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mimic-icd-visit

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nlisinopril / Keflex / rifampin / Vicodin\n \nAttending: ___.\n \nChief Complaint:\nLeft shoulder pain\n \nMajor Surgical or Invasive Procedure:\nLeft shoulder hemiarthroplasty\n\n \nHistory of Present Illness:\n___ is a ___ woman who sustained a traumatic \ninjury to her left shoulder resulting in a proximal humerus \nfracture. She was taken to the operating room undergoing an \nopen reduction and internal fixation of her left proximal \nhumerus fracture on ___. Following surgery there is a \nfailure of the hardware. She was taken back to the operating \nroom on ___ undergoing a removal of hardware. \n\nShe was subsequently referred our my attention and went on to \nhave a left proximal humeral nonunion/malunion. Having had \nprior trauma to her right shoulder, she had a significant \ndysfunction in her dominant right hand. She became dependent on \nher left side. For this reason, she and I discussed the\nrisks and benefits of conservative and surgical treatment, and \nit was her preference to proceed with revision fixation of her \nleft shoulder\n \nPast Medical History:\n1. Scleroderma\n2. Hepatic steatosis/Primary biliary Cirrhosis\n3. PUD\n4. Dyslipidemia\n5. Hypertension\n6. Depression\n7. Migraine Headaches\n\n \nSocial History:\n___\nFamily History:\nSignificant for stroke in father (CAD of father's side), DM in\nMGF and Aunt w/ lung CA (smoker); no other FHx of CA.\n\n \nPhysical Exam:\nAfebrile\nTcurrent: 99.0\nHR: 85 BP:114/66 RR:18 SpO2:100 % RA\nUrine output last shift:900cc\nThe left shoulder dressing is clean and dry.\nShe is intact distally with + APB/EPL/ADQ\nThe fingers are warm to touch with good capillary refill. \n \nBrief Hospital Course:\nThe patient was admitted to the Orthopaedic Sports Medicine \nService for post-traumatic left glenohumeral arthropathy. The \npatient was taken to the OR and underwent a left shoulder \nhemiarthroplasty. Please see operative report for full details. \nThe patient tolerated the procedure without difficulty and was \ntransferred to the PACU in stable condition, and then \ntransferred to the floor in the usual fashion. Postoperatively, \npain was controlled with an interscalene nerve block, with \ntransition to oral pain medication as tolerated. Perioperative \nantibiotics and Aspirin for DVT prophylaxis were given as per \nroutine. Diet was advanced without complication and the patient \nmade steady progress. The hospitalization has otherwise been \nuneventful and the patient has done well.\n \n At discharge, vital signs are stable, the patient is afebrile, \ntolerating a regular diet, voiding spontaneously every shift and \npain is well controlled. The extremities are neurovascularly \nintact distally throughout the left upper extremity. All \nincisions are clean, dry and intact without evidence of \ninfection, hematoma or seroma.\n \n The patient is discharged home in stable condition. Patient \ngiven detailed precautionary instructions and instructions for \nthe appropriate follow up care. \n\n \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Losartan Potassium 25 mg PO DAILY \n2. Tiotropium Bromide 1 CAP IH DAILY \n3. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN shoulder pain \n4. ClonazePAM 1 mg PO BID:PRN anxiety \n5. ibandronate 150 mg oral once per month \n6. Methocarbamol 500 mg PO DAILY:PRN muscle spasm \n7. Atorvastatin 40 mg PO QPM \n8. Ursodiol 300 mg PO TID \n9. ValACYclovir 500 mg PO BID:PRN cold sore \n10. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - \nModerate \n11. FLUoxetine 20 mg PO DAILY \n12. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN nasal \ncongestion \n13. FoLIC Acid 1 mg PO DAILY \n14. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever \n15. DICYCLOMine 10 mg PO Q8H:PRN abdominal spasm/pain \n16. butalbital-acetaminophen-caff 50-300-40 mg oral DAILY:PRN \n17. Prochlorperazine 10 mg PO DAILY:PRN Nausea/Vomiting - First \nLine \n18. Cetirizine 10 mg PO DAILY \n19. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea \n\n \nDischarge Medications:\n1. Aspirin EC 325 mg PO DAILY \nPlease use for a total of 6 weeks following surgery. \n2. Docusate Sodium 100 mg PO BID \nPlease use as needed while taking narcotic pain medication. \n3. butalbital-acetaminophen-caff 50 300 40 mg oral DAILY:PRN \nmigraine headaches \n4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain \nRX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*42 \nTablet Refills:*0 \n5. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever \n6. Atorvastatin 40 mg PO QPM \n7. Cetirizine 10 mg PO DAILY \n8. ClonazePAM 1 mg PO BID:PRN anxiety \n9. DICYCLOMine 10 mg PO Q8H:PRN abdominal spasm/pain \n10. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea \n11. FLUoxetine 20 mg PO DAILY \n12. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN nasal \ncongestion \n13. FoLIC Acid 1 mg PO DAILY \n14. ibandronate 150 mg oral once per month \n15. Losartan Potassium 25 mg PO DAILY \n16. Methocarbamol 500 mg PO DAILY:PRN muscle spasm \n17. Prochlorperazine 10 mg PO DAILY:PRN Nausea/Vomiting - First \nLine \n18. Tiotropium Bromide 1 CAP IH DAILY \n19. Ursodiol 300 mg PO TID \n20. ValACYclovir 500 mg PO BID:PRN cold sore \n21. HELD- Lidocaine 5% Patch 1 PTCH TD DAILY:PRN shoulder pain \nThis medication was held. Do not restart Lidocaine 5% Patch \nuntil your incision has healed and sutures are removed. \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPosttraumatic left glenohumeral arthropathy\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nShoulder Hemiarthroplasty\n Post-Operative Instructions\n(with/without Biceps Tenodesis)\n\nMedications\nYou will be given a prescription for pain medicine. The pain \nmedication is a codeine derivative and should be taken as \ndirected. \n\nPlease take one full strength aspirin (325 mg) each day for six \nweeks to decrease the risk of having a complication related to a \nblood clot.\n\nPlease take a stool softener, like Colace (Docusate Sodium \n100mg), twice a day while taking narcotics to prevent \nconstipation.\n\nDressing\nLeave your dressing for 48 hours after your surgery. After 48 \nhours, you may remove your dressing. LEAVE THE TAPE STRIPS OVER \nYOUR INCISIONS. These will stay on for 1.5 to 2 weeks and will \nslowly peel off.\n\nShowering\nYou may shower 48 hours after your surgery and get your \nincisions wet. DO NOT immerse in a tub or pool for 7 – 10 days \nto avoid excessive scarring and risk of infection.\n\nWhen you shower, let your arm hang at your side (Do NOT raise \nyour arm). \n\nTo wash under your arm, lean forward carefully and let your arm \nhang. Using your other hand, wash under your operative arm. Do \nNOT scrub the incision. When you are done, stand up and let \nyour arm hang at your side. Pat yourself dry and put your sling \non.\n\nIce Packs\nKeep Ice Packs on at all times exchanging every hour while \nawake. Icing is very important to decrease swelling and pain \nand improve mobility. After 24 hours, continue to use the cuff \n3 – 4 times a day, 15 – 20 minutes each time to keep swelling to \na minimum.\n\nActivity\n•Take it easy.\n•Wear your sling for comfort and safety. \n•Keep your arm at your side at ALL TIMES – no reaching, \ngrabbing or pulling with your operative arm.\n\nWhen to Contact Us\nIf you experience severe pain that your pain medication does not \nhelp, please let us know. \n\nIf you have a temperature over 101.5º, please contact our office \nat ___\n\nPhysical Therapy:\nSling/nonweightbearing left upper extremity times 6 weeks.\n\nThere should be no formal shoulder range of motion including \npendulums.\nTreatments Frequency:\nDressing changes beginning on ___ as needed for persistent \nwound drainage.\n \nFollowup Instructions:\n___\n" ]

[ "M12512", "S42252P", "S42292K", "T8489XA", "M96622", "Y793", "I9581", "M85822", "M349", "K743", "I10", "F329", "E785" ]

[ "M12512: Traumatic arthropathy, left shoulder", "S42252P: Displaced fracture of greater tuberosity of left humerus, subsequent encounter for fracture with malunion", "S42292K: Other displaced fracture of upper end of left humerus, subsequent encounter for fracture with nonunion", "T8489XA: Other specified complication of internal orthopedic prosthetic devices, implants and grafts, initial encounter", "M96622: Fracture of humerus following insertion of orthopedic implant, joint prosthesis, or bone plate, left arm", "Y793: Surgical instruments, materials and orthopedic devices (including sutures) associated with adverse incidents", "I9581: Postprocedural hypotension", "M85822: Other specified disorders of bone density and structure, left upper arm", "M349: Systemic sclerosis, unspecified", "K743: Primary biliary cirrhosis", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "E785: Hyperlipidemia, unspecified" ]

[ "I10", "F329", "E785" ]

[]

[ " \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:\nAbnormal CT, BRBPR, Transfer from OSH\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ yo man with ___ year history of BRBPR, hemmorhoids s/p\nresection, EGD ___ showing ___ esophagus who presents\nwith persistent BRBPR. Reports every ___ weeks for many years \nhas\n___ BRBPR output which coincide with swelling of known\nhemorrhoids. He reports that these episodes usually last for ___\ndays at a time and self resolve.\n\n8 days ago he had a BBQ, and the following day had crampy\nabdominal pain with diarrhea every 1.5-2 hours with blood in the\nstool every time. Has felt his hemorrhoids swell and become\npainful during this time. He denies N/V, hematemesis, and \nmelena.\nDoes have chest discomfort with profuse sweating only when \nhaving\nthe BMs. Never any exertional chest discomfort. Of note that\npatient reports that his daughter and uncle were also sick after\nthe BBQ, with his uncle having emesis. \n\nPatient reports having colonoscopies in the past but that they\nnever showed a true cause of his bleeding. He also reports that\non his last colonoscopy he was told that he had some polyps\nremoved. \n\nAt OSH, CT A/P showed SMA thrombus/dissection. Vascular surgery\nhere recommending anticoagulation but need to evaluate GI bleed\nfirst. \n\nNotable labs at OSH: Lactate 1.1, Hb 14.3. \n\nIn the ED, initial vitals were: \nT 97.6, HR 61, BP 142/95, RR 19, 100% RA\n \nExam notable for: \n- Mild TTP in LLQ, soft, mildly distended \n- Rectal: numerous large but soft non-bleeding external\nhemorrohoids tender to touch \n\nLabs notable for: \nHb 13.1, bicarb 17, Cr 1.0, lactate 2.1->1.4 \n\nImaging was notable for: \nCT from OSH as above \n\nPatient was given: \n1L NS\nZosyn 4.5 g IV\nAtorvastatin 40 mg\nMaintenance fluids NS started at 125 ml/hr\n\nConsults: \nVascular, will follow. Rec please start ASA81 and statin \n\nUpon arrival to the floor, patient reports that he is feeling\nfine just 'ready to get to sleep.' He reports that his abdomen \nis\nless tender now than it had been in the emergency room but he\nattributes this to not eating anything. He denies any current\nF/C, CP, SOB, N/V. \n\nREVIEW OF SYSTEMS:\n\nComplete ROS obtained and is otherwise negative.\n\n \nPast Medical History:\nLarge external hemorrhoids persistent despite remote resection \nx1, complicated by ongoing intermittent BRBPR\nSMA thrombus with ?dissection, likely chronic\n___ esophagus\nHypertension,\nHyperlipidemia\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVITALS: T98.0 PO, BP 166 / 89 Lying, HR 58, RR 16, O2 99 ra \nGENERAL: Alert and interactive. In no acute distress.\nHEENT: NCAT. PERRL, EOMI. Sclera anicteric and without \ninjection.\nMMM.\nCARDIAC: RRR, no m/r/g\nLUNGS: CTAB no r/r/w\nABDOMEN: Soft, TTP RUQ and LLQ\nEXTREMITIES: No clubbing, cyanosis, or edema. \nSKIN: Warm. No rash.\nNEUROLOGIC: CN2-12 grossly intact. ___ strength throughout.\nNormal sensation. Gait is normal. AOx3.\n\nDISCHARGE PHYSICAL EXAM:\n24 HR Data (last updated ___ @ 359)\n Temp: 97.9 (Tm 98.5), BP: 116/74 (99-167/61-99), HR: 58\n(48-66), RR: 18 (___), O2 sat: 96% (96-99), O2 delivery: Ra \n\nGENERAL: Alert and interactive. In no acute distress.\nHEENT: NCAT. PERRL, EOMI. Sclera anicteric and without \ninjection.\nMMM.\nCARDIAC: RRR, no m/r/g\nLUNGS: CTAB no r/r/w\nABDOMEN: Obese, nontender, +Bowel sounds\nEXTREMITIES: No clubbing, cyanosis, or edema. \nSKIN: Warm. No rash.\nNEUROLOGIC: CN2-12 grossly intact. ___ strength throughout.\nNormal sensation. Gait is normal. AOx3.\n \nPertinent Results:\nADMISSION LABS:\n___ 03:16AM BLOOD WBC-7.4 RBC-4.21* Hgb-13.1* Hct-39.6* \nMCV-94 MCH-31.1 MCHC-33.1 RDW-12.5 RDWSD-43.4 Plt ___\n___ 03:16AM BLOOD Neuts-64.3 ___ Monos-8.7 Eos-5.4 \nBaso-0.7 Im ___ AbsNeut-4.72 AbsLymp-1.53 AbsMono-0.64 \nAbsEos-0.40 AbsBaso-0.05\n___ 03:16AM BLOOD ___ PTT-32.3 ___\n___ 03:16AM BLOOD Glucose-102* UreaN-18 Creat-1.0 Na-140 \nK-4.3 Cl-109* HCO3-17* AnGap-14\n___ 06:56PM BLOOD CRP-3.7\n___ 06:23AM BLOOD Lactate-2.1*\n___ 10:28AM BLOOD Lactate-1.4\n\nDISCHARGE LABS:\n___ 07:48AM BLOOD WBC-4.6 RBC-4.10* Hgb-13.0* Hct-37.6* \nMCV-92 MCH-31.7 MCHC-34.6 RDW-12.2 RDWSD-41.0 Plt ___\n___ 07:48AM BLOOD Plt ___\n___ 07:48AM BLOOD Glucose-103* UreaN-14 Creat-1.0 Na-144 \nK-4.6 Cl-108 HCO3-22 AnGap-14\n___ 07:48AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0\n\nPERTINENT STUDIES:\n___ CT A/P from OSH \n 1. There is questionable segmental irregular thickening of the\nwall of the ascending colon for which I would recommend\ncolonoscopy for further evaluation. This could be due to\nsegmental colitis. Neoplastic disease cannot be excluded. There\nis no paracolic inflammatory change or adenopathy. \n \n 2. There are a few colonic diverticula. There is no gross\nevidence of acute diverticulitis. \n \n 3. There is moderate segmental narrowing of the proximal SMA in\nassociation with a predominantly noncalcified plaque or possibly\na short segmental dissection with thrombosis of the false \n lumen. \n \n 4. Small hiatal hernia. \n\nMICROBIOLOGY:\n__________________________________________________________\n___ 9:00 am BLOOD CULTURE\n\n Blood Culture, Routine (Pending): No growth to date. \n__________________________________________________________\n___ 7:56 am BLOOD CULTURE\n\n Blood Culture, Routine (Pending): No growth to date. \n__________________________________________________________\n___ 4:14 am STOOL CONSISTENCY: WATERY Source: \nStool. \n\n **FINAL REPORT ___\n\n MICROSPORIDIA STAIN (Final ___: NO MICROSPORIDIUM \nSEEN. \n\n CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN. \n\n FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA \nFOUND. \n\n CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER \nFOUND. \n\n OVA + PARASITES (Final ___: \n This test does not reliably detect Cryptosporidium, \nCyclospora or\n Microsporidium. While most cases of Giardia are detected \nby routine\n O+P, the Giardia antigen test may enhance detection when \norganisms\n are rare. \n NO OVA AND PARASITES SEEN. \n ___ CRYSTALS PRESENT. \n MODERATE RBC'S. \n\n FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO \nFOUND. \n\n FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA \nFOUND. \n\n FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___: \n No E. coli O157:H7 found. \n\n Cryptosporidium/Giardia (DFA) (Final ___: \n NO CRYPTOSPORIDIUM OR GIARDIA SEEN. \n \nBrief Hospital Course:\n___ yo man with ___ year history of frequent intermittent BRBPR \nsecondary to large external hemorrhoids that have persisted \ndespite resection x1, EGD ___ showing ___ esophagus who \npresented with diarrhea, abd pain and persistent BRBPR following \na BBQ with family, found to have SMA thrombus vs dissection on \nCT A/P as well as a thickened segment of ascending colon with \nconcern for colitis vs vs neoplasm, transferred to ___ for \nfurther management. At ___ findings felt to be chronic by \nvascular service and noncontributory to patient's current \nsymptoms. Upon careful review of images jointly by the GI and \nradiology services, segmental thickening of ascending colon felt \nto represent an artifact created by ___ difference in colonic \ndistention, with low suspicion for \ninfectious/inflammatory/ischemic or neoplastic process. \nPatient's rapid clinical improvement supported these \nconclusions.\n\n=============\nACTIVE ISSUES\n=============\n\n# BRBPR \n# Diarrhea\n# Abdominal pain\n# ?Colitis\nBRBPR has been 20+ yr chronic issue for patient, so in current \ncontext is likely from known hemorrhoids as opposed acute LGIB. \nHemorrhoidal bleeding likely exacerbated in setting of new onset \ndiarrhea following a BBQ cookout. Others who attended the \ncookout also developed diarrhea shortly after, raising the \nsuspicion for food poisoning or a viral gastroenteritis. CTA \nfrom OSH was initially concerning for colitis vs neoplasm given \nfinding of segmental thickening of ascending colon, however upon \ncareful review of images jointly by the GI and radiology \nservices, segmental thickening of ascending colon felt more \nlikely to represent an artifact created by ___ difference in \ncolonic distention, with low suspicion for \ninfectious/inflammatory/ischemic or neoplastic process. \nAdditionally, patient has had a colonoscopy within the past 6 \nmonths, further lowering the suspicion for neoplasm. Combined \nwith the patient's stable H&H and overall clinical stability and \nrapid improvement, further studies such as colonoscopy or \nflexible sigmoidoscopy were not indicated. Cipro/flagyl was \nstarted empirically upon admission for empiric coverage of \npossible infectious colitis, but following new interpretation by \nGI and radiology services, completion of just a short 5 day \ncourse was recommended. Recommend outpatient referral to \ncolorectal surgery for possible excision of external \nhemorrhoids.\n\n# SMA thombosis/dissection \nOSH CTA showed segmental narrowing of proximal SMA concerning \nfor dissection w/\nfalse lumen and thrombosis. Per vascular surgery, this is likely \nchronic and patient has no signs of acute abdomen or labs \nsuggestive of ischemia. The segmental thickening of the \nascending colon seen on the same imaging was also determined to \nbe a likely artifact. Patient was also monitored on telemetry, \nwhich found no thrombogenic arrhythmias such as afib. Vascular \nsurgery recommended starting ASA and statin, but no \nanticoagulation. Will follow-up with vascular surgery in 1 month \nfor duplex ultrasound of abdominal vasculature.\n\n#Chest pain\npatient had a brief episode of sharp chest pain located over \nleft pectoral waking him from sleep and also found himself in a \ncold sweat. Rubbing his chest helped. Pain resolved \nspontaneously without intervention. Patient denies hx of heart \nattack, stroke, or CAD. Does endorse feeling similar chest pain \nabout a week ago while having a bowel movement. FSBG 78 (patient \nhad been NPO for potential colitis as discussed above). EKG \nunremarkable and stable from prior. Telemetry unremarkable. \nMonitored without recurrence. Potentially related to GERD as \npatient has known ___ esophagus and hadn't received his \nhome omeprazole on that day or the day prior. \n\nTRANSITIONAL ISSUES:\n====================\n[]Patient was started on baby aspirin and atorvastatin 40mg per \nvascular surgery recommendations for his chronic SMA thrombus. \nNo anticoagulation indicated at this time.\n[]Please ensure follow-up with Vascular Surgery at ___ in \nabout 1 month for duplex ultrasound to monitor his chronic SMA \nthrombus. \n[]Completing 5 day course of ciprofloxacin for diarrhea, last \nday is ___.\n[x]Stool cultures all negative as of ___\n[]Please refer patient for colorectal surgery for consideration \nof operative intervention of large chronic external hemorrhoids \ncomplicated by ongoing bleeding. We emphasized to the patient \nthat an operation such as excision has a very good chance of \nstopping his chronic-intermittent hemorrhoidal bleeding, even if \nnot ___ guaranteed (which he had expressed to us was his reason \nfor not pursuing recommended surgery in the past).\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Omeprazole 20 mg PO QAM \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 at bedtime Disp #*30 \nTablet Refills:*0 \n3. Ciprofloxacin HCl 500 mg PO Q12H \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve \n(12) hours Disp #*6 Tablet Refills:*0 \n4. Omeprazole 20 mg PO QAM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nBRBPR\nDiarrhea\nChronic SMA 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 ___,\n\nIt was a pleasure taking care of you at ___.\n\nWhy you were in the hospital:\n-You were admitted for diarrhea and abdominal pain.\n \nWhat was done for you in the hospital:\n-We gave you antibiotics to treat for a potential infection, and \ngave you fluids for your volume loss.\n \nWhat you should do after you leave the hospital:\n\n- Please take your medications as detailed in the discharge \npapers. If you have questions about which medications to take, \nplease contact your regular doctor to discuss.\n\n- Please go to your follow up appointments as scheduled in the \ndischarge papers. Most of them already have a specific date & \ntime set. If there is no specific time specified, and you do not \nhear from their office in ___ business days, please contact the \noffice to schedule an appointment.\n\n- Please monitor for worsening symptoms. If you do not feel like \nyou are getting better or have any other concerns, please call \nyour doctor to discuss or return to the emergency room.\n\nWe wish you the best!\n\nSincerely,\n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "K644", "K55069", "K5010", "E872", "D649", "K2270", "K219", "I10", "E7849", "Z87891", "F1290" ]

[ "K644: Residual hemorrhoidal skin tags", "K55069: Acute infarction of intestine, part and extent unspecified", "K5010: Crohn's disease of large intestine without complications", "E872: Acidosis", "D649: Anemia, unspecified", "K2270: Barrett's esophagus without dysplasia", "K219: Gastro-esophageal reflux disease without esophagitis", "I10: Essential (primary) hypertension", "E7849: Other hyperlipidemia", "Z87891: Personal history of nicotine dependence", "F1290: Cannabis use, unspecified, uncomplicated" ]

[ "E872", "D649", "K219", "I10", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / Percocet\n \nAttending: ___.\n \nChief Complaint:\nPneumonia\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ is a ___ year old with PMH of anorexia,\nosteoporosis, depression/anxiety, alcohol abuse who presents \nwith\n___ days of cough, chest tightness, SOB, and fevers and was \nfound\nto have a multifocal PNA on CTA chest for which she is being\nadmitted. \n\nPatient states she had a pneumonia in ___ which developed in\nthe setting of bilateral rib fractures from a work-related\ninjury. Patient works as a ___ and was doing CPR and developed\nsevere chest pain and was later found to have bilateral six and\nseven rib fractures. She presented to the ED due to worsening\npain and was found to have RUL opacities concerning for PNA. She\ncompleted a course of doxycycline and augmentin and her chest\npain slowly improved with treatment with PO Toradol but still \nhas\nbeen dealing with chest pain that has required activity\nrestrictions at work. \n\nShe states she was feeling well other than an exacerbation of \nher\nchest pain which she thinks was a muscles strain earlier this\nweek. On ___, she states she awoke feeling acutely short of\nbreath and began to develop a significant cough. She states she\nalso had two low fevers to 100.4. She presented to her PCP and\ngot ___ X-ray for her chest pain, dyspnea and cough which showed \nno\nrib fracture but recurrence of RUL opacities. She was referred \nto\nurgent care and had a CTA chest which showed a new multifocal\nPNA. \n\nIn the ED, patient was found to be dyspneic and uncomfortable\nappearing but with stable vitals: T 97.7 HR 73 BP 144/98 RR 16\nSpO2 97% RA. Initial labs without leukocytosis, normal lactate,\nand negative flu swab. She was placed on 3L O2 for comfort and\nrecommended admission for IV antibiotics given patient\nill-appearing. \n\nOn arrival to the floor, the patient states she already feels\nmuch better after receiving the antibiotics in the ED. She is\nable to speak in complete sentences which was difficult earlier\ntoday. She states her chest pain has completely resolved but is\nstill having occasional bouts of a dry cough. She did have some\nnausea earlier today but improved with Zofran. Denies\nfever/chills, N/V, abdominal pain, diarrhea, dysuria. She states\nshe gets sinus infections and bronchitis yearly but no history \nof\nimmunodeficiency or frequent bacterial infections. \n\nROS negative , or as detailed above. \n\n \nPast Medical History:\n- History of anorexia nervosa\n- Osteoporosis\n- Depression\n- Anxiety\n- Vitamin D deficiency\n \nSocial History:\n___\nFamily History:\nFamily history of hypertension in Mother and Father.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVITALS: ___ Temp: 98.2 PO BP: 148/75 L Sitting HR: 86\nRR: 20 O2 sat: 97% O2 delivery: ra \nGENERAL: Alert and interactive. In no acute distress.\nHEENT: PERRL, EOMI. MMM.\nNECK: No cervical lymphadenopathy. No JVD.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: Intermittent bursts of dry cough. Decreased breath sounds\nover RUL but without wheezes, rhonchi or rales. No increased \nwork\nof 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, or edema. Pulses DP/Radial \n2+\nbilaterally.\nSKIN: Warm. Cap refill <2s. No rashes.\nNEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs\nspontaneously. ___ strength throughout. Normal sensation.\n\nDISCHARGE EXAM:\n===============\nVS: ___ ___ Temp: 98.0 PO BP: 131/88 L Standing HR: 85 RR:\n18 O2 sat: 95% O2 delivery: Ra \nGENERAL: Alert and interactive, pleasant. Comfortable. \nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: No increased work of breathing. Clear to auscultation \nb/l.\nNo wheezes/rales/rhonchi.\nEXTREMITIES: No edema, warm. \n\n \nPertinent Results:\nADMISSION LABS:\n===============\n\n___ 11:44AM BLOOD WBC-4.3 RBC-4.06 Hgb-11.4 Hct-35.0 MCV-86 \nMCH-28.1 MCHC-32.6 RDW-14.6 RDWSD-46.6* Plt ___\n___ 11:44AM BLOOD Neuts-56.2 ___ Monos-13.1* \nEos-1.4 Baso-0.5 Im ___ AbsNeut-2.44 AbsLymp-1.22 \nAbsMono-0.57 AbsEos-0.06 AbsBaso-0.02\n___ 11:44AM BLOOD Glucose-105* UreaN-8 Creat-0.5 Na-140 \nK-4.2 Cl-106 HCO3-23 AnGap-11\n___ 07:15AM BLOOD ALT-14 AST-15 LD(LDH)-178 AlkPhos-67 \nTotBili-0.2\n___ 07:15AM BLOOD Albumin-3.9 Calcium-8.5 Phos-2.5* Mg-1.9\n___ 07:35AM BLOOD HIV Ab-NEG\n___ 05:46PM BLOOD Lactate-0.8\n\nRELEVANT LABS:\n==============\n___ 07:35AM BLOOD HIV Ab-NEG\n\nDISCHARGE LABS:\n===============\n___ 07:04AM BLOOD WBC-3.7* RBC-3.76* Hgb-10.3* Hct-31.6* \nMCV-84 MCH-27.4 MCHC-32.6 RDW-14.0 RDWSD-42.8 Plt ___\n___ 07:04AM BLOOD Neuts-50 ___ Monos-9 Eos-1 Baso-0 \nAtyps-4* Plasma-1* AbsNeut-1.85 AbsLymp-1.44 AbsMono-0.33 \nAbsEos-0.04 AbsBaso-0.00*\n___ 07:04AM BLOOD Glucose-113* UreaN-6 Creat-0.5 Na-143 \nK-3.8 Cl-102 HCO3-21* AnGap-20*\n___ 07:04AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.0\n\nIMAGING:\n========\nCTA Chest ___:\nNo evidence of pulmonary embolism or aortic abnormality. \nRight upper lobe pneumonia has increased. New areas of milder \npneumonia in the left upper lobe, lingula and left lower lobe. \nFollowing treatment, suggest a follow-up chest CT to confirm \nclearance of these findings, such as in 3 months.\nMediastinal and right hilar adenopathy, possibly reactive. \nHepatic steatosis. Possible small hiatal hernia \n\nCXR ___:\nMultifocal pneumonia, re-demonstrated, and more apparent \nradiographically than \non ___. \n \n\nMICROBIOLOGY:\n=============\n__________________________________________________________\n___ 2:50 am BLOOD CULTURE\n\n Blood Culture, Routine (Pending): No growth to date. \n__________________________________________________________\n___ 10:18 am MRSA SCREEN Source: Nasal swab. \n\n **FINAL REPORT ___\n\n MRSA SCREEN (Final ___: No MRSA isolated. \n__________________________________________________________\n___ 7:35 am BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n__________________________________________________________\n___ 5:30 pm BLOOD CULTURE 2 OF 2; LEFT. \n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n__________________________________________________________\n___ 5:30 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n \nBrief Hospital Course:\nSUMMARY\n=========\n___ is a ___ year old with PMH of anorexia, \nosteoporosis, depression/anxiety who presents with ___ days of \ncough, chest tightness, SOB, and fevers and was found to have a \nmultifocal PNA on CTA chest for which she was admitted and \ntreated with several days of IV antibiotics. \n\nACUTE/ACTIVE ISSUES:\n====================\n#Community Acquired Pneumonia\nHistory of recent pneumonia three months ago that resolved and \nnow presenting with dyspnea, cough, and fever with CT showing \nworsening multifocal pneumonia. Unclear why developed recurrent \npneumonia. Is a smoker and patient notably was just treated for \nPNA with doxycycline. The patient received IV ceftriaxone and \nazithromycin while at ___ Urgent care and transferred \nto ___. She was continued on CAP coverage with ceftriaxone and \nazithromycin but continued to have fevers. She was then \nbroadened to Cefepime/azithromycin on ___. We de-escalated to \nlevofloxacin on ___ to complete a total 5-day course as patient \nwas afebrile, and it was felt that her pneumonia was most likely \nviral in etiology. She remained on room air during her entire \nhospital stay.\n\n#Mild leukopenia\nWBC 2.6 on ___, from 4.4 day prior. Most likely acute \nsuppression iso virus. WBC was uptrending on discharge and was \n3.7 at time of discharge. \n\n#Hepatic Steatosis\nNoted on CT chest incidentally. Suspect NAFLD but given alcohol \nhistory could be alcohol related as well.\n- consider repeat HbA1c, lipid panel \n\nCHRONIC/STABLE ISSUES:\n======================\n#Hypertension\n- Continued home amlodipine 2.5mg daily\n- Continued home atenolol 50mg daily\n- Continued home clonidine 0.1mg QHS\n\n#Depression\n#Anxiety\n- Venlafaxine XR 150 mg PO DAILY \n- QUEtiapine Fumarate 300 mg PO QHS\n- QUEtiapine Fumarate 25 mg PO DAILY:PRN anxiety \n- LamoTRIgine 250 mg PO/NG QPM DAILY \n\n#GERD\n- Omeprazole 20mg BID\n\n#?Osteoporosis\n#Recent rib fractures\nHas documented history of osteoporosis but no DEXA scan on file. \nGiven rib fracture with minimal trauma based on history, should \nlikely have DEXA scan to evaluate as outpatient.\n- started on vitamin D while in house givne ___ level < 20, \nstarted on 50K once a week\n- started on calcium while in house \n\nTRANSITIONAL ISSUES:\n=====================\n[] Consider DEXA as outpatient\n[] Continue to encourage smoking cessation \n[] Consider further pulmonary referral and work-up for recurrent \npneumonia \n[] Would recommend follow-up of patient's WBC to ensure it has \nnormalized\n[] Patient has hepatic steatosis seen incidentally on imaging, \nconsider repeat HbA1c and lipid panel \n[] Repeat CXR in ___ weeks to ensure resolve of PNA\nCTA read:\nRight upper lobe pneumonia has increased. New areas of milder \npneumonia in the left upper lobe, lingula and left lower lobe. \nFollowing treatment, \nsuggest a follow-up chest CT to confirm clearance of these \nfindings, such as in 3 months. Mediastinal and right hilar \nadenopathy, possibly reactive. Hepatic steatosis. Possible small \nhiatal hernia \n\n# CODE: Full (presumed)\n# CONTACT: ___ \nRelationship: mother \nPhone number: ___ \n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 2.5 mg PO DAILY \n2. Atenolol 50 mg PO DAILY \n3. CloNIDine 0.1 mg PO QHS \n4. Omeprazole 20 mg PO BID \n5. Venlafaxine XR 150 mg PO DAILY \n6. QUEtiapine Fumarate 300 mg PO QHS \n7. LamoTRIgine 250 mg PO QHS \n8. QUEtiapine Fumarate 25 mg PO DAILY:PRN anxiety \n9. Acetaminophen 1000 mg PO BID:PRN Pain - Mild/Fever \n10. Naproxen 500 mg PO Q12H:PRN Pain - Moderate \n\n \nDischarge Medications:\n1. Calcium Carbonate 1000 mg PO DAILY \nRX *calcium carbonate 500 mg calcium (1,250 mg) 2 tablet(s) by \nmouth once a day Disp #*100 Tablet Refills:*0 \n2. Vitamin D ___ UNIT PO 1X/WEEK (___) \nRX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by \nmouth once a week Disp #*10 Capsule Refills:*0 \n3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \n4. amLODIPine 2.5 mg PO DAILY \n5. Atenolol 50 mg PO DAILY \n6. CloNIDine 0.1 mg PO QHS \n7. LamoTRIgine 250 mg PO QHS \n8. Naproxen 500 mg PO Q12H:PRN Pain - Moderate \n9. Omeprazole 20 mg PO BID \n10. QUEtiapine Fumarate 300 mg PO QHS \n11. QUEtiapine Fumarate 25 mg PO DAILY:PRN anxiety \n12. Venlafaxine XR 150 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n==================\nCommunity acquired pneumonia \n\nSECONDARY DIAGNOSIS\n=====================\nAnxiety\nDepression \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___.\n\nWHY WAS I IN THE HOSPITAL? \n- You were transferred to the hospital for evaluation for \npneumonia. \n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- You were given IV fluids and antibiotics while in the \nhospital. You received a full course for community-acquired \nbacterial pneumonia; however, it was felt that the most likely \ncause of your pneumonia was a virus. \n- We gave you breathing support with nebulizer breathing \ntreatments.\n- We set up follow up with your primary care doctor. \n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n- Continue to take all your medicines and keep your \nappointments. \n- If you experience worsening shortness of breath, please go to \nthe Emergency Room.\n\nWe wish you the best! \n\nSincerely, \nYour ___ Team \n\n \nFollowup Instructions:\n___\n" ]

