, bulky or fried foods. \n\n-___ medical attention for fevers (temp>101.5), worsening pain, \ndrainage or excessive\nbleeding from incision, chest pain or shortness of breath.\n\n \nFollowup Instructions:\n___\n" ]

[ "C61", "E785", "E890", "Z85850" ]

[ "C61: Malignant neoplasm of prostate", "E785: Hyperlipidemia, unspecified", "E890: Postprocedural hypothyroidism", "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: SURGERY\n \nAllergies: \nPenicillins / Epinephrine / Shellfish Derived / Latex / Ginseng \n/ Moxifloxacin / Avelox / lisinopril\n \nAttending: ___.\n \nChief Complaint:\nventral hernia\n \nMajor Surgical or Invasive Procedure:\n___: Exploratory laparotomy, lysis of adhesions, component \nseparation, with incisional hernia repair with mesh.\n\n \nHistory of Present Illness:\n___ had abdominal surgery with the extraction site of a \nspecimen in the midline and developed a midline bulge in the \nsetting of diastasis recti. Was offered surgical repair with \ncomponent separation for resolution of the hernia. \n \nPast Medical History:\n-cervical spondylosis\n-spinal stenosis\n-adenomatous colonic polyps\n-acid reflux disease with ___ esophagus\n-osteoarthritis \n-osteopenia\n-neurogenic pruritus\n-idiopathic thrombocytopenic purpura for which she receives \noccasional infusions of IVIGthrough Dr. ___. Her platelets \nhave recently been stable. \n-severe COPD. She is followed by Dr. ___. Her most \nrecent\nFEV1 is 1.3 liters. She has never required hospitalization for\nintubation or steroids. She can walk half a mile without \nstopping and has only needed home oxygen temporarily after her \nhip replacement.\n\n \nSocial History:\n___\nFamily History:\nSister with uterine cancer \nMother, deceased at ___, had h/o COPD\nFather, deceased at ___, h/o lung ca \n\n \nPhysical Exam:\nDischarge Physical Exam: \n VS: 98.1 PO 111 / 67 76 18 94% \n GEN: AA&O x 3, NAD, calm, cooperative. \n HEENT: mucous membranes moist, no scleral icterus\n CARDIAC: regular rate and rhythm, no murmurs appreciated\n CHEST: Clear to auscultation bilaterally\n ABDOMEN: soft, +periwound tenderness without rebound tenderness \nor guarding,\n + ___ soft bulge above incision which is c/d/i \ncovered with steri- \n strips \n EXTREMITIES: Warm, well perfused, no edema, bilaterally \n \nPertinent Results:\nLABS:\n___ 05:13AM BLOOD WBC-12.3*# RBC-3.46* Hgb-10.5* Hct-31.7* \nMCV-92 MCH-30.3 MCHC-33.1 RDW-15.4 RDWSD-52.0* Plt ___ \nGlucose-116* UreaN-10 Creat-0.6 Na-140 K-4.3 Cl-102 HCO3-29 \nAnGap-9\n\n___ 09:05AM BLOOD WBC-10.1* RBC-3.59* Hgb-10.7* Hct-33.3* \nMCV-93 MCH-29.8 MCHC-32.1 RDW-15.1 RDWSD-51.7* Plt ___ \n___ PTT-29.5 ___ glucose-156* UreaN-6 Creat-0.6 \nNa-137 K-4.2 Cl-97 HCO3-27 AnGap-13\n \nBrief Hospital Course:\nMs. ___ presented pre-op on ___ where she was \nevaluated by anaesthesia and surgery. She was subsequently \ntaken to the operating room where she underwent an sxploratory \nlaparotomy, lysis of adhesions, component separation, with \nincisional hernia repair with mesh. There were no adverse events \nin the operating room; please see the operative note for \ndetails. Pt was extubated, taken to the PACU until stable, then \ntransferred to the ward for observation. \nNeuro: The patient was alert and oriented throughout \nhospitalization; pain was initially managed with a thoracic \nepidural, which was removed on POD3. She was then transitioned \nto oral oxycodone with good pain control. \nCV: The patient remained stable from a cardiovascular \nstandpoint; vital signs were routinely monitored.\nPulmonary: The patient remained stable from a pulmonary \nstandpoint; vital signs were routinely monitored. Good pulmonary \ntoilet, early ambulation and incentive spirometry were \nencouraged throughout hospitalization with gradual weaning of \nsupplemental oxygen, which she did continue to require at the \ntime of discharge to the rehabilitation facility. Her home \nAdvair, Singulair and Spiriva were resumed on POD2.\nGI/GU/FEN: The patient was initially on a clear liquid diet, \nwhich was sequentially advanced to regular on POD3. She \ntolerated po intake well without nausea, vomiting or pain. \nPatient's intake and output were closely monitored\nID: The patient's fever curves were closely watched for signs of \ninfection, of which there were none.\nHEME: The patient's blood counts were closely watched for signs \nof bleeding, of which there were none.\nProphylaxis: The patient received subcutaneous heparin and ___ \ndyne boots were used during this stay and was encouraged to get \nup and ambulate as early as possible.\nAt the time of discharge, the patient was doing well, afebrile \nand hemodynamically stable. The patient was tolerating a diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan.\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID \n3. Tiotropium Bromide 1 CAP IH DAILY \n4. Aspirin 81 mg PO DAILY \n5. Albuterol Sulfate (Extended Release) 4 mg PO Q12H \n6. TraZODone 25 mg PO QHS:PRN insomnia \n7. BusPIRone 10 mg PO TID \n8. dexlansoprazole 60 mg oral BID \n9. DICYCLOMine 10 mg PO TID \n10. Montelukast 10 mg PO DAILY \n11. pitavastatin 2 mg oral DAILY \n12. Metoprolol Succinate XL 25 mg PO DAILY \n13. FLUoxetine 60 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild \n2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing/ SOB \n3. Heparin 5000 UNIT SC BID \n4. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting \n5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain \n6. Sarna Lotion 1 Appl TP TID:PRN pruritis \n7. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush \n\n8. Albuterol Sulfate (Extended Release) 4 mg PO Q12H \n9. Aspirin 81 mg PO DAILY \n10. BusPIRone 10 mg PO TID \n11. dexlansoprazole 60 mg oral BID \n12. DICYCLOMine 10 mg PO TID \n13. FLUoxetine 60 mg PO DAILY \n14. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n15. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID \n16. Metoprolol Succinate XL 25 mg PO DAILY \n17. Montelukast 10 mg PO DAILY \n18. pitavastatin 2 mg oral DAILY \n19. Tiotropium Bromide 1 CAP IH DAILY \n20. TraZODone 25 mg PO QHS:PRN insomnia \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nIncisional hernia\nSevere diastasis\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 have undergone repair of your abdominal wall hernia, \nrecovered in the hospital and are now preparing for discharge to \nthe rehabilitation facility ___ in ___ with the \nfollowing instructions:\n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon.\n\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\nIncision Care:\n*Please call your doctor or nurse practitioner if you have \nincreased pain, swelling, redness, or drainage from the incision \nsite.\n*Avoid swimming and baths until your follow-up appointment.\n*You may shower, and wash surgical incisions with a mild soap \nand warm water. Gently pat the area dry.\n*If you have staples, they will be removed at your follow-up \nappointment.\n*If you have steri-strips, they will fall off on their own. \nPlease remove any remaining strips ___ days after surgery.\n\n \nFollowup Instructions:\n___\n" ]

[ "K432", "Q7959", "D693", "J449", "M47892", "K219", "K2270", "I9581" ]

[ "K432: Incisional hernia without obstruction or gangrene", "Q7959: Other congenital malformations of abdominal wall", "D693: Immune thrombocytopenic purpura", "J449: Chronic obstructive pulmonary disease, unspecified", "M47892: Other spondylosis, cervical region", "K219: Gastro-esophageal reflux disease without esophagitis", "K2270: Barrett's esophagus without dysplasia", "I9581: Postprocedural hypotension" ]