[ "J129", "F17210", "F1010", "F418", "K760", "K219", "E559", "I10", "E860", "D72819", "R112" ]

[ "J129: Viral pneumonia, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F1010: Alcohol abuse, uncomplicated", "F418: Other specified anxiety disorders", "K760: Fatty (change of) liver, not elsewhere classified", "K219: Gastro-esophageal reflux disease without esophagitis", "E559: Vitamin D deficiency, unspecified", "I10: Essential (primary) hypertension", "E860: Dehydration", "D72819: Decreased white blood cell count, unspecified", "R112: Nausea with vomiting, unspecified" ]

[ "F17210", "K219", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nlorazepam / sulfa\n \nAttending: ___.\n \nChief Complaint:\nFalls, urinary incontinence\n \nMajor Surgical or Invasive Procedure:\nNone.\n\n \nHistory of Present Illness:\n___ with right temporal glioblastoma on Avastin, presents with\nfrequent falls and urinary incontinence. Says she is \"unsteady \non\nher feet\". Only has \"soft falls\", tends to sit down after \ngetting\nup. Says she shuffles \"a lot\" while walking (not new). She does\nloose her urine, sometimes a lot.\nPatient was recently admitted in early ___ for similar\nsymptoms with improvement after large volume LP. Was seen in\nclinic on ___ with incontinence and frequent falls. Dr. ___ patient to be directly admitted to OMED from clinic, but\nthere were no beds, so the patient was sent to the ED while\nawaiting a bed. \nIn the ED, initial VS were: HR 74, BP 150/92, RR 16, O2 100% RA\n- Labs notable for: K ___ s/p PO supplementation 40mEq KCL PO\n- Imaging notable for: Deep vein thrombosis extending from the\nleft mid femoral vein into the popliteal vein.\n- Patient given: Weight based Heparin IV and started on 1300\nUnits / hr for PTT goal 60-100 secs, Heparin not given until\n12:20am. Was cleared by Dr ___ (covering for Dr \n___ oncologist) after Dr ___ (ED) spoke with him.\nThis morning she has no additional complaints. Denies pain or\nnausea.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\n___ right-handed woman, with history of hypertension,\nhyperlipidemia, GERD and anxiety, who has a right temporal\nglioblastoma. She had:\n(1) a resection of a right temporal lobe glioblastoma by Dr. \n___ on ___,\n(2) received from ___ to ___ involved-field cranial\nirradiation and concomitant daily temozolomide at DFCI ___, \n(3) ophthalmic shingle eruption at right V1 on ___,\n(4) placement of a Portacath on ___ at ___ \n___,\n(5) started C1D1 bevacizumab at 10 mg/kg on ___,\n(6) received C1D15 bevacizumab at 10 mg/kg on ___,\n(7) received C2D1 bevacizumab at 10 mg/kg on ___,\n(8) received C2D15 bevacizumab at 10 mg/kg on ___,\n(9) received C3D1 bevacizumab at 10 mg/kg on ___\n(10) received C3D15 bevacizumab at 10 mg/kg on ___,\n(11) received C4D1 bevacizumab at 10 mg/kg on ___,\n(12) received C4D15 bevacizumab at 10 mg/kg on ___,\n(13) received C5D1 bevacizumab at 10 mg/kg on ___,\n(14) received C5D15 bevacizumab at 10 mg/kg on ___,\n(15) received C6D1 bevacizumab at 10 mg/kg on ___,\n(16) received C6D15 bevacizumab at 10 mg/kg on ___,\n(17) revision of the Portacath on ___,\n(19) received C7D1 bevacizumab at 10 mg/kg on ___,\n(20) received C7D15 bevacizumab at 10 mg/kg on ___,\n(21) received C8D1 bevacizumab at 10 mg/kg on ___,\n(22) received C8D15 bevacizumab at 10 mg/kg on ___,\n(23) received C9D1 bevacizumab at 10 mg/kg on ___,\n(24) received C9D15 bevacizumab at 10 mg/kg on ___,\n(25) received C10D1 bevacizumab at 10 mg/kg on ___,\n(26) received C10D15 bevacizumab at 10 mg/kg on ___,\n(27) received C11D1 bevacizumab at 10 mg/kg on ___,\n(28) received C11D15 bevacizumab at 7.5 mg/kg on ___,\n(29) received C12D1 bevacizumab at 7.5 mg/kg on ___, and\n(30) received C12D15 bevacizumab at 7.5 mg/kg on ___,\n(31) received C13D1 bevacizumab at 7.5 mg/kg on ___,\n\nPAST MEDICAL HISTORY:\n-Hypertension\n-Hyperlipidemia\n-GERD\n-Anxiety\n-Chronic low back pain\n\nPAST SURGICAL HISTORY: \nShe had a bladder suspension surgery, tonsillectomy, tubal\nligation, athroscopy of both wrists and bunionectomy.\n\n \nSocial History:\n___\nFamily History:\nHer parents are deceased; her mother had COPD, diabetes and\ncoronary artery disease while her father has coronary artery\ndisease and diabetes. She does not have any sibling. Her 2\ndaughters are healthy.\n \nPhysical Exam:\nVS: T 98.5 137/90 67 18 O2 100%RA\n GEN: NAD\n HEENT: MMM, no OP lesions \n HEART: RRR, normal S1 S2, no murmurs \n LUNGS: Clear, no wheezes, rales, or rhonchi \n ABD: Soft, nontender, nondistended, normal BS \n EXT: No ___ edema \n NEURO: CN ___ tested and intact. EOMI. ___ strength in upper\nand lower extremities. Normal gross sensation. Alert and\noriented.\n\n \nPertinent Results:\nCT Head (___): \n1. No acute intracranial abnormality. \n2. Similar appearance of the right anterior temporal lobe lesion\nand posttreatment changes. \n3. Air fluid level in the right sphenoid sinus; recommend\ncorrelation for possible acute sinusitis. \n___ Doppler: \n1. Deep vein thrombosis extending from the left mid superficial \nfemoral vein into the popliteal vein. \n2. No deep vein thrombosis seen in the right lower extremity. \n\n___ 05:59AM BLOOD WBC-3.9* RBC-3.35* Hgb-10.9* Hct-32.5* \nMCV-97 MCH-32.5* MCHC-33.5 RDW-13.9 RDWSD-49.8* Plt ___\n___ 05:25AM BLOOD ___ PTT-42.5* ___\n___ 05:59AM BLOOD Glucose-96 UreaN-7 Creat-0.5 Na-139 K-4.0 \nCl-109*\n___ 06:39AM BLOOD ALT-16 AST-18 AlkPhos-48 TotBili-0.5\n___ 06:39AM BLOOD Calcium-9.5 Phos-3.3 Mg-2.___ with right temporal glioblastoma on Avastin who presented \nwith frequent falls and urinary incontinence.\n\nFREQUENT FALLS\n- Given frequent falls and urinary incontinence there is a \nconcern for NPH. She also responded well to a LP last month. \nCase was discussed with neuro oncology and her primary neuro \noncologist recommended an LP which was performed. ___ was also \nconsulted who recommended home ___. Of note after the patient was \ndischarged I was notified by the lab that her CSF had one colony \nof gram positive cocci on one plate. This was discussed with \nneuro oncology who did not think this was significant at this \ntime give the patient had no symptoms of meningitis and it was \nso isolated.\n\nDVT\n- Diagnosed on admission by ___. Per discussion with \nneuro oncology was originally started on heparin IV and then was \ntransitioned to lovenox which she was discharged on.\n\nGLIOBLASTOMA\n- Her home medications were continued. She will follow up with \nher primary neuro oncologist as an outpatient. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. LeVETiracetam 1000 mg PO TID \n2. Megestrol Acetate 40 mg PO QID \n3. Docusate Sodium 100 mg PO TID:PRN constipation \n4. Senna 8.6 mg PO EVERY OTHER DAY constipation \n5. Simvastatin 20 mg PO QPM \n6. Multivitamins 1 TAB PO DAILY \n7. TraMADOL (Ultram) 50 mg PO BID:PRN pain \n8. Omeprazole Dose is Unknown PO DAILY \n9. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500 \nmg(1,250mg) -125 unit oral DAILY \n10. MethylPHENIDATE (Ritalin) 10 mg PO BID \n11. Sertraline 150 mg PO DAILY \n12. Thiamine 100 mg PO DAILY \n13. Ascorbic Acid Dose is Unknown PO DAILY \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO TID:PRN constipation \n2. LeVETiracetam 1000 mg PO TID \n3. Megestrol Acetate 40 mg PO QID \n4. MethylPHENIDATE (Ritalin) 10 mg PO BID \n5. Multivitamins 1 TAB PO DAILY \n6. Omeprazole 20 mg PO DAILY \n7. Senna 8.6 mg PO DAILY:PRN constipation \n8. Sertraline 150 mg PO DAILY \n9. Simvastatin 20 mg PO QPM \n10. Thiamine 100 mg PO DAILY \n11. TraMADOL (Ultram) 50 mg PO BID:PRN pain \n12. Acetaminophen 650 mg PO Q6H:PRN Pain \n13. Ascorbic Acid ___ mg PO DAILY \n14. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500 \nmg(1,250mg) -125 unit oral DAILY \n15. Enoxaparin Sodium 80 mg SC Q12H \nStart: Today - ___, First Dose: Next Routine Administration \nTime \nRX *enoxaparin 80 mg/0.8 mL ___very twelve (12) hours \nDisp #*60 Syringe Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nGlioblastoma\nGait Instability\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:\nYou were admitted with increased falls and instability and \nurinary incontinence. A lumbar puncture was done because this \nwas thought to be the cause. You were also found to have a DVT \nand were started on lovenox for treatment of this.\n \nFollowup Instructions:\n___\n" ]

[ "C712", "I82412", "I10", "R414", "R2681", "N39498", "E785", "K219", "F419", "Z923", "Z9221", "W1830XA", "Z9181", "Y92009", "M545" ]

[ "C712: Malignant neoplasm of temporal lobe", "I82412: Acute embolism and thrombosis of left femoral vein", "I10: Essential (primary) hypertension", "R414: Neurologic neglect syndrome", "R2681: Unsteadiness on feet", "N39498: Other specified urinary incontinence", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "F419: Anxiety disorder, unspecified", "Z923: Personal history of irradiation", "Z9221: Personal history of antineoplastic chemotherapy", "W1830XA: Fall on same level, unspecified, initial encounter", "Z9181: History of falling", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "M545: Low back pain" ]

[ "I10", "E785", "K219", "F419" ]

[]

[ " \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \noxycodone\n \nAttending: ___.\n \nChief Complaint:\nTachycardia, Electrolyte abnormalities\n \nMajor Surgical or Invasive Procedure:\nBronchoscopy and EBUS ___\nLumbar puncture ___\nLumbar puncture ___\n\n \nHistory of Present Illness:\nMs. ___ is a ___ former smoker with PMH significant for HTN,\nHLD, DM2, GERD, CKD3, diverticulosis who presents to the ED \nafter\nreceiving routine labs by her PCP showing hypocalcemia,\nhypomagnesemia, and leukocytosis. Patient was instructed by her\nPCP to come to the ED. There on ROS, she notes 1 week of mild\nshortness of breath and some weakness but otherwise has been in\nher usual state of health. Denies chest pain, cough, fevers,\nchills, nausea or vomiting. No recent travel history or visits\nfrom friends located in other countries. No history of TB\nexposure or IVDU.\n\nWhile in ED, patient triggered for tachycardia. \n\nIn the ED, initial VS were: \n134-102, 214-160s/50-70s, 34-12, 97% on 2L \n\nExam notable for: \nNot documented\n\nECG: tachycardia with no ischemic changes \n\nLabs showed: \nLactate 4.5 -> 3.1\nCa 7.0 -> 7.4\nMg .8 -> 1.3\nCr 1.4\nPro BNP 1597\nCBC WBC 17.0 \nUA small leuks, few bacteria, 9WBC\nVBG pH 7.42/ pCO2 42 \n\nImaging showed:\nCTA chest: \n1. No evidence of pulmonary embolism or aortic abnormality.\n2. 3.5 cm cavitary lesion in the superior segment left lower\nlobe. The\ndifferential includes cavitary mass lesion or pulmonary abscess.\n3. Multiple old right healed rib fractures.\n4. Indeterminate 2.0 cm left adrenal nodule.\n\nConsults: \nThoracic surgery: No acute thoracic surgery intervention\nindicated at this time. Admit to medicine for electrolyte\ncorrection, further workup for pulmonary mass (?biopsy), IV abx\nfor possible abscess. Thoracic surgery will follow. Patric \n___\n \nPatient received:\n___ 18:25 IVF NS \n___ 18:25 IV CefePIME \n___ 18:35 IV Vancomycin \n___ 18:35 IV Magnesium Sulfate \n___ 18:38 IV CefePIME 2 g \n___ 18:58 IVF NS 500 mL\n___ 19:50 IV Magnesium Sulfate 2 gm \n___ 20:31 IV Vancomycin 1000 mg \n___ 20:44 IV Calcium Gluconate \n___ 22:10 IV Calcium Gluconate 1 g \n___ 22:13 IV Calcium Gluconate \n___ 22:14 IV Calcium Gluconate 1 g \n___ 23:21 IV MetroNIDAZOLE \n___ 00:20 IV MetroNIDAZOLE 500 mg \n___ 01:10 PO/NG Gabapentin 600 mg \n___ 01:10 SC Insulin 4 Units \n___ 01:10 IVF LR \n\nTransfer VS were:\n104 151/61 20 98% 2L NC \n \nPast Medical History:\nHTN, HLD, DM2, GERD, CKD3, diverticulosis \n\n \nSocial History:\n___\nFamily History:\nMother - ___ disease, breast cancer\nFather - CAD, Kidney stones\n \nPhysical Exam:\nADMISSION PHYSICAL:\n=====================\nVS: 97.8 PO 181 / 77 109 28 98 2l \nGENERAL: NAD, watching TV loudly, hard of hearing \nHEENT: AT/NC, MMM, OP clear \nNECK: supple, no LAD, no JVD \nHEART: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNGS: CTAB, decreased breath sounds at left lower base, mild \nexp\nwheezes, no rales, rhonchi, breathing comfortably without use of\naccessory muscles \nABDOMEN: nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly \nEXTREMITIES: no cyanosis, clubbing, or edema \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========================\nVS: Tm 97.7 119/78 113 18 99% RA \nGeneral: NAD, alert \nHEENT: PERRL, MMM, oropharynx clear \nNeck: supple, no JVP elevation \nLungs: CTAB, no wheezing, crackles \nCV: tachycardic, regular. nl S1 S2. No murmurs. \nAbd: Soft, non-distended, non-tender, normoactive bowel sounds \nExt: warm, trace edema bilaterally, nontender \nSkin: erythematous, blanching patch on anterior chest. \nImproving. \nNeuro: A/O x2 to name and place, moving all extremities with \npurpose\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 05:09PM BLOOD WBC-17.0* RBC-4.61 Hgb-11.3 Hct-36.1 \nMCV-78* MCH-24.5* MCHC-31.3* RDW-16.5* RDWSD-46.6* Plt ___\n___ 05:09PM BLOOD Neuts-66.0 ___ Monos-8.5 Eos-0.9* \nBaso-0.6 Im ___ AbsNeut-11.20* AbsLymp-3.98* AbsMono-1.45* \nAbsEos-0.15 AbsBaso-0.11*\n___ 05:09PM BLOOD ALT-13 AST-22 AlkPhos-77 TotBili-0.3\n___ 05:09PM BLOOD proBNP-1597*\n___ 05:09PM BLOOD Albumin-4.0 Calcium-7.0* Phos-3.7 Mg-0.8*\n___ 10:16PM BLOOD Calcium-7.4* Phos-3.6 Mg-1.3*\n___ 05:09PM BLOOD D-Dimer-1489*\n___ 05:09PM BLOOD TSH-3.5\n___ 12:16PM BLOOD PTH-204*\n___ 07:07AM BLOOD ___-63\n___ 05:11PM BLOOD Lactate-4.5*\n___ 10:17PM BLOOD Lactate-3.1*\n___ 07:27AM BLOOD Lactate-1.2\n\n===============\nIMAGING:\n===============\n___ CTA CHEST:\n1. No evidence of pulmonary embolism or aortic abnormality.\n2. 3.5 cm cavitary lesion in the superior segment of the left \nlower lobe, concerning for malignancy. Recommend PET-CT for \nfurther evaluation.\n3. Multiple old right healed rib fractures.\n4. Indeterminate 2.0 cm left adrenal nodule.\n5. Mild emphysema\n\n___ CT Head:\n1. No acute intracranial abnormalities.\n2. Sequelae of chronic age-related involutional changes and \nsmall vessel\nischemic disease.\n\n___ CT Head\n1. No acute intracranial abnormalities. \n2. Sequelae of chronic age-related involutional changes and \nsmall vessel \nischemic disease. \n \nCT CHEST ___\nIMPRESSION: \nStable cavitary lesion in the left lower lobe which is \ninseparable from the adjacent subsegmental atelectasis. This \ncould represent a resolving pneumonia however of a follow-up in \n___ weeks after a course of antibiotics to exclude an underlying \nneoplastic process is recommended. \nSubsegmental atelectasis in the right lung base. \nStable small mediastinal lymph nodes. \nMultiple old healed right-sided rib fractures. \nStable 2 cm left adrenal nodule. \n \nMRI HEAD W/ and W/O CONTRAST ___\nIMPRESSION: \n1. Study is degraded by motion. \n2. No acute intracranial abnormality. \n3. Within limits of study, no definite evidence of intracranial \nmass or \nabscess. \n4. Paranasal sinus disease and nonspecific bilateral mastoid \nfluid, as \ndescribed \n\nMRI HEAD W/ and W/O CONTRAST ___\nIMPRESSION: \n1. Age-appropriate atrophy. \n2. No evidence of mass, hemorrhage, infarction or abnormal \nenhancement. \n\nMRI HEAD W/ and W/O CONTRAST ___\nIMPRESSION:\n-No abnormal leptomeningeal or parenchymal signal abnormality or \nenhancement\nto suggest meningitis or encephalitis, respectively. No \nlocalizing source of\ninfection.\n-Age-appropriate atrophy.\n-Nonspecific periarticular T2/FLAIR hyperintensities likely \nsecondary to\nchronic small vessel ischemic changes.\n\n=====================\nMICROBIOLOGY\n=====================\n\n___ 8:26 am URINE\n **FINAL REPORT ___\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n\n___ 4:10 pm URINE Source: ___. \n **FINAL REPORT ___\n Legionella Urinary Antigen (Final ___: \n NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. \n (Reference Range-Negative). \n Performed by Immunochromogenic assay. \n A negative result does not rule out infection due to other \nL.\n pneumophila serogroups or other Legionella species. \nFurthermore, in\n infected patients the excretion of antigen in urine may \nvary. \n\n___ 11:46 am BRONCHOALVEOLAR LAVAGE LEFT LOWER LOBE \nBAL.. \n\n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n\n RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000 \nCFU/ml. \n\n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. \n\n ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. \n\n\n FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED. \n\n POTASSIUM HYDROXIDE PREPARATION (Final ___: \n Test cancelled by laboratory. \n PATIENT CREDITED. \n This is a low yield procedure based on our in-house \nstudies. \n if pulmonary Histoplasmosis, Coccidioidomycosis, \nBlastomycosis,\n Aspergillosis or Mucormycosis is strongly suspected, \ncontact the\n Microbiology Laboratory (___).\n\n___ 1:00 pm SEROLOGY/BLOOD\n CRYPTOCOCCAL ANTIGEN (Final ___: \n CRYPTOCOCCAL ANTIGEN NOT DETECTED. \n \n___ 2:41 pm CSF;SPINAL FLUID Source: LP. \n CRYPTOCOCCAL ANTIGEN (Final ___: \n CRYPTOCOCCAL ANTIGEN NOT DETECTED. \n\n___ 2:41 pm CSF;SPINAL FLUID Source: LP #3. \n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count.. \n FLUID CULTURE (Final ___: NO GROWTH. \n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. \n ACID FAST CULTURE (Preliminary): \n NO MYCOBACTERIA ISOLATED. \n\n___ 6:05 am SEROLOGY/BLOOD\n RAPID PLASMA REAGIN TEST (Final ___: \n NONREACTIVE. \n Reference Range: Non-Reactive. \n\n___ 2:30 pm Blood (CMV AB) Source: Line-PICC. \n **FINAL REPORT ___\n CMV IgG ANTIBODY (Final ___: \n NEGATIVE FOR CMV IgG ANTIBODY BY EIA. \n <4 AU/ML. \n Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml. \n\n If acute infection is suspected request IgM antibody \ntesting and/or \n submit convalescent serum in ___ weeks. \n \n___ 2:30 pm Blood (LYME) Source: Line-PICC.\n Lyme IgG (Final ___: \n NEGATIVE BY EIA. \n (Reference Range-Negative). \n Lyme IgM (Final ___: \n NEGATIVE BY EIA. \n (Reference Range-Negative). \n Negative results do not rule out B. burg___ infection. \n Patients\n in early stages of infection or on antibiotic therapy may \nnot produce\n detectable levels of antibody. \n\n___ 2:30 pm Blood (EBV) Source: Line-PICC. \n **FINAL REPORT ___\n ___ VIRUS VCA-IgG AB (Final ___: POSITIVE \nBY EIA. \n ___ VIRUS EBNA IgG AB (Final ___: POSITIVE \nBY EIA. \n ___ VIRUS VCA-IgM AB (Final ___: \n NEGATIVE <1:10 BY IFA. \n INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION. \n In most populations, 90% of adults have been infected at \nsometime\n with EBV and will have measurable VCA IgG and EBNA \nantibodies.\n Antibodies to EBNA develop ___ weeks after primary \ninfection and\n remain present for life. Presence of VCA IgM antibodies \nindicates\n recent primary infection\n\n___ 2:30 pm Blood (Toxo) Source: Line-PICC. \n **FINAL REPORT ___\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 The FDA is advising that the result from any one \ntoxoplasma IgM\n commercial test kit should not be used as the sole \ndeterminant of\n recent toxoplasma infection when screening a pregnant \npatient. \n \n___ 2:45 pm CSF;SPINAL FLUID Source: LP #2. \n **FINAL REPORT ___\n CRYPTOCOCCAL ANTIGEN (Final ___: \n CRYPTOCOCCAL ANTIGEN NOT DETECTED. \n (Reference Range-Negative). \n Test performed by Lateral Flow Assay. \n Results should be evaluated in light of culture results \nand clinical\n presentation. \n\n___ 2:45 pm CSF;SPINAL FLUID SOURCE: LP; #2. \n **FINAL REPORT ___\n Enterovirus Culture (Final ___: No Enterovirus \nisolated.\n\n====================\nOTHER RELAVANT LABS\n====================\n\n___ 12:16PM BLOOD PTH-204*\n___ 04:30AM BLOOD Cortsol-29.2*\n___ 12:00AM BLOOD ANCA-NEGATIVE B\n___ 05:55AM BLOOD CRP-8.8*\n___ 05:40AM BLOOD CRP-19.4*\n___ 06:05AM BLOOD CRP-17.8*\n___ 09:06AM BLOOD CRP-3.9\n___ 06:01AM BLOOD PEP-SLIGHT HYP IgG-718 IgA-387 IgM-87 \nIFE-NO MONOCLO\n___ 06:01AM BLOOD C3-109 C4-23\n___ 06:05AM BLOOD HIV Ab-NEG\n___ 02:30PM BLOOD CMV VL-NOT DETECT\n\n \n___ 02:45PM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-1 Polys-0 \n___ Monos-18 ___ Macroph-6 Other-4\n___ 02:41PM CEREBROSPINAL FLUID (CSF) TNC-105* RBC-1128* \nPolys-2 ___ ___ 02:41PM CEREBROSPINAL FLUID (CSF) TNC-50* RBC-2 Polys-3 \n___ ___ 02:45PM CEREBROSPINAL FLUID (CSF) TotProt-53* \nGlucose-151 LD(LDH)-36\n___ 02:41PM CEREBROSPINAL FLUID (CSF) TotProt-67* \nGlucose-132 LD(LDH)-26\n\n==========================================\nFLOW CYTOMETRY CSF for immunophenotyping.\nProcedure date Tissue received Report Date Diagnosed \nby \n___ ___ ___ ___. ___. \n___ \n\nDIAGNOSIS: \nFLOW CYTOMETRY IMMUNOPHENOTYPING \nThe following tests (antibodies) were performed: Kappa, lambda, \nand CD antigens 2,3,4,5,7,8,10,11c,19,20,23,34,38,45, and 56\nRESULTS:\n10-color analysis with linear side scatter vs. CD45 gating is \nused to evaluate for leukemia/lymphoma. Approximately 25.2% of \ntotal acquired events are evaluable non-debris events. The \nviability of the analyzed non-debris events, done by 7-AAD is \n74.21%. Due to the paucicellular nature of the specimen, a \nlimited panel is performed to evaluate B cells/look for residual \ndisease. CD45-bright, low side-scattered gated lymphocytes \ncomprised 29.63% of total analyzed events. B cells are scant in \nnumber precluding evaluation of clonality/further \ncharacterization. B cells comprise 1.8% of lymphoid gated \nevents. T cells comprise 83.3% of lymphoid gated events and \nexpress mature lineage antigens (CD3, CD5, CD2, and CD7). A \nminor subset (13.7%) of the CD4 positive T-cell showed \ndim/variable loss of CD7 (non-specific finding). T cells have a \nCD4:CD8 ratio of 3.74 (usual range and blood 0.7-3.0). There is \na population of double negative (CD4 negative/CD8 negative) T \ncells comprising 2.22% of CD3 positive cells. Approximately 0.9% \nof CD3 positive T-cells coexpress CD56. CD56 positive, CD3 \nnegative natural killer cells represent 11.1% of gated \nlymphocytes and are normal/increased in number (usual range in \nblood 5.15%). They co-express CD2, CD7, and CD8 (subset).\nINTERPRETATION\nNonspecific T-cell predominant lymphoid profile; diagnostic \nimmunophenotypic features of involvement by leukemia/lymphoma \nare not seen in this specimen. Correlation with clinical, \nmorphologic (see separate cytology ___) and other \nancillary findings is recommended. Flow cytometry \nimmunophenotyping may not detect all abnormal populations due to \ntopography, sampling or artifacts of sample preparation.\n====================================================\n\n=================\nPATHOLOGY\n=================\n___ CSF HSV PCR: negative\n___ Blastomyces Quantitative Antigen : negative\n___ Paraneoplastic Autoantibody Evaluation, CSF : \nNEGATIVE\n___ Herpes Simplex Virus PCR CSF : NEGATIVE\n\n===========LUNG MASS==========\nSURGICAL PATHOLOGY REPORT - Final\nPATHOLOGIC DIAGNOSIS:\nLung, left lower lobe mass, transbronchial biopsy:\nLUNG ADENOCARCINOMA.\nNote: By immunohistochemistry the tumor cells are positive for \nTTF1 and Napsin A, supporting the\nabove diagnosis.\nCLINICAL HISTORY:\nLung mass\n===============================\n\nEEG ___\nIMPRESSION: This is an abnormal continuous EEG monitoring study \nbecause of \nmoderate to severe diffuse background slowing and \ndisorganization, as well as prolonged runs of frontally \npredominant generalized sharp waves with triphasic morphology, \noccupying approximately 60% of the record. These findings are \nindicative of moderate to severe diffuse cerebral dysfunction, \nwhich is nonspecific as to etiology, but can be seen in \ntoxic-metabolic disturbances, infection or medication. The \ngeneralized periodic sharp waves indicate high risk degenerate \nepileptic seizures, but no electrographic seizures are present \nin this recording. Compared to the prior day's study, there is \nsome \nimprovement in the prevalence of the runs of generalized \nperiodic epileptiform discharges now occupying only 60% as \ncompared to 90% of the recording. \n\n===========================\nKUB ___ \nNonobstructive gas pattern. Dobbhoff tube with the tip in the \nstomach. \n\nEEG ___ \nThis is an abnormal continuous video EEG due to slow background \nactivity in the theta range with intermittent bursts frontally \npredominant \ndelta ( FIRDA). This is indicative of mild to diffuse \nencephalopathy that is nonspecific as to etiology but common \ncauses are medication effect, infection. There were no \nepileptiform discharges or electrographic seizures. Compared to \nthe prior day recording, there is no significant change. \n\nCXR ___ \nThe study is compromised as the lung apices are not included on \nthe \nradiograph. On the first x-ray the tip of the Dobhoff catheter \nis in the \nmidesophagus. On the second x-ray the tip is in the distal \nstomach. The \ncardiomediastinal silhouette appears unchanged. There is stable \nelevation of the right hemidiaphragm. The aorta is \natherosclerotic and tortuous. There is likely a small left \npleural effusion.\n\nDISCHARGE LABS\n==============\n___ 06:12AM BLOOD WBC-9.8 RBC-3.13* Hgb-8.9* Hct-28.1* \nMCV-90 MCH-28.4 MCHC-31.7* RDW-17.7* RDWSD-57.9* Plt ___\n___ 06:12AM BLOOD Plt ___\n___ 06:12AM BLOOD Glucose-80 UreaN-18 Creat-1.5* Na-145 \nK-4.1 Cl-106 HCO3-23 AnGap-16\n___ 06:12AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.6\n \nBrief Hospital Course:\nPATIENT SUMMARY FOR ADMISSION:\n===============================\nMs. ___ is a ___ former smoker with PMH \nsignificant for HTN, HLD, DM2, GERD, CKD3, diverticulosis who \npresented to the ED after receiving routine labs by her PCP \nshowing hypocalcemia, hypomagnesemia, and leukocytosis. In the \nsetting of dyspnea, Ms. ___ underwent a CTA which \ndemonstrated a 3.5cm cavitary lesion. She subsequently underwent \nan extensive evaluation of her cavitary lesion with bronchoscopy \nand biopsy and was treated empirically for a pulmonary abscess. \nBiopsy revealed adenocarcinoma. \n\nFollowing the bronchoscopic procedure on ___, her mental status \ndeclined and she developed a persistent fever with tachycardia \nand leukocytosis. CSF analysis ___ raised concern for \nmeningitis, and she was started on empiric bacterial meningitis \ntherapy with vancomycin/cefepime/ampicillin, as well as \nacyclovir. MRI did not reveal evidence of a meningeal process \nsuch as leptomeningeal carcinomatosis. EEG revealed triphasic \nwaves, prompting initiation of lacosamide and phenytoin with \nfurther EEG monitoring. Repeat lumbar puncture ___ showed \nresolution of initial findings, and she completed these parallel \ncourses of treatment for bacterial and viral meningitis with \nresolution of her persistent fevers. Her mental status slowly \nimproved off anti-epileptics suggesting encephalopathy due to \naseptic meningitis rather than seizure, but leukocytosis, and \ntachycardia persisted. \n\nACUTE Issues Addressed:\n========================\n# Toxic-metabolic encephalopathy\n# Epileptiform discharges on EEG\nPatient with worsening mental status and initial LP studies \nconsistent with aseptic meningitis vs viral encephalitis vs \ninflammatory process. Repeat CSF shows WBC and RBC normalized. \nElectrolyte abnormalities have included hypernatremia, \npersistent hypocalcemia,\nintermittent hypomagnesemia and hypophosphatemia, which have now \nresolved. Initially verbalizing one word on rare occasions, and \nintermittently followed commands. AEDs: initiated on lacosamide \n___, then fosphenytoin ___, then weaned to lacosamide only as \nEEG and clinical status improved. Clinical exam then worsened, \nEEG again revealed more epileptiform discharges, so titrated \nback up lacosamide. MRI unrevealing x3. LP attempted on ___ \nwithout success. Concern for paraneoplastic syndrome, but both \nCSF and serum paraneoplastic panels were negative. Restarted \nfosphenytoin on ___, but stopped on ___ after her mental \nstatus improved slowly (despite downtrending phenytoin levels). \nLacosamide was also discontinued on ___. Mental status \ncontinued to improve off anti-epileptics making siezure less \nlikely the cause of her AMS. Leading diagnosis is encephalopathy \ndue to aseptic meningitis. \n\n# Aseptic Meningitis vs Viral encephalitis\n# FUO, resolved\nPt with profound obtundation, tachycardia, leukocytosis, fever \nand LP studies as above. After broad infectious, oncologic, \nneurologic, and rheumatologic work up, suspect aseptic \nmeningitis vs viral encephalitis. Pt completed course of empiric \ntreatment for bacterial and viral meningitis (dates below), and \nfevers resolved. S/p vancomycin/Ampicillin at BM dosing x14 days \n(ended ___. S/p Cefetpime -> CTX for 14 days (ended ___. S/p \nacyclovir (started ___ completed 10 day course. \n\n#NUTRITION\nTube feeds through Dobhoff started on ___ as pt was too \nobtunded to take PO. Tolerated TFs until ___, when patient \npulled dobhoff out. Given improvement in mental status, patient \nwas re-evaluated by speech and swallow who advanced her diet to \nground, moist solids and thin liquids with aspiration \nprecautions. \n\n#Rash\nNew erythematous, blanchable rash developed on chest overnight \ninto ___. Per dermatology, likely eczematous dermatitis vs \nbenign drug eruption (no evidence of SJS/TEN or DRESS). \nDermatomyositis was also considered but CK and aldolase was \nnormal making this unlikely. Treated with clobetasol ointment \nBID, fexofenadine 60 mg BID, eucerin lotion. Skin biopsy was \ndeferred given improvement with topical steroids. Clobetasol \nointment was stopped after two weeks (___) as dermatology \nrecommended using less than 2 weeks per month. Continued on \nfexofenadine 60 mg BID and eucerin lotion. \n\n# Lung adenocarcinoma \nPatient presented with dyspnea, and was found to have 3.5cm \ncavitary lesion on CTA imaging. Biospy revealed adenocarcinoma. \nNo evidence of superinfection. Oncology was consulted for \npossible paraneoplastic syndrome but unlikely given negative \ntesting. Patient will need to follow-up with oncology and \nthoracic surgery as outpatient with possible need for PET scan \nand further work-up/treatment of likely early stage lung cancer \ndepending on her goals of care. \n\n# Leukocytosis\nPt with persistent leukocytosis since admission, with \ndifferential notable for very mild eosinohila and monocytosis. \nHeme onc was consulted for evaluation of smear, which was \nunremarkable. Paraneoplastic syndrome negative as above. Patient \ncontinued to be afebrile and normotensive, improving clinically \nso low suspicion for infection. Likely stress response to acute \nillness, malignancy or pruritic rash. Consider outpatient \nhematology follow-up. \n\n# HYPOXEMIC RESPIRATORY FAILURE\n# Acute on chronic Diastolic heart failure\nPatient presented with dyspnea and CTA was consistent \nw/emphysema likely related to smoking history. Pt had persistent \nO2 requirement with large volume IV antibiotic requirements. Her \nhypoxemia resolved with diuresis with 100 mg IV Lasix. Suspect \ncombination of volume overload, mild emphysema, with newly \ndiagnosed lung cancer. Patient had elevated LA volume on TTE and \nelevated E-e', concerning for diastolic dysfunction. Patient \nshould have TTE after resolution of this illness. She was not \nplaced on standing PO diuretic regimen as she appeared euvolemic \nprior to discharge and required intermittent, low volume boluses \ndue to poor PO intake. She should be monitored for volume \noverload. Discharge weight 186 lbs (84.3 kg). \n\n___ on CKD\nPt with baseline 1.2-1.4, developed elevation of serum \ncreatinine to 2.0. Renal consulted, urine studies consistent \nwith ATN in the setting of diuresis for hypoxemic respiratory \nfailure and critical illness. Creatinine and electrolytes were \ntrended. After NJT was removed, patient has had limited PO \nintake and requires frequent redirection to drink fluids. \nPatient's Cr intermittently rose due to pre-renal ___ from \nlimited PO intake. Improved steadily with increased fluids. If \nCr rises and she appears euvolemic on exam, she should be \nencouraged to drink more fluids. Discharge creatinine was 1.5. \n\n# HYPOCALCEMIA\n# HYPOMAGNESEMIA \nPatient initially sent to ED by PCP due to hypocalcemia. Ca \nremarkably low as outpatient 6.9 and Magnesium level 0.8. On \nadmission PTH elevated to 84. Endocrine was consulted and \nhypocalcemia was felt to be in the setting of hypomagnasemia. \nMagnesium was repleted with IV repletion and Calcium was \nrepleted with Calcium carbonate. Subsequent Ca and Mag \nnormalized and PTH levels appropriately down trended. Patient \ncontinued home Vitamin D ___ units daily and Ca remained within \nnormal limits without CaCO3 supplementation. \n\n# HTN: SBP was significantly elevated compared to recent \noutpatient blood pressure readings, then normalized. CT with \nadrenal nodule. Secondary HTN is possible given adrenal nodule,\nbut cannot complete the work up in the setting of ongoing \nillness. Due to decreased blood pressures prior to discharge, \nhome metoprolol succinate was decreased to 12.5 mg daily and \nhome HCTZ and lisinopril were held. \n\n# ANEMIA: \nHgb 11 on admission, near prior baseline. Outpatient labs \nconsistent with iron deficiency anemia. Now suspect with \ncomponent of hypoproliferation in setting of severe illness. Hb \nremained stable around 9. CBC was trended and remained stable. \n\n# ADRENAL NODULE: \nNoted on CTA. Will require further imaging given malignancy as \nabove. Endocrine will follow as outpatient.\n\n# HLD: Continued statin, ASA discontinued as NSAIDS can cause \naseptic meningitis\n\n# DM2: On metformin and glipizde at home, Lantus 20U w/ \nbreakfast and at bedtime and ISS while in house.\n\nTRANSITIONAL ISSUES:\n=====================\n[] Patient needs frequent redirection to encourage PO intake to \nreduce risk of pre-renal ___ \n[] Discharge diet (per speech and swallow): ground, moist solids \nand thin liquids with strict 1:1 supervision. Medications \ncrushed in puree. Aspiration precautions. Patient should \ncontinue to be re-evaluated by speech and swallow for \nadvancement of diet. \n[] After encephalopathy, patient has experienced agitation which \nhas been controlled with Seroquel 25 mg QHS. Intermittently has \nneeded Seroquel 12.5 mg PRN for agitation. If agitation improves \nover time, can discontinue Seroquel as this should not be \ncontinued chronically. \n[] Follow-up with neurology for encephalopathy \n[] Follow-up with oncology/hematology for lung adenocarcinoma \nand chronic leukocytosis\n[] Follow-up with thoracic surgery follow up for lung \nadenocarcinoma\n[] Will need PET scan after discharge as outpatient for surgical \nplanning\n[] Home aspirin held as NSAIDs can cause aseptic meningitis \n[] Home gabapentin and zolpidem held given encephalopathy \n[] Follow-up with endocrine as outpatient for hypocalcemia, \nhypomagnesemia and adrenal nodule. ___ need further \nimaging/work-up. \n[] Recommend repeat TTE as outpatient to reevaluate patient's \ndiastolic heart failure. Patient not discharged on diuretics as \nshe has appeared euvolemic. She should be monitored for volume \noverload. Discharge weight: 186 lbs (84.3 kg). \n[] Home metoprolol succinate decreased to 12.5 mg daily and \nHCTZ, lisinopril were held due to soft blood pressures. Her \nanti-hypertensives should be adjusted base on blood pressure \nmonitoring; if she remains mildy tachycardic with normal BP, can \nconsider increase of metoprolol \n[] Patient's blood sugars should continue to be monitored as she \nwas transition back to her home metformin and glipizide at \ndischarge \n[]please check chem 10 panel on ___ as patient required \nfrequent magnesium repletion while inpatient \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Gabapentin 600 mg PO QHS \n2. GlipiZIDE XL 12.5 mg PO DAILY \n3. Hydrochlorothiazide 12.5 mg PO DAILY \n4. Lisinopril 20 mg PO DAILY \n5. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY \n6. Metoprolol Succinate XL 25 mg PO DAILY \n7. Omeprazole 20 mg PO DAILY \n8. Pravastatin 80 mg PO QPM \n9. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia \n10. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild \n11. Aspirin 81 mg PO DAILY \n12. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Medications:\n1. Cyanocobalamin 100 mcg PO DAILY \n2. Fexofenadine 60 mg PO BID \n3. Hydrocerin 1 Appl TP QID:PRN Apply to rash for pruritus \n4. QUEtiapine Fumarate 25 mg PO QHS \n5. Metoprolol Succinate XL 12.5 mg PO DAILY \n6. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild \n7. GlipiZIDE XL 12.5 mg PO DAILY \n8. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY \n9. Omeprazole 20 mg PO DAILY \n10. Pravastatin 80 mg PO QPM \n11. Vitamin D ___ UNIT PO DAILY \n12. HELD- Aspirin 81 mg PO DAILY This medication was held. Do \nnot restart Aspirin until you follow-up with your PCP\n13. HELD- Gabapentin 600 mg PO QHS This medication was held. Do \nnot restart Gabapentin until you follow-up with your PCP\n14. HELD- Zolpidem Tartrate 10 mg PO QHS:PRN insomnia This \nmedication was held. Do not restart Zolpidem Tartrate until you \nfollow-up with your PCP\n\n \n___:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nToxic metabolic encephalopathy \nLung adenocarcinoma\nAcute kidney injury\nEczematous dermatitis \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\nThanks for choosing ___ as your site of care.\n\nWhy was I admitted?\n-You had abnormal levels of calcium and magnesium.\n-You were also having trouble breathing.\n\nWhat was done for me while I was hospitalized?\n-You were given calcium and magnesium.\n-We took a sample of lesion in your lung, and found that it was \ncancer\n-You developed a fever and an infection in your brain and we \ngave you antibiotics\n-Your mental status improved after receiving antibiotics and \nmedications to prevent seizures \n\nWhat should I do when I leave the hospital?\n-Please continue taking all of your medications as prescribed.\n-You will follow up with your providers as detailed below.\n\nThanks, \n\nYour ___ treatment team\n \nFollowup Instructions:\n___\n" ]

[ "C3432", "J9601", "I5033", "G030", "G92", "R6520", "N170", "A419", "I130", "E871", "E870", "E873", "Z87891", "E785", "K219", "E8351", "E8342", "Z66", "J439", "D509", "E279", "E669", "Z6838", "E1121", "E1122", "E1165", "N183", "L309", "T508X5A", "Y92239", "E8339", "R338" ]

[ "C3432: Malignant neoplasm of lower lobe, left bronchus or lung", "J9601: Acute respiratory failure with hypoxia", "I5033: Acute on chronic diastolic (congestive) heart failure", "G030: Nonpyogenic meningitis", "G92: Toxic encephalopathy", "R6520: Severe sepsis without septic shock", "N170: Acute kidney failure with tubular necrosis", "A419: Sepsis, unspecified organism", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E871: Hypo-osmolality and hyponatremia", "E870: Hyperosmolality and hypernatremia", "E873: Alkalosis", "Z87891: Personal history of nicotine dependence", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "E8351: Hypocalcemia", "E8342: Hypomagnesemia", "Z66: Do not resuscitate", "J439: Emphysema, unspecified", "D509: Iron deficiency anemia, unspecified", "E279: Disorder of adrenal gland, unspecified", "E669: Obesity, unspecified", "Z6838: Body mass index [BMI] 38.0-38.9, adult", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E1165: Type 2 diabetes mellitus with hyperglycemia", "N183: Chronic kidney disease, stage 3 (moderate)", "L309: Dermatitis, unspecified", "T508X5A: Adverse effect of diagnostic agents, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "E8339: Other disorders of phosphorus metabolism", "R338: Other retention of urine" ]

[ "J9601", "I130", "E871", "Z87891", "E785", "K219", "Z66", "D509", "E669", "E1122", "E1165" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Amoxicillin / Ciprofloxacin / Bactrim DS / \nGadavist / dexamethasone\n \nAttending: ___\n \nChief Complaint:\nadmission for egd/colonoscopy \n \nMajor Surgical or Invasive Procedure:\nEGD and Colonoscopy ___\n \nHistory of Present Illness:\nMs. ___ is a pleasant ___ w/ neuroendocrine tumor c/b\ncarcinoid syndrome who c/o recurrent bouts of dry heaving. She\nhas been admitted numerous times and unfortunately despite\nantiemetics, her nausea remains refractory. She also has an iron\ndeficiency anemia. This prompted her oncology team to recommend\nan EGD/colonoscopy. However she is unable to manage the prep at\nhome and hence she is being admitted for bowel prep as her\npsychosocial situation precludes her from doing this as an\noutpatient. She states her nausea is under control right now and\ndoes not have any abd pain. She does note last night she had an\nanxiety attack and had to call her ___ for help with ativan\ndosing. She states just thinking about the procedure tomorrow is\ngiving her an anxiety attack and is overwhelmed about the idea \nof\nhaving incontinence. \n \nPast Medical History:\nPAST ONCOLOGIC HISTORY (per OMR):\nMetastatic Neuroendocrine Tumor of the small bowel\n- ___ Presented to the ED with back pain. A CT scan of \nher\nabdomen and pelvis was performed and showed mesenteric soft\ntissue masses including centrally necrotic mass abutting the\nproximal SMA and two additional masses within the right lower\nmesentery. \n- ___, she underwent a diagnostic laparoscopy and an open\nsmall bowel resection. A section of her small bowel was \nresected\nwidely but grossly appeared involved with a neuroendocrine \ntumor.\nIn addition, there was palpable extension of adenopathy and \ntumor\nin and around the SMA and caudate hindering further, complete\nresection. Pathology report from her surgery showed a\nwell-differentiated neuroendocrine carcinoma 1.9 cm extending\nthrough the small intestinal wall into the serosa. There was \nalso\nmetastatic tumor involving 4 of the 12 lymph nodes. A CT scan \nof\nher abdomen and pelvis was unremarkable. A CT and MRI scan of\nher head showed increased signal along the left posterior \nfrontal\nsulcus suggestive of a small area of subarachnoid hemorrhage. \n- ___ She commenced TID octreotide injections on ___ with\nsymptom improvement and started Depo-Octreotide on ___. \n- ___ TACE\n- ___ Repeat TACE to the right hepatic artery\n- ___ Underwent cyberknife for new hepatic lesions in\nsegments IV and V \n- ___ MRI with new liver metastasis\n- ___ RFA to the new liver mets\n- ___: Admission for N/V/constipation. \n- ___-: Re-admitted for N/V. Repeat CT Abdomen/Pelvis\nwithout disease progression. \n- ___ MR abdomen showed RFA response and two small liver\nmets one of which may be new, CT chest stable\n- ___ CT chest and MR abdomen no evidence of progressive\ndisease, stable mets\n- ___ MR abdomen and CT chest showed stable metastatic\ndisease\n- ___ MR abdomen and CT chest showed stable metastatic\ndisease\n- ___ MR abdomen showed minimal progression of disease, \nCT\nchest ___\n- ___ MR abdomen and CT chest showed minimal if any\nprogression of abdominal disease but stable overall\n- ___ MR abdomen and CT chest showed minimal if any\nprogression of abdominal disease but stable overall\n- ___ Start telotristat ethyl 250mg TID\n- ___ Admitted for abdominal pain and constipation\n- ___ Stopped telotristat ethyl due to abdominal\npain/constipation\n- ___ Octreotide scan shows uptake in interval increase \nin\nsize and octreotide avidity of the mesenteric mass and\nretroperitoneal lymphadenopathy since ___. Focus of\nmildly increased uptake in the right lobe of the liver \nsuspicious\nfor metastasis. \n- ___ CT shows stable disease\n- Current treatment: Octreotide 40 mg Q14 days since ___\n- ___ Octreotide scan showed increased mesenteric mass\n- ___ CT chest showed progression of lung and nodal mets\n- ___ Offered consent for ___ ___\n- ___ Consented for ___ ___\n- ___ C1D1 PEN221 18 mg on ___ ___\n- ___ C2D1 PEN221 12 mg on ___ ___ for G3 ALT in C1\n- ___ EOT due to risk of liver toxicity\n- ___ CT torso with progression of liver mets, overall\nstable mesenteric LAD\n\nPAST MEDICAL HISTORY (per OMR):\n- Fibrocystic changes in breast\n- GERD\n- Fibroid s/p BSO\n- Osteopenia\n- HTN\n\n \nSocial History:\n___\nFamily History:\nMother had a stroke and died at age ___. Father had 'lung \nproblems' and died of a pneumonia at age ___. No known family\nhistory of cancer.\n \nPhysical Exam:\nVITAL SIGNS: 97.9 PO 118 / 75 88 20 99 Ra\nGeneral: NAD, Resting in bed comfortably \nHEENT: MMM, no OP lesions \nCV: RR, NL S1S2 no S3S4 No MRG\nPULM: CTAB, No C/W/R, No respiratory distress\nABD: BS+, soft, tender (at baseline)\nLIMBS: WWP, no ___, no tremors\nSKIN: No notable rashes on trunk nor extremities\nNEURO: CN III-XII intact, strength b/l ___ intact\nPSYCH: Thought process logical, linear, future oriented, not \nanxious at this time\nACCESS: Chest port site intact w/o overlying erythema, accessed\nand dressing C/D/I \n \nPertinent Results:\nEGD ___: no obvious explanation for nausea based on this \nexamination. further distal obstruction related to extrinsic \ncompression from mesenteric mass vs dysmotility vs known \ncarcinoid \nColonoscopy ___: high residue material noted throughout. \nMultiple attempts were made to irrigate the colon but the mucosa \ncould not be visualized adequately. No overt bleeding, ulcers, \nor mass lesions were seen. This procedure will not service as a \nscreening for CRC \n\n___ 01:26PM BLOOD WBC-5.2 RBC-3.59* Hgb-9.6* Hct-29.7* \nMCV-83 MCH-26.7 MCHC-32.3 RDW-15.9* RDWSD-48.0* Plt Ct-98*\n___ 01:26PM BLOOD Glucose-100 UreaN-12 Creat-0.8 Na-135 \nK-3.6 Cl-102 HCO3-23 AnGap-10\n___ 01:26PM BLOOD ALT-15 AST-17 LD(LDH)-155 AlkPhos-182* \nTotBili-1.2\n___ 01:26PM BLOOD Albumin-3.3* Calcium-8.8 Phos-3.5 Mg-1.___ w/ metastatic neuroendocrine tumor of small bowel, admitted \nfor EGD/colonoscopy for workup of refractory nausea. Due to \nsignificant inability to manage the bowel prep at home, she was \nadmitted. She tolerated the prep well overnight. The bowel prep \nunfortunately despite 3 movipreps did not clear the colon enough \nfor an adequate study but no overt colonic pathology was seen. \nIn addition, EGD did not reveal any pathology to explain her \nrecurrent nausea. She tolerated her food well here and her \nnausea was most provoked by anxiety. She will see her ___, with \nwhom she reports a good rapport, and noted a psychiatrist from \ntheir company will visit her at home. Her anxiety stems most \nfrom \"feeling alone,\" with a lack of social support. When she \ndoes have an escalation of anxiety, she is paralyzed in fear and \ninaction. I offered Wellbutrin but she would prefer to see her \npsychiatrist first. \n\n# Neuroendocrine tumor w/ carcinoid syndrome\nShe is on high dose octreotide and has PRN octreotide at home \nfor\ndiarrhea as well as prns. No changes to her meds were made and \nshe will f/u with Dr ___ \n- cont ms contin BID for cancer pain\n- cont gabapentin for neuropathy \n\n# Anemia\nShe's developed microcytic anemia since ___, MCV dipping to\nlow ___. Her Hg has downtrended from baseline of 11 to 9.6 now.\nFerritin low at 33. \n- f/u oncology \n\n# Hypokalemia in s/o diarrhea: repleted with IV sliding scale\n# Anxiety: cont ativan prn \n# HTN: Continue home amlodipine\n\nFEN: regular diet, small frequent meals\nPPX: HSC\nACCESS: L POC\nCODE: FULL, presumed\nDISPO: Home w/ ___\n_____________\n___, D.O.\nHeme/Onc Hospitalist\n___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 2.5 mg PO DAILY \n2. Gabapentin 300 mg PO TID \n3. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Severe \n4. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild \n5. LORazepam 0.5 mg PO Q6H:PRN anxiety \n6. Morphine SR (MS ___ 15 mg PO Q12H \n7. Octreotide Acetate 100 mcg SC Q8H:PRN diarrhea \n8. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line \n9. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea \n10. LOPERamide 2 mg PO QID:PRN diarrhea \n\n \nDischarge Medications:\n1. amLODIPine 2.5 mg PO DAILY \n2. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea \n3. Gabapentin 300 mg PO TID \n4. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Severe \n5. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild \n6. LOPERamide 2 mg PO QID:PRN diarrhea \n7. LORazepam 0.5 mg PO Q6H:PRN anxiety \n8. Morphine SR (MS ___ 15 mg PO Q12H \n9. Octreotide Acetate 100 mcg SC Q8H:PRN diarrhea \n10. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First \nLine \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nNeuroendocrine tumor w/ carcinoid syndrome\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nYou were admitted for an EGD and a colonoscopy. You tolerated \nthe procedures well. Unfortunately the colonoscopy was not \nadequate to screen for cancer as you still had a fair amount of \nstool. Please follow up with your oncologist regarding biopsy \nresults. We made no changes to your medications. We feel you \nwould benefit greatly from speaking to your psychiatrist about \nyour anxiety and whether starting a medication called Wellbutrin \nmight be helpful for you. \n \nFollowup Instructions:\n___\n" ]

[ "K2950", "D509", "C7A8", "E340", "C7B8", "Z23", "M1712", "Z6825", "M545", "Z8673", "E669", "M8580", "I10", "E876", "R634", "D696", "F3289" ]

[ "K2950: Unspecified chronic gastritis without bleeding", "D509: Iron deficiency anemia, unspecified", "C7A8: Other malignant neuroendocrine tumors", "E340: Carcinoid syndrome", "C7B8: Other secondary neuroendocrine tumors", "Z23: Encounter for immunization", "M1712: Unilateral primary osteoarthritis, left knee", "Z6825: Body mass index [BMI] 25.0-25.9, adult", "M545: Low back pain", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "E669: Obesity, unspecified", "M8580: Other specified disorders of bone density and structure, unspecified site", "I10: Essential (primary) hypertension", "E876: Hypokalemia", "R634: Abnormal weight loss", "D696: Thrombocytopenia, unspecified", "F3289: Other specified depressive episodes" ]

[ "D509", "Z8673", "E669", "I10", "D696" ]

[]