[ "J449", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nSulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\npprom\n \nMajor Surgical or Invasive Procedure:\nexam under anesthesia s/p vaginal delivery, bakri placed \npostpartum, removed\n\n \nPhysical Exam:\nOn discharge:\n Vitals: \n24 HR Data (last updated ___ @ 018)\n Temp: 97.5 (Tm 98.1), BP: 101/67 (97-131/61-77), HR: 99\n(94-99), RR: 18, O2 sat: 99% (98-99), O2 delivery: RA\nFluid Balance (last updated ___ @ 020)\n Last 8 hours Total cumulative -900ml\n IN: Total 0ml\n OUT: Total 900ml, Urine Amt 900ml\n Last 24 hours Total cumulative -2600ml\n IN: Total 1000ml, PO Amt 1000ml\n OUT: Total 3600ml, Urine Amt 3600ml\n\n General: NAD, A&Ox3\n CV: RRR\n Lungs: No respiratory distress\n Abd: soft, overall nontender excepting some mild tenderness\nover umbilicus, fundus firm below umbilicus\n Lochia: minimal\n Extremities: no calf tenderness, no edema\n \nPertinent Results:\n___ 03:05AM BLOOD WBC-17.2* RBC-2.59* Hgb-8.6* Hct-25.2* \nMCV-97 MCH-33.2* MCHC-34.1 RDW-15.1 RDWSD-52.8* Plt Ct-81*\n___ 01:18AM BLOOD WBC-16.9* RBC-2.67* Hgb-9.0* Hct-25.3* \nMCV-95 MCH-33.7* MCHC-35.6 RDW-14.6 RDWSD-50.4* Plt Ct-83*\n___ 08:45PM BLOOD WBC-16.2* RBC-2.54* Hgb-8.9* Hct-26.7* \nMCV-105* MCH-35.0* MCHC-33.3 RDW-14.1 RDWSD-53.8* Plt ___\n___ 03:10PM BLOOD WBC-10.1* RBC-3.07* Hgb-10.7* Hct-31.0* \nMCV-101* MCH-34.9* MCHC-34.5 RDW-14.2 RDWSD-52.0* Plt ___\n___ 10:40AM BLOOD WBC-8.2 RBC-2.82* Hgb-9.9* Hct-29.3* \nMCV-104* MCH-35.1* MCHC-33.8 RDW-14.2 RDWSD-53.3* Plt ___\n___ 12:30PM BLOOD WBC-11.2* RBC-2.98* Hgb-10.5* Hct-30.4* \nMCV-102* MCH-35.2* MCHC-34.5 RDW-13.8 RDWSD-50.6* Plt ___\n___ 01:18AM BLOOD Glucose-92 UreaN-9 Creat-0.4 Na-133* \nK-3.7 Cl-107 HCO3-17* AnGap-9*\n \nBrief Hospital Course:\nANTEPARTUM\n\nShe was admitted to antepartum after it was confirmed that her \namniotic membranes ruptured. She was given latency antibiotics, \nunderwent a NICU consult, and received betamethasone. She \nremained stable until 34 weeks gestational age and underwent \ninduction of labor. \n\nPOST PARTUM\nOn ___, patient had a spontaneous vaginal delivery. This was \ncomplicated by post partum hemorrhage and chorioamnionitis.\n\nRegarding her postpartum hemorrhage, her total estimated blood \nloss was 2400mL due to uterine atony and a posterior cervical \nlaceration. She necessitated an OR takeback for improved \nvisualization and repair of the cervical laceration. She \nreceived pitocin, cytotec, methergine, TXA. A Bakri balloon \nballoon for 240mL was placed as well as vaginal packing. She \nreceived 2 units of packed RBCs. Her hematocrit was obtained and \nnoted to be 25.3 (___) with platelets of 83. Her fibrinogen was \n180. Her INR was 1.3 over two measurements (___). Her vitals \nremained stable and her vaginal packing and bakri balloon were \nremoved on ___. \n\nRegarding her chorioamnionitis, patient received 2g of ancef in \nthe OR. She had a fever of approximately ___ on ___ at \n2145. She received ampicillin and gentamicin for 24 hours first \nafebrile ___ afebrile 0300 ___. \n\nFor her GDMA1, patient's fingersticks were not followed.\n\nOn post partum day 3, ___, patient had stable vitals and \naccomplished all her post partum milestones. Her bleeding was \nstable and she was thus discharged to home in stable condition. \n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever \n2. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild/Fever NOT relieved \nby Acetaminophen \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours \nDisp #*40 Tablet Refills:*0 \n3. Docusate Sodium 100 mg PO BID \n4. Levothyroxine Sodium 50 mcg PO 5X/WEEK (___) \n5. Levothyroxine Sodium 25 mcg PO 2X/WEEK (___) \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\ns/p vaginal delivery\npostpartum hemorrhage\n\n \nDischarge Condition:\nstable\n\n \nDischarge Instructions:\npelvic rest for 6 weeks, rest\n \nFollowup Instructions:\n___\n" ]

[ "O42113", "Z370", "O411230", "O4443", "O4403", "O721", "O713", "O403XX0", "O24420", "O418X30", "O368930", "Z3A32", "O631", "O701", "O99284", "E039", "O9989", "H9041", "O26893", "L298" ]

[ "O42113: Preterm premature rupture of membranes, onset of labor more than 24 hours following rupture, third trimester", "Z370: Single live birth", "O411230: Chorioamnionitis, third trimester, not applicable or unspecified", "O4443: Low lying placenta NOS or without hemorrhage, third trimester", "O4403: Complete placenta previa NOS or without hemorrhage, third trimester", "O721: Other immediate postpartum hemorrhage", "O713: Obstetric laceration of cervix", "O403XX0: Polyhydramnios, third trimester, not applicable or unspecified", "O24420: Gestational diabetes mellitus in childbirth, diet controlled", "O418X30: Other specified disorders of amniotic fluid and membranes, third trimester, not applicable or unspecified", "O368930: Maternal care for other specified fetal problems, third trimester, not applicable or unspecified", "Z3A32: 32 weeks gestation of pregnancy", "O631: Prolonged second stage (of labor)", "O701: Second degree perineal laceration during delivery", "O99284: Endocrine, nutritional and metabolic diseases complicating childbirth", "E039: Hypothyroidism, unspecified", "O9989: Other specified diseases and conditions complicating pregnancy, childbirth and the puerperium", "H9041: Sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side", "O26893: Other specified pregnancy related conditions, third trimester", "L298: Other pruritus" ]