[ " \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:\nSOB, RUE edema\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ y/o M who after a cholecystectomy in ___ was found to \nhave symptoms of hypotension and was found to be in complete \nheart block. In ___, a pacer was placed and the patient \nhad been asymptomatic for one year until this ___ when \nhe was found to be passing out and having decreases in his blood \npressure. He was admitted at ___ where he was found to \nhave a clot in his R IJ, extending into his SVC and he was \nstarted on Coumadin. \n\nAdditionally, he was started on fludrocortisone and midodrine \nfor his orthostatic hypotension. He was discharged to rehab. 2 \nweeks ago, the patient's last week in rehab, the patient noticed \nto have increasing DOE. He denied CP, PND, orthopnea or f/c. He \nwas d/c'd from rehab 1 week ago and over the last 3 days, his \nDOE has been worsening and associated with a dry cough. He went \nto ___ where he was found to have multifocal PNA by CXR \nand was started on vacn/cefepime.\n\n \nPast Medical History:\nHypothyroidisim \n3rd degree AV block s/p PPM \nHx of R IJ and subclavian thrombosis on coumadin \nOrthostatic Hypotension \n\n \nSocial History:\n___\nFamily History:\nDenies FH of clotting/bleeding disorders.\n \nPhysical Exam:\nADMISSION\nVS: T 99 BP 147/83 HR 81 R 18 ___\nGen: NAD\nHEENT: + R facial flushing, external jugular veins engourged \nb/l. IJ pulsations not visualized\nLungs: audible wheezing, no increased WOB, crackles and wheezing \nscattered throughout\n___: Difficult to hear over transmitted upper airway noise. \nRegular\nABD: NTND\nExt: Warm, no edema ___ b/l. RUE grossly edematous, sensation and \npulses intact\nSkin: + venous engourgment on R back. L anterior chest has well \nhealed scar with pacer beneath. No edema, errythema or \ninduration\n\nDISCHARGE\nVital Signs: 97.6 128/72 84 20 93%2L\nGEN: Alert, NAD\nHEENT: NC/AT\nCV: RRR, no m/r/g\nPULM: still with scattered wheezing; some coughing noted with \ndeep breathing; breathing comfortably overall\nGI: S/NT/ND, BS present \nEXT: 2+ pitting edema in the RUE; 1+ pitting edema in the LUE\n \nPertinent Results:\nAdmission Labs:\n___ 07:00PM BLOOD WBC-9.1 RBC-3.20* Hgb-10.6* Hct-32.3* \nMCV-101* MCH-33.1* MCHC-32.8 RDW-13.7 RDWSD-50.8* Plt ___\n___ 07:00PM BLOOD Neuts-71.4* Lymphs-11.7* Monos-14.9* \nEos-1.5 Baso-0.3 Im ___ AbsNeut-6.46* AbsLymp-1.06* \nAbsMono-1.35* AbsEos-0.14 AbsBaso-0.03\n___ 07:00PM BLOOD ___ PTT-38.0* ___\n___ 07:00PM BLOOD Glucose-122* UreaN-22* Creat-1.0 Na-137 \nK-3.3 Cl-95* HCO3-28 AnGap-17\n___ 07:00PM BLOOD ___\n___ 07:00PM BLOOD Calcium-9.4 Phos-3.5 Mg-2.0\n\nDischarge Labs:\n___ 06:00AM BLOOD WBC-8.6 RBC-3.01* Hgb-10.1* Hct-31.1* \nMCV-103* MCH-33.6* MCHC-32.5 RDW-13.8 RDWSD-51.9* Plt ___\n___ 06:00AM BLOOD Glucose-105* UreaN-24* Creat-1.0 Na-138 \nK-3.7 Cl-96 HCO3-34* AnGap-12\n\n___ 07:00PM BLOOD ___\n___ 02:16AM BLOOD ___\n___ 06:10AM BLOOD proBNP-3912*\n\n___ 07:39PM BLOOD Lactate-1.8\n___ 01:54PM BLOOD Lactate-1.0\n___ 03:26AM BLOOD Lactate-1.2\n\n___ 01:35AM URINE Color-Yellow Appear-Clear Sp ___\n___ 01:35AM URINE Blood-TR Nitrite-NEG Protein-30 \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG\n___ 01:35AM URINE RBC-7* WBC-<1 Bacteri-FEW Yeast-NONE \nEpi-<1\n\n========================================\nMicro:\n\nBCx negative x2\nMRSA screen +\n\n========================================\n\nECG - A-V sequentially paced rhythm with capture as evidenced in \nlead V1. No previous tracing available for comparison. \n\n========================================\nImaging:\n\nCTA Chest - IMPRESSION: \n1. Left subclavian vein and proximal SVC are not well assessed \nalong the course of the pacemaker leads and there is artifact \nfrom the pacer leads. Patency of these portions of the vessel \ncannot be confirmed on this study. No definite contrast is seen \nalong the proximal to mid left subclavian and proximal svc, \nwhich may be chronically occluded. No thrombus within the right \natrium. Multiple collateral vessels are seen.\n2. Patent right IJ. Left IJ not visualized, may be very \nattenuated chronically, chronically occluded comparison with \nprior study would be helpful. \n3. No evidence of pulmonary embolism up to the lobar level or \naortic abnormality. \n4. Multifocal pneumonia with ground-glass opacities within right \nupper and left lower lobes. 3 cm hypodensity along right major \nfissure may represent loculated pleural fluid or less likely \nfat, lipoid pneumonia not excluded. 5. Limited evaluation of \nthe neck demonstrates peritracheal soft tissue swelling and \nconcern for retropharyngeal edema. The airway is patent. \nConsider neck CT for better assessment. \n6. Small pericardial effusion. \n7. 1.7 cm left thyroid nodule. If indicated and not previously \nassessed consider nonurgent thyroid ultrasound for further \nevaluation. \n\nBilateral Upper Extremity U/S - FINDINGS: \nThere is normal flow with respiratory variation in the bilateral \nsubclavian veins. \nThe bilateral internal jugular veins contain non-occlusive \nthrombus of indeterminate age. The right internal jugular vein \nis thick walled with slow flow within which may be indicative of \nmore chronic thrombus. The subclavian veins are patent \nbilaterally. \nThe right brachial, basilic, and cephalic veins are patent and \ncompressible. \nIMPRESSION: \nNonocclusive thrombus in the bilateral internal jugular veins. \n\nTTE - The left atrium is mildly dilated. A density in the \nposterior right atrium likely represents prominent eustachian \nvalve. Left ventricular wall thicknesses and cavity size are \nnormal. There is mild global left ventricular hypokinesis (LVEF \n= 45-50 %). The estimated cardiac index is normal \n(>=2.5L/min/m2). Tissue Doppler imaging suggests a normal left \nventricular filling pressure (PCWP<12mmHg). The right \nventricular cavity is mildly dilated with borderline normal free \nwall function. The aortic root is mildly dilated at the sinus \nlevel. The ascending aorta is mildly dilated. The aortic valve \nleaflets (3) are mildly thickened but aortic stenosis is not \npresent. Trace aortic regurgitation is seen. The mitral valve \nleaflets are mildly thickened. There is no mitral valve \nprolapse. Mild (1+) mitral regurgitation is seen. There is mild \npulmonary artery systolic hypertension. There is a trivial \npericardial effusion. \nIMPRESSION: Normal biventricular cavity sizes with borderline \nright and mildly depressed left ventricular systolic function. \nMildly dilated thoracic aorta. Mild mitral regurgitation. Mild \npulmonary hypertension. \n\nLLE U/S - IMPRESSION: No evidence of deep venous thrombosis in \nthe left lower extremity veins. Peripheral nonocclusive thrombus \n(of indeterminate age) or wall thickening in a \nsuperficial/varicose vein along the popliteal fossa \n\nCXR (___) - IMPRESSION: \nNo previous images. Cardiac silhouette is enlarged and there is \nindistinctness of engorged pulmonary vessels consistent with \nelevated pulmonary venous pressure. Retrocardiac opacification \nwith poor definition of the hemidiaphragms consistent with \nvolume loss in left lower lobe and pleural fluid. Dual-chamber \npacer device is in place with leads in the right atrium and \nright ventricle. \n\nCXR (___) - IMPRESSION: \nPacemaker and its leads are in unchanged position. Right upper \nlobe consolidation is re- demonstrated, concerning for \npneumonia. No pulmonary edema demonstrated. No appreciable \npleural effusion seen. There is no pneumothorax. \n\nRight Fool X-rays \nIMPRESSION: No evidence of acute bone or joint space \nabnormality. Of incidental note is vascular calcification about \nthe lower leg and ankle. \n \n\nRight Foot U/S - IMPRESSION: \nNo acute process identified in the region of the dorsal lateral \nright foot, in the area of pain. Specifically, no suspicious \nfluid collection or soft tissue swelling.\n \nBrief Hospital Course:\n___ y/o M with PMHx of sCHF, 3rd degree heart block s/p PPM, and \nrecent RIJ thrombus, who presented to ___ with SOB and \ncough concerning for CHF exacerbation vs PNA and was also found \nto have a new left-sided thrombus. Hematology was consulted. He \nis on Lovenox for the thrombus. Treated with abx for PNA. Course \nalso notable for persistent wheezing, attributed to reactive \nairways, improving with steroids and nebs.\n\n# Dyspnea: On presentation, dysphagia and audible wheezing were \ninitially concerning for upper airway obstruction likely from \noropharynx edema ___ venous thrombosis. He was evaluated by ENT \nwho was not concerened for a mass, and he was found to have \npossible retropharyngeal edema on chest CT. Patient was given \ndexamethasone 10mg IV. On the floor, the patient had difficulty \nbreathing with an increase O2 requirment from 4 to 5L and \ndiffuse wheezing on exam. He was given a duoneb and transfered \nto the ICU briefly. Ultimately, his shortness of breath was felt \nto be multifactorial. Pt had a pneumonia, for which he received \nan 8 day course of abx. There is also likely a component of \nairway inflammation contributing as well, given wheezing on \nexam. Treated with nebs, also started steroids ___ (last \nday ___. Finally, there may also have been a component of \nvolume overload contributing; although this seems less likely to \nstill be present given recent CXR and downtrending\nBNP. Propagation of known thrombi seems less likely given that \npatient is therapeutically anticoagulated at this time. \nRespiratory status much improved by the time of discharge.\n\n# Bialteral Internal Jugular Thromboses: He presented with a \nrecent history of thrombosis in R IJ. He now presented with \nthrombus in L IJ in setting of Coumadin with therapeutic INR \nalthough there is no prior study to compare with. R extremity is \nmarkedly edematous with R sided facial flushing and fullness. \nThere was initial concern for SVC syndrome; however, pt improved \nclinically. Ongoing clot formation raises concern for malignancy \ngiven that he was therapeutic on warfarin. Thromboses could also \nbe associated with pacer leads. Hematology involved. He was \ninitially placed on a heparin gtt and then trantioned to ___ \nper the Hematology consult recs. \n\n# Edema: Most notable in the upper extremities, R>L. Likely \nrelated to known clots. Improved with wrapping/elevating upper \nextremities.\n\n# PNA: Pt with evidence of multifocal PNA. There was a question \nof lipoid PNA per radiology read. Pt has been reporting \nconstipation, possible that he may have aspirated mineral oil. \nWas initially treated as HCAP given recent hospitalization with \nvanc/cefepime. However, given stable overall clinical picture as \nwell as absence of fever/leukocytosis, narrowed abx to \nCTX/azithro. He completed an 8 day course of antibiotics.\n\n# Dysphagia: Pt has had progressive dysphagia to both liquids \nand solids which is concerning for an upper airway obstruction. \nPossibly CA given h/o smoking (cigars and pipes ___ and \n___ esophagitis. ENT did an upper airway scope on ___ \nwhich was negative. Swallowing improved over the course of his \nhospitalization. Could consider formal swallow evaluation if any \nfurther complaints of dysphagia.\n\n# Orthostatic Hypotension: Per outpt records this is attributed \nto IJ/SVC clots leading to decreased pre-load. Could have \ncomponent of pacer dysynchrony. On midodrine and \nfludrocortisone.\n\n# Right Ankle Pain: Sudden onset during admission without \npreceding trauma. X-ray and u/s negative for acute process. Pain \nresolved spontaneously.\n\n# LLE Pain: Patient underwent LLE ultrasound and found to have \nthrombosed distended varicose vein on imaging. Superficial \nthrombophlebitis. Treating supportively.\n\n# CHB s/p PPM: No acute issues.\n# Hypothyroidism: On levothyroxine.\n# Thyroid Nodule: Seen on CT scan. Will need outpatient \nfollow-up.\n\nTRANSITIONAL ISSUES:\n- Continue prednisone burst (last day ___\n- Continue Lovenox, Factor Xa level checked on the day of \ndischarge to ensure appropriate dosing and will need to be \nfollowed up\n- Continue arm elevation/wrapping\n- Consider swallow evaluation if any further episodes of \ndysphagia\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Levothyroxine Sodium 25 mcg PO DAILY \n2. Omeprazole 20 mg PO DAILY \n3. Midodrine 10 mg PO TID \n4. Warfarin 2 mg PO DAILY16 \n5. Fludrocortisone Acetate 0.2 mg PO QAM \n6. Fludrocortisone Acetate 0.1 mg PO QPM \n7. Nabumetone 500 mg PO DAILY \n8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing \n9. Senna 8.6 mg PO QHS:PRN constipation \n10. Bacitracin Ointment 1 Appl TP BID \n11. Testosterone Cypionate 1 ml TP EVERY OTHER WEEK \n\n \nDischarge Medications:\n1. Fludrocortisone Acetate 0.1 mg PO BID \n2. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing \n3. Levothyroxine Sodium 25 mcg PO DAILY \n4. Midodrine 10 mg PO TID \n5. Senna 8.6 mg PO QHS:PRN constipation \n6. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB \n7. Benzonatate 100 mg PO TID:PRN cough \n8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n9. Docusate Sodium 100 mg PO BID \n10. Enoxaparin Sodium 70 mg SC Q12H \nStart: Today - ___, First Dose: Next Routine Administration \nTime \n11. Fluticasone Propionate 110mcg 1 PUFF IH BID \n12. PredniSONE 40 mg PO DAILY Duration: 1 Day \nTake for 1 more day (last day is ___. \n13. Omeprazole 20 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \n___ Diagnosis:\nBilateral IJ Thromboses\nPneumonia\nReactive Airways\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 \nDischarge Instructions:\nYou were admitted to the hospital with worsening swelling in \nyour arms. You were found to have new clots. Because of this, \nyour blood thinning medications were changed.\n\nYou also were having a lot of shortness of breath. This was felt \nto be related to a number of issues, particularly pneumonia and \nairway inflammation. You were treated with steroids, nebulizers, \nand antibiotics. Your breathing was much improved at the time of \ndischarge.\n\nYou should continue to elevated your arms to prevent swelling.\n\nOf note, your CT scan showed a nodule in your thyroid. This is a \nrelatively common finding, but it is important that you \nfollow-up with your PCP to have an ultrasound to further \nevaluate this.\n \nFollowup Instructions:\n___\n" ]

[ "I871", "J189", "J691", "I5023", "I429", "D6869", "J449", "I82B11", "K2270", "I82C13", "Z7901", "R0600", "R232", "Z950", "M7989", "E039", "K219", "I951", "Z87891", "E041", "M25571", "Z66", "Z7952", "T474X1A", "R1310", "I8000", "J45909" ]

[ "I871: Compression of vein", "J189: Pneumonia, unspecified organism", "J691: Pneumonitis due to inhalation of oils and essences", "I5023: Acute on chronic systolic (congestive) heart failure", "I429: Cardiomyopathy, unspecified", "D6869: Other thrombophilia", "J449: Chronic obstructive pulmonary disease, unspecified", "I82B11: Acute embolism and thrombosis of right subclavian vein", "K2270: Barrett's esophagus without dysplasia", "I82C13: Acute embolism and thrombosis of internal jugular vein, bilateral", "Z7901: Long term (current) use of anticoagulants", "R0600: Dyspnea, unspecified", "R232: Flushing", "Z950: Presence of cardiac pacemaker", "M7989: Other specified soft tissue disorders", "E039: Hypothyroidism, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "I951: Orthostatic hypotension", "Z87891: Personal history of nicotine dependence", "E041: Nontoxic single thyroid nodule", "M25571: Pain in right ankle and joints of right foot", "Z66: Do not resuscitate", "Z7952: Long term (current) use of systemic steroids", "T474X1A: Poisoning by other laxatives, accidental (unintentional), initial encounter", "R1310: Dysphagia, unspecified", "I8000: Phlebitis and thrombophlebitis of superficial vessels of unspecified lower extremity", "J45909: Unspecified asthma, uncomplicated" ]

[ "J449", "Z7901", "E039", "K219", "Z87891", "Z66", "J45909" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nLipitor / Enalapril\n \nAttending: ___.\n \nChief Complaint:\nChest Pain and Dyspnea\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ yo ___ speaking female w/ PMH HTN, pAfib\non apixaban, severe AS, HLD who presents with mild chest pain \nand\nintermittent lightheadedness. The patient states that on ___ \nshe\ndeveloped a squeezing sensation over her chest and pain in her\nback which lasted overnight and eventually got better by morning\nafter she took a couple of ___ relaxation medications\nthat she cannot recall the name of. She was seen by her PCP ___\n___ at which time she was asymptomatic. He sent her for labs\nwhich were all normal. On ___, she states the symptoms\nreturned and she noticed that the pain was becoming \nprogressively\nworse. She reached out to her cardiologist who referred her to\nthe ___ where she had an EKG showing afib w/ RVR to 169. At \nthat\ntimes she was referred to the ED for further management. \n\nWhile in the ED, the patient was given diltiazem push followed \nby\na diltiazem gtt with improvement in her heart rates and\nresolution in her chest pain. \n\nOf note, patient is followed by Dr. ___ as an outpatient and\nhas been monitored for severe AS. It appears that despite her\nsevere AS, she has been asymptomatic and therefore they have\ndeferred a TAVR. She does not have any history of syncope.\nAdditionally, on chart review it appears that patient has been\nendorsing episodes of chest discomfort for several months. \n\nIn the ED:\n- Initial vital signs were notable for: T 98.2 HR 68 BP 85/49 RR\n16 O2 96% RA \n \n- Labs were notable for: WBC 13.6 H 12.2 Plts 212 \n ___ 22441\n trop 0.04 lactate 1.4 \n BUN 41 Cr 1.7 \n\n- Studies performed include: CXR: Cardiomegaly with mild\npulmonary edema with small right and suspected small \n left pleural effusion as well. \n\n- Patient was given: diltiazem 10 mg \n diltiazem gtt \n\n- Consults: Cardiology \n\nVitals on transfer: HR 104-110s BP 127/93 RR 22 O2 93% RA \n\nUpon arrival to the floor, the patient states that she feels\nwell. She states she last had chest pain earlier in the morning\nbut says that has completely resolved. She reports good\nmedication compliance. Denies any fever, chills or other\ninfectious symptoms. Per her daughter, ___, she endorses the\nhistory above as well. \n\nREVIEW OF SYSTEMS: Complete ROS obtained and is otherwise\nnegative.\n \nPast Medical History:\nANEMIA \nBLADDER CANCER \n transurethral resection at ___ \nGASTROESOPHAGEAL REFLUX \nHYPERLIPIDEMIA \nHYPERTENSION \nLOW BACK PAIN \nOSTEOARTHRITIS \nOSTEOPOROSIS \nRENAL CA \n R side,hx of cryoablation ___ ___\nL kidney mass x 2 ,cyberknife ___ \n___ FRACTURE \n ___ at ___ \nSHOULDER PAIN \nINSOMNIA \nRHINITIS \nAORTIC STENOSIS \n heart murmur \nH/O KIDNEY CANCER \n \nSocial History:\n___\nFamily History:\nNon- contributory \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n=======================\n___ Temp: 98.3 PO BP: 112/74 HR: 93 RR: 20 O2\nsat: 97% O2 delivery: Ra \nGENERAL: Alert and interactive. In no acute distress. Very hard\nof hearing. \nEYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection. \n\nENT: MMM. JVD difficult to appreciate.\nCARDIAC: Irregular rhythm, normal rate. SEM heard loudest at the\nRUSB. \nRESP: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. No increased work of breathing.\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. No organomegaly.\nMSK: No spinous process tenderness. 2+ pitting edema to the knee\nbilaterally. Pulses DP/Radial 2+ bilaterally.\nSKIN: Warm. Cap refill <2s. No rash.\nNEUROLOGIC: moving all extremities with purpose\nPSYCH: appropriate mood and affect\n\nDISCHARGE PHYSICAL EXAM:\n===========================\n___ 1102 Temp: 98.2 PO BP: 102/49 R Sitting HR: 55 RR: 20 \nO2\nsat: 95% O2 delivery: RA \nGENERAL: Alert and interactive. In no acute distress. Very hard\nof hearing. \nCARDIAC: RRR. ___ systolic ejection murmur at the LUSB. \nRESP: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales.\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants.\nMSK: Trace pitting edema\nSKIN: Warm. \n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 05:45PM BLOOD WBC-13.6* RBC-3.97 Hgb-12.2 Hct-38.5 \nMCV-97 MCH-30.7 MCHC-31.7* RDW-14.9 RDWSD-52.8* Plt ___\n___ 05:45PM BLOOD Neuts-70.1 Lymphs-16.5* Monos-12.0 \nEos-0.4* Baso-0.6 Im ___ AbsNeut-9.54* AbsLymp-2.24 \nAbsMono-1.63* AbsEos-0.06 AbsBaso-0.08\n___ 05:45PM BLOOD Plt ___\n___ 05:45PM BLOOD ___ PTT-30.9 ___\n___ 05:45PM BLOOD Glucose-118* UreaN-41* Creat-1.7* Na-142 \nK-5.1 Cl-104 HCO3-20* AnGap-18\n___ 05:45PM BLOOD CK-MB-2 ___\n___ 05:45PM BLOOD Calcium-9.8 Phos-3.8 Mg-2.0\n___ 05:52PM BLOOD Lactate-1.4\n\nDISCHARGE LABS:\n==============\n___ 07:16AM BLOOD WBC-7.6 RBC-3.63* Hgb-11.1* Hct-35.6 \nMCV-98 MCH-30.6 MCHC-31.2* RDW-14.6 RDWSD-51.9* Plt ___\n___ 07:16AM BLOOD Plt ___\n___ 07:16AM BLOOD Glucose-89 UreaN-48* Creat-1.7* Na-143 \nK-5.4 Cl-102 HCO3-23 AnGap-18\n___ 07:16AM BLOOD Calcium-9.4 Phos-4.9* Mg-2.1\n\nIMAGING:\n============\n___ CHEST (PORTABLE AP)\nCardiomegaly with mild pulmonary edema with small right and \nsuspected small left pleural effusion as well.\n\n___ CHEST (PA & LAT)\nComparison to ___. Improved ventilation of the \nright lung\nbases. Moderate cardiomegaly persists. Mild pulmonary edema is \nstable. \nStable moderate hiatal hernia. No pneumonia\n \n \nBrief Hospital Course:\nTRANSITIONAL ISSUES:\n======================\n[] Recheck creatinine on ___ to evaluate ___. Cr at discharge \n1.7\n[] Recheck potassium on ___ to evaluate hyperkalemia. K at \ndischarge 5.4.\n[] Obtain a ECG on ___ to assess for arrhythmia on amiodarone\n[] Performed recommended amiodarone monitoring\n [] Check TFTs in 6 months.\n [] Check LFTs in 6 months\n [] Check CXR in ___ year obtain PFTs on amio\n [] Consider PFTs as needed \n [] Consider dermatologic, neurologic, dermatologic exams as \nneeded\n[] Consider starting ACE inhibitor for long-term cardiac benefit \n(was previously on lisinopril 10 mg)\n[] Ensure that patient is up-to-date with all preventative \nhealth screenings and vaccinations\n[] Apixaban dose reduced to 2.5mg BID during this admission\n[] Note Amiodarone taper 400 BID x7d (___), 200 BID x7d \n(___), then 200mg daily from ___ onwards\n\nSUMMARY:\n======================\nMs. ___ is a ___ yo ___ speaking female w/ history of \nhypertension, atrial fibrillation on apixaban, severe aortic \nstenosis, hyperlipidemia who presented with chest pain and \nlightheadedness, found to be in atrial fibrillation with rapid \nventricular rate and heart failure exacerbation. She is \ninitiated on diltiazem with difficult rate control, eventually \ntransition to rhythm control with amiodarone. She continued to \nbe in atrial fibrillation with rates in ventricular rates \n100s–110s at discharge. She was diuresed with intermittent IV \nLasix 20mg and was euvolemic at discharge.\n\n# Atrial fibrillation with rapid ventricular rate:\nPatient presented with A. fib with RVR to the ___ outpatient \nclinic after reporting acute onset chest pain for the preceding \ndays. Upon arrival to the ED, patient was started on a diltiazem \ngtt for tachycardia with hypotension. Diltiazem drip overnight \nwith ventricular rate improved to 120s. She was switched over to \ntitration of home metoprolol 25mg XL. She continued to have \nelevated rates, especially exacerbated by activity. She was \ninitiated on digoxin load (___) and amiodarone load \n(___). Her home metoprolol was increased to 200 mg daily. \nAt discharge, she had improved with a controlled ventricular \nrates 100-110s. She was hemodynamically stable and asymptomatic \nthroughout admission. Unclear trigger for atrial fibrillation, \npossibly infectious although unclear source. No echo was \nobtained in this admission given last performed ___. She \nwas anticoagulated with reduced home apixaban 2.5 mg given old \nage and kidney injury (CHADsVASc score 4). Digoxin was \ndiscontinued prior to discharge. She was discharged on \namiodarone taper, apixaban 2.5 mg, metoprolol 100 XL, and 20 mg \nPO furosemide.\n\n# HFpEF (EF 70% in ___:\nPresented with shortness of breath to be volume overloaded with\npulmonary edema on CXR, elevated weight 80 kg (dry weight 78 \nkg),\nelevated BNP 22000, elevated JVP, lower extremity edema. Likely\nexacerbated by atrial fibrillation. Patient states dietary\ncompliance avoiding any salty foods. She had adequate urine \noutput to IV Lasix 20 mg with resolution of trace lower \nextremity edema and creatinine rise likely from overdiuresis. \nShe was discharged with PO Lasix 20mg daily. Her home metoprolol \nwas increased to 100 XL. She was briefly on 200 XL, but this was \ndecreased due to bradycardia with heart rates ___. Weight at \ndischarge: 77.8 kg (171.52 lb) \n\n# ___:\nPresented with elevated creatinine 1.7 from baseline 1.3-1.4. \nLikely prerenal due to poor perfusion in setting of Afib with \nRVR, improved with rate control. She then developed a slight \ncreatinine bump attributed to overdiuresis. Creatinine at \ndischarge was 1.7.\n\n# Leukocytosis: \nShe presented with leukocytosis to 13.6 with lymphocyte \npredominance. Leukocytosis resolved with no intervention. There \nwas no localizing symptoms with negative urinalysis and CXR to \nwarrant treatment. \n\nCHRONIC ISSUES:\n===============\n# Aortic stenosis \nShe has documented severe aortic stenosis from TTE ___ (4.8 \nm/s, 92/53 mmHg, ___ 0.9cm2). Per chart review, given patient's \nage and that she has\nbeen asymptomatic, they have deferred intervention at this \npoint. Given acute A. fib, this discussion was also deferred at \nthis inpatient admission and can be rediscussed as an \noutpatient. She ___ scheduled an outpatient appointment for \nevaluation.\n\n#HLD: Her home lovastatin was held given it was nonformulary \npatient and she had an allergy to atorvastatin.\n\n#Chronic low back pain: She received Tylenol and lidocaine \npatch.\n\n#GERD: continued omeprazole \n\n#Urinary: held home vesicare \n\nCORE MEASURES\n=============\n#CODE: Full Code Presumed \n#CONTACT: ___ (___)\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Apixaban 5 mg PO BID \n2. Betamethasone Dipro 0.05% Cream 1 Appl TP BID \n3. diclofenac sodium 1 % topical QID \n4. ipratropium bromide 42 mcg (0.06 %) nasal TID \n5. Ketoconazole 2% 1 Appl TP QHS \n6. LORazepam 0.5 mg PO BID:PRN anxiety \n7. Lovastatin 20 mg oral DAILY \n8. Meclizine 25 mg PO Q8H:PRN nausea \n9. Metoprolol Succinate XL 25 mg PO DAILY \n10. nystatin 100,000 unit/gram topical DAILY:PRN \n11. Fish Oil (Omega 3) Dose is Unknown PO DAILY \n12. Omeprazole 40 mg PO DAILY \n13. Vesicare (solifenacin) 5 mg oral DAILY \n14. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever \n15. Oyster Shell Calcium 500 (calcium carbonate) 500 mg calcium \n(1,250 mg) oral BID \n16. Capsaicin 0.025% 1 Appl TP TID:PRN pain \n17. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q4H:PRN \ndry eye \n18. Vitamin D3 (cholecalciferol (vitamin D3)) 3000 units oral \nDAILY \n19. Ferrous Sulfate 325 mg PO DAILY \n20. Lidocaine 5% Ointment 1 Appl TP Frequency is Unknown \n\n \nDischarge Medications:\n1. Amiodarone 400 mg PO BID Duration: 4 Days \n2. Amiodarone 200 mg PO BID Duration: 7 Days \n3. Amiodarone 200 mg PO DAILY \n4. Furosemide 20 mg PO DAILY \n5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n6. Apixaban 2.5 mg PO BID \n7. Fish Oil (Omega 3) 1000 mg PO DAILY \n8. Lidocaine 5% Ointment 1 Appl TP ONCE Duration: 1 Dose \n9. Metoprolol Succinate XL 100 mg PO DAILY \n10. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q4H:PRN \ndry eye \n11. Betamethasone Dipro 0.05% Cream 1 Appl TP BID \n12. Capsaicin 0.025% 1 Appl TP TID:PRN pain \n13. diclofenac sodium 1 % topical QID \n14. Ferrous Sulfate 325 mg PO DAILY \n15. ipratropium bromide 42 mcg (0.06 %) nasal TID \n16. Ketoconazole 2% 1 Appl TP QHS \n17. LORazepam 0.5 mg PO BID:PRN anxiety \n18. Lovastatin 20 mg oral DAILY \n19. Meclizine 25 mg PO Q8H:PRN nausea \n20. nystatin 100,000 unit/gram topical DAILY:PRN \n21. Omeprazole 40 mg PO DAILY \n22. Oyster Shell Calcium 500 (calcium carbonate) 500 mg calcium \n(1,250 mg) oral BID \n23. Vesicare (solifenacin) 5 mg oral DAILY \n24. Vitamin D3 (cholecalciferol (vitamin D3)) 3000 units oral \nDAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnosis:\n–Heart failure exacerbation\n–Atrial fibrillation\n\nSecondary diagnoses:\n–Severe aortic stenosis\n–Hyperlipidemia\n–Hypertension\n–Low back\n–Acute kidney injury\n–GERD\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 care of you at the ___ \n___! \n\nWHY WAS I IN THE HOSPITAL? \n========================== \n- You were admitted because your heart rate was very fast\n\nWHAT HAPPENED IN THE HOSPITAL? \n============================== \n- You received medications to control your rapid heart rate.\n- You received medications to remove fluid from your body.\n\nWHAT SHOULD I DO WHEN I GO HOME? \n================================ \n- Be sure to take all your medications and attend all of your \nappointments listed below. \n\nThank you for allowing us to be involved in your care, we wish \nyou all the best! \n\nYour ___ Healthcare Team \n \nFollowup Instructions:\n___\n" ]

[ "I480", "I5033", "I350", "M545", "M1990", "M810", "G4700", "I959", "D72828", "G8929", "I110", "I872", "E875", "R001", "T447X5A", "T502X5A", "N289", "Z7901", "Z8551", "Z85528", "Y92239" ]

[ "I480: Paroxysmal atrial fibrillation", "I5033: Acute on chronic diastolic (congestive) heart failure", "I350: Nonrheumatic aortic (valve) stenosis", "M545: Low back pain", "M1990: Unspecified osteoarthritis, unspecified site", "M810: Age-related osteoporosis without current pathological fracture", "G4700: Insomnia, unspecified", "I959: Hypotension, unspecified", "D72828: Other elevated white blood cell count", "G8929: Other chronic pain", "I110: Hypertensive heart disease with heart failure", "I872: Venous insufficiency (chronic) (peripheral)", "E875: Hyperkalemia", "R001: Bradycardia, unspecified", "T447X5A: Adverse effect of beta-adrenoreceptor antagonists, initial encounter", "T502X5A: Adverse effect of carbonic-anhydrase inhibitors, benzothiadiazides and other diuretics, initial encounter", "N289: Disorder of kidney and ureter, unspecified", "Z7901: Long term (current) use of anticoagulants", "Z8551: Personal history of malignant neoplasm of bladder", "Z85528: Personal history of other malignant neoplasm of kidney", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]

[ "I480", "G4700", "G8929", "I110", "Z7901" ]

[]

[ " \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:\nAcute on chronic kidney failure\nHyperkalemia\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with h/o of hypertension, CKD most recent Cr 4.47 on \n___,\nHFREF (EF 50-55%), dilated CMP, CAD s/p CABG x 4 on ___, DM2,\nwho presented to ___ from his cardiologist's office for\nelevated potassium and creatinine levels to 6.25 and 6.0\nrespectively. Last levels were K 5.3, Cr 4.47 on ___. \n\nOnly complaint today is R dorsum and lateral foot pain. He\ndescribes the pain as muscular in nature and notes that it \ncauses\ndifficulty ambulating due to discomfort. No trauma noticed, with\nsudden onset around ___ days ago. Denies numbness or tingling. \n\nROS notable for diarrhea off and on for last week and a half\n(___). Otherwise denies fevers, headache, lightheadedness,\nchest pain, palpitations, abdominal pain, nausea, vomiting,\narthralgias, weakness.\n\nRegarding his history of heart failure: patient was recently\nadmitted ___ to ___ due to volume overload. This\nwas his first hospital admission for heart failure. Labs were\nnotable for NT pro-BNP of 33857 and a new ___ of 3.92 \n(previously\n1.4). He was diuresed with IV Lasix, and started on hydralazine,\nnorvasc, and isordil. His Lisinopril was held d/t ___ but \nresumed\nupon d/c. An Echo demonstrated LVEF 50-55% with grade III\ndiastolic dysfunction. He was diuresed 40 pounds and \ntransitioned\nto torsemide 100mg BID upon discharge. \n\nRegarding his history of CKD: Creatinine prior to admission in\n___ was 1.4. Was 3.92 on admission and was stable at discharge.\nCreatinine rise was thought to be secondary to progression of\nCKD, given no improvement with diuresis. UA was also notable for\nproteinuria, thought to be nephrotic syndrome. Nephrology was\nconsulted during admission, with plans for follow up upon\ndischarge with likely renal biopsy. Other workup included:\nnegative ___, elevated C3/C4/light chains thought to be \nsecondary\nto renal failure. Renal U/S in the ED was notable for no\nhydronephrosis. \n\n - At ___, initial vitals were: \nVitals: T: 98.6 BP: 133/66 HR: 76 RR: 18 O2 Sat: 98 RA \n\n- Exam was notable for: NAD, MMM, EOMI, CTAB, RRR no mrg, soft\nNTND, b/l edema with venous statis skin changes, no neurologic\ndefects\n- Labs were notable for: Hgb 10.0, K 5.9, Cr 6.1, Phos 7.1 \n- Studies were notable for: renal U/S showed no hydronephrosis,\nXR of foot showed no fracture or acute abnormalities. \n\nOn arrival to the floor, patient was sitting comfortably with no\nacute complaints. \n\n \nPast Medical History:\nHypertension\nHyperlipidemia\nDilated cardiomyopathy diagnosed in ___: LVEF 33% on ETT\nType 2 diabetes\nRecurrent abscess on back, last drained about a month and a\nhalf ago\nPast Surgical History:\nBack abscess s/p drainage\nPast Cardiac Procedures: none\n\n \nSocial History:\n___\nFamily History:\nPremature coronary artery disease- Brother has\nbicuspid aortic valve s/p AVR. Father had CAD and heart failure\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVITALS: 98.5, 168/81, 82, 20, 98% on RA\nGENERAL: Alert and interactive. In no acute distress.\nHEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.\nNECK: No cervical lymphadenopathy. JVP at 9cm at 90 degrees.\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.\nABDOMEN: Obese abdomen, non distended, non-tender to deep\npalpation in all four quadrants.\nEXTREMITIES: 2+ pitting edema to bilateral knees with overlying\nskin thickening and discoloration. Pulses DP/Radial 2+\nbilaterally. TTP over R dorsal and lateral foot.\nNEUROLOGIC: AOx3. CN2-12 intact with no focal neuro deficits.\nMoving all 4 limbs spontaneously. ___ strength throughout. \n\nDISCHARGE PHYSICAL EXAM:\n========================\nVITALS: ___ 0712 Temp: 98.9 PO BP: 154/72 HR: 76 RR: 20 O2 \nsat: 97% O2 delivery: RA \nGENERAL: Alert and interactive. In no acute distress.\nHEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.\nNECK: No cervical lymphadenopathy. Improving 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.\nABDOMEN: Obese abdomen, non distended, non-tender to deep\npalpation in all four quadrants.\nEXTREMITIES: improving 2+ pitting edema to bilateral knees with \noverlying\nskin thickening and purple discoloration. Unable to appreciate\npedal pulses on RLE secondary to edema. Much improved TTP across \nR dorsal foot.\nSensation intact bilaterally.\nNEUROLOGIC: AOx3. CN2-12 intact with no focal neuro deficits.\nMoving all 4 limbs spontaneously. ___ strength throughout.\n \nPertinent Results:\n___ 09:10AM BLOOD WBC-8.6 RBC-3.07* Hgb-8.6* Hct-27.7* \nMCV-90 MCH-28.0 MCHC-31.0* RDW-15.6* RDWSD-51.3* Plt ___\n___ 09:10AM BLOOD Glucose-155* UreaN-108* Creat-6.6* Na-139 \nK-4.7 Cl-104 HCO3-14* AnGap-21*\n___ 09:10AM BLOOD ALT-24 AST-10 LD(LDH)-176 AlkPhos-118 \nTotBili-0.2\n___ 09:10AM BLOOD Albumin-3.0* Calcium-8.1* Phos-8.6* \nMg-1.9\n___ 08:04AM BLOOD %HbA1c-6.2* eAG-131*\n___ 08:01AM BLOOD HIV Ab-NEG\n \nBrief Hospital Course:\n___ with HTN, CKD (last Cr 4.47 ___, HFrEF (EF 50-55%) and \ndilated CMP, CAD s/p CABG x 4 (___) and diet-controlled DM2, \nwho presented with acute on chronic renal failure and worsening \nhyperkalemia.\n\n# Acute on Chronic Renal Failure c/b Hyperkalemia, Metabolic \nAcidosis, and Hyperphosphatemia\nThe patient's creatinine had been ~4 in ___ at the time of \ndischarge from ___ for decompensated CHF (previous Cr \n~1.4 in ___, where he underwent aggressive IV diuresis (lost \n40lbs). However, the patient has developed an acute worsening of \nrenal function on admission to 5.3. On admission, he had \nnephrotic range proteinuria (urine protein/Cr = 4.4). Etiology \nof renal failure was unclear with a plan to pursue renal biopsy \nas an outpatient. He continued to produce urine and only had \nmild symptoms of uremia (some dysgeusia) and was not found to \nhave an indication for HD. Before discharge, the patient \nunderwent vein mapping given likelihood of future dialysis. He \nhad previously been worked up at ___ with unremarkable renal \nUS, no M-spike on urine or serum IFE, ___, C3/C4, and HCV Ab. \nUrine free K/L = 3.27 (kappa FLC = 369, lambda FLC = 113). Serum \nfree K/L = 1.22 (kappa FLC = 115, lambda FLC 95). Here, HIV \nnegative, A1c 6.2%, with UPEP/SPEP pending at the time of \ndischarge. Home Lisinopril was held, and home carvedilol, \nhydralazine, isosorbid, and amlodipine were continued with good \nBP control. During his admission rise in Cr stabilized ~6.5. The \npatient received insulin, Kayexalate, and IV diuresis with \nnormalization of potassium. At the time of discharge, K was \nstable on home torsemide 100mg BID, and he was started on daily \nKayexalate. For acidosis, he received bicarbonate \nsupplementation with slow improvement. He was started on \nsevelamer for hyperphosphatemia. \n\n#R Foot Pain \nThe patient endorsed nontraumatic pain across dorsum of right \nfoot that worsened over the preceding week. XR at outside \nhospital was without acute abnormality. Etiology was unclear - \npossibly gout (uric acid 8.7) but atypical distribution. Charcot \nchanges also considered but A1c 6.2%. ABIs and LENIs were \nunremarkable. Pain gradually subsided and was well-controlled on \nPO Tylenol at discharge. \n\n#HFpEF (EF 50-55%, grade III diastolic dysfunction). The patient \nremained euvolemic - mildly hypervolemic. We continued home \ncarvedilol and held lisinopril. \n\nCHRONIC/STABLE ISSUES:\n======================\n#DM2: A1c 6.2%. He did not require ISS.\n\n#Hypertension: We continued home carvedilol and hydralazine and \nheld home lisinopril. \n\n#CAD s/p 4 vessel CABG in ___. Held home ASA (last dose ___ \ngiven plans for renal biopsy after discussion with outpatient \ncardiologist, Dr. ___. We continued home statin, carvedilol.\n\nTRANSITIONAL ISSUES:\n======================\n- Please trend renal function labs. The patient was discharged \non home torsemide 100mg BID and started on daily Kayexalate, \nsevelamer, and bicarbonate at discharge.\n- Please follow up volume status and weights given concurrent \nrenal failure and HFpEF.\n- Please restart ASA after renal biopsy (last dose ___. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 5 mg PO DAILY \n2. CARVedilol 25 mg PO BID \n3. HydrALAZINE 100 mg PO TID \n4. Isosorbide Dinitrate 40 mg PO TID \n5. Atorvastatin 80 mg PO QPM \n6. CoQ-10 (coenzyme Q10) 30 mg oral DAILY \n7. Aspirin 81 mg PO DAILY \n8. sevelamer CARBONATE 800 mg PO TID W/MEALS \n9. Torsemide 100 mg PO BID \n10. amLODIPine 2.5 mg PO DAILY \n\n \nDischarge Medications:\n1. Sodium Bicarbonate ___ mg PO TID \nRX *sodium bicarbonate 650 mg 3 (Three) tablet(s) by mouth three \ntimes a day Disp #*30 Tablet Refills:*0 \n2. Sodium Polystyrene Sulfonate 30 gm PO ONCE Duration: 1 Dose \nRX *sodium polystyrene sulfonate 15 gram/60 mL 120 mL by mouth \nonce a day Refills:*0 \n3. sevelamer CARBONATE 1600 mg PO TID W/MEALS \nRX *sevelamer carbonate 800 mg 2 (Two) tablet(s) by mouth three \ntimes a day Disp #*180 Tablet Refills:*0 \n4. amLODIPine 2.5 mg PO DAILY \n5. Atorvastatin 80 mg PO QPM \n6. CARVedilol 25 mg PO BID \n7. CoQ-10 (coenzyme Q10) 30 mg oral DAILY \n8. HydrALAZINE 100 mg PO TID \n9. Isosorbide Dinitrate 40 mg PO TID \n10. Torsemide 100 mg PO BID \n11. HELD- Aspirin 81 mg PO DAILY This medication was held. Do \nnot restart Aspirin until renal biopsy is done\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAcute on chronic renal failure\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====================== \n\nDear Mr. ___, \nIt was a pleasure caring for you at ___ ___ \n___.\n\nWHY WAS I IN THE HOSPITAL? \n- Your kidney function was declining with high potassium and \ncreatinine levels.\n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- We gave you medications to lower the amount of potassium in \nyour blood.\n- You were seen by the nephrology team.\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?\n- Continue to take all your medicines and keep your \nappointments.\n\nWe wish you the best!\n\nSincerely, \nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "I130", "E872", "I5030", "N184", "E1122", "E875", "E8339", "M79671", "I2510", "Z951", "E785", "I420", "R197" ]

[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E872: Acidosis", "I5030: Unspecified diastolic (congestive) heart failure", "N184: Chronic kidney disease, stage 4 (severe)", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E875: Hyperkalemia", "E8339: Other disorders of phosphorus metabolism", "M79671: Pain in right foot", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "E785: Hyperlipidemia, unspecified", "I420: Dilated cardiomyopathy", "R197: Diarrhea, unspecified" ]

[ "I130", "E872", "E1122", "I2510", "Z951", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nFlovent Diskus / Cipro\n \nAttending: ___.\n \nChief Complaint:\ncervical dilation\n \nMajor Surgical or Invasive Procedure:\ncerclage placement\n\n \nHistory of Present Illness:\n___ yo G2P0 at 21w0d with cervical dilation 2-3cm noted at\ntime of fetal survey ___. Denies ctx, VB, LOF. +FM. No \nfevers,\nchills, abd pain, dysuria, constipation or diarrhea. \n \n \nPast Medical History:\nPNC: \n- ___ ___ by ___ ultrasound\n- Labs Rh +/Abs neg/Rub I/RPR NR/HBsAg neg/HIV neg/GBS unk\n- Screening declined serum screening\n- FFS normal anatomy, cervical shortening with SSE 2-3cm dilated\n- GTT n/a\n- Issues\n*) Zika exposure (travel to ___ with negative testing\n*) 3.6cm posterior fibroid\n*) asthma - rare albuterol use, last in ___ when treated for\nbronchitis\n \nOBHx:\n- G1 TAB D&C\n- G2 current\n \nGynHx:\n- denies abnormal Pap, STIs\n \nPMH: \n- asthma\n- obesity \n\nPSH: \n- D&C\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nAdmission Physical Exam\nVS: HR 75 BP 102/52\nGen: A&O, comfortable\nCV: RRR\nPULM: normal work of breathing\nAbd: soft, gravid, nontender\nExt: no calf tenderness\nSSE: cervix visually 1-2cm with membranes visible, not \nprotruding\nthrough os\n\nDischarge Physical Exam\nGen: A&O, comfortable\nPULM: normal work of breathing\nAbd: soft, gravid, nontender\nExt: no calf tenderness\n\n \nPertinent Results:\n___ 12:20AM WBC-6.3 RBC-4.13 HGB-11.2 HCT-34.4 MCV-83 \nMCH-27.1 MCHC-32.6 RDW-13.2 RDWSD-40.2\n___ 12:20AM PLT COUNT-262\n \nBrief Hospital Course:\nMs. ___ was admitted to the hospital on ___ for painless \ncervical dilation noted at the time of her full fetal survey. \nShe was counseled by the ___ team, and agreed to proceed with a \ncerclage placement.\n\nShe had ___ cerclage placed on ___. Please see the \noperative report for full details. She completed a 24 hour \ncourse of IV Kefzol and oral Indocin. \n\nShe had reassuring fetal heart tone checks throughout her stay.\n\nShe was discharged on ___ with scheduled follow-up.\n\n \nMedications on Admission:\nPNV, albuterol prn, zyrtex\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain \ndon't take more than 4000mg in 24 hrs \nRX *acetaminophen 500 mg 1 tablet(s) by mouth every 12 hrs Disp \n#*40 Tablet Refills:*0 \n2. Prenatal Vitamins 1 TAB PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\npregnancy at 21 weeks gestation\nshort cervix\n\n \nDischarge Condition:\nstable\n\n \nDischarge Instructions:\nYou were admitted to the antepartum service for observation due \nto a shortened, dilated cervix. You had no evidence of preterm \nlabor. You underwent an uncomplicated cervical cerclage patient \non ___ and remained stable postoperatively. Please maintain \npelvic rest (nothing in the vagina) and avoid strenuous \nexercise. Stay well hydrated.\n \nFollowup Instructions:\n___\n" ]

[ "O3432", "Z3A21", "O26872" ]

[ "O3432: Maternal care for cervical incompetence, second trimester", "Z3A21: 21 weeks gestation of pregnancy", "O26872: Cervical shortening, second trimester" ]

[]

[]

[ " \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:\nRash\n \nMajor Surgical or Invasive Procedure:\n___: DFA of right arm lesion\n\n \nHistory of Present Illness:\nMr. ___ is a very pleasant ___\nyear-old male with history of HCV/EtOH cirrhosis s/p OLT in\n___ c/b recurrent HCV s/p treatment and acute rejection, and\nmore recently disseminated HSV infection s/p Valacyclovir and\npyogenic liver abscess s/p Cefepime/Flagyl who was admitted for\nnew 1 week history of right upper extremity rash. \n\nPatient reports 1 week of rash. He woke up last ___ \nwith\npainful red rash described as \"boils.\" He denies prodromal pain,\nitching or burning sensation. Rash has been stable over the\ncourse of the week. Of note, patient has a prior history of\ndisseminated HSV infection as well as a liver abscess in ___.\nAt that time he presented with fever and lesions on palms and\nright buttock. These were biopsied and found to be ___ HSV 2 \nwith\ncorresponding viral load of 495,000. He was treated with\nacyclovir in-house-> PO valacyclovir in the outpatient setting. \nPatient states that rash at that time was different; he notes\nsingle pustules over his digits and did not see rash over his\nbuttocks.\n\n In the ED, initial VS were: 98 78 123/87 16 98% RA \n Exam notable for: vesicular rash noted on right forearm. \n Labs showed: \n 4.1 > 14.3/40.8 < 81 \n 136 103 30 AGap=11 \n -------------< 166 \n 8.5 22 1.6 \n Repeat K 5.1 \n INR 1.0 \n Imaging showed: n/a \n Patient received: acyclovir 850 IV + NS @ 125, mycophenolate\n360, tacro 2.5 \n Renal transplant was consulted \n ___ with Child's ___ C HCV and EtOH cirrhosis, c/b HE,\nvarices,and ascites who received deceased donor liver transplant\non ___, currently creatinine at baseline, please consult\nliver transplant for IS.' \n Hepatology was consulted and recommended: \n -start IV acyclovir \n -monitor kidney function closely \n -needs airborne and contact isolation \n -pan-culture for any fever \n -Admit to inpatient hepatology service under Dr. ___ \n\n ___ VS were: 97.3 64 126/87 16 100% RA \n\n On arrival to the floor, patient reports the above history. He\nendorses bifrontal HA, ___ for the past hour but otherwise\ndenies symptoms including neck stiffness,\nphotophobia/phonophobia, nausea, vomiting, diarrhea, abdominal\npain, parasthesia, leg swelling.\n\n REVIEW OF SYSTEMS: \n 10 point ROS reviewed and negative except as per HPI \n\n \nPast Medical History:\n1) Hepatitis C/ETOH Cirrhosis - genotype 3, not treated, Childs \nClass C, MELD 18, complicated by grade II/III varices (last EGD \n___ on nadolol; hepatic encephalopathy; ascites/SBP (recent \n\nepisode ___, on augmentin for SBP ppx); no hx. of GI \nbleeding, s/p OLT ___ \n2) GERD (well controlled on Famotidine)\n3) Right tibial fracture s/p repair ___\n4) DM2 (possibly steroid or tacrolimus induced), diet controlled\n5) Disseminated HSV infection s/p Valacyclovir (___)\n6) Pyogenic Liver Abscess (___)\n6) R inguinal hernia\n \nSocial History:\n___\nFamily History:\nThere is no family history of liver disease or GI disesase \n\n \nPhysical Exam:\nAdmission physical exam:\nVS: Temp 97.4 BP 109 / 73HR 58 RR 18SaO2 96%RA\nGENERAL: Well-appearing man in NAD. Pleasant and conversational.\nAAOx3 \nHEENT: normocephalic, atraumatic, no conjunctival pallor or\nscleral icterus, PERRLA, EOMI, OP clear. \nNECK: Supple, no LAD, JVP flat.\nHEART: RRR, normal S1/S2, no murmurs rubs or gallops. \nLUNGS: Clear to auscultation bilaterally, without wheezes or\nrhonchi. \nABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, \nno organomegaly. \nEXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or \nedema.\nSKIN: Numerous vesicles in cluster over right medial forearm on\nerythematous base. Painful to touch (picture taken with patient\npermission and uploaded in OMR)\nNEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,\nwith strength ___ throughout, no asterixis. \n\nDischarge physical exam:\nT 97.4 PO 116 / 82 65 16 97 Ra \nGENERAL: Well-appearing man in NAD. Pleasant and conversational.\nHEENT: normocephalic, atraumatic, no conjunctival pallor or\nscleral icterus, \nNECK: Supple, no LAD, JVP flat.\nHEART: RRR, normal S1/S2, no murmurs rubs or gallops. \nLUNGS: Clear to auscultation bilaterally, without wheezes or\nrhonchi. \nABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, \nno organomegaly. \nEXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or \nedema.\nSKIN: vesicles in cluster over right medial forearm with\nsurrounding erythema, vesicles are decreased in size; not \npainful to palpation\nNEUROLOGIC: A&Ox3, grossly normal\n\n \nPertinent Results:\nAdmission labs:\n---------------\n___ 08:40PM BLOOD WBC-4.1 RBC-4.65 Hgb-14.3 Hct-40.8 MCV-88 \nMCH-30.8 MCHC-35.0 RDW-12.0 RDWSD-38.5 Plt Ct-81*\n___ 08:40PM BLOOD Neuts-63.0 ___ Monos-8.4 Eos-2.0 \nBaso-0.5 Im ___ AbsNeut-2.55 AbsLymp-1.05* AbsMono-0.34 \nAbsEos-0.08 AbsBaso-0.02\n___ 08:40PM BLOOD ___ PTT-29.2 ___\n___ 08:40PM BLOOD Plt Ct-81*\n___ 08:40PM BLOOD Glucose-166* UreaN-30* Creat-1.6* Na-136 \nK-8.5* Cl-103 HCO3-22 AnGap-11\n___ 08:40PM BLOOD Calcium-8.6 Phos-4.4 Mg-1.7\n___ 10:16PM BLOOD K-5.1\n\nPertinent labs:\n---------------\n___ 09:20AM BLOOD Glucose-142* UreaN-27* Creat-1.5* Na-144 \nK-4.4 Cl-106 HCO3-23 AnGap-15\n___ 06:09AM BLOOD Glucose-117* UreaN-23* Creat-1.5* Na-145 \nK-4.6 Cl-109* HCO3-23 AnGap-13\n___ 08:10AM BLOOD Glucose-118* UreaN-20 Creat-1.5* Na-145 \nK-5.2* Cl-109* HCO3-24 AnGap-12\n___ 09:20AM BLOOD ALT-92* AST-31 LD(LDH)-163 AlkPhos-59 \nTotBili-1.1\n___ 06:09AM BLOOD ALT-67* AST-21 AlkPhos-51 TotBili-0.8\n___ 08:10AM BLOOD ALT-62* AST-32 AlkPhos-47 TotBili-0.7\n___ 09:20AM BLOOD tacroFK-6.3\n___ 06:09AM BLOOD tacroFK-6.5\n___ 08:10AM BLOOD tacroFK-4.4*\n\nDischarge labs:\n---------------\n___ 08:10AM BLOOD WBC-4.4 RBC-4.33* Hgb-13.7 Hct-38.2* \nMCV-88 MCH-31.6 MCHC-35.9 RDW-12.1 RDWSD-38.7 Plt Ct-69*\n___ 08:10AM BLOOD Plt Ct-69*\n___ 08:10AM BLOOD ___ PTT-31.7 ___\n___ 08:10AM BLOOD Glucose-101* UreaN-21* Creat-1.4* Na-143 \nK-4.8 Cl-107 HCO3-22 AnGap-14\n___ 08:10AM BLOOD ALT-57* AST-24 AlkPhos-51 TotBili-0.6\n___ 09:08AM BLOOD tacroFK-PND\n\nMicrobiology:\n-------------\n___ 3:05 pm \n Direct Antigen Test for Herpes Simplex Virus Types 1 & 2\n Source: right forearm. \n\n **FINAL REPORT ___\n\n Direct Antigen Test for Herpes Simplex Virus Types 1 & 2 \n(Final\n ___: \n Reported to and read back by ___ ___ ___ AT \n1012). \n POSITIVE FOR HERPES SIMPLEX TYPE 2 (HSV2). \n Viral antigen identified by immunofluorescence. \n \n___ 3:05 pm DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS\n Source: right forearm. \n **FINAL REPORT ___\n DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Final \n___: \n Negative for Varicella zoster by immunofluorescence. \n\n \nBrief Hospital Course:\nMr. ___ is a ___ year-old male with history of HCV/EtOH \ncirrhosis s/p deceased-donor orthotopic liver transplant in \n___ c/b recurrent HCV s/p treatment with virologic clearance \nand mild acute rejection (___), and more\nrecently disseminated HSV infection s/p acyclovir (to po \nvalacyclovir) and pyogenic liver abscess s/p Cefepime/Flagyl who \nis admitted for right arm vesicular rash.\n\n ACUTE ISSUES: \n ============= \n# Herpes simplex 2 rash: Patient's rash was initially concerning \nfor herpes simplex vs. varicella, so dermatology performed a DFW \n(Showing herpes 2). He had no clinical evidence of disseminated \ndisease, although the downtrending LFTs with antiviral treatment \nwere concerning for liver involvement. A PCR was sent, but the \nresults will not affect management (pathology was notified to \ncancel order). He was discharged on a regimen of Valacyclovir 1g \nTID until the lesions crust over (and then he will be continued \non prophylactic Valacyclovir 500mg BID). He also has follow up \nwith ID transplant. Medications were dispensed via ___ \ndelivery.\n\n# Anxiety: Patient reported feeling anxious, confused, and \nhungover during hospitalization. He reports that he was recently \nplaced on hydroxyzine, which has helped. There was no concern \nfor alcohol withdrawal during hospitalization. \n\nCHRONIC ISSUES: \n ===============\n# HCV/EtoH Cirrhosis s/p liver transplantation (___): His \ncourse was previously complicated by mild acute rejection (most \nrecently ___ treated with pulse IV Methylprednisolone) \nfollowed by prolonged PO prednisone and increased MMF dose for 3 \nmonths. Now he is currently controlled on tacrolimus currently \nat 2.5 mg BID) and 360mg MMF BID. His Tacrolimus was maintained \nat the same level (was at goal during hospitalization), and he \nwas discharged back to his mandatory alcohol abstinence program \n(for ongoing alcohol use in setting of prior liver transplant).\n \n#Hyperkalemia: Patient has chronic hyperkalemia thought \nsecondary to CKD and has weekly labs drawn at ___. \nHe is instructed to take kayexalate PRN based on levels. He was \nmaintained on a low potassium diet.\n\n#CKD: Patient was at baseline Cr 1.5. He received fluids (250cc \nbefore and after acyclovir dosing) for hydration prophylaxis.\n\n# Alcohol use disorder: Patient currently resides in a mandatory \nfacility ___) for alcohol use following liver \ntransplant. He should be discharged back to this facility.\n\nNEW MEDICATIONS\n- Valacyclovir 1g TID until lesions are crusted over\n- Valacyclovir 500mg BID for herpes prophylaxis after lesions \nhave crossed over.\n\n[ ] You can keep the rash covered if you would like. You can use \nregular gauze and tape. Most of general population has already \nbeen exposed to herpes simplex 2, so there is low risk of \ninfecting others. The infectious disease team reported that it \nis safe for him to discharge back to his shared living space.\n[ ] Patient should continue to take his Valtrex (1g TID) until \nhis lesions crust over. This should likely occur within the next \nfew days but can take up to two weeks. Then he should take the \nreduced and less frequent dose (500mg BID) as prophylaxis.\n[ ] Please check his renal function (Creatinine) one week after \ndischarge to ensure that his kidney function is stable after \ntaking acyclovir\n[ ] Patient reported feeling very anxious and powerless based on \nhis current program restrictions. He was stable on hydroxyzine, \nbut continue to assess his symptoms.\n[ ] Please continue him on his immunosupressive medications.\n[ ] Please continue to abide by a low potassium diet.\n\nFull code (attempt resuscitation) \nName of health care proxy: ___ \nRelationship: Sister \nPhone number: ___ \nCell phone: ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Famotidine 20 mg PO DAILY \n2. Mycophenolate Sodium ___ 360 mg PO BID \n3. Tacrolimus 2.5 mg PO Q12H \n4. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild \n5. HydrOXYzine 25 mg PO Q8H:PRN anxiety \n6. FoLIC Acid 1 mg PO DAILY \n7. Vitamin D ___ UNIT PO 1X/WEEK (TH) \n8. Sodium Polystyrene Sulfonate 15 gm PO ASDIR \n\n \nDischarge Medications:\n1. ValACYclovir 1000 mg PO Q8H Duration: 14 Days \nKeep taking this until your herpes sores have crusted. Then stop \ntaking this and start prophylaxis. \nRX *valacyclovir 1,000 mg 1 tablet(s) by mouth three times a day \nDisp #*42 Tablet Refills:*0 \n2. ValACYclovir 500 mg PO Q12H \nStart taking this after your lesions have crusted over. This is \nfor prophylaxis. \nRX *valacyclovir 500 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n3. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild \n4. Famotidine 20 mg PO DAILY \n5. FoLIC Acid 1 mg PO DAILY \n6. HydrOXYzine 25 mg PO Q8H:PRN anxiety \n7. Mycophenolate Sodium ___ 360 mg PO BID \n8. Sodium Polystyrene Sulfonate 15 gm PO ASDIR \n9. Tacrolimus 2.5 mg PO Q12H \n10. Vitamin D ___ UNIT PO 1X/WEEK (TH) \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\n============\nHerpes simplex 2 rash\n\nSecondary:\n============\nAlcoholic cirrhosis status post liver transplant\nChronic kidney 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 Mr. ___,\n\nWhy were you admitted?\n- You were admitted for a rash on your right arm\n\nWhat happened in the hospital?\n- We determined it was a herpes simplex 2 infection, which is \nthe same kind of infection as the one that you had in ___\n- You are more susceptible to getting this infection because you \nare on two medications that can suppress your immune system\n- We started you on an antiviral medication to treat the rash\n\nWhat should you do when you leave the hospital?\n- It is safe for you to go back to ___ with your \nrash. You can keep the rash covered until it crusts although it \nis unlikely to cause infections in others\n- Be sure to wash your hands carefully, and try to avoid letting \nothers touch your rash.\n- After the lesions crust over, continue to take prophylactic \nantivirals. This is a reduced dosage of your antiviral \nmedication (and is a lower frequency).\n- It is important to continue refraining from drinking alcohol! \nThis is very important as ongoing alcohol use can hurt your \nliver. \n- If you develop any fever, chills, or other concerning \nsymptoms, please let someone know.\n\nIt was a pleasure taking care of you! We wish you all the best.\n- Your ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "B0089", "Z944", "E119", "E875", "N189", "Z8619", "K219", "Z87891", "F419", "F1010" ]

[ "B0089: Other herpesviral infection", "Z944: Liver transplant status", "E119: Type 2 diabetes mellitus without complications", "E875: Hyperkalemia", "N189: Chronic kidney disease, unspecified", "Z8619: Personal history of other infectious and parasitic diseases", "K219: Gastro-esophageal reflux disease without esophagitis", "Z87891: Personal history of nicotine dependence", "F419: Anxiety disorder, unspecified", "F1010: Alcohol abuse, uncomplicated" ]

[ "E119", "N189", "K219", "Z87891", "F419" ]

[]