[ "E039" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / Nsaids / Influenza Virus \nVaccine\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with a PMH notable for CKD\nstage ___ who presents with recurrent abdominal pain.\n\nOriginally presented to ___ ED on ___ with severe, achy,\nepigastric abdominal pain, sudden onset, radiates to back,\nassociated with nausea, vomiting. No fevers or chills. Found to\nhave pancreatitis by labs and CT. Enrolled in pancreatitis\npathway and discharged with outpatient management after safe to\ntake PO.\n\nPain worsened at home yesterday evening, associated with nausea.\nAte mostly bland diet, nothing oily, some fruit. Represented to\nED. Initial vitals notable for BP 192/137, improved to 167/88 on\ntransfer. Received 1L IVF, morphine 4 mg IV x2, ondansetron 4 mg\nIV x1.\n\n \nPast Medical History:\n- CKD stage ___ (L brachiocephalic AV fistula placed ___\n- Hypertension\n- Hyperlipidemia\n- Gout\n- Palpitations\n- Anemia\n- Anxiety/Depression\n- Back pain\n- Cholecystectomy\n \nSocial History:\n___\nFamily History:\nNo family history of pancreatitis \n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION:\n===============================\nVITALS: T 98.2 PO, BP 159/67, HR 85, RR 18, O2 SAT 94% RA\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.\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored.\nGI: Abdomen soft, non-distended, epigastric tenderness with\nmilder diffuse pain in the LLQ and RLQ. Bowel sounds present. \nNo HSM.\nGU: No suprapubic fullness with some tenderness to palpation. \nNo\nCVA tenderness.\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs.\nSKIN: No rashes or ulcerations noted.\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs, sensation to light touch grossly\nintact throughout.\n\nDISCAHRGE PHSYICAL EXAM:\n=======================\nAfebrile, aVSS\nAmbulatory saturations were normal\nAppears well, ambulating the room independently and in NAD\nLungs with mild coarse rhonchi throughout but otherwise CTAB \nwithout wheezing\nCV normal\nAbdominal exam with mild tenderness to palpation in RUQ but \notherwise normal\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 06:00AM BLOOD WBC-21.3* RBC-3.73* Hgb-11.2 Hct-34.4 \nMCV-92 MCH-30.0 MCHC-32.6 RDW-16.0* RDWSD-54.4* Plt ___\n___ 06:00AM BLOOD ___ PTT-26.8 ___\n___ 06:00AM BLOOD Glucose-132* UreaN-41* Creat-2.6* Na-140 \nK-3.2* Cl-99 HCO3-27 AnGap-14\n___ 06:00AM BLOOD ALT-172* AST-104* CK(CPK)-125 \nAlkPhos-178* TotBili-1.0\n___ 06:00AM BLOOD Lipase-127*\n___ 06:00AM BLOOD Albumin-3.5 Calcium-9.3 Phos-2.4* Mg-1.4*\n\nIMAGING\n=======\n** OF NOTE, FROM MOST RECENT ___ ER VISIT, NOT THIS \nADMISSION **\nCT ABD & PELVIS W/O CONTRAST Study Date of ___ 1:53 AM \nIMPRESSION: \n1. Moderate fat stranding surrounding the head of the pancreas,\nconcerning for acute pancreatitis. \n2. Indeterminate left adrenal nodule. Adrenal protocol CT can \nbe\nconsidered on a nonemergent basis. \n3. Patulous fluid-filled distal esophagus with a moderate hiatal\nhernia, raising suspicion for dysmotility. \n4. Other incidental findings include diverticulosis, an \nascending\ncolonic lipoma, and possible fibroids. \n\nMICROBIOLOGY\n============\nCDiff negative\nAll BCx and UCx negative\n\nDISCHARGE LABS\n==============\n___ 06:02AM BLOOD WBC-11.7* RBC-3.33* Hgb-9.8* Hct-30.4* \nMCV-91 MCH-29.4 MCHC-32.2 RDW-16.9* RDWSD-56.6* Plt ___\n___ 06:02AM BLOOD Glucose-110* UreaN-36* Creat-2.4* Na-145 \nK-3.8 Cl-111* HCO3-18* AnGap-16\n___ 06:02AM BLOOD ALT-66* AST-95* LD(LDH)-356* AlkPhos-186* \nTotBili-0.4\n___ 06:02AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.___ year old woman with history notable for CKD-stage IV/V (with \nLUE AVF, not yet on HD), with recent diagnosis of acute \npancreatitis (treated as outpatient), who returned with \nabdominal pain & failure of outpatient treatment for acute \npancreatitis, course complicated by influenza.\n\nActive Issues:\n# Acute pancreatitis: Seen in ___ ED on ___ and diagnosed \nwith mild pancreatitis, and per pathway, was stable for \ndischarge home and outpatient management of pancreatitis. \nReturned with abdominal pain. CT abdomen/pelvis (___) \ndemonstrated normal liver, s/p cholecystectomy, without biliary \nductal dilatation, as well as moderate peripancreatic fat \nstranding. No alcohol history; history of cholecystectomy. \nPerhaps idiopathic etiology; could also considered IgG-4-related \ndisease, given patulous appearance of Esophagus, but \nimmunoglobulins mostly low. LFTs improved over course of stay, \nRUQ US unremarkable. She was treated with IVFs and NPO until \nshe dramatically improved and by discharge she was tolerating a \nregular diet for several days. Abdominal pain resolved soon \nafter admission. \n \n# Influenza B: Flu B positive. WBC count largely stable. \nEndorses nasal fullness and pharyngitis, and was treated \nsymptomatically. She was placed on oseltamivir for a five-day \ncourse. \n \n# Bradycardia: noted on palpation of pulse, but normal heart \nrate on telemetry. She was placed on telemetry. Carvedilol was \ninitially held and then restarted without recurrent episodes of \nbradycardia.\n \n# Back pain: acute, central in lower area, which resolved during \nadmission. Given downtrending WBC count, low concern for \nprimary infectious etiology. She was provided pain control as \nneeded. Neurologic exam was stable. \n \n# Leukocytosis: Last WBC (___) before admission normal. On \n___, at ___ ED visit, WBC 18.9K. WBC count downtrended \nwithout specific antimicrobial therapy. Blood cultures with no \ngrowth, urine culture negative. Chest imaging without \nconsolidations. Suspect secondary to pancreatitis.\n \n# Acute on chronic kidney disease\n# s/p Kidney transplant: LUE AVF in place & mature, but renal \nfunction at baseline, and no indication yet for HD. Creatinine \nimproved with IVFs during admission. She was continued on her \nhome calcitriol.\n \n# Hypertension: blood pressure was elevated during her \nadmission. Her carvedilol dosing was uptitrated during her \nadmission. Home furosemide was initially held and then \nrestarted.\n \n# Hyperlipidemia: atorvastatin 80 mg PO QPM \n\n# Gout: allopurinol ___ mg PO every other day, given eGFR\n\n====================\nTRANSITIONAL ISSUES:\n====================\n# ADRENAL NODULE \nIndeterminate left adrenal nodule. Adrenal protocol CT can be \nconsidered on a nonemergent basis. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Carvedilol 12.5 mg PO BID \n2. Atorvastatin 80 mg PO QPM \n3. Furosemide 40 mg PO BID \n4. Allopurinol ___ mg PO DAILY \n5. Calcitriol 0.25 mcg PO DAILY \n\n \nDischarge Medications:\n1. amLODIPine 5 mg PO DAILY \nRX *amlodipine 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet \nRefills:*0 \n2. Fluticasone Propionate NASAL 1 SPRY NU BID \nRX *fluticasone 50 mcg/actuation 1 spray IN twice a day Disp #*1 \nSpray Refills:*0 \n3. Carvedilol 25 mg PO BID \nRX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*0 \n4. Allopurinol ___ mg PO DAILY \n5. Atorvastatin 80 mg PO QPM \n6. Calcitriol 0.25 mcg PO DAILY \n7. Furosemide 40 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPancreatitis\nInfluenza B infection\nAcute on chronic renal failure\nBradycardia\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 the hospital with abdominal pain, and this \nwas due to PANCREATITIS. We treated you with IV fluids and rest, \nand you began to improve. He will need to follow-up with her \ngastroenterologist to identify the underlying cause of \npancreatitis and for possible further imaging in the future. \nWhen you go home, you should keep a low-fat diet\n \nWhile you are here it was also found that he had influenza B \ninfection for which you were treated with Tamiflu and completed \na course while in the hospital. \n\nBe sure to follow up with your doctors as below.\n\nIt was a pleasure caring for you. We wish you the very best,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "K8500", "I120", "R001", "N185", "J101", "E785", "E876", "M109", "F329", "F419", "E279" ]

[ "K8500: Idiopathic acute pancreatitis without necrosis or infection", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "R001: Bradycardia, unspecified", "N185: Chronic kidney disease, stage 5", "J101: Influenza due to other identified influenza virus with other respiratory manifestations", "E785: Hyperlipidemia, unspecified", "E876: Hypokalemia", "M109: Gout, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "E279: Disorder of adrenal gland, unspecified" ]

[ "E785", "M109", "F329", "F419" ]

[]

[ " \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:\nabdominal pain\n \nMajor Surgical or Invasive Procedure:\nEUS\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with history of HTN,\nDMII, cirrhosis who initially presented to an outside hospital\nwith abdominal pain and was found to have gallstone \npancreatitis,\ntransferred to ___ for ERCP.\n\nThe patient reports that she was in her usual state of health\nuntil the day of presentation, when she developed acute onset of\nsevere epigastric and right-sided abdominal pain with radiation\nto her back. This pain was associated with nausea and vomiting.\nShe denies any fevers or chills. \n\nNo changes in bowels. She presented to ___, where was\nfound to have lipase over 12,000, TBili 2.2 and DBili 1.2, AST\n64, ALT 28, alk phos 241, CT with distal CBD stones and\npancreatitis. BUN 10, no pleural effusion, no SIRS criteria met.\n\nShe was treated supportively with fluids, analgesics, and\nantiemetics, and today her TBili was 1.3, AST 53, alk phos 196.\nShe was accepted in transfer for advanced endoscopy evaluation\nand likely cholecystectomy. VS prior to transfer 98.0 77 111/90\n100% RA.\n\nOn arrival to the floor, she reports that she has ongoing\nright-sided back pain, ___. She denies any abdominal pain,\nnausea, vomiting, fevers, chills, or any other complaints at\npresent.\n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n\n \nPast Medical History:\nHTN\nNIDDMI\nCirrhosis (unknown etiology) c/b esophageal varices\n \nSocial History:\n___\nFamily History:\nMother with hypertension and hyperlipidemia. No\nknown family history of gallbladder disease.\n\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, nontender Bowel sounds present. \n \nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: No rashes or ulcerations noted\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\n \nPertinent Results:\nPer report from OSH\nImaging: \nCT A/P\n1. Cirrhosis with portal hypertension, splenomegaly and multiple\nvarices as detailed.\n2. ___ucts calculus and findings consistent \nwith\nmild pancreatitis evidence by peripancreatic inflammation. MRCP\nmay be helpful for further assessment, depending on clinical\nfactors.\n3. No drainable collection or ascites.07:10AM BLOOD Calcium-9.0 \nPhos-3.1 Mg-1.6\n\nEUS: 2 grade 2 esophageal varices, mild portal gastropathy, \nnormal CBD without stone. \n\nMRCP: Cirrhotic liver morphology with evidence of portal \nhypertension. No lesions \nmeeting optn criteria for ___. \n \nCholelithiasis. No choledocholithiasis. \n\n \nBrief Hospital Course:\nSUMMARY/ASSESSMENT: Ms. ___ is a ___ woman with\nhistory of HTN, DMII, cirrhosis who initially presented to an\noutside hospital with abdominal pain and was found to have\ngallstone pancreatitis, transferred to ___ for ERCP.\n\nACUTE/ACTIVE PROBLEMS:\n# Abdominal pain, nausea, vomiting\n# Presumed Acute gallstone pancreatitis\n# Choledocholithiasis with biliary obstruction: Patient \npresented\nwith abdominal pain, found to have gallstone pancreatitis and\ncholedocholithiasis with biliary obstruction, now improving. \nEvaluated by ERCP team, and underwent EUS, which found no stone \nin CBD. Therefore an ERCP was not pursued. Tbili peaked at \n2.5, and was trended during hospital course. It decreased on a \ndaily basis. Transplant service was consulted, and they were \nnot keen on doing a CCY until patient's MELD score was low \nenough. MRCP showed no choledocholithiasis, but Cholelithiasis. \nIn the future, she will likely need a cholecystectomy. \nInitially needed pain control with Tylenol (max daily dose \n2grams), oxycodone as\nneeded, but on final three days of admission, was totally pain \nfree and eating a regular diet. \n\nCHRONIC/STABLE PROBLEMS:\n# DMII: \n- Hold metformin, hISS while hospitalized, ___ qID. Restart \nmetformin on discharge. \n\n# Cirrhosis: Unknown etiology. Patient denies any history of\nalcohol. History of ascites at time of diagnosis but none since.\nNo history of HE. History of varices; last EGD ___ years ago per\npatient. She needs to follow up with hepatologist. Interested \nin following up with specialists at ___. Can coordinate this \nwith her PCP. \n- Continue nadolol, ursodiol\n\n# Hypertension:\n- losartan held initially, but restarted as there was no plan \nfor further invasive procedures.\nif blood pressures allow\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Losartan Potassium 50 mg PO DAILY \n2. Nadolol 20 mg PO DAILY \n3. MetFORMIN (Glucophage) 500 mg PO BID \n4. Ursodiol 500 mg PO DAILY \n5. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Medications:\n1. Losartan Potassium 50 mg PO DAILY \n2. MetFORMIN (Glucophage) 500 mg PO BID \n3. Nadolol 20 mg PO DAILY \n4. Ursodiol 500 mg PO DAILY \n5. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\ngallstone pancreatitis, acute\ncirrhosis\n\n \nDischarge Condition:\nGood, ambulatory, tolerating diet\n \nDischarge Instructions:\nYou were admitted for evaluation of abdominal pain presumed due \nto gallstone pancreatitis. For this, you underwent an endoscopic \nultrasound, during which they could not find a stone. You will \neventually need to have your gallbladder removed, but this \ndiscussion can continue between you and your primary care and \nliver specialist. Please take all your medications as indicated. \n\n \nFollowup Instructions:\n___\n" ]

[ "K8510", "I8510", "E870", "K7460", "K7581", "K269", "I10", "E119", "K8020", "Z7984" ]

[ "K8510: Biliary acute pancreatitis without necrosis or infection", "I8510: Secondary esophageal varices without bleeding", "E870: Hyperosmolality and hypernatremia", "K7460: Unspecified cirrhosis of liver", "K7581: Nonalcoholic steatohepatitis (NASH)", "K269: Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation", "I10: Essential (primary) hypertension", "E119: Type 2 diabetes mellitus without complications", "K8020: Calculus of gallbladder without cholecystitis without obstruction", "Z7984: Long term (current) use of oral hypoglycemic drugs" ]

[ "I10", "E119" ]

[]