[ " \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:\nFevers\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old man with CLL/SLL diagnosed in ___, \ns/p 2 cycles R-CHOP for concern for Richter's transformation, \nofatumumab trial ___, then ibrutinib ___, and now on \nvenetoclax ABT-199 trial, who presents with fevers.\n\nThe patient shares that 4 days prior to presentation, he was \nfeeling less well than his normal self. He was having diffuse \nmyalgias and malaise. He took his temperature, and had a fever \nof 101. He continued to feel this way, and took his temperature \nagain 2 day priors to presentation, and had a fever of 102. He \ncalled the clinic, and he presented into clinic. He had blood \ncultures and labs done. ANC in clinic was 1000, and he was \ninstructed to present to the ED. Prior to arriving to the ED, he \ntook his temperature and it was 101. \n\nHe was afebrile upon presentation to the ED, and vitals were \nstable. He was given a dose of Tamiflu because he was treated \nfor the flu 1 month ago. Tamiflu was discontinued when his flu \nswab returned negative. He was also started on vancomycin and \ncefepime, which he was continued on overnight.\n\nThis morning Mr. ___ says he is feeling relatively well, just \nfatigued. He does have a headache today, which he describes as \nencompassing his whole head. He has no photophobia, no \nconfusion, no neck stiffness. He also has no rhinorrhea, no \nshortness or breath, no cough, no abdominal pain, no change in \nbowel habits or diarrhea, no dysuria, no rashes. He has a right \nsided port, with no recent manipulation, and no pain or drainage \nat the site that he has noticed.\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \n ___ year old man with relapsed/refractory \n CLL is enrolled onto ___ protocol ___: A Phase 2 \nOpen-Label \n Study of the Efficacy and Safety of ABT-199 (___) in \nChronic \n Lymphocytic Leukemia Subjects with Relapse or Refractory to \n B-Cell Receptor Signaling Pathway Inhibitor Therapy. \n ___: Week 1 ABT-199 20 mg daily \n ___: Week 2 ABT-199 50 mg daily \n ___: Week 3 ABT-199 100 mg daily \n ___: Week 4 ABT-199 200 mg daily \n ___: Week 5 ABT-199 400 mg daily \n \nPAST MEDICAL HISTORY:\n 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia \n 2. CARDIAC HISTORY: \n -CABG: none \n -PERCUTANEOUS CORONARY INTERVENTIONS: none \n -PACING/ICD: none \n 3. OTHER PAST MEDICAL HISTORY: \n -p53 deleted CLL/SLL/transformation \n - left hip arthritis sp steroid injection \n\n \nSocial History:\n___\nFamily History:\nFather had MI in ___, died s/p valve replacement in ___. Mother \nalive with asthma no h/o heart disease.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\nGeneral: NAD\nVITAL SIGNS: T 99.1 Bp 150/74 HR 84 RR 19 O2 100%RA\nHEENT: MMM, no OP lesions\nCV: RR, NL S1S2\nPULM: CTAB\nABD: Soft, NTND, no masses or hepatosplenomegaly\nLIMBS: No edema, clubbing, tremors, or asterixis\nSKIN: No rashes or skin breakdown\nNEURO: Alert and oriented, no focal deficits.\n\nDISCHARGE PHYSICAL EXAM\nVitals: Tm99.4 BP 120s-140s/70s-80s HR ___ O2 98 RA\nGen: Pleasant, well appearing, NAD.\nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. No \nneck stiffness, can touch head to neck comfortably; no ear \nlesions or rashes on the head; no vesicles to suggest zoster. \nLYMPH: No palpable cervical or supraclavicular LAD\nCV: RRR. Normal S1,S2. No MRG. \nLUNGS: No increased WOB. CTAB. No wheezes, rales, or rhonchi. \nABD: NABS. Soft, NT, ND. \nEXT: WWP. No ___ edema. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3, BUE/BLE ___, CN grossly intact.\nLine: Right sided port, no erythema.\n \nPertinent Results:\nADMISSION LABS\n====================================================\n___ 10:50AM BLOOD WBC-2.1* RBC-4.82 Hgb-13.7 Hct-39.6* \nMCV-82 MCH-28.4 MCHC-34.6 RDW-14.2 RDWSD-42.3 Plt ___\n___ 10:50AM BLOOD Neuts-47 Bands-1 ___ Monos-24* \nEos-0 Baso-1 ___ Myelos-0 AbsNeut-1.01* \nAbsLymp-0.57* AbsMono-0.50 AbsEos-0.00* AbsBaso-0.02\n___ 10:50AM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL \nPoiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL \nOvalocy-OCCASIONAL Schisto-OCCASIONAL Burr-OCCASIONAL\n___ 10:50AM BLOOD Glucose-134* UreaN-16 Creat-1.0 Na-134 \nK-3.9 Cl-97 HCO3-24 AnGap-17\n___ 10:50AM BLOOD ALT-54* AST-33 LD(LDH)-314* AlkPhos-138* \nTotBili-1.3\n___ 10:50AM BLOOD Albumin-4.7 Calcium-9.3 Phos-3.2 Mg-1.6 \nUricAcd-5.7\n___ 10:50AM BLOOD IgG-453*\n___ 10:09PM BLOOD Lactate-1.3\n___ 11:40PM URINE Color-Yellow Appear-Clear Sp ___\n___ 11:40PM URINE Color-Yellow Appear-Clear Sp ___\n___ 11:40PM URINE Blood-SM Nitrite-NEG Protein-30 \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG\n___ 11:40PM URINE RBC-4* WBC-0 Bacteri-FEW Yeast-NONE Epi-0\n___ 11:10AM OTHER BODY FLUID FluAPCR-NEGATIVE \nFluBPCR-NEGATIVE\n\nINTERMITTENT PERTINENT LABS\n====================================================\n___ 12:00AM BLOOD WBC-6.0 RBC-4.02* Hgb-11.6* Hct-33.5* \nMCV-83 MCH-28.9 MCHC-34.6 RDW-14.2 RDWSD-43.3 Plt ___\n___ 12:00AM BLOOD Neuts-74* Bands-7* Lymphs-13* Monos-3* \nEos-0 Baso-0 Atyps-3* ___ Myelos-0 AbsNeut-4.86 \nAbsLymp-0.96* AbsMono-0.18* AbsEos-0.00* AbsBaso-0.00*\n___ 12:00AM BLOOD Glucose-133* UreaN-15 Creat-0.9 Na-136 \nK-3.9 Cl-99 HCO3-24 AnGap-17\n___ 12:00AM BLOOD ALT-59* AST-30 LD(LDH)-359* AlkPhos-140* \nTotBili-0.9\n___ 12:00AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.8\n___ 02:00PM BLOOD IgG-357*\n___ 05:58AM BLOOD Vanco-12.2\n\nDISCHARGE LABS\n====================================================\n___ 12:00AM BLOOD WBC-4.9 RBC-3.99* Hgb-11.3* Hct-33.1* \nMCV-83 MCH-28.3 MCHC-34.1 RDW-14.4 RDWSD-43.5 Plt ___\n___ 12:00AM BLOOD Neuts-69 Bands-4 Lymphs-14* Monos-12 \nEos-1 Baso-0 ___ Myelos-0 AbsNeut-3.58 AbsLymp-0.69* \nAbsMono-0.59 AbsEos-0.05 AbsBaso-0.00*\n___ 12:00AM BLOOD Glucose-172* UreaN-11 Creat-0.8 Na-134 \nK-3.9 Cl-98 HCO3-23 AnGap-17\n___ 12:00AM BLOOD ALT-54* AST-26 LD(LDH)-336* AlkPhos-143* \nTotBili-0.6\n___ 12:00AM BLOOD Albumin-3.9 Calcium-8.4 Phos-2.8 Mg-1.8\n\nMICROBIOLOGY\n====================================================\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH. \n\nIMAGING AND DIAGNOSTICS\n====================================================\nCXR ___:\nIMPRESSION: \nNo acute intrathoracic process. \n\nCT head ___:\nIMPRESSION: \n1. No acute intracranial abnormality. Specifically no acute \nintracranial \nhemorrhage. \n\n \nBrief Hospital Course:\nMr. ___ is a ___ year old man with CLL/SLL diagnosed in ___, \ns/p 2 cycles R-CHOP for concern for Richter's transformation, \nofatumumab trial ___, then ibrutinib ___, and now on \nvenetoclax ABT-199 trial since ___, who presented with grade \n3 febrile neutropenia.\n\nPatient presented with a four day history of fevers >101, in the \nsetting of being on ABT-199 trial and neutropenia. He had no \nclear infectious source. Urine culture was negative, blood \ncultures had no growth, and CXR was nonsuggestive of pneumonia. \nHe was started on vancomycin and cefepime. He was also \nmaintained on the ABT-199 trial, as per protocol the only \nindication to stop the drug is if he had an ANC of less than 500 \nfor one week while on neupogen. He was given 2 doses of \nneupogen, and neutropenia resolved. Antibiotics were stopped \nafter 48 hours of being afebrile and resolution of neutropenia. \nHe was afebrile after this with no signs of decompensation. He \nwas continued on the study drug ABT-199 while hospitalized. \n\nOn second day of hospitalization had new global headache, with \nno confusion or neck stiffness and intact neurologic exam. CT \nhead was done to rule out bleed or large new mass, and was \nnegative. The was low suspicion for meningitis as patient looked \nvery well and headache improved.\n\nFor chronic issues of hypertension and coronary artery disease, \nhe was continued on amlodipine and aspirin, respectively.\n\nTRANSITIONAL ISSUES:\n- Patient is on ___-199 trial\n- Follow-up on headache post-discharge\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO TID \n2. Allopurinol ___ mg PO DAILY \n3. Omeprazole 20 mg PO DAILY \n4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain \n7. amLODIPine 10 mg PO DAILY \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO TID \n2. Allopurinol ___ mg PO DAILY \n3. amLODIPine 10 mg PO DAILY \n4. Aspirin 81 mg PO DAILY \n5. Omeprazole 20 mg PO DAILY \n6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\nFebrile neutropenia \n\nSECONDARY DIAGNOSES\nChronic lymphocytic leukemia\nHypertension\nHeadache\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 during your hospitalization \nat the ___. You were admitted \nbecause you were having fevers and your white blood cell count \n(called absolute neutrophil count or ANC) was low. You were \nstarted on antibiotics through the IV. No cause of the infection \nwas found, and you may have had a virus that your body got rid \nof on its own as your cell count increased. Therefore, your \nantibiotics were stopped. \n\nYou also had a headache during this hospitalization. You had a \nscan of your head, and there was no bleed. Your headache \nimproved somewhat, and we hope will continue to improve once you \nleave the hospital. If your headache persists, you can try \n200-400 mg ibuprofen or oxycodone. Please do not take Tylenol or \nany medication containing acetaminophen. \n\nIf you have a persistent or worsening headache, fever, chills, \nor any symptoms that concern you, please call into Dr. ___ \n___ or seek medical evaluation. You have follow-up schedule \non ___ at 3 pm. \n\nWe wish you the best of luck in your health!\n\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "D709", "C9112", "E119", "R5081", "I10", "I2510", "R51", "E785", "Z87891", "Z96642" ]

[ "D709: Neutropenia, unspecified", "C9112: Chronic lymphocytic leukemia of B-cell type in relapse", "E119: Type 2 diabetes mellitus without complications", "R5081: Fever presenting with conditions classified elsewhere", "I10: Essential (primary) hypertension", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "R51: Headache", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "Z96642: Presence of left artificial hip joint" ]

[ "E119", "I10", "I2510", "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:\nbleeding around catheter site\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\n___ inmate HCV, ESRD ___ ___ s/p R IJ HD catheter placement by \n___ ___ with persistent bleeding around the line \ninsertion site s/p ___ placement by transplant surgery, \ndeveloped fevers in ED with concern for HD line infection. \n\n Patient reports he underwent an uneventful placement of R IJ HD \ncatheter with ___ on ___ and was dicharged after a ___ \nrecovery. He noticed slow but steady oozing from the skin site. \nUnderwent HD today through catheter without issues today, \nhowever with continued oozing after HD controlled with direct \npressure and was sent to the ED. Pt denies pain, swelling, \ndischarge from the catheter site. No fever, no cp, no sob. \nChronic neuropathy of LEs without recent change. ROS otherwise \nnegative. \n In the ED, initial vitals were: 96.8 60 194/77 20 100% RA \n - Labs were significant for: \n\n - Imaging: U/s of catheter site--No evidence of pseudoaneurysm \nor large hematoma at the level of the dialysis \n catheter insertion site into the right internal jugular vein. \n\n CXR: w/o acute intrathoracic process \n - The patient was given: \n ___ 18:45 PO Acetaminophen 1000 mg \n ___ 21:05 PO Haloperidol 2.5 mg Partial Administration \n ___ 21:05 PO OxycoDONE (Immediate Release) 10 mg \n ___ 23:30 PO Acetaminophen 1000 mg \n ___ 23:31 IV Vancomycin 1000 mg \n ___ 00:23 PO HydrALAzine 25 mg \n ___ 00:23 PO Amlodipine 10 mg \n ___ 00:54 IV Heparin Flush (1000 units/mL) 1700 UNIT \n\n Transplant surgery consulted, placed 2-u stitches around \ncatheter site with adequate hemostasis. Later in ED course, \npatient developed fever to 103. Admitted to medicine for further \nwork-up with specific concern for HD line infection. \n Vitals prior to transfer were: 103 90 154/70 20 94% RA \n\n Upon arrival to the floor, pt reports R leg pain ___ to \nreported \"broken leg\" months ago. Endorses chills, denies N/V. \nEndorses recent diarrhea. Denies cough, sputum production. \nDenies dysuria. \n\n \nPast Medical History:\nPMH: Stage V chronic kidney disease, type 2 diabetes, HCV \ninfection, hypertension, schizoaffective disorder and BPH\n\nPSH: LUE brachiobasilic AVF\n\n \nSocial History:\n___\nFamily History:\nNon contributory\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n Vitals: 102.7 129/81 84 19 97%RA \n wt 90.2 kg \n General: Alert, oriented, no acute distress \n HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL \n Neck: Supple, JVP not elevated, no LAD \n Chest: Regular rate and rhythm, normal S1 + S2, no murmurs, \nrubs, gallops. HD line in place, overlying erythema and edema \nwith tenderness, not present on exam of surgery and ed intial \nevals. \n Lungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \n Abdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \n GU: No foley \n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. \nMild b/l ___ edema R>L. \n Neuro: AAOx3 \n\nDISCHARGE PHYSICAL EXAM:\n\n PHYSICAL EXAM: \n Vitals: Tm 100.9 (once at 4am), Tc 100.5, HR ___, BP \n102-149/40s-60s, 18, 94% on RA. FSBG 93->202\n General: A&Ox3. Conversational, in no acute distress. \n HEENT: Sclera anicteric, MMM, EOMI, PERRL \n Neck: Supple, no LAD \n Chest: Regular rate and rhythm, normal S1 + S2, III/VI systolic \nmurmur radiating to the clavicles. Site of HD line with minimal \ntenderness to palpation, covered in dressing.\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \n Abdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \n GU: No foley \n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. \nScars as before. Right leg larger and with evidence of prior \ntibial fracture. LUE with fistula. RUE with one PIV.\n Neuro: AAOx3, MAEW. \n \nPertinent Results:\nADMISSION LABS:\n___ 10:48PM BLOOD WBC-5.6 RBC-3.13* Hgb-9.0* Hct-29.9* \nMCV-96# MCH-28.8 MCHC-30.1*# RDW-18.4* RDWSD-63.9* Plt ___\n___ 10:48PM BLOOD Neuts-80.4* Lymphs-11.7* Monos-5.9 \nEos-1.4 Baso-0.2 Im ___ AbsNeut-4.47 AbsLymp-0.65* \nAbsMono-0.33 AbsEos-0.08 AbsBaso-0.01\n___ 10:48PM BLOOD ___ PTT-34.7 ___\n___ 10:48PM BLOOD Glucose-103* UreaN-29* Creat-4.7*# Na-139 \nK-4.3 Cl-94* HCO3-35* AnGap-14\n___ 10:48PM BLOOD ALT-21 AST-35 AlkPhos-89 TotBili-0.4\n___ 09:30AM BLOOD Calcium-9.4 Phos-2.1*# Mg-1.9\n___ 12:00PM BLOOD calTIBC-173* Ferritn-974* TRF-133*\n___ 12:03AM BLOOD Type-ART pO2-78* pCO2-36 pH-7.51* \ncalTCO2-30 Base XS-5\n\nDISCHARGE LABS:\n\n___ 06:20AM BLOOD Plt ___\n___ 06:20AM BLOOD Glucose-96 UreaN-43* Creat-6.7*# Na-134 \nK-4.0 Cl-93* HCO3-32 AnGap-13\n___ 06:20AM BLOOD Calcium-8.8 Phos-2.1* Mg-2.0\n___ 06:20AM BLOOD Vanco-18.2\n\nMICRO:\n___ 10:48 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: \n STAPH AUREUS COAG +. \n Consultations with ID are recommended for all blood \ncultures\n positive for Staphylococcus aureus, yeast or other \nfungi. \n Oxacillin RESISTANT Staphylococci MUST be reported as \nalso\n RESISTANT to other penicillins, cephalosporins, \ncarbacephems,\n carbapenems, and beta-lactamase inhibitor combinations. \n\n Rifampin should not be used alone for therapy. \n FINAL SENSITIVITIES. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n STAPH AUREUS COAG +\n | \nCLINDAMYCIN-----------<=0.25 S\nERYTHROMYCIN---------- =>8 R\nGENTAMICIN------------ <=0.5 S\nLEVOFLOXACIN---------- =>8 R\nOXACILLIN------------- =>4 R\nRIFAMPIN-------------- 16 R\nTRIMETHOPRIM/SULFA---- <=0.5 S\nVANCOMYCIN------------ 1 S\n\n Aerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE COCCI IN CLUSTERS. \n Reported to and read back by ___ ___ ___ \n325PM. \n\n Anaerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE COCCI IN CLUSTERS. \n.\n___ 12:50 am BLOOD CULTURE QUINTON LINE. \n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: \n STAPH AUREUS COAG +. \n SENSITIVITIES PERFORMED ON CULTURE # ___ \n___. \n\n Aerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE COCCI IN CLUSTERS. \n Reported to and read back by ___ ___ ___ \n325PM. \n\n Anaerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE COCCI IN CLUSTERS. \n.\n___ 9:30 am BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: \n STAPH AUREUS COAG +. \n SENSITIVITIES PERFORMED ON CULTURE # ___ \n___. \n\n Anaerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. \n\n Aerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. \n.\n___ 9:35 am BLOOD CULTURE\n\n Blood Culture, Routine (Preliminary): \n STAPH AUREUS COAG +. \n SENSITIVITIES PERFORMED ON CULTURE # ___ \n___. \n\n Anaerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. \n\n Aerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. \n.\n___ 12:45 pm BLOOD CULTURE Source: Venipuncture. \n\n Blood Culture, Routine (Pending): \n.\nIMAGING:\n___ TTE:\nConclusions \n The left atrium is mildly dilated. The right atrium is \nmoderately dilated. Left ventricular wall thickness, cavity \nsize, and global systolic function are normal (LVEF>55%). The \nestimated cardiac index is normal (>=2.5L/min/m2). Doppler \nparameters are indeterminate for left ventricular diastolic \nfunction. Right ventricular chamber size and free wall motion \nare normal. The aortic root is mildly dilated at the sinus \nlevel. The ascending aorta is mildly dilated. The aortic valve \nleaflets (3) are mildly thickened but aortic stenosis is not \npresent. No masses or vegetations are seen on the aortic valve. \nTrace aortic regurgitation is seen. The mitral valve leaflets \nare mildly thickened. There is no mitral valve prolapse. No mass \nor vegetation is seen on the mitral valve. Mild (1+) mitral \nregurgitation is seen. There is mild pulmonary artery systolic \nhypertension. There is no pericardial effusion. \n\n IMPRESSION: No echocardiographic evidence of endocarditis. \nNormal biventricular cavity size and regional/global systolic \nfunction. Mild mitral regurgitation. Trivial aortic \nregurgitation. Mild thoracic aortic dilatation. \n.\n___ US neck:\nIMPRESSION: \nNo focal fluid collection. \n.\n___ CXR:\nIMPRESSION: \nMild pulmonary edema. \nRetrocardiac opacity best seen on the lateral view could be due \nto atelectasis or vascular structures, however, consolidation is \nnot excluded in the appropriate clinical setting. \n.\n___ UNILAT UP EXT VEINS US \nIMPRESSION: \nNo evidence of pseudoaneurysm or hematoma at the level of the \ndialysis \ncatheter insertion site into the right internal jugular vein. \n\n \nBrief Hospital Course:\n___ inmate HCV, ESRD ___ ___ s/p R IJ HD catheter placement by \n___ ___ with subsequent line infection with MRSA, treated \nwith line removal and vancomycin. \n \n#HD line infection: Cultures have grown MRSA, vanc sensitive. \nLine was pulled on evening of ___ and he was given 2gm Vanc \ndosed at HD since admission. Had persistent fevers for first few \ndays not controlled by Tylenol, which was likely due to severity \nof his initial bacteremia. Abscess at site of prior HD line was \nruled out by repeat US. No signs or symptoms of epidural \nabscess. TTE was negative for vegetation; per ID, ___ was not \npursued given defervescence and Blood Cx from ___ being \nnegative for 48 hours. Blood cultures were drawn QD when \npossible, otherwise everytime he goes to HD. He had vanc levels \nwith each day of HD, redosed after HD. Anticipate 14 day course \nof vancomycin since first clear blood culture on ___, last day \nis ___.\n\n#ESRD: T, Th, ___ HD. Initially there was concern given a \nshallow ulcer on his fistula site, but this was deemed clear for \nuse by transplant surgery.\n\n#Right leg pain: from prior injury. Pt was kept on oxycodone \n___ PRN, hold for sedation or AMS. Was previously held due to \npersistent AMS in the setting of high fevers.\n\n#HTN: stable since admission. Difficulty getting consistent BPs \ngiven he has fistula in left arm and PIVs in right. BPs while he \nwas admitted were obtained from left calf. Initially labetalol, \namlodipine, hydral were held in setting of potential \nbacteremia/sepsis, but these were restarted. His metolazone was \nd/c'd as he is anuric. \n\n#HLD -Continued statin \n\n#mood d/o -Continued home amitriptyline.\n\nTRANSITIONAL ISSUES:\n[ ] Vancomycin - ___osed with sliding scale at TTS \nHD (last day of Vanc ___. SLIDING SCALE used as inpatient:\nVanco Level < 15: 1000 mg ONCE\nVanco Level 15 - 25: 500 mg ONCE\nVanco Level > 25: Hold Dose\nRenal Dose Data:\n Pt Height: 5 ft 9 in\n Pt Weight: 90.20 kg\n Last Serum Creat: 5.7 mg/dl - From: \n Est CRCL: 16 ml/min\n Body Mass Index: 29.37 kg/m2\n[ ] FYI most recent HD was on ___.\n[ ] Metolazone was discontinued per renal given nearly anuric.\n[ ] Hydralazine and labetalol restarted on day of discharge. \nPlease continue to monitor BP.\n[ ] Anemic, appears to be AoCD. Continue to monitor. EPO with HD \nper renal.\n[ ] Continue ___ HD schedule.\n[ ] F/u appointments will be needed with renal, transplant \nsurgery, each within ___ weeks.\n[ ] Blood cultures from ___ and ___ NGTD. ___ still grew \nCoag+ Staph.\n\n # CODE STATUS: Full code\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amlodipine 10 mg PO DAILY \n2. Amitriptyline 100 mg PO QHS \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 40 mg PO DAILY \n5. Calcium Acetate 667 mg PO TID W/MEALS \n6. Docusate Sodium 100 mg PO BID \n7. Doxercalciferol 2 mcg IV 3X/WEEK (___) \n8. Epoetin Alfa 20,000 UNIT IV 3X/WEEK (___) \n9. HydrALAzine 25 mg PO TID \n10. Haloperidol 2 mg PO QHS:PRN agitation \n11. NPH 10 Units Bedtime\n12. Labetalol 200 mg PO TID \n13. Metolazone 5 mg PO DAILY \n14. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain \n15. sevelamer CARBONATE 3200 mg PO TID W/MEALS \n16. Nephrocaps 1 CAP PO DAILY \n17. Vitamin D 50,000 UNIT PO 1X/WEEK (___) \n\n \nDischarge Medications:\n1. Amlodipine 10 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Calcium Acetate 667 mg PO TID W/MEALS \n4. Docusate Sodium 100 mg PO BID \n5. Doxercalciferol 2 mcg IV 3X/WEEK (___) \n6. Epoetin Alfa 20,000 UNIT IV 3X/WEEK (___) \n7. HydrALAzine 25 mg PO TID \n8. NPH 10 Units Bedtime\n9. Labetalol 200 mg PO TID \n10. Nephrocaps 1 CAP PO DAILY \n11. sevelamer CARBONATE 3200 mg PO TID W/MEALS \n12. Vitamin D 50,000 UNIT PO 1X/WEEK (___) \n13. OxycoDONE (Immediate Release) ___ mg PO Q8H:PRN Leg pain \n\n14. Amitriptyline 100 mg PO QHS \n15. Atorvastatin 40 mg PO DAILY \n16. Haloperidol 2 mg PO QHS:PRN agitation \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnoses\n1. Catheter related blood stream infection -MRSA\n2. End stage renal 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 Mr. ___,\n\nWe had the pleasure of taking care of you during your time at \n___. You were here because you initially had a bleed from the \nsite of your newly placed dialysis catheter in your right \nshoulder, but spiked a fever suggesting that the catheter was \ninfected. The catheter was removed and you were given \nantibiotics to fight the infection. A scan was done of the right \nshoulder and showed no abscess. A scan was done of your heart \nand showed no infection had spread to there that we could see. \n\nSince you have an infection, you will continue to get your \nantibiotic after each round of dialysis until ___. \n\nThank you for coming to ___. We wish you the best of luck,\n\n-Your ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "T80211A", "N186", "I959", "E1122", "E871", "I120", "N400", "B9562", "M79604", "F259", "E785", "F39", "D649", "E8770", "Z992", "Z794", "Z7982", "Y848", "Y92009" ]

[ "T80211A: Bloodstream infection due to central venous catheter, initial encounter", "N186: End stage renal disease", "I959: Hypotension, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E871: Hypo-osmolality and hyponatremia", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "B9562: Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere", "M79604: Pain in right leg", "F259: Schizoaffective disorder, unspecified", "E785: Hyperlipidemia, unspecified", "F39: Unspecified mood [affective] disorder", "D649: Anemia, unspecified", "E8770: Fluid overload, unspecified", "Z992: Dependence on renal dialysis", "Z794: Long term (current) use of insulin", "Z7982: Long term (current) use of aspirin", "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" ]

[ "E1122", "E871", "N400", "E785", "D649", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: CARDIOTHORACIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAortic Stenosis\n \nMajor Surgical or Invasive Procedure:\n___ Aortic valve replacement with a 21-mm ___ \nBiocor Epic tissue valve.\n\n \nHistory of Present Illness:\nMs. ___ is a very pleasant ___ year old woman with a known \nheart murmur since childhood. She has been followed with serial \nechocardiograms for her bicuspid aortic valve. An echocardiogram \nin ___ demonstrated severe aortic stenosis with peak and \nmean gradients of 68 mmHg and 43 mmHg, respectively. A cardiac \ncatheterization revealed normal coronary arteries. Given the\nprogression of her aortic stenosis, she was referred to Dr. \n___ surgical consultation. \n\n \nPast Medical History:\nAortic Stenosis\nBicuspid Aortic Valve\nHyperlipidemia\nHypertension\n\n \nSocial History:\n___\nFamily History:\nMother - died of breast cancer at age ___\nFather - died of cancer at age ___\nNo known family history of coronary artery disease\n \nPhysical Exam:\nVital Signs sheet entries for ___: \nBP: 136/86. HR: 88. O2 Sat%: 98 (RA). RR: 17. Pain Score: 0.\nHeight: 66\" Weight: 155 lbs\n\nGeneral: Pleasant woman, appears younger than stated age, NAD\nSkin: Warm, dry, intact\nHEENT: NCAT, PERRLA, EOMI, OP benign \nNeck: Supple, full ROM \nChest: Lungs clear bilaterally \nHeart: Regular rate and rhythm, III/VI SEM heard best at LUSB\nAbdomen: Normal BS, soft, non-distended, non-tender \nExtremities: Warm, well-perfused, no edema\nVaricosities: left thigh\nNeuro: Grossly intact\nPulses:\nFemoral Right: 2+ Left: 2+\nDP Right: 2+ Left: 2+\n___ Right: 2+ Left: 2+\nRadial Right: 2+ Left: 2+\n\nCarotid Bruit: transmitted murmur vs. bruit\n\nDischarge Exam: \n___ 93 RA wt 74.2 \nAlert and oriented x3 no focal deficits \nRRR no murmur \nCTA \nAbd soft NT ND \nEdema trace \nSternal incision no erythema or drainage \n\n \nPertinent Results:\nEchocardiogram ___\nLEFT ATRIUM: Normal LA size. Good (>20 cm/s) ___ ejection \nvelocity. No thrombus in the ___. \nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. \nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. \nOverall normal LVEF (>55%). \nRIGHT VENTRICLE: Normal RV chamber size. Normal RV systolic \nfunction. \nAORTA: Normal ascending aorta diameter. No atheroma in ascending \naorta. Normal aortic arch diameter. No atheroma in aortic arch. \nNormal descending aorta diameter. No atheroma in descending \naorta. \nAORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed \naortic valve leaflets. Severe AS (area <1.0cm2). \nMITRAL VALVE: Trivial MR. \n___ VALVE: Physiologic TR. \nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. \nPERICARDIUM: No pericardial effusion. \nConclusions \n PRE-BYPASS: The left atrium is normal in size. No thrombus is \nseen in the left atrial appendage. There is a very small PFO \nwith L->R shunting.. Left ventricular wall thicknesses are \nnormal. The left ventricular cavity size is normal. Overall left \nventricular systolic function is normal (LVEF>55%). Right \nventricular chamber size is normal with normal free wall \ncontractility. The aortic valve is bicuspid. The aortic valve \nleaflets are severely thickened/deformed. There is severe aortic \nvalve stenosis (valve area <1.0cm2). Trivial mitral \nregurgitation is seen. There is no pericardial effusion.\n\nPOST-BYPASS: Patient is A paced on no inotropes. Biventricular \nfunction is unchanged. A new well seated bioprosthetic AV is \nvisualized with no AI. Pk and mean gradients across the valve is \n33mmHg and 14mmHg respectively with Stroke Volume of 61cc by \nContinuity equation. Remaining valves are unchanged. Aorta \nremains intact. \n \nChest PA & Lat ___\nTiny left apical pneumothorax cannot be excluded, but the \npreviously seen \nright apical pneumothorax has resolved. \nLeft base opacity consistent with collapse and/or consolidation \nsmall effusion is grossly unchanged. \nRight base opacity is similar in extent, possibly slightly \ndenser though I \nsuspect this is related to technique. New blunting of the right \ncostophrenic angle suggests a small right pleural effusion. \n\nAdmission Labs:\n___ 09:56AM BLOOD WBC-8.4 RBC-2.91*# Hgb-8.6*# Hct-25.9*# \nMCV-89 MCH-29.6 MCHC-33.2 RDW-12.5 RDWSD-40.5 Plt ___\n___ 09:56AM BLOOD ___ PTT-28.7 ___\n___ 11:05AM BLOOD UreaN-20 Creat-0.8 Cl-109* HCO3-25 \nAnGap-10\n___ 09:51AM BLOOD Mg-2.1\n\nDischarge Labs \n___ 06:50AM BLOOD WBC-10.2* RBC-3.02* Hgb-8.8* Hct-27.9* \nMCV-92 MCH-29.1 MCHC-31.5* RDW-13.2 RDWSD-44.3 Plt ___\n___ 10:10AM BLOOD K-4.4\n___ 04:49AM BLOOD Glucose-123* UreaN-16 Creat-0.9 Na-136 \nK-5.2* Cl-101 HCO3-30 AnGap-10\n___ 04:49AM BLOOD Mg-2.6\n \nBrief Hospital Course:\nShe presented same day admission and was brought to the \noperating room for aortic valve replacement. Please see \noperative report for further details. Post operatively she was \ntaken to the intensive care unit for management. That evening \nshe was weaned from sedation, awoke neurologically intact and \nwas extubated without complications. Post operative day one she \nwas started on Lasix and betablocker. She continued to progress \nand was transitioned to the floor. Chest tubes and epicardial \nwires were removed per protocol. She worked with physical \ntherapy on strength and mobility. She continued to progress and \nwas ready for discharge home on post operative day four with \nservices. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 10 mg PO QPM \n2. Fish Oil (Omega 3) 1000 mg PO DAILY \n3. Hyzaar (losartan-hydrochlorothiazide) 100-25 mg oral DAILY \n4. Metoprolol Succinate XL 50 mg PO DAILY \n5. Multivitamins 1 TAB PO DAILY \n6. FoLIC Acid 1 mg PO DAILY \n7. Vitamin D 800 UNIT PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity \n2. Aspirin EC 81 mg PO DAILY \n3. Atorvastatin 10 mg PO QPM \n4. Docusate Sodium 100 mg PO BID \n5. Furosemide 20 mg PO BID Duration: 7 Days \nRX *furosemide 20 mg 1 tablet(s) by mouth twice a day Disp #*14 \nTablet Refills:*0 \n6. Metoprolol Tartrate 12.5 mg PO BID \nRX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth \ntwice a day Disp #*30 Tablet Refills:*1 \n7. 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 \n8. Ranitidine 150 mg PO DAILY Duration: 30 Days \nRX *ranitidine HCl [Heartburn Relief (ranitidine)] 150 mg 1 \ntablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 \n9. FoLIC Acid 1 mg PO DAILY \n10. Multivitamins 1 TAB PO DAILY \n11. Vitamin D 800 UNIT PO DAILY \n12. HELD- Fish Oil (Omega 3) 1000 mg PO DAILY This medication \nwas held. Do not restart Fish Oil (Omega 3) until your surgeon \ninstructs you \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAortic Stenosis s/p aortic valve replacement \n\nSecondary Diagnosis:\nHyperlipidemia\nHypertension\n\n \nDischarge Condition:\nAlert and oriented x3 non-focal \nAmbulating, gait steady \nSternal pain managed with oxycodone and acetaminophen \nSternal Incision - healing well, no erythema or drainage \nEdema: Trace \n\nAlert and oriented x3 non-focal\nAmbulating, gait steady\nSternal pain managed with oxycodone and acetaminophen \nSternal Incision - healing well, no erythema or drainage\nEdema: Trace\n\nAlert and oriented x3 non-focal\nAmbulating, gait steady\nSternal pain managed with oxycodone and acetaminophen \nSternal Incision - healing well, no erythema or drainage\nEdema: Trace\n\n \nDischarge Instructions:\n1). Please shower daily including washing incisions gently with \nmild soap, no baths or swimming, and look at your incisions\n2). Please NO lotions, cream, powder, or ointments to incisions\n3). Each morning you should weigh yourself and then in the \nevening take your temperature, these should be written down on \nthe chart\n4). 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\n5). No lifting more than 10 pounds for 10 weeks\n6). Please wear bra to reduce pulling on incision, avoid rubbing \non 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\n \nFollowup Instructions:\n___\n" ]