[ " \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:\nabdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with a past medical\nhistory of HTN, hypothyroidism, and recent compression fracture,\nwho presented with abdominal pain.\n\nShe presented with acute onset of abdominal pain that occurred\napproximately 1 ___ yesterday that was diffuse primarily\nepigastric, worse with movement, that was preceded by ___ hours\nof chest and back pain that has since resolved. Chest and back\npain moderate not worsened with exertion or movement or deep\ninspiration. Without radiation to her abdomen. Patient then had \na\nmeal earlier on today at around 30 minutes later began having\ndiffuse abdominal pain without any associated black or bloody\nstools or radiation to the back or chest. Abdominal pain\nassociated with nausea no vomiting. No fevers or cough.\n\nIn the ED, lipase was elevated > 7000s. CTA was negative for PE\nor aortic dissection but was suggestive of pancreatitis. She\nreceived IV fluids and pain medication. She was transferred to\nthe floor for further management.\n\nOn the floor, she reports that pain is still present but \nsomewhat\nimproved. She denies any shortness of breath.\n \nPast Medical History:\nDIVERTICULOSIS (last colonoscopy in ___\nCOLONIC ADENOMAS S/P RESECTION\nHTN\nHYPOTHYROIDISM \nHYSTERECTOMY ___\nBILATERAL CATERACT SURGERY\nCompression fracture\n \nSocial History:\n___\nFamily History:\nMother died at ___ of agranulocytic leukemia. \nFather died at ___ of a motor vehicle accident. He was a\n___. Sister is ___ and has hypertension. Paternal aunt\ndied at ___ of liver cancer. There is a history of arthritis in\nseveral of her family members. \n \nPhysical Exam:\nAdmission Physical Exam:\n========================\nVITALS: Afebrile and vital signs stable (see eFlowsheet)\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. No HSM\nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, strength grossly full\nand symmetric bilaterally in all limbs\nSKIN: No rashes or ulcerations noted\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 Physical Exam:\n=========================\n \nPertinent Results:\nAdmission Labs:\n===============\n___ 09:52PM BLOOD WBC-15.4* RBC-3.69* Hgb-7.2*# Hct-25.6*# \nMCV-69*# MCH-19.5*# MCHC-28.1*# RDW-20.8* RDWSD-52.1* Plt \n___\n___ 09:52PM BLOOD Neuts-92.5* Lymphs-3.9* Monos-2.7* \nEos-0.0* Baso-0.3 Im ___ AbsNeut-14.26*# AbsLymp-0.60* \nAbsMono-0.41 AbsEos-0.00* AbsBaso-0.04\n___ 11:34PM BLOOD ___ PTT-23.1* ___\n___ 09:52PM BLOOD Glucose-138* UreaN-16 Creat-0.6 Na-137 \nK-4.3 Cl-100 HCO3-24 AnGap-13\n___ 09:52PM BLOOD ALT-7 AST-13 LD(LDH)-178 AlkPhos-90 \nTotBili-0.3\n___ 09:52PM BLOOD Lipase-7980*\n___ 11:23PM BLOOD cTropnT-<0.01\n___ 06:03AM BLOOD cTropnT-<0.01\n___ 06:03AM BLOOD Calcium-8.2* Phos-3.7 Mg-1.9\n___ 09:52PM BLOOD calTIBC-477* Hapto-229* Ferritn-9.7* \nTRF-367*\n___ 09:52PM BLOOD Triglyc-66\n___ 11:31PM BLOOD Lactate-1.6\n\nImaging:\n========\nCXR:\nRight upper lobe opacity is better demonstrated on subsequent \nCT.\n\nCTA:\n1. Peripancreatic stranding and extensive mesenteric edema is \nsuggestive of\nacute pancreatitis.\n2. 2.8 cm right upper lung opacity may be infectious, \ninflammatory, or\nneoplastic in etiology.\n3. Enlarged pulmonary arteries may reflect underlying pulmonary \nhypertension.\n4. Moderate hiatal hernia.\n\nMRCP:\n1. Acute interstitial pancreatitis with multiple small acute \nperipancreatic\nfluid collections. No evidence of necrosis.\n2. Limited study due to non breath hold technique, with no \nunderlying mass\nidentified.\n3. Bilateral pleural effusions with associated atelectasis.\n\nCTA chest ___\n1. No evidence of pulmonary embolism to the segmental level. \nSeveral \nsubsegmental arteries are incompletely evaluated in the setting \nof worsened bilateral lower lobe atelectasis. \n2. Since the prior study, moderate sized bilateral \nnonhemorrhagic pleural \neffusions have increased in size, along with fluid in the left \nmajor fissure. \n3. New partially imaged areas of fluid surrounding the \npancreas, compatible with acute peripancreatic collections in \nthe setting of known pancreatitis. \n4. Persistent 2.8 cm opacification in the right upper lobe, of \nunclear \netiology. This may be infectious, inflammatory, or neoplastic, \nas described previously. \n5. Persistent enlarged main pulmonary arteries, likely \nreflecting underlying pulmonary arterial hypertension. \n6. Moderate sized hiatal hernia. \n\nECHO ___\nThe left atrium is elongated. Left ventricular wall thickness, \ncavity size and regional/global systolic function are normal \n(LVEF >55%). Right ventricular chamber size and free wall motion \nare normal. The diameters of aorta at the sinus, ascending and \narch levels are normal. The aortic valve leaflets (3) are mildly \nthickened but aortic stenosis is not present. Mild (1+) aortic \nregurgitation is seen. The mitral valve appears structurally \nnormal with trivial mitral regurgitation. The pulmonary artery \nsystolic pressure could not be determined. There is no \npericardial effusion. \nIMPRESSION: Normal global and regional biventricular systolic \nfunction. Mild aortic regurgitation. \n\nDischarge Labs:\n===============\n\n___ 06:45AM BLOOD proBNP-635*\n___ 08:58AM BLOOD 25VitD-12*\n___ 09:52PM BLOOD Albumin-3.9 Iron-17*\n___ 09:52PM BLOOD calTIBC-477* Hapto-229* Ferritn-9.7* \nTRF-367*\n \nBrief Hospital Course:\nMs. ___ is a ___ female with a past medical history of \nHTN, hypothyroidism, and recent compression fracture, who \npresented with abdominal pain.\n\nACUTE/ACTIVE PROBLEMS:\n\n# Acute idiopathic Pancreatitis:\nUnclear trigger. No evidence of gallstones and ___ normal. No \nmasses visualized on CTA. She was hydrated with IV fluids and \npain and nausea were treated. Diet was advanced as tolerated. \nMRCP was obtained to evaluate for underlying malignancy given \nlack of clear cause of pancreatitis but was negative for any \nmasses (although limited study). She has several ___ \nfluid collections. She was seen by GI and recommended for \noutpatient f/u with Dr. ___ in 2 months. A decision will be \nmade at that time whether to pursue repeat MRCP.\n\n# Iron deficiency anemia: Hg 7.2 on admission, down from 12.2 \nnearly a year ago. Given microcystosis, thrombocytosis, and \nferritin of 9, suspect chronic intermittent blood loss despite \nguaiac negative stools in the ED. Prior colonoscopy in ___ with\npolyps, repeat recommended in ___ years. Thrombocytosis could \nbe secondary to iron deficiency but could also be secondary to \nunderlying malignancy. She was transfused for Hg < 7, and then \ntransfused 1gm IV iron dextran and then Sodium ferric Gluconate \n125mg IV on ___ and ___. She was seen by GI who agree with \nneed for short term EGD +/- ___ +/ capsule study, but she \nwishes to have this done as an outpatient. \n\n# Hypoxia\n# Pleural effusions\n# R lung opacity (RUL 2.8cm)\n# Atelectasis \n# Hiatal Hernia\nNew 1- 2L oxygen requirement likely a reflection of combination \nof above. She was treated empirically for pneumonia \n(Ceph/Azithro) in light of RUL opacity and leukocytosis. Suspect \nhypoxia due to combination of above. A BNP was elevated and she \nwas diuresed with IV Lasix (80mg IV daily for 3 days) and \ntolerated this well, though the need for O2 persisted. She had \nSaO2 of 68% on RA with a transition and 80% on 1L ambulating \nwhich normalized with 2L O2 and rest. Surprisingly, she did not \nreport any symptoms during any of these events, though RNs noted \nshe appeared dyspnic. She will go home on home oxygen, currently \nat 1 liter per minute. An ECHO was without findings of systolic \nheart failure and inadequate for pHTN evaluation. A CTA chest \ndid not show PE though showed other findings above as well as \nenlarged pulmonary arteries. She was transitioned to oral Lasix \n20mg PO daily. We arranged for her to have a F/U appointment in \npulmonology for hypoxemia, pleural effusions, and for new lung \nopacity. (patient and provider informed -- to r/o cancer). \n\nCHRONIC/STABLE PROBLEMS:\n# Hypothyroidism: continued home synthroid\n# Hypertension: held home amlodipine due to acute pancreatitis\n\nTransitional Issues:\n====================\n- needs EGD / colonoscopy, possible CS to evaluate iron \ndeficiency anemia\n- needs repeat CT chest to ensure resolution of R lung opacity \nafter treatment for pneumonia is completed and/or further workup \nto r/o malignancy but this can be discussed with her new \npulmonologist. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Levothyroxine Sodium 75 mcg PO DAILY \n2. amLODIPine 2.5 mg PO DAILY \n3. Vitamin D 1000 UNIT PO DAILY \n4. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry \neyes \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild \n2. Furosemide 20 mg PO DAILY \nWeigh daily, and if > 3 lbs in 48 hours, call your PCP to see if \nyou should take more. \n3. Omeprazole 20 mg PO BID \n4. amLODIPine 2.5 mg PO DAILY \n5. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry \neyes \n6. Levothyroxine Sodium 75 mcg PO DAILY \n7. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAcute Idiopathic Pancreatitis\nIron deficiency anemia\nPneumonia\nR lung nodule (2.8cm) -- needs follow up\nHypoxemia w/ pleural effusions\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou came into the hospital because you were having severe \nabdominal pain. We found that you had inflammation of your \npancreas called pancreatitis. We treated you with IV fluids and \nyour pain improved. You will need to follow up with Dr. ___ \n(___) to ensure that the pancreatitis has fully \nresolved. You were found to have severe iron deficiency anemia \nwithout evidence of active bleeding. We gave you IV iron therapy \nand you will need outpatient endoscopy and and colonoscopy to \ncomplete evaluation. We also treated you for a possible \npneumonia. You continued to need O2 despite Lasix for pleural \neffusion, so a CT scan chest was done which showed persistent \nlung opacity (mass) and fluid in the chest cavity. You will need \nrepeat chest imaging to whether it has resolved or whether it \nremains and further workup is needed to rule out cancer. You \nwere given a diuretic to assist in removing fluid off the lungs \nand you were placed on oxygen and will need to use it \nconsistently. \n \nFollowup Instructions:\n___\n" ]

[ "K8500", "J189", "J90", "J9811", "D509", "R911", "I10", "E039", "Z87891", "R1310", "E876", "M47896", "E559", "R0902", "K449", "K5790" ]

[ "K8500: Idiopathic acute pancreatitis without necrosis or infection", "J189: Pneumonia, unspecified organism", "J90: Pleural effusion, not elsewhere classified", "J9811: Atelectasis", "D509: Iron deficiency anemia, unspecified", "R911: Solitary pulmonary nodule", "I10: Essential (primary) hypertension", "E039: Hypothyroidism, unspecified", "Z87891: Personal history of nicotine dependence", "R1310: Dysphagia, unspecified", "E876: Hypokalemia", "M47896: Other spondylosis, lumbar region", "E559: Vitamin D deficiency, unspecified", "R0902: Hypoxemia", "K449: Diaphragmatic hernia without obstruction or gangrene", "K5790: Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding" ]