[ "Q231", "D62", "I10", "E785", "Y831", "Y92239" ]

[ "Q231: Congenital insufficiency of aortic valve", "D62: Acute posthemorrhagic anemia", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, 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" ]

[ "D62", "I10", "E785" ]

[]

[ " \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:\ns/p arrest\n \nMajor Surgical or Invasive Procedure:\nn/a\n \nHistory of Present Illness:\nMr ___ is a ___ yom with a history of alcoholism and \nrecent not well controlled fevers who presented from ___ \n___ in ___ s/p asystolic arrest. Patient was \nintubated and sedated on arrival. Per HCP, patient has struggled \nwith alcoholism and recently has had problems with seizures that \nwere not well contolled. He missed an appointment yesterday and \nwas found by a nurse this morning non-responsive which prompted \npresentation to OSH ED. \n\nPer OSH records he presented with complaints of lethargy. He was \nfound by a visiting nurse minimally responsive to painful \nstimuli. Per OSH records, he has a long history of alcohol \nabuse. With painful stimuli he awoke but nothing more than moan \nand move his arms before returning to sleep. He was noted to \nhave bruises on his chest, left/right shoulder and left abdomen. \nA CTH was reportedly negative. Patient was noted to be SOB and \nhe was sent to CT scan. There he was noted to have a seizure. He \nwas brought back to to the ED and was noted to be asystolic. CPR \nwas started and was continued for 53 minutes. He received epi \nx4. During CPR he went into vfib and was shocked x2 @ 150 \njoules. He had return of spontaneous circulation with pulse of \n90 and BP of 92/60. A CXR was done with concern of bleeding in \nthe mediastinum. For this there was an empiric \npericardiocentesis which reportedly had no bleeding. After ___ \nminutes he became progressively more hypotensive and then had \nanother episode of asystolic arrest. s/p epi x3 and dopamine gtt \nwith ROSC. Patient was given vanc, zosyn, Dilantin. Patient went \ninto asystolic arrest for third time and was given epi x 2 and \nstarted on epi gtt. He was then medflighted to ___ on 4 \npressors peripherally epi/norepi/dopamine/phenylephrine. Of \nnote, at OSH he was noted to be hyponatremic to 121. He was \ngiven 2L NS for this. A tox screen was negative including \nnegative alcohol level. Lactate was 5. \n\nIn the ED initial vitals were \n76 65/palp 22 100% Intubation \n\nFast was negative, no pericardial effusion but with poor EF. On \nexam, he withdraws to pain in all 4. Rectal with guaiac negative \nstools. \n\nLabs notable for:\n125 97 5 \n-----------< 170 \n5.1 16 1.1 \n\n20.5>--10.7--<276\n 32.2 \n\nArterial gas: ___\nTox notable for TCA\n\nEKG with inferior 1-2mm STE that is new since ___. Trop \nnegative x2\n\nPost arrest team was consulted and recommended cooling to 34-36.\n\nOn transfer, patient with right femoral CVL and aline on 4 \npressors: epi, norepi, dopa, neo with pressures in the 100s/70s. \nPatient \n\nPatient was sent to CT scanner for pan scan on the way up to \nMICU given extensive bruising c/f trauma. \n\n \nPast Medical History:\nAlcohol abuse, seizures\n \nSocial History:\n___\nFamily History:\nunknown\n \nPhysical Exam:\nAdmission Exam\nGENERAL: Intubated and sedated.\nHEENT: Sclera anicteric, MMM, PERRL \nNECK: supple, no LAD \nLUNGS: Crackles and rhonchi, worse on the right, no wheezes. \nMechanical BS\nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, non-distended, bowel sounds present, no rebound \ntenderness or guarding, no organomegaly \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema. Right shoulder abducted with overlying ecchymosis. \nSKIN: No rash \nNEURO: MOves all 4 extremities, withdraws to pain\n\nDischarge\n-Decreased \n \nPertinent Results:\n___ 01:30PM BLOOD WBC-20.5* RBC-3.52* Hgb-10.7* Hct-32.2* \nMCV-92 MCH-30.4 MCHC-33.2 RDW-14.1 RDWSD-45.4 Plt ___\n___ 08:31AM BLOOD WBC-27.5* RBC-3.58* Hgb-10.6* Hct-30.6* \nMCV-86 MCH-29.6 MCHC-34.6 RDW-14.0 RDWSD-42.5 Plt ___\n___ 01:30PM BLOOD ___ PTT-30.0 ___\n___ 08:31AM BLOOD ___ PTT-40.8* ___\n___ 01:30PM BLOOD Glucose-170* UreaN-5* Creat-1.1 Na-125* \nK-5.1 Cl-97 HCO3-16* AnGap-17\n___ 08:31AM BLOOD Glucose-177* UreaN-10 Creat-1.2 Na-140 \nK-5.5* Cl-96 HCO3-29 AnGap-21*\n___ 01:30PM BLOOD ALT-138* AST-263* AlkPhos-112 \nTotBili-2.0*\n___ 08:31AM BLOOD ALT-285* AST-455* LD(LDH)-717* \nCK(CPK)-402* TotBili-1.1\n___ 01:30PM BLOOD cTropnT-<0.01\n___ 05:25PM BLOOD CK-MB-32* MB Indx-4.5 cTropnT-0.01\n___ 11:34PM BLOOD CK-MB-32* MB Indx-5.0 cTropnT-0.03*\n___ 04:06AM BLOOD CK-MB-29* cTropnT-0.05*\n___ 01:30PM BLOOD Albumin-2.6* Calcium-7.1* Phos-6.4* \nMg-1.7\n___ 08:31AM BLOOD Calcium-6.8* Phos-5.2* Mg-1.8\n___ 01:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-POS*\n___ 03:02PM BLOOD ___ pO2-53* pCO2-52* pH-7.23* \ncalTCO2-23 Base XS--6\n___ 08:39AM BLOOD Type-ART pO2-87 pCO2-58* pH-7.38 \ncalTCO2-36* Base XS-6\n___ 01:39PM BLOOD Glucose-155* Lactate-5.7* Na-125* K-5.0 \nCl-95*\n___ 05:42PM BLOOD Lactate-2.4*\n___ 11:46PM BLOOD Lactate-4.2*\n___ 05:18AM BLOOD Lactate-3.8*\n___ 08:39AM BLOOD Glucose-167* Lactate-6.8* Na-136 K-5.4* \nCl-93*\n\nCT abd/pelvis:\n1. Multiple fractures in the torso including a comminuted \nfracture in the \nright humeral head and neck, multiple nondisplaced fractures in \nthe bilateral \nribs, sternum, and a fracture of the anterior inferior aspect of \nthe left \nacetabulum and left inferior pubic rami. \n2. A moderate to large consolidative process is noted in the \nright posterior \nlung, possibly from aspiration. \n3. No evidence of aortic or other vascular injury. \n4. Mild to moderate amount of ascites is noted in the abdomen \nand pelvis, \nlikely from third-spacing. \n5. Multiple support devices are noted including enteric tube, \nETT, Foley \ncatheter, rectal catheter, right lower extremity central line, \nand right lower \nextremity arterial catheter. \n\nCT spine:\nIMPRESSION: \n1. Patient is intubated. There is a nondisplaced fracture \nthrough the left \nfirst rib. \n2. Alignment is otherwise grossly maintained. \n3. A large right pleural effusion is noted with adjacent streak \nartifact from \nthe posterior spinal fusion hardware, and is incompletely \nevaluated on this \nnondedicated exam. \n\nTTE: Conclusions: \n Due to suboptimal technical quality, a focal wall motion \nabnormality cannot be fully excluded. Overall left ventricular \nsystolic function is grossly normal (LVEF>55%). The right \nventricular free wall thickness is normal. Right ventricular \nchamber size is normal with severe global free wall hypokinesis. \nThere is no pericardial effusion. There is an anterior space \nwhich most likely represents a prominent fat pad. \n\n \nBrief Hospital Course:\nPt EU CRITICAL ___ aka ___ transferred to ___ from\n___ s/p 3 arrests, on 4 pressors and intubated.\nStarted on cooling protocol here. He had a history of alcohol \nabuse and recent seizures and presented post arrest with \nevidence of large aspiration PNA and RV dysfunction. He had a \nsubsequent PEA arrest at 812 AM\n___. ROSC achieved briefly, epi drip started and rapidly\nuptitrated. HCP Pat ___: ___ contacted with grim\nprognosis. Decision to transition to DNR was made although\npressor support was continued. Patient's blood pressure quickly\ndecreased until pulselessness. MD at bedside to declare\nexpiration at 844 ___. No pulse, no breath sounds, no\nwithdrawal to pain, fixed pupils, without corneal reflex. \nMedical\nexaminer called and accepted case to be performed at ___ by \nME.\nDr. ___.\n \n\n \nMedications on Admission:\nunknown\n \nDischarge Medications:\ndeceased\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\ndeceased\n \nDischarge Condition:\ndeceased\n \nDischarge Instructions:\ndeceased\n \nFollowup Instructions:\n___\n" ]

[ "J690", "J9600", "I469", "R6521", "A419", "R569", "S32402A", "S2220XA", "E871", "S42201A", "S42301A", "S32592A", "F1020", "X58XXXA", "Z87820", "Y929", "I10", "Z66" ]

[ "J690: Pneumonitis due to inhalation of food and vomit", "J9600: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia", "I469: Cardiac arrest, cause unspecified", "R6521: Severe sepsis with septic shock", "A419: Sepsis, unspecified organism", "R569: Unspecified convulsions", "S32402A: Unspecified fracture of left acetabulum, initial encounter for closed fracture", "S2220XA: Unspecified fracture of sternum, initial encounter for closed fracture", "E871: Hypo-osmolality and hyponatremia", "S42201A: Unspecified fracture of upper end of right humerus, initial encounter for closed fracture", "S42301A: Unspecified fracture of shaft of humerus, right arm, initial encounter for closed fracture", "S32592A: Other specified fracture of left pubis, initial encounter for closed fracture", "F1020: Alcohol dependence, uncomplicated", "X58XXXA: Exposure to other specified factors, initial encounter", "Z87820: Personal history of traumatic brain injury", "Y929: Unspecified place or not applicable", "I10: Essential (primary) hypertension", "Z66: Do not resuscitate" ]

[ "E871", "Y929", "I10", "Z66" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \naspirin / lisinopril / amlodipine / atenolol / Losartan / \nPercocet / Imdur / Actos / lactose / Tylenol\n \nAttending: ___\n \nChief Complaint:\n\"Is this prolapse causing my UTI\"\n \nMajor Surgical or Invasive Procedure:\n1. Dilation and curettage.\n2. ___ colpocleisis.\n3. Perineorrhaphy.\n4. Cystoscopy.\n\n \nHistory of Present Illness:\nMrs. ___ is a ___ yo Gravida 7 Para 7 who presents today in\nthe office for a consultation requested by Dr. ___\nvaginal prolapse. She has been managed with a pessary placed by\nDr. ___. She does report daily expulsion with BM's and having\nher husband help replace it.\nShe had a recent UTI in ___ with a subsequent renal U/S that\nshowed some thickenning of the posterior bladder wall.\n \nShe denies any incontinence or change in her urinary habits. \nShe is otherwise without any other significant complaints.\n \nPast Medical History:\nPAST MEDICAL HISTORY:\n 1. HTN\n 2. DM\n 3. Colon cancer\n 4. Hypercholesterolemia\n 5. Arthritis\n\nPAST SURGICAL HISTORY\n 1. Spine surgery\n 2. Cataracts\n 3. Colon resection (had colostomy)\n\nPAST OB HISTORY\n___\nVaginal: 7\n\nPAST GYN HISTORY\nShe is Postmenopausal and denies post-menopausal bleeding.\n \nSocial History:\n___\nFamily History:\nHer family history is unremarkable for Breast, Ovarian or Colon\ncancer.\n \nPhysical Exam:\nDischarge physical exam\nVitals: VSS\nGen: NAD, A&O x 3\nCV: RRR\nResp: no acute respiratory distress\nAbd: soft, appropriately tender, no rebound/guarding\nExt: no TTP\n \nPertinent Results:\nNone \n \nBrief Hospital Course:\nOn ___, Ms. ___ was admitted to the gynecology service \nafter undergoing dilation and curettage, ___ colpocleisis, \nperineorrhaphy, and cystoscopy. Please see the operative report \nfor full details.\n\nHer post-operative course was uncomplicated. Immediately \npost-op, her pain was controlled with IV dilaudid and toradol. \nOn post-operative day 1, her urine output was adequate so her \nfoley was removed with a urogyn voiding trial and she voided \nspontaneously. Her diet was advanced without difficulty and she \nwas transitioned to tramadol and ibuprofen.\n\nBy post-operative day #1, she was tolerating a regular diet, \nvoiding spontaneously, ambulating independently, and pain was \ncontrolled with oral medications. She was then discharged home \nin stable condition with outpatient follow-up scheduled.\n\n \nMedications on Admission:\namlodipine 2.5mg PRN BP>150/90, metformin 1000mg BID, metoprolol \n50mg XR, simvastatin 10mg QHS\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*50 Capsule Refills:*2\n2. Ibuprofen 400 mg PO Q6H:PRN pain \ntake with food \nRX *ibuprofen 400 mg 1 tablet(s) by mouth every 6 hours Disp \n#*50 Tablet Refills:*1\n3. MetFORMIN (Glucophage) 1000 mg PO BID \n4. Metoprolol Succinate XL 50 mg PO DAILY \n5. TraMADOL (Ultram) ___ mg PO Q6H:PRN pain \ndo not drive while taking, use with stool softener \nRX *tramadol 50 mg 0.5 to 1 tablet(s) by mouth every 6 hours \nDisp #*30 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPelvic organ prolapse\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 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 to \nprevent 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* 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\nIncision care:\n* You may shower and allow soapy water to run over incision; no \nscrubbing of incision. No tub baths for 6 weeks.\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 \nFollowup Instructions:\n___\n" ]

[ "N812", "E780", "I10", "M545", "G8929", "E1165", "E11319", "J8410", "Z85828", "Z85038", "Z980", "Z23" ]

[ "N812: Incomplete uterovaginal prolapse", "E780: Pure hypercholesterolemia", "I10: Essential (primary) hypertension", "M545: Low back pain", "G8929: Other chronic pain", "E1165: Type 2 diabetes mellitus with hyperglycemia", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "J8410: Pulmonary fibrosis, unspecified", "Z85828: Personal history of other malignant neoplasm of skin", "Z85038: Personal history of other malignant neoplasm of large intestine", "Z980: Intestinal bypass and anastomosis status", "Z23: Encounter for immunization" ]

[ "I10", "G8929", "E1165" ]

[]

[ " \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:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ y/o male with CAD (MI s/p 3 stents), HFrEF \n(40%), DM2, strep bacteremia, cervical and lumbar abscesses, \nEtOH/NASH cirrhosis c/b esophageal varices, GIB s/p GDA \nembolization and TIPS (___), and liver dome lesion who \npresents for acute onset of RUQ and epigastric abdominal pain. \n\nPatient has had several recent admissions. Most notably, during \na ___ admission, he was treated for strep anginosus \nbacteremia and spinal abscesses s/p debridement, C4-C7 \nlaminectomy, and long course of antibiotics, all thought to be \nfrom a dental source. \n\nHe was readmitted in late ___ due to BRBPR requiring \nsignificant pRBC resuscitation. CTA at the time showed severe \ncolitis, and EGD showed two duodenal ulcers presumed to be the \nsource of the bleeding as well as 4 cords of medium sized \nvarices and portal HTN gastropathy. HBV/HCV serologies were \nnegative. Serologies positive for hpylori, and he was treated \nwith quadruple therapy. \n\nHe was then readmitted a few days later for BRBPR again. Repeat \nEGD showed duodenal ulcers and esophageal varices. Capsule \nendoscopy showed possible bleed in duodenum. GI was consulted \nand felt the bleed was ultimately from ectopic varices. The \npatient underwent GDA embolization and TIPS on ___. His post \nTIPS course was complicated by hepatic encephalopathy, so he was \nstarted on lactulose/rifaximin.\n\nHe was found to be cdiff positive in ___ and started on \nPO vancomycin. He was seen in liver clinic on ___ ___.\n\nOf note, patient was recently admitted for a C4-T1 cervical \nposterior fusion surgery on ___ at ___. He was discharged \non ___ without complication.\n\nHe was doing well at home until 2 days ago. He reports that he \ndeveloped severe epigastric abdominal pain two days ago after \ndinner. The pain was sharp and lasted about 8 hours. The next \nday, he again developed severe sharp epigastric abdominal pain \nafter lunch, lasting 6 hours. This prompted him to present to \nthe ED. He denies fevers, chills, RUQU pain (until arriving to \nthe ED), vomiting, melena, or BRBPR. \n \nPast Medical History:\nDM2 \nCAD s/p MI x3\nHFrEF\nHTN \nHLD \nHx of spinal abscesses\nHx of bacteremia\nS/p laminectomy\n \nSocial History:\n___\nFamily History:\nFather s/p MI x3\nMother ___, healthy\n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION: \nVS:97.7 107 / 69 83 16 95 RA \nGENERAL: NAD, c-collar in place\nHEENT: EOMI, MMM \nNECK: supple, c-collar in place (can not evaluate neck)\nHEART: RRR, S1/S2 \nLUNGS: CTAB, no wheezes\nABDOMEN: Soft, nondistended, nontender in any quadrant\nEXTREMITIES: no cyanosis, clubbing, trace ___ 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 EXAMINATION:\nVS: ___ 0715 Temp: 97.4 PO BP: 93/59 R Sitting HR: 74 RR: \n18\nO2 sat: 93% O2 delivery: Ra \nGENERAL: Standing in the bathroom combing his hair, in NAD\nHEENT: NC/AT, EOMI, MMM\nNECK: C-collar in place \nHEART: RRR, normal S1/S2, no m/r/g\nLUNGS: Breathing comfortably on RA without use of accessory\nmuscles\nABDOMEN: Soft, nondistended, nontender in any quadrant\nEXTREMITIES: NO c/c/e\nNEURO: A&Ox3, moving all 4 extremities with purpose, no \nasterixis\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 09:30PM ___ PTT-33.3 ___\n___ 09:30PM PLT COUNT-240\n___ 09:30PM NEUTS-67.4 LYMPHS-17.3* MONOS-13.5* EOS-1.1 \nBASOS-0.4 IM ___ AbsNeut-5.33 AbsLymp-1.37 AbsMono-1.07* \nAbsEos-0.09 AbsBaso-0.03\n___ 09:30PM WBC-7.9 RBC-3.49* HGB-10.2* HCT-31.6* MCV-91 \nMCH-29.2 MCHC-32.3 RDW-18.9* RDWSD-61.8*\n___ 09:30PM ALBUMIN-2.5*\n___ 09:30PM LIPASE-104*\n___ 09:30PM ALT(SGPT)-25 AST(SGOT)-49* ALK PHOS-128 TOT \nBILI-2.2*\n___ 09:30PM estGFR-Using this\n___ 09:30PM GLUCOSE-166* UREA N-10 CREAT-0.7 SODIUM-138 \nPOTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-23 ANION GAP-16\n___ 09:32PM LACTATE-5.6*\n___ 09:32PM ___ COMMENTS-GREEN TOP \n___ 06:50AM PLT SMR-NORMAL PLT COUNT-220\n___ 06:50AM HYPOCHROM-NORMAL ANISOCYT-2+* POIKILOCY-1+* \nMACROCYT-1+* MICROCYT-1+* POLYCHROM-1+* OVALOCYT-1+* \nTEARDROP-OCCASIONAL\n___ 06:50AM NEUTS-47.6 ___ MONOS-20.1* EOS-2.8 \nBASOS-0.5 IM ___ AbsNeut-3.97 AbsLymp-2.38 AbsMono-1.67* \nAbsEos-0.23 AbsBaso-0.04\n___ 06:50AM WBC-8.3 RBC-3.29* HGB-9.6* HCT-29.6* MCV-90 \nMCH-29.2 MCHC-32.4 RDW-19.0* RDWSD-62.3*\n___ 06:50AM ALBUMIN-2.3*\n___ 06:50AM ALT(SGPT)-21 AST(SGOT)-39 ALK PHOS-113 TOT \nBILI-1.7*\n___ 07:04AM LACTATE-2.3*\n___ 07:04AM ___ COMMENTS-GREEN TOP\n\nDISCHARGE LABS:\n===============\n___ 05:11AM BLOOD WBC-5.5 RBC-3.02* Hgb-8.8* Hct-27.4* \nMCV-91 MCH-29.1 MCHC-32.1 RDW-18.6* RDWSD-61.4* Plt ___\n___ 05:11AM BLOOD Plt ___\n___ 05:11AM BLOOD ___ PTT-36.0 ___\n___ 05:11AM BLOOD Glucose-96 UreaN-7 Creat-0.6 Na-141 \nK-3.2* Cl-102 HCO3-28 AnGap-11\n___ 05:11AM BLOOD ALT-20 AST-38 AlkPhos-100 TotBili-1.6*\n___ 05:11AM BLOOD Albumin-2.1* Calcium-8.1* Phos-3.9 Mg-2.0\n\nMICROBIOLOGY:\n=============\n___ Blood cx: pending\n\nIMAGING:\n========\n___ CT A&P:\n1. Markedly distended gallbladder containing gallstones without \ngallbladder \nwall edema or surrounding inflammatory changes. Trace \nperihepatic ascites and trace mesenteric free fluid in the right \nupper quadrant is likely related to patient's underlying liver \ndisease. Findings are overall equivocal for cholecystitis. \n2. Cirrhosis with unchanged indeterminate 2.4 cm hypoenhancing \nlesion in \nsegment ___ at the hepatic dome. \n3. Patent TIPS with unchanged thrombosis of the right posterior \nportal vein. \n\n___ HIDA scan:\nNo evidence of cholecystitis. Delayed uptake of tracer from \nbnlood \nconsistent with poor liver function. \n\n___ MRCP:\n1. Cirrhosis, with sequela of portal hypertension, including \nsmall amount of ascites and mild splenomegaly. \n2. Indeterminate lesion in segment ___ is surrounded by \nfibrosis. This does not meet OPTN-5 criteria. Sclerosing \nhemangioma is favored given the location and appearance. \nAtypical HCC is felt to be less likely but remains a \npossibility. 3-month surveillance MRI is recommended. \n3. Indeterminate lesion in segment ___ does not meet OPTN-5 \ncriteria and may represent a regenerative nodule. This can also \nbe evaluated at the time of follow-up imaging. \n4. TIPS in situ, with unchanged thrombosis of right posterior \nportal vein \nbranches. \n5. Cholelithiasis with mild gallbladder wall edema, which is \npresumed related to known chronic liver disease. No MR evidence \nfor acute cholecystitis. \n \nRECOMMENDATION(S): 3 month followup liver MRI. \n\n \nBrief Hospital Course:\nMr. ___ is a ___ with PMH notable for EtOH/NASH cirrhosis\n(Childs C, MELD 15) c/b esophageal varices, GIB s/p GDA\nembolization and TIPS (___) and liver dome lesion who\npresented with acute RUQ abdominal pain c/f cholecystitis, now\nwith resolution of pain and negative HIDA scan and MRCP.\n\nACTIVE ISSUES:\n==============\n# RUQ abdominal pain, resolved \n# Cholelithiasis\nPresented with two episodes of RUQ/epigasric pain after meals \nc/f biliary\ncholic/cholecystitis. Initial RUQUS showed distended gallbladder \ncontaining sludge but no gallbaldder wall thickening. Initial CT \nshowed distended gallbladder with gallstones without gallbladder \nwall edema. Transplant surgery was consulted and recommended \nHIDA, which was negative for cholecystitis. Given continued high \nsuspicion for cholelithiasis/choledocolithiasis, MRCP was \nperformed and was without evidence of biliary pathology. His \nabdominal pain resolved upon admission to the hospital and did \nnot recur. Tbili was initially elevated to 2.2 but downtrended \nto 1.6 on discharge. He was initially on a liquid diet but \ntolerated a regular, low-fat diet prior to discharge. Nutrition \nwas consulted to provide recommendations on a low-fat diet. We \nultimately suspect these symptoms were due to a passed \ngallstone.\n\n# EtOH cirrhosis (Child C, MELD 15) decompensated by minimal \nascites, previously c/b portal hypertension, esophageal varices, \nGIB s/p GDA embolization and ___, and hepatic \nencephalopathy. \n- Volume: Trace ascites on admission RUQUS. S/p TIPS. Continued\nhome furosemide 40 mg BID\n- Infection: Minimal ascites on admission RUQUS. No fevers or\nleukocytosis. \n- Bleeding: Hx of GIB from duodenal ulcer and non-bleeding\nesophageal varices grade I s/p TIPS. \n- Encephalopathy: History of HE in early ___. Continued home\nlactulose/rifaximin. \n- PVT: None on CTA\n\n# Anemia\nNo e/o active bleeding. Normal iron studies and normal retic\ncount. \n\n# Liver dome lesion\nAdmission CTA again demonstrates 2.4 cm hypoenhancing lesion in\nsegment ___ at the hepatic dome. MRI Abdomen was performed on \n___ to further characterize this lesion, and noted that lesion \ndid not meet OPTN-5 criteria. Lesion looked most concerning for \nsclerosing hemangioma, but could represent atypical HCC. \nSurveillance with MRI in 3 months was recommended on read.\n\nCHRONIC ISSUES:\n===============\n# Hx of duodenal ulcer\nContinued home PPI BID\n\n# C. diff infection \nHas had prior cdiff in ___ treated with PO vancomycin. Then in\nlate ___ had second recurrence of cdiff, so was started \non\nprolonged taper. Currently on vancomycin 125 mg PO qOD x2 weeks \n(___), which we continued. \n\n# Recent spinal fusion surgery\nAs per patient, he was supposed to have an outpatient \nappointment with Dr. ___ on ___. Spine surgery was consulted \ninpatient, and saw the patient on ___.\n\n# Heart failure with preserved ejection fraction\nHistory of CAD with three MIs and three prior stents. TTE in\n___ showed preserved EF, moderate MR, mild pulm HTN. \nContinued home furosemide, metoprolol\n\n# CAD c/b MI s/p stents x3\nContinued home aspirin 81, atorvastatin, and metoprolol \n\n# DM2\nHeld home metformin while inpatient and started HISS\n\nTRANSITIONAL ISSUES:\n====================\n[] Check electrolytes at follow-up appointment with PCP, \nspecifically potassium in the setting of starting spironolactone \n\n[] Follow-up volume status and electrolytes; adjust diuretic \nregimen as needed \n[] F/u Ca ___ and CEA \n[] Ensure patient continues low-fat diet\n\n[] MRI Abdomen performed inpatient, read as follows. Consider \nfollow-up with MRI sooner than 3 months. \n 1. Indeterminate lesion in segment ___ does not meet OPTN \ncriteria for \nhepatocellular carcinoma, and may represent a sclerosing \nhemangioma. \nRecommend follow-up imaging in 3 months for further evaluation. \n 2. Indeterminate lesion in segment ___ which does not meet OPTN \ncriteria for \nhepatocellular carcinoma, and may represent a regenerativeg \nnodule. This \nshould be further evaluated at the time of follow-up imaging in \n3 months. \n\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. Furosemide 40 mg PO BID \n4. Lactulose 20 mL PO QAM \n5. Pantoprazole 40 mg PO Q12H \n6. Potassium Chloride 40 mEq PO BID \n7. Rifaximin 550 mg PO BID \n8. TraZODone 25 mg PO QHS:PRN insomnia \n9. Vancomycin Oral Liquid ___ mg PO QOD \n10. MetFORMIN XR (Glucophage XR) 1000 mg PO BID \n11. Metoprolol Succinate XL 25 mg PO DAILY \n\n \nDischarge Medications:\n1. Potassium Chloride 40 mEq PO DAILY \nHold for K > \n2. Spironolactone 50 mg PO DAILY \nRX *spironolactone 50 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0 \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 80 mg PO QPM \n5. Furosemide 40 mg PO BID \n6. Lactulose 20 mL PO QAM \n7. MetFORMIN XR (Glucophage XR) 1000 mg PO BID \n8. Metoprolol Succinate XL 25 mg PO DAILY \n9. Pantoprazole 40 mg PO Q12H \n10. Rifaximin 550 mg PO BID \n11. TraZODone 25 mg PO QHS:PRN insomnia \n12. Vancomycin Oral Liquid ___ mg PO QOD \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnosis:\n- Cholelithiasis\n\nSecondary diagnoses:\n- Diabetes mellitus type 2\n- Coronary artery disease\n- Heart failure reduced ejection fraction\n- Hypertension\n- Hyperlipidemia\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 due to severe abdominal pain \nafter eating food. We suspect this is due to gallstones. You had \nan ultrasound, CT scan, and MRI of your abdomen which showed \ngallstones but no significant infection or inflammation of your \ngallbladder to warrant removal. You were able to tolerate a \nnormal diet before leaving the hospital.\n\nOnce you leave, you should continue to eat a low-fat diet, as \nfoods high in fat can increase the likelihood of this pain \nrecurring. If this pain does recur, you should call your \nphysician or come back to the emergency room as this may be a \nsign that your gallbladder is inflamed.\n\nIt was a pleasure to take care of you!\n\nSincerely,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "K8020", "E119", "I2510", "Z955", "I252", "I110", "I5022", "E785", "K828", "K7031", "K7581", "D649", "K769", "Z8719", "A0471", "I340", "I2720", "Z981", "Z87891" ]

[ "K8020: Calculus of gallbladder without cholecystitis without obstruction", "E119: Type 2 diabetes mellitus without complications", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "I252: Old myocardial infarction", "I110: Hypertensive heart disease with heart failure", "I5022: Chronic systolic (congestive) heart failure", "E785: Hyperlipidemia, unspecified", "K828: Other specified diseases of gallbladder", "K7031: Alcoholic cirrhosis of liver with ascites", "K7581: Nonalcoholic steatohepatitis (NASH)", "D649: Anemia, unspecified", "K769: Liver disease, unspecified", "Z8719: Personal history of other diseases of the digestive system", "A0471: Enterocolitis due to Clostridium difficile, recurrent", "I340: Nonrheumatic mitral (valve) insufficiency", "I2720: Pulmonary hypertension, unspecified", "Z981: Arthrodesis status", "Z87891: Personal history of nicotine dependence" ]

[ "E119", "I2510", "Z955", "I252", "I110", "E785", "D649", "Z87891" ]

[]