[ "D509", "I10", "E039", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins\n \nAttending: ___.\n \nChief Complaint:\nleg pain\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ man with hx HTN, T2DM, necrotizing skin\ninfection of left foot, opiate use disorder with IV heroin use\nnow on Suboxone who was recently admitted at ___ 1 month ago where he underwent skin graft for left foot\nnecrotizing infection who now presenting with worsening left \nfoot\npain and discharge.\n\nPatient notes that recently had a skin graft applied to the left\nleg about a month ago. He also reported having elevated blood\nsugars and a foul smell coming from the wound. He presented to\n___ yesterday ___, where they were\nconcerned for osteomyelitis based off of plain film x-rays. \nGiven\nvanc/cefe and transferred ___ for further care. \n\nIn the ED:\n- Initial vital signs were notable for:\nT 98.0 HR 94 BP 108/72 RR 14 SaO2 100% RA \n- Exam notable for:\nMSK: Dorsum left foot with approximately 10 x 10 cm open wound,\nexposed fat vs granulation tissue. Linear healed incision\ntracking up L calf with granulation tissue. No discharge noted.\nNo palpable crepitus. Palpable ___ and dopplerable DP pulse.\nSensation intact to noxious stimuli but cannot feel light touch.\nIntact motor distally. compartments soft. \n\n- Labs were notable for:\nWBC 5.9, Hb 10.9, plt 343\nCRP 6.3 -> 7.2\nCr 1.2 -> 1.7 -> 1.3, Na 141, K 3.5 Lactate 0.9\nNa 141 -> 133\nUA trace prot, 1000 gluc, ketones 10\npH 7.39, pCO2 36\n\n- Studies performed include:\nCT LLE with contrast\n1. Extensive cutaneous defect and subcutaneous edema which\nextends into the anterior and likely posterior lower leg\ncompartments. No drainable fluid collection. No definite\nsubcutaneous gas in the imaged field. Given the history, this is\ncompatible with infection. Please note that the absence of\nsubcutaneous gas does not exclude arising fasciitis, and that\nthis is primarily a clinical diagnosis.\n2. Periosteal reaction and cortical irregularity along the \ndistal\nfibula is concerning for osteomyelitis.\n\n- The patient was given: \nIVF, Vancomycin, Piperacillin-Tazobactam, and clindaymycin. \n\n- Ortho were consulted:\nFelt Labs reassuring against NSTI, osteomyelitis is low given\nCRP, although this would be definitively excluded with MRI.\nPassive ROM reassuring against septic arthritis. Recommended IV\nclindamycin and admission to medicine for wound care and abx \n \nPast Medical History:\nHTN, T2DM, Depression, Anxiety\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVITALS: Temp: 97.6, BP 105/68, HR 68, RR 18, Sat 98% RA\nGENERAL: Alert and interactive. In no acute distress.\nHEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.\nNECK: No cervical lymphadenopathy. No JVD.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing.\nBACK: No CVA tenderness.\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. No organomegaly.\nEXTREMITIES: No clubbing, cyanosis,\nMSK: Dorsum left foot with approximately 10 x 10 cm open wound,\nexposed fat vs granulation tissue. Linear healed incision\ntracking up L calf with granulation tissue. Edemaous with bloody\ndrainage. Able to move toes. Skin graft site- slightly tender to\npalpation.\nNEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs\nspontaneously.\n\nDISCHARGE PHYSICAL EXAM:\n========================\n___ Temp: 98.2, BP: 118/75, HR: 110, RR: 18, O2 sat: 95%, \nO2 delivery: RA \nGENERAL: Alert, interactive, pleasant, found sleeping in bed. In\nno acute distress.\nHEENT: Sclera anicteric and without injection.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: CTAB. No 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\nMSK: Bandages clean and intact on L. leg extending from midfoot\nuntil knee. Dorsum left foot with approximately 10 x 10 cm open\nwound, granulation tissue. Linear healed incision tracking up L\ncalf with granulation tissue. No drainage. Able\nto move toes. Skin graft site is minimally tender to palpation.\nToes warm and well-perfused bilaterally. Both skin grafts intact\nand well-perfused.\nNEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs\nspontaneously.\n \nPertinent Results:\nADMISSION LABS:\n================\n___ 06:30PM BLOOD WBC-5.9 RBC-3.95* Hgb-10.9* Hct-33.8* \nMCV-86 MCH-27.6 MCHC-32.2 RDW-13.2 RDWSD-40.8 Plt ___\n___ 06:30PM BLOOD Neuts-33.4* Lymphs-53.1* Monos-9.1 \nEos-3.4 Baso-1.0 AbsNeut-1.97 AbsLymp-3.14 AbsMono-0.54 \nAbsEos-0.20 AbsBaso-0.06\n___ 06:30PM BLOOD ___ PTT-28.5 ___\n___ 06:30PM BLOOD Plt ___\n___ 06:30PM BLOOD Glucose-172* UreaN-18 Creat-1.2 Na-141 \nK-3.5 Cl-111* HCO3-20* AnGap-10\n___ 06:30PM BLOOD CRP-6.3*\n\nRELEVANT LABS:\n=============\n___ 02:02AM BLOOD WBC-5.5 RBC-3.94* Hgb-10.8* Hct-33.8* \nMCV-86 MCH-27.4 MCHC-32.0 RDW-13.2 RDWSD-41.1 Plt ___\n___ 07:27AM BLOOD WBC-4.1 RBC-3.65* Hgb-10.1* Hct-31.6* \nMCV-87 MCH-27.7 MCHC-32.0 RDW-13.2 RDWSD-41.9 Plt ___\n___ 05:50AM BLOOD WBC-4.9 RBC-3.74* Hgb-10.3* Hct-33.8* \nMCV-90 MCH-27.5 MCHC-30.5* RDW-13.2 RDWSD-43.5 Plt ___\n___ 07:18AM BLOOD WBC-4.4 RBC-3.49* Hgb-9.4* Hct-30.7* \nMCV-88 MCH-26.9 MCHC-30.6* RDW-13.4 RDWSD-42.9 Plt ___\n___ 07:41AM BLOOD ___ PTT-28.0 ___\n___ 07:41AM BLOOD Plt ___\n___ 05:50AM BLOOD Plt ___\n___ 07:18AM BLOOD Plt ___\n___ 07:57AM BLOOD Ret Aut-0.6 Abs Ret-0.02\n___ 02:02AM BLOOD Glucose-294* UreaN-23* Creat-1.7* Na-133* \nK-4.7 Cl-97 HCO3-21* AnGap-15\n___ 07:41AM BLOOD Glucose-278* UreaN-11 Creat-0.9 Na-134* \nK-4.4 Cl-100 HCO3-23 AnGap-11\n___ 07:27AM BLOOD Glucose-352* UreaN-14 Creat-0.9 Na-135 \nK-5.4 Cl-99 HCO3-26 AnGap-10\n___ 07:57AM BLOOD Glucose-328* UreaN-17 Creat-0.9 Na-136 \nK-5.2 Cl-99 HCO3-24 AnGap-13\n___ 05:50AM BLOOD Glucose-397* UreaN-18 Creat-0.9 Na-135 \nK-5.1 Cl-97 HCO3-26 AnGap-12\n___ 07:18AM BLOOD Glucose-519* UreaN-17 Creat-0.9 Na-132* \nK-4.9 Cl-95* HCO3-25 AnGap-12\n___ 07:35AM BLOOD Glucose-348* UreaN-15 Creat-0.9 Na-138 \nK-4.9 Cl-101 HCO3-26 AnGap-11\n___ 07:41AM BLOOD ALT-16 AST-21 AlkPhos-80 TotBili-0.2\n___ 07:41AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.1*\n___ 07:57AM BLOOD Calcium-9.2 Phos-3.9 Mg-1.4* Iron-36*\n___ 07:18AM BLOOD Calcium-9.2 Phos-4.5 Mg-1.5*\n___ 07:57AM BLOOD calTIBC-351 Ferritn-69 TRF-270\n___ 07:41AM BLOOD %HbA1c-11.1* eAG-272*\n___ 02:02AM BLOOD CRP-7.2*\n___ 01:10PM BLOOD HIV Ab-NEG\n___ 05:03PM BLOOD ___ pO2-74* pCO2-32* pH-7.46* \ncalTCO2-23 Base XS-0\n___ 05:03PM BLOOD Glucose-471* Creat-0.9 Na-130* K-4.5 \nCl-102\n___ 02:13AM BLOOD Lactate-0.9\n___ 05:03PM BLOOD Hgb-11.3* calcHCT-34\n\nRELEVANT IMAGING:\n=================\n___ Imaging CT LOWER EXT W/C LEFT\nFINDINGS:\n1. Extensive irregular thickened superficial soft tissues, \npresumably\ncorresponding to skin graft, which extends into the anterior and \nlikely\nposterior lower leg compartments. No drainable fluid \ncollection. Findings\nare nonspecific but marked thickening particularly along the \ndorsal sided the\nfoot may reflect inflammation or infection. Correlation with \nclinical\ncircumstances is recommended.\n2. Periosteal reaction and cortical irregularity along the \nlateral distal\nfibular cortex is a possible indication of underlying \nosteomyelitis but not\nspecific. No frank lysis, however. In assessing the \nsignificance,\ncomparisons any prior outside imaging that may be available \ncould be useful in\naddition a consideration of MR imaging.\n\n___ Imaging MR ANKLE ___ CONTRAST\nIMPRESSION:\n1. Redemonstrated severe inflammatory changes and edema within \nthe anterior\nand lateral compartments of the visualized left lower extremity. \n No abscess.\n2. No convincing evidence of osteomyelitis. Minimal irregularity \nof the distal\nfibula may reflect nonspecific reactive osteitis.\n3. Phlegmon surrounds the extensor and peroneal tendons with \nabnormal signal\nwithin the peroneal tendons making septic tenosynovitis \ndifficult to exclude.\n4. A soft tissue defect exposes the anterior tibialis tendon.\n\nDISCHARGE LABS:\n=================\n___ 07:35AM BLOOD WBC-3.8* RBC-3.32* Hgb-9.1* Hct-29.5* \nMCV-89 MCH-27.4 MCHC-30.8* RDW-13.6 RDWSD-44.6 Plt ___\n___ 07:35AM BLOOD Plt ___\n___ 07:35AM BLOOD Glucose-348* UreaN-15 Creat-0.9 Na-138 \nK-4.9 Cl-101 HCO___ AnGap-11\n___ 07:35AM BLOOD Calcium-9.2 Phos-4.4 Mg-1.5*\n\n \nBrief Hospital Course:\n___ with history of DMII, opiate use disorder with IV heroin \nuse, hypertension and recent necrotizing skin and soft tissue \ninfection s/p recent grafting who was transferred from OSH due \nto concern for osteomyelitis which was ruled out by MRI now on \nAugmentin for SSTI after finishing his course of vancomycin and \ncefepime.\n\nACUTE/ACTIVE ISSUES:\n====================\n#Left ___ wound/infection\nMost likely inflammation/granulation tissue or nonsevere \ncellulitis given benign appearance of wound on exam and \nreassuring imaging studies. Less concern for osteomyelitis with \nMRI (___) indicating severe inflammatory change, and his CRP \n7.2 is reassuring. Necrotizing soft tissue infection also less \nlikely given LRINEC score is 5, which Scores <6 were low risk. \n___ showed no definite subcutaneous gas. On exam, minimal \ntenderness over wound is reassuring against nec fasciitis. ID \nwas consulted and MRI was done which ruled out osteomyelitis. \nPer ID recs, patient was treated with IV Vancomycin/cefepime for \n7 days before transitioning to po Augmentin for 5 additional \ndays, with last dose on ___. Patient was discharged with ___ \nfor wound care and will need to follow up with wound care as an \noutpatient.\n\n#DMII w/ hyperglycemia\nHbA1c of 11.1% (___). Patient had elevated BGs in the ED and \nthroughout his hospitalization. Ketones and high glucose in \nurine(>1000) while in ED, but blood gases showed pH within \nnormal range (7.39) so unlikely to be in DKA. ___ was \nconsulted and patient had uptitration of his insulin. He is \nbeing discharged on Lantus 60u QAM and 40u QPM with Humalog 20u \nwith meals. He was restarted on his home metformin. He was seen \nby the diabetes educator and nutrition. He will need ongoing \ntitration of insulin as outpatient.\n\n#Acute pain\nPatient was treated with his home pain regimen of oxycodone 5mg \nQ6H:PRN, Gabapentin 800 mg PO TID:PRN pain, \nBuprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL BID. ___ \nwas reviewed.\n\n#Active IV Drug Use\nMr. ___ admitted to using IV heroin shortly before his \nadmission, when he previously denied. HIV negative. Screening \nfor HCV VL was negative. Patient also recieved tDAP booster. He \ncontinued his home suboxone as noted above and was advised to \nfollow up with his PCP\n\n___ ISSUES:\n======================\n# Anemia\nMild normocytic, suspect anemia of inflammation. Trend is \nstable. Iron studies indicated no deficiency.\n\n# Multiple sedating meds\nHe is on numerous sedating meds and would ideally reduce this \ngiven risk of sedation with combination of benzodiazepines and \nopiates.\n\n#penile lesions\nTwo small ulcers which appear to be due to skin breakdown, that \ndo not appear herpetic. Improved with Aquaphor.\n\n#HTN\nContinue Losartan Potassium 100 mg PO DAILY\n\n#Depression/ Anxiety:\nContinued on Sertraline 100 mg PO DAILY, Amitriptyline 25 mg PO \nQHS, and ALPRAZolam 0.5 mg PO TID:PRN\n\n#HLD\nContinued on home Atorvastatin 40 mg PO QPM\n\n#Migraine\nHeld home butalbital-acetaminophen-caff 50-325-40 mg oral \nBID:PRN. Continued Amitriptyline 25 mg PO QHS\n\nTRANSITIONIONAL ISSUES:\n[ ] Consider simplifying Pain regiment as outpatient\n[ ] Continue Augmentin until ___\n[ ] Continue titration of insulin as an outpatient\n[ ] ___ to assist with wound care: Xeroform dressing to LLE with \nKerlix\n\nCODE: full Code\n\nPatient seen and examined on day of discharge. >30 minutes on \ndischarge activities.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate \n\n2. Bacitracin Ointment 1 Appl TP QID \n3. Vitamin D ___ UNIT PO 1X/WEEK (___) \n4. Thiamine 100 mg PO DAILY \n5. Sumatriptan Succinate 50 mg PO ONCE \n6. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL BID \n7. Sertraline 100 mg PO DAILY \n8. MetFORMIN (Glucophage) 1000 mg PO BID \n9. Losartan Potassium 100 mg PO DAILY \n10. HydrOXYzine 25 mg PO TID:PRN anxiety \n11. CloNIDine 0.2 mg PO TID \n12. butalbital-acetaminophen-caff 50-325-40 mg oral BID:PRN \n13. ALPRAZolam 0.5 mg PO TID:PRN anxiety \n14. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia \n15. Omeprazole 20 mg PO DAILY \n16. Gabapentin 800 mg PO TID \n17. Amitriptyline 25 mg PO QHS \n18. Glargine 40 Units Breakfast\nGlargine 20 Units Bedtime\nNovolog 20 Units Breakfast\nNovolog 20 Units Lunch\nNovolog 20 Units Dinner\nInsulin SC Sliding Scale using Novolog Insulin\n19. Aspirin 81 mg PO DAILY \n20. Atorvastatin 40 mg PO QPM \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \nRX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day \nDisp #*180 Tablet Refills:*0 \n2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Days \nRX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by \nmouth every twelve (12) hours Disp #*6 Tablet Refills:*0 \n3. Glargine 60 Units Breakfast\nGlargine 40 Units Bedtime\nHumalog 20 Units Breakfast\nHumalog 20 Units Lunch\nHumalog 20 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin\nRX *insulin glargine [Basaglar KwikPen U-100 Insulin] 100 \nunit/mL (3 mL) AS DIR 60 Units before BKFT; 40 Units before BED; \nDisp #*1 Syringe Refills:*3\nRX *insulin lispro [Humalog KwikPen Insulin] 100 unit/mL AS DIR \n20 Units before meals (breakfast, lunch, dinner) Disp #*1 \nSyringe Refills:*2 \n4. ALPRAZolam 0.5 mg PO TID:PRN anxiety \nRX *alprazolam 0.5 mg 1 tablet(s) by mouth three times a day \nDisp #*7 Tablet Refills:*0 \n5. Amitriptyline 25 mg PO QHS \nRX *amitriptyline 25 mg 1 tablet(s) by mouth at bedtime Disp \n#*30 Tablet Refills:*0 \n6. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n7. Atorvastatin 40 mg PO QPM \nRX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n8. Bacitracin Ointment 1 Appl TP QID \n9. Buprenorphine-Naloxone Tablet (8mg-2mg) 1 TAB SL BID \nConsider prescribing naloxone at discharge \nRX *buprenorphine-naloxone 8 mg-2 mg 1 tablet(s) sublingually \ntwice a day Disp #*60 Film Refills:*0 \n10. CloNIDine 0.2 mg PO TID \nRX *clonidine HCl 0.2 mg 1 film by mouth three times a day Disp \n#*90 Tablet Refills:*0 \n11. Gabapentin 800 mg PO TID \nRX *gabapentin 800 mg 1 capsule(s) by mouth three times a day \nDisp #*30 Tablet Refills:*0 \n12. HydrOXYzine 25 mg PO TID:PRN anxiety \nRX *hydroxyzine HCl 25 mg 1 tablet by mouth three times a day \nDisp #*30 Tablet Refills:*0 \n13. Losartan Potassium 100 mg PO DAILY \nRX *losartan 100 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n14. MetFORMIN (Glucophage) 1000 mg PO BID \nRX *metformin 1,000 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*2 \n15. Omeprazole 20 mg PO DAILY \nRX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30 \nCapsule Refills:*0 \n16. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp \n#*12 Tablet Refills:*0 \n17. Sertraline 100 mg PO DAILY \nRX *sertraline 100 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n18. Sumatriptan Succinate 50 mg PO ONCE Duration: 1 Dose \n19. Thiamine 100 mg PO DAILY \nRX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a \nday Disp #*30 Tablet Refills:*0 \n20. Vitamin D ___ UNIT PO 1X/WEEK (___) \n21. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia \n22. HELD- butalbital-acetaminophen-caff 50-325-40 mg oral \nBID:PRN This medication was held. Do not restart \nbutalbital-acetaminophen-caff until you see your PCP\n23.Crutches\nDX S81.802, PX: good, and ___ 13 months\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n#SSTI\n#Uncontrolled DM2\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n====================== \nDISCHARGE INSTRUCTIONS \n====================== \nDear Mr. ___, \nIt was a privilege caring for you at ___ \n___. \n\nWHY WAS I IN THE HOSPITAL? \n- You were in the hospital because worsening left foot pain.\n- You also reported having elevated blood sugars and a foul \nsmell coming from the wound.\n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- At the hospital we did blood work and imaging of the left foot \nand started you on IV antibiotic which we transitioned you to \noral antibiotic.\n- We also did blood work to keep track of your sugars and up \ntitrated your insulin through out the admission. \n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n-Please continue to take all of your medications and follow-up \nwith your appointments as listed below.\n\nWe wish you the best! \n\nSincerely, \nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "L03116", "F1120", "N179", "L929", "E1165", "Z794", "G4700", "F419", "R52", "D638", "I10", "F329", "G43909", "E785", "F17210", "L98491", "E1142" ]

[ "L03116: Cellulitis of left lower limb", "F1120: Opioid dependence, uncomplicated", "N179: Acute kidney failure, unspecified", "L929: Granulomatous disorder of the skin and subcutaneous tissue, unspecified", "E1165: Type 2 diabetes mellitus with hyperglycemia", "Z794: Long term (current) use of insulin", "G4700: Insomnia, unspecified", "F419: Anxiety disorder, unspecified", "R52: Pain, unspecified", "D638: Anemia in other chronic diseases classified elsewhere", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "E785: Hyperlipidemia, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "L98491: Non-pressure chronic ulcer of skin of other sites limited to breakdown of skin", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy" ]

[ "N179", "E1165", "Z794", "G4700", "F419", "I10", "F329", "E785", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nPenicillins / azithromycin\n \nAttending: ___\n \nChief Complaint:\ns/p MVC\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nEU Critical ___ aka ___ was transferred from\nOSH after a intoxicated MVA for concern for C6 R facet fracture.\nPatient was a restrained driver who per report first struck a\npedestrian and then struck a pole. When EMS arrived on scene\npatient was found half ejected through the drivers side vehicle\nwith the vehicle upside down. He denied taking any Xanax but was\nfound with a bottle of pills. Upon arrival to ___ patient\ndenies remember the events of the accident. He denies any neck\npain, numbness, tingling. Given his level of intoxication he is \na\npoor historian. \n \nPast Medical History:\nAnxiety \n\n \nSocial History:\n___\nFamily History:\nnoncontributory\n \nPhysical Exam:\nPHYSICAL EXAMINATION\nHR: 58 BP: 110/80 Resp: 10 O(2)Sat: 100% Normal\n Constitutional: Comfortable\nHEENT: Blood tinge to scalp; 2 mm pupils bilaterally; ,\nPupils equal, round and reactive to light, Extraocular\nmuscles intact\nAirway clear; No hemotympanum; C-spine tenderness\nChest: B/l breath sounds; no chest wall instability\nCardiovascular: Regular Rate and Rhythm\nAbdominal: Soft, Nontender, Nondistended\nExtr/Back: 2+ distal pulses. No evidence of trauma to\nextremities. No thoracic or lumbar midline tenderness.\nSkin: Abrasion to bridge of nose; Abrasion to left shoulder\nand right knee\nNeuro: Slurred speech\nPsych: intoxicated\n___: No petechiae\n\nPHYSICAL EXAM:\nGen: WD/WN, comfortable, NAD. Lying on stretcher in hard \ncervical\ncollar. \nHEENT: Pupils: 6mm-->3mm EOMs intact \nNeuro:\nMental status: Appears intoxicated. Awake and alert, cooperative\nwith exam, normal affect.\nOrientation: Oriented to person, place, and date.\n \nPertinent Results:\n___ 06:45AM BLOOD WBC-6.4 RBC-4.34* Hgb-14.2 Hct-44.7 \nMCV-103* MCH-32.7* MCHC-31.8* RDW-12.1 RDWSD-45.9 Plt ___\n___ 11:20PM BLOOD WBC-5.9 RBC-4.46* Hgb-14.5 Hct-46.2 \nMCV-104* MCH-32.5* MCHC-31.4* RDW-12.1 RDWSD-46.6* Plt ___\n___ 06:45AM BLOOD Glucose-97 UreaN-5* Creat-1.0 Na-142 \nK-3.9 Cl-104 HCO3-27 AnGap-15\n___ 06:45AM BLOOD Lipase-53\n___ 11:20PM BLOOD Lipase-239*\n___ 06:45AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.0\n___ 11:20PM BLOOD ASA-NEG ___ Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n\nIMAGING:\nC-Spine MRI:\n1. No evidence of fracture. Prevertebral soft tissue swelling \nextending from C4 through C6 is concerning for anterior \nlongitudinal ligament injury. 2. Edema pattern in the \ninterspinous ligaments and posterior paraspinal muscles at the \nlevel of C3 through C6, can be seen in whiplash injuries. 3. \nAcute C5/C6 right central disc protrusion, resulting in moderate \nright neural foraminal narrowing and contact with the exiting \nright C6 nerve root. 4. No cord signal abnormalities identified. \n\n\nShoulder XRay:\nPortable views show no evidence of acute fracture or \ndislocation. No evidence of rib fracture or pneumothorax. \n\n \nBrief Hospital Course:\n___ year old male transferred for trauma evaluation. Patient had \nCT head, C-spine, and torso at outside hospital only significant \nfor C6 fracture. Patient is neurologically intact. C-Spine MRI \nnegative for ligamentous injury. Neurosurgery recommended hard \ncollar and follow-up in clinic in 6 weeks. The patient was \nadmitted for pain control and further work-up. Tertiary exam was \nnegative for other injuries. The patient was having \n\nPain was well controlled. Diet was progressively advanced as \ntolerated to a regular diet with good tolerability. The patient \nvoided without problem. During this hospitalization, the patient \nambulated early and frequently, was adherent with respiratory \ntoilet and incentive spirometry, and actively participated in \nthe plan of care. The patient received subcutaneous heparin and \nvenodyne boots were used during this stay.\n.\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating a regular \ndiet, ambulating, voiding without assistance, and pain was well \ncontrolled. The patient was discharged home without services, \nin the hard collar, with Neurosurgery follow-up. The patient \nreceived discharge teaching and follow-up instructions with \nunderstanding verbalized and agreement with the discharge plan.\n..\n\n \nMedications on Admission:\nALPRAZolam 0.5 mg PO QAM:PRN anxiety \nALPRAZolam 1 mg PO TID:PRN anxiety \n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild \nRX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6) \nhours Disp #*40 Tablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*10 Capsule Refills:*0 \n3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*10 Tablet Refills:*0 \n4. Senna 8.6 mg PO BID:PRN constipation \n5. ALPRAZolam 0.5 mg PO QAM:PRN anxiety \n6. ALPRAZolam 1 mg PO TID:PRN anxiety \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nC6 nondisplaced endplate fracture\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were transferred to ___ after being involved in a motor \nvehicle collision. You were found to have a fracture of your \ncervical spine. An MRI was done, which was negative for any \nligamentous injury. The Spine doctors were ___ and \nrecommend wearing the hard collar for 4 weeks and following up \nin clinic for a repeat CT scan. Please wear your hard cervical \ncollar at all times except for hygiene. \n\nYou are now medically cleared for discharge. Please note the \nfollowing instructions:\n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\n \nFollowup Instructions:\n___\n" ]

[ "S12501A", "V405XXA", "V4752XA", "Y929", "F10129", "F419", "F17210" ]

[ "S12501A: Unspecified nondisplaced fracture of sixth cervical vertebra, initial encounter for closed fracture", "V405XXA: Car driver injured in collision with pedestrian or animal in traffic accident, initial encounter", "V4752XA: Car driver injured in collision with fixed or stationary object in traffic accident", "Y929: Unspecified place or not applicable", "F10129: Alcohol abuse with intoxication, unspecified", "F419: Anxiety disorder, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]

[ "Y929", "F419", "F17210" ]

[]