[ " \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:\nChest Pain\n \nMajor Surgical or Invasive Procedure:\n___: Exercise Treadmill Stress Test\n \nHistory of Present Illness:\nMs. ___ is a ___ year old female with history of CAD \n(s/p anterior MI in ___, medical management), infarct-related \ncardiomyopathy (LVEF 28% by CMR, s/p ICD placement), prediabetes \n(A1c 5.9-6.1), depression, anxiety, hypothyroidism, osteoporosis \nwho was referred from clinic (seen by ___ NP on \n___ for chest pain that occurred 2 days prior to \nadmission. \n\nPer patient she awoke 2 days prior with ___ chest \npressure/tightness, took BP at home which was 148/80. Pain \nrelieved after second Nitroglycerin tablet with BP that returned \nto her baseline at 110/60. She states that the pain she \nexperienced felt the same as her first MI, although not as \nintense.\n\nIn clinic today, the patient denied any pain, but does feel more \nfatigued, causing her to rest more over the past two days when \npreviously she would walk ___ minutes per day. The patient \ndenies any palpitations or syncope. Patient has felt no ICD \nshocks. \n\nEKG in clinic notable for atrial pacing with motion artifact \n?dynamic ST changes ?ST depression, new TWI aVR, II.\n\nHistory of Cardiovascular Testing:\nCMR ___: dilated LV, LVEF 28%, normal RV, 1+MR, 2+TR\nEcho ___: EF 27%, akinetic septum, nl RV function, 1+ MR/TR.\nMibi ___: lg, fixed perfusion defect at apex, no reversible\ndefects in RCA or LCx territory. apical akinesis with EF 31%.\n\nIn the Emergency Department, initial vitals were 99.2 55 143/77 \n18 97/RA. Lung and heart sounds were unremarkable per ED report. \nLabs were notable for negative troponin, K of 5.1, Cr of 1.0. \nWBC, Hgb, and Plt were wnl. A chest X-ray was negative for \ncardiopulmonary process. The patient was given aspirin.\n\nThe patient was admitted to the ___ cardiology service for \nfurther workup and management. \n\nUpon arrival to the floor, the patient reports no current \nsymptoms. She feels well, and has no complaints or concerns.\n\n \nPast Medical History:\nPrior MI in ___ - no records available, occurred in the \n___ \n___ stomach problems-has frequent heartburn and pressure \nafter eating\n.\n\n1. CARDIAC RISK FACTORS: \n(-)Diabetes,(-)Dyslipidemia,(-)Hypertension \n2. CARDIAC HISTORY: \n-CABG: none \n-PERCUTANEOUS CORONARY INTERVENTIONS: none \n-PACING/ICD: none \n \nSocial History:\n___\nFamily History:\nMother-stroke at ___\nFather-3 MI'___, first MI in early ___, died of an MI at ___\n \nPhysical Exam:\n===============\nADMISSION EXAM:\n===============\nVS: T= 97.7 BP= 124/72 HR= 56 RR= 16 O2 sat= 97RA\nGENERAL: WDWN 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 with JVP non-elevated\nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. RR, normal S1, S2. No murmurs/rubs/gallops. No thrills, \nlifts. \nLUNGS: Fine bibasilar crackles R > L. Resp were unlabored, no \naccessory muscle use. No crackles, wheezes or rhonchi. \nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: No c/c/e. \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \nPULSES: Distal pulses palpable and symmetric\n\n===============\nDISCHARGE EXAM:\n===============\nVS: 97.6, 112/66, 56, 18, 99% on RA\nI/O last 24hrs: ___\nI/O since MN: ___\nWt: 54.9 -> 57.4kg\nGENERAL: WDWN 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. \nNECK: Supple with JVP elevated to mandible \nCARDIAC: heart sounds distant, normal S1, S2. No \nmurmurs/rubs/gallops. No thrills, lifts. \nLUNGS: Fine bibasilar crackles R > L. Resp were unlabored, no \naccessory muscle use. No wheezes or rhonchi. \nABDOMEN: Soft, NTND. \nEXTREMITIES: No c/c/e. \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \nPULSES: Distal pulses palpable and symmetric\n \nPertinent Results:\n===============\nADMISSION LABS:\n===============\n___ 06:40PM cTropnT-<0.01\n___ 01:00PM GLUCOSE-84 UREA N-18 CREAT-1.0 SODIUM-139 \nPOTASSIUM-5.1 CHLORIDE-105 TOTAL CO2-25 ANION GAP-14\n___ 01:00PM estGFR-Using this\n___ 01:00PM cTropnT-<0.01\n___ 01:00PM WBC-7.3 RBC-3.76* HGB-11.9 HCT-36.6 MCV-97 \nMCH-31.6 MCHC-32.5 RDW-12.3 RDWSD-43.4\n___ 01:00PM NEUTS-71.5* LYMPHS-17.0* MONOS-8.8 EOS-2.1 \nBASOS-0.5 IM ___ AbsNeut-5.20 AbsLymp-1.24 AbsMono-0.64 \nAbsEos-0.15 AbsBaso-0.04\n___ 01:00PM PLT COUNT-184\n\n==================\nPERTINENT RESULTS:\n==================\nCXR (___):\nDual lead left-sided AICD is stable in position. The lungs \nremain \nhyperinflated. No focal consolidation is seen. There is no \npleural effusion or pneumothorax. The cardiac and mediastinal \nsilhouettes are stable. No pulmonary edema is seen. \nNo acute cardiopulmonary process. \n\nExercise Treadmill Stress Test (___):\nINTERPRETATION: This ___ year old woman with prior MI and \nICD/pacer \nEF ___ was referred to the lab for evaluation of chest \ndiscomfort. \nThe patient exercised for 5.75 minutes of a Gervino protocol \n___ METS) \nand was stopped at her request for lightheadedness and fatigue. \nThis \nrepresents a poor functional capacity for her age. There were no \nchest, \nneck, back, or arm discomforts reported by the patient \nthroughout the \nprocedure. There were no significant ST segment changes from \nbaseline. \nThe rhythm was sinus with rare isolated VPBs. The heart rate and \nblood \npressure responses to exercise were blunted. \nMPRESSION: Poor functional exercise capacity. No anginal \nsymptoms or \nEKG changes from baseline to achieved low workload. Blunted \nhemodynamic response to exercise with lightheadedness. \n\n___ 01:00PM BLOOD cTropnT-<0.01\n___ 06:40PM BLOOD cTropnT-<0.01\n___ 08:08AM BLOOD cTropnT-<0.01\n\n===============\nDISCHARGE LABS:\n===============\n___ 05:50AM BLOOD WBC-5.4 RBC-3.99 Hgb-12.3 Hct-38.9 MCV-98 \nMCH-30.8 MCHC-31.6* RDW-12.3 RDWSD-44.3 Plt ___\n___ 05:50AM BLOOD Plt ___\n___ 05:50AM BLOOD Glucose-93 UreaN-23* Creat-1.1 Na-142 \nK-5.2* Cl-107 HCO3-28 AnGap-12\n___ 05:50AM BLOOD Calcium-9.6 Phos-3.7 Mg-2.2\n___ 01:18PM BLOOD K-4.___ year old female with history of CAD (s/p anterior MI in ___, \nmedical management), infarct-related cardiomyopathy (LVEF 28% by \nCMR, s/p ICD placement), prediabetes (A1c 5.9-6.1), depression, \nanxiety, hypothyroidism, osteoporosis who was referred from \nclinic for chest pain that occurred at rest 2 days ago in the \nsetting of hypertension to SBP 160s (baseline 110-120), which \nimproved with SL nitroglycerin x2. Since then, patient reports \nworsening fatigue. ED labs notable for negative troponins and \nnegative CXR.\n\n# CORONARIES: History of MI in ___, medically-managed\n# PUMP: EF 27%, akinetic septum, nl RV function, 1+ MR/TR on \nmost recent echocardiogram (___)\n# RHYTHM: Normal sinus rhythm\n\n# Coronary Artery Disease: Patient with a history of coronary \nartery disease with MI in ___, since then has been managed \nmedically (large unrevascularized anterior MI resulting in \nsevere LV dysfunction). She reported an episode of chest pain 3 \ndays prior to admission that awoke her from rest. She took her \nblood pressure at home and BP was 148/80, baseline is 110/60s. \nShe visited her outpatient cardiologist's office on ___, \nmentioned this episode of chest pain, and was referred to ___ \nED for further evaluation. Patient was chest pain free since the \nepisode prior to admission. No further chest pain while \nin-house. The patient was initially maintained on her home \nmedications including simvastatin, aspirin, metoprolol, \nlisinopril, and isosorbide mononitrate (later held for \nhypotension, see below). A cardiac stress test performed on ___ \nwas inconclusive due to hypotension and lightheadedness which \nlimited the test (patient was hypotensive entering stress test \ndue to medication effect (see below). As patient remained chest \npain free, the decision was made to not pursue further stress \ntesting on an inpatient basis. She was re-introduced to a \nreduced dose of Metoprolol succinate 25mg daily and isosorbide \nmononitrate ER 30mg daily due to her hypotensive episode while \nadmitted.\n\n# Hypotension: The patient triggered for hypotension on ___ \nto the high ___ systolic. Patient with mild lightheadedness, but \nwithout chest pain. Upon further questioning patient reported \nhaving blood pressures to as low as ___ systolic after taking \nher home dose of isosorbide mononitrate ER 120mg daily. This \nmedication, as well as her beta-blocker and lisinopril were \nheld. The patient was administered 750cc NS in fractionated \nboluses with improvement in her blood pressures to low 100s \nsystolic. Labs were stable during hypotension, negative lactate, \nno disturbance in LFTs. Patient was restarted on reduced doses \nof metoprolol succinate and isosorbide mononitrate as per above.\n\n# Systolic Heart Failure, not in acute exacerbation: Patient \nwith an ejection fraction of 27% on previous echocardiograms. \nShe is s/p ICD placement, per record review is on \nmaximally-tolerated lisinopril and metoprolol on an outpatient \nbasis. Patient does not take home diuretics. Patient was \neuvolemic on examination, and remained euvolemic during her \nhospitalization. \n\n# Prediabetes (A1c 5.9-6.1): Patient with a history of \nprediabetes, does not take any medications at home for diabetes. \nBlood sugars were monitored while admitted, and the patient was \nmaintained on a constant carbohydrate diet.\n\n# Hypothyroidism: Continued home dose levothyroxine 50mcg daily\n\n# Depression and Anxiety: Patient with depression surrounding \nher husband's medical problems. Per report and record review she \ndoes not take any medications for depression/anxiety at home. \nMental status and mood were monitored while in-house. \n\n# GERD: Continued omeprazole 20mg daily\n\nTRANSITIONAL ISSUES:\nDischarge weight: 54.7kg\nDischarge Creatinine: 1.0\n\n# Chest pain: No recurrence of chest pain. Exercise stress test \nattempted in house but limited by lightheaded secondary to \nrelative hypotension and blunted blood pressure response (no \nexertional hypotension). Patient observed for 72 hours without \nrecurrent episode. Further stress tests deferred given clinical \nstability. Consider stress test as outpatient. \n\n# Systolic CHF (___ class II HF): Patient with LVEF of 31% on \nperfusion scan obtained ___. Patient does not take home \ndiuretic, and was euvolemic on examination during \nhospitalization. \n - Cardiac Meds: Changed to ASA 81mg daily, Lisinopril 2.5mg \ndaily, Metoprolol Succinate 25mg daily, Simvastatin 40mg QHS, \nIsosorbide Mononitrate ER 30mg daily; please uptitrate beta \nblocker and nitrate as needed for chest pain, blood pressures \nallowing \n\n# Medication Changes: Isosorbide mononitrate was decreased to \n30mg daily due to hypotension (patient has reported blood \npressures as low as 70mmHg SBP at home). Metoprolol succinate \nwas reduced to 25mg daily Can further evaluation blood pressure \non outpatient basis and uptitrate if indicated.\n\n# Code Status: Full\n# Emergency Contacts: ___ (daughter) ___ ___ \n(son) ___ ___ (grandson) ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 2.5 mg PO QHS \n2. Metoprolol Succinate XL 50 mg PO DAILY \n3. Simvastatin 40 mg PO QPM \n4. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY \n5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n6. Aspirin 81 mg PO DAILY \n7. Levothyroxine Sodium 50 mcg PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Levothyroxine Sodium 50 mcg PO DAILY \n3. Lisinopril 2.5 mg PO QHS \n4. Simvastatin 40 mg PO QPM \n5. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \nCall your doctor if you take this medication. Call ambulance if \npain persists after taking 3 pills. \n6. Metoprolol Succinate XL 25 mg PO DAILY \nRX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis:\n- Chest Pain\n- Hypotension\n- Ischemic Cardiomyopathy s/p ICD placement \n\nSecondary Diagnosis:\n- Prediabetes (A1c 5.9-6.1)\n- Hypothyroidism \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 care of you at ___ \n___. You were admitted to the hospital because of an \nepisode of chest pain that occurred several days ago. You have \nnot had any further chest pain in the interim. A stress test was \nattempted on ___ but had to be discontinued because of low \nblood pressure and lightheadedness. You had no further chest \npain and as a result no further testing was performed. Your \nblood tests were negative for any heart injury.\n\nYour Imdur (isosorbide mononitrate) dose was discontinued \nbecause you had low blood pressure in the hospital and reported \nblood pressures as low as 60-70mmHg. Blood pressures that low \nput you at risk of heart injury, passing out, and other health \nproblems. As a result, we decreased the dose of this medication. \nWe also reduced the dose of metoprolol from 50mg to 25mg daily. \nWe recommend that you follow-up with your cardiologist and your \nprimary care physicians to discuss whether you should resume \nyour previous dose or not.\n\nIt is important that you take all of your medications as \nprescribed and that you attend all of your follow-up \nappointments as scheduled. Please call your doctor if you have \nany questions or concerns.\n\nWe wish you the best of health,\nYour Care Team at ___\n\nIt is important that you take all of your medications as \nprescribed and that you attend all of your follow-up \nappointments as scheduled.\n\nWeigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n\nWe wish you the best of health,\nYour Care Team at ___\n \nFollowup Instructions:\n___\n" ]

[ "R079", "I2510", "I5022", "I255", "I472", "R7309", "E039", "I952", "T463X5A", "Y92230", "F329", "F419", "K219", "M810", "I252", "Z95810" ]

[ "R079: Chest pain, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I5022: Chronic systolic (congestive) heart failure", "I255: Ischemic cardiomyopathy", "I472: Ventricular tachycardia", "R7309: Other abnormal glucose", "E039: Hypothyroidism, unspecified", "I952: Hypotension due to drugs", "T463X5A: Adverse effect of coronary vasodilators, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "M810: Age-related osteoporosis without current pathological fracture", "I252: Old myocardial infarction", "Z95810: Presence of automatic (implantable) cardiac defibrillator" ]

[ "I2510", "E039", "Y92230", "F329", "F419", "K219", "I252" ]

[]

[ " \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 \n___ Complaint:\nPain and dyspnea\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ F with a history of CAD, ?COPD, HTN, HLD,\nwho presents with dyspnea. Last night, she reports that she\ndeveloped progressive SOB associated with epigastric pressure\nthat she described as a wrapped band around her upper abdomen. \nIn\nthe morning, she then called her outpatient pulmonologist, Dr.\n___ could not see her today and recommended that she\npresent to the ED. She denied any lightheadedness, nausea,\nvomiting, chest pain, diaphoresis. Her shortness of breath is\nresolved upon my evaluation. She denies any fevers or cough. She\ndenies any trauma or falls. \n \n- In the ED, initial vitals were: \n97.7 | 53 | 150/65 | 22 at 95% on RA \n\n- Exam was notable for: No crackles, no JVP. Warm extremities \n\n\n- Labs were notable for: \n\\8.5 / \n 8.3----232 \n/30.7\\ \n\n 142 | 109 | 21 \n --------------<100 \n 4.8 | 22 | 0.9 \n \n___ 30232 \nTrop-T 0.01 (1140) and <0.01 (1746) \n\n- Studies were notable for: \nECG: TWI II, III, avF(changed from prior) \n \nCHEST (PA & LAT) \nLarge hiatal hernia. No acute cardiopulmonary abnormality. \n\n- In the ED, the patient was not given anything. \n- No consults \n\nOn arrival to the floor, she reported that the SOB spontaneously\nresolved while in the ED. Reports ongoing epigastric band of\ndiscomfort, worse on inspiration. Has chronic LBP which is\nactually mild currently. Denies cough, orthopnea, PND, wt gain \nor\n___ edema. \n\n \nPast Medical History:\nSpinal stenosis \n Left hip replacement \n Coronary artery disease status post CABG ___ \n COPD \n CVA ___ \n Hypertension \n Hyperlipidemia \n CHF \n Thyroid disease \n Anxiety and depression \n Hiatal hernia \n H/O TOBACCO ABUSE \n Left shoulder rotator cuff impingement and rotator cuff \n tendonitis following a fall ___ \n \n \nSocial History:\n___\nFamily History:\nEarly CAD in both mother's and father's side, also brother\n \nPhysical ___:\nADMISSION PHYSICAL EXAM:\n========================\nVITALS: 98.2 145 / 66 53 18 99 Ra \nGENERAL: Alert and interactive. In no acute distress. \nHEENT: PERRL, EOMI. Mild blepharitis and conjunctival injection\nb/l. MMM. \nNECK: No cervical lymphadenopathy. No JVD appreciated. \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, mild epigastric\ntenderness without rebound or guarding; no organomegaly. \nEXTREMITIES: WWP, no ___ edema. Pulses DP/Radial 2+ bilaterally. \n\nSKIN: No rashes. \nNEUROLOGIC: AOx3 but appear forgetful. Moving all 4 limbs\nspontaneously. ___ strength throughout, + nonradiating LBP with\n___ strength testing, Normal sensation. \n\nDISCHARGE PHYSICAL EXAM:\n=======================\nVITALS: 98.2 145 / 66 53 18 99 Ra \nGENERAL: Alert and interactive. In no acute distress. \nCARDIAC: RRR, no m/r/g \nLUNGS: CTAB, no wheezes, ronchi or crackles \nABDOMEN: NABS, soft, NT, ND \nEXTREMITIES: WWP, no ___ edema \nNEUROLOGIC: AOx3, CN grossly intact, moving all 4 extremities\nspontaneously and with purpose, speech fluent. \n \nPertinent Results:\n___ 11:40AM BLOOD WBC-8.3 RBC-3.70* Hgb-8.5* Hct-30.7* \nMCV-83 MCH-23.0* MCHC-27.7* RDW-18.6* RDWSD-55.6* Plt ___\n___ 06:58AM BLOOD WBC-7.4 RBC-3.84* Hgb-9.1* Hct-31.0* \nMCV-81* MCH-23.7* MCHC-29.4* RDW-18.6* RDWSD-53.6* Plt ___\n___ 11:40AM BLOOD Glucose-100 UreaN-21* Creat-0.9 Na-142 \nK-4.8 Cl-109* HCO3-22 AnGap-11\n___ 06:58AM BLOOD Glucose-98 UreaN-19 Creat-1.0 Na-143 \nK-3.7 Cl-102 HCO3-25 AnGap-16\n___ 06:58AM BLOOD Calcium-8.7 Phos-4.0 Mg-1.7 Iron-15*\n \nBrief Hospital Course:\nMs. ___ is a ___ F with a history of CAD, COPD, HTN, HLD,\nwho presents with band like distribution of pain under her\nbreasts that resolved after increased dose of Torsemide x1. \n\nThe etiology of her pain/dyspnea is unclear, though potentially \nsecondary to volume overload given elevated BNP and improvement \nafter an additional dose of Torsemide. Her EKG had some \nnon-specific changes without prior EKGs for comparison, but her \ntrops were negative. Her pain also was not consistent with \ncardiac chest pain. As her workup was negative and her symptoms \nhad improved completely the day after admission she was \ndischarged at home.\n\nTransitional Issues:\n[ ] Diuresis - discharged on her home Torsemide 20mg, though \nwould check weight and volume status at ___ follow up \nappointment and would consider increasing home dose of Torsemide \nif indicated.\n#CODE: Full presumed\n#CONTACT: Daughter, ___, ___\n \n___ on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Potassium Chloride 20 mEq PO DAILY \n2. Ezetimibe 10 mg PO DAILY \n3. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain \n4. Torsemide 20 mg PO DAILY \n5. Clopidogrel 75 mg PO DAILY \n6. Atorvastatin 80 mg PO QPM \n7. CARVedilol 12.5 mg PO BID \n8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n9. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - \nModerate \n10. DULoxetine ___ 60 mg PO DAILY \n11. DULoxetine ___ 30 mg PO QHS \n12. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation \ndaily \n13. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze \n\n \nDischarge Medications:\n1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze \n2. Atorvastatin 80 mg PO QPM \n3. CARVedilol 12.5 mg PO BID \n4. Clopidogrel 75 mg PO DAILY \n5. DULoxetine ___ 60 mg PO DAILY \n6. DULoxetine ___ 30 mg PO QHS \n7. Ezetimibe 10 mg PO DAILY \n8. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation \ndaily \n9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain \n11. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain \n- Moderate \n12. Potassium Chloride 20 mEq PO DAILY \n13. Torsemide 20 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\nChest pain\nDyspnea\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 came to the hospital because you were having some shortness \nof breath due to a band-like distribution around your chest \nbeneath your breasts.\n\nYou were given an extra dose of Torsemide and your symptoms \nresolved. It is unclear what exactly caused your symptoms, but \nit may have been due to having a little extra volume on board \nwhich the Torsemide helped with.\n\nAs your symptoms improved and your workup was otherwise negative \nyou were discharged home. All cardiac function tests suggested \nthe pain was not coming from a problem with your heart.\n\nThere were no changes made to your home medications so please \ntake all of your medications as previously prescribed. \n\nPlease also call your primary care doctor on ___ to make an \nappointment to be seen this week.\n\nPlease weigh yourself every morning and call your PCP if your \nweight goes up by more than 3 pounds in 2 days or 5 pounds in \none week. \n\nIt was a pleasure caring for you. We wish you all the best!\n\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "R0600", "R0789", "J449", "D649", "I2510", "Z951", "I110", "I509", "Z7902", "E785", "M25512", "M479", "M4800", "M5410", "F419", "F329", "Z87891", "Z8673" ]

[ "R0600: Dyspnea, unspecified", "R0789: Other chest pain", "J449: Chronic obstructive pulmonary disease, unspecified", "D649: Anemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "I110: Hypertensive heart disease with heart failure", "I509: Heart failure, unspecified", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "E785: Hyperlipidemia, unspecified", "M25512: Pain in left shoulder", "M479: Spondylosis, unspecified", "M4800: Spinal stenosis, site unspecified", "M5410: Radiculopathy, site unspecified", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Z87891: Personal history of nicotine dependence", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits" ]

[ "J449", "D649", "I2510", "Z951", "I110", "Z7902", "E785", "F419", "F329", "Z87891", "Z8673" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROLOGY\n \nAllergies: \nIodinated Contrast Media / Compazine / Tigan\n \nAttending: ___.\n \nChief Complaint:\ngait disturbance\n \nMajor Surgical or Invasive Procedure:\nThrombectomy ___\n\n \nHistory of Present Illness:\nMr. ___ Critical ___ is a ___ with a medical\nhistory notable for osteosarcoma in remission s/p chemotherapy\nc/b cardiomyopathy, depression on Effexor, hypertension on\nlisinopril, polysubstance abuse on suboxone who presents with\ngait disturbance. As per the patient's mother, the patient's \nlast\nknown well time was approximately 8pm yesterday when he went out\nwith his band mates. He drank approximately 3 shots of hard\nalcohol. He returned home at approximately 11pm last night when\nhis band mates had to carry him up the stairs to his bed. His\nmother assumed he was intoxicated, but noted a left sided facial\ndroop. At approximately 8am this morning he woke up and called\nout to his mother saying he was unable to get up out of bed and\nget to the bathroom. He eventually was taken to the ___\nat approximately 11am, where he underwent a CTH that revealed a\ndense R MCA syndrome. He also underwent MRA which revealed acute\ninfarct in the right basal ganglia and concern for right sided \nM1\ncutoff. He was not given tPA as he was outside the window, and \nhe\nwas transferred to ___ for EVT which was performed on arrival.\nHe was admitted to neuro ICU for post EVT care.\n \nPast Medical History:\nOsteosarcoma in remission\nchemotherapy induced cardiomyopathy\nHTN\nDepression\nPolysubstance abuse\n \nSocial History:\n___\nFamily History:\nUnable to be obtained during code stroke\n \nPhysical Exam:\nAdmission Exam:\n-Mental Status: Alert, oriented x 3. Able to relate history\nwithout difficulty. Language is fluent with intact repetition \nand\ncomprehension. Normal prosody. There were no paraphasic errors.\nAble to name both high and low frequency objects. Able to read\nwithout difficulty. No dysarthria. Able to follow both midline\nand appendicular commands. Able to register 3 objects and recall\n___ at 5 minutes. There was no evidence of apraxia or neglect.\n\n-Cranial Nerves:\n\nII, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without\nnystagmus. Normal saccades. VFF to confrontation.\nV: Facial sensation intact to light touch.\nVII: Prminent left facial droop, UMN pattern\nVIII: Hearing intact to finger-rub bilaterally.\nIX, X: Palate elevates symmetrically.\nXI: ___ strength in trapezii bilaterally.\nXII: Tongue protrudes in midline with good excursions. \n\n-Motor: Normal bulk and tone throughout. No adventitious\nmovements, such as tremor or asterixis noted.\n\n [Delt][Bic][Tri][ECR][FEx][IP][Quad][Ham][TA][Gas]\n\nL 0 0 0 0 0 3* 3* 3* 3* 3* \nR 5 5 5 5 5 5 5 5 5 5 \n* = unable to complete formal confrontation testing\n\n-Sensory: Sensation decreased to pinprick and light touch along\nleft arm. No extinction to DSS. Romberg absent. \n\nDischarge Exam:\n\nGeneral: Awake, cooperative, NAD.\nLungs, nonlabored breathing at room air\nRegular rate and rhythm\nTrace lower extremity edema\n\nNeurologic:\nAwake, alert, conversant. Oriented to person, knows month, \nyear, and current president. Thinks he is in ___ (first \nhospital presented to). \n\nPERRL 4 to 2mm and brisk. EOMI without nystagmus. Left-sided\nfacial droop. Palate elevates symmetrically. Tongue protrudes\nmidline w/ good excursions.\n\n-Motor: \n [Delt][Bic][Tri][ECR][FEx][FFx][IP][Quad][Ham][TA][Gas]\nL 0 0 0 0 0 0 2 4 2 4 4 \nR 5 5 5 5 5 1 5 5 5 5 4 \n\nNo Sensory deficit to light touch, No dysmetria. \n\n \nPertinent Results:\nADMISSION \n___ 09:34PM BLOOD WBC-5.0 RBC-4.19* Hgb-10.6* Hct-33.4* \nMCV-80* MCH-25.3* MCHC-31.7* RDW-17.6* RDWSD-51.3* Plt ___\n___ 09:34PM BLOOD ___ PTT-31.0 ___\n___ 09:34PM BLOOD Glucose-124* UreaN-10 Creat-0.8 Na-140 \nK-3.8 Cl-106 HCO3-21* AnGap-13\n___ 09:34PM BLOOD ALT-9 AST-15 LD(LDH)-177 CK(CPK)-93 \nAlkPhos-75 TotBili-0.3\n___ 09:34PM BLOOD CK-MB-2 cTropnT-<0.01\n___ 09:34PM BLOOD Calcium-8.9 Phos-3.0 Mg-1.5* Cholest-149\n\nPERTINENT \n___ 09:34PM BLOOD %HbA1c-5.2 eAG-103\n___ 09:34PM BLOOD Triglyc-30 HDL-47 CHOL/HD-3.2 LDLcalc-96\n___ 09:34PM BLOOD TSH-1.3\n\n___ Echo Report\nNo thrombus or mass is seen in the left ventricle. The visually \nestimated left ventricular ejection\nfraction is 15%.\nIMPRESSION: Limited study- no evidence of filling defect or \nthrombus within the left ventricle.\nCompared with the prior TTE ___, LV function appears \nsimilar\n\n___ Echo Report\nThe left atrial volume index is normal. There is no evidence of \nan atrial septal defect or patent foramen ovale\nby 2D/color Doppler or agitated saline at rest and with \nmaneuvers. The estimated right atrial pressure is\n>15mmHg. There is normal left ventricular wall thickness with a \nnormal cavity size. There is SEVERE global\nleft ventricular hypokinesis. A left ventricular thrombus/mass \nwas not seen but cannot be excluded with\ncertainty. Quantitative biplane left ventricular ejection \nfraction is 23 % (normal 54-73%). There is\nno resting left ventricular outflow tract gradient. Mildly \ndilated right ventricular cavity with moderate global\nfree wall hypokinesis. Tricuspid annular plane systolic \nexcursion (TAPSE) is depressed. The aortic sinus\ndiameter is normal for gender with a normal ascending aorta \ndiameter for gender. The aortic arch diameter is\nnormal with a normal descending aorta diameter. There is no \nevidence for an aortic arch coarctation. The\naortic valve leaflets (3) appear structurally normal. There is \nno aortic valve stenosis. There is no aortic\nregurgitation. The mitral valve leaflets appear structurally \nnormal with no mitral valve prolapse. There is mild\n[1+] mitral regurgitation. The pulmonic valve leaflets are \nnormal. The tricuspid valve leaflets appear\nstructurally normal. There is physiologic tricuspid \nregurgitation. The estimated pulmonary artery systolic\npressure is normal. There is no pericardial effusion.\nIMPRESSION: Suboptimal image quality. Severe left ventricular \nsystolic dysfunction. No obvious\nintracardiac mass or shunt (but suboptimal image quality \nprecludes definitive exclusion)\n\n___ UNILAT\n\nRight common femoral artery: Arteriotomy is above the \nbifurcation. There is\ngood distal runoff. There is no evidence of dissection. Vessel \ncaliber\nappropriate for closure device.\n \nRight internal carotid artery: Vessel caliber smooth and \nregular. There is\nfilling of the anterior cerebral artery and their distal \nterritory. The right\nmiddle cerebral artery fills distal to the anterior temporal \nartery but does\nnot fill distal which is unchanged from the previous CT and MRI.\n \nRight internal carotid artery post thrombectomy: Vessel caliber \nsmooth and\nregular. There is filling of the anterior and middle cerebral \narteries and\ntheir distal territories. There is a mild degree spasm the \nmiddle cerebral\nartery bifurcation however there is filling of the M2 M3 and M4 \nvessels.\n \nRight Common carotid artery: There is filling of the internal \nand external\ncarotid arteries. There is a mild degree of spasm in mid \ncervical internal\ncarotid artery with the catheter had been. However there is no \nevidence of\natherosclerosis or stenosis by NASCET criteria\n \nIMPRESSION: \n \nTICI 3 right MCA mechanical thrombectomy\n\n___ HEAD W/O CONTRAST\nModerately large hypodense area involving on right \nperiventricular white\nmatter and the right lentiform nucleus is consistent with \nevolving infarction.\nThere is also an area of involving infarct involves along the \nanterior right\ntemporal lobe. However, CT evidence for infarction is limited \nto these areas.\nRight lentiform nucleus is mildly swollen, but there is no \nmidline shift or\nhydrocephalus. No evidence of hemorrhage. No extra-axial \ncollection. \nSurrounding soft tissue structures are unremarkable. Small \nposterior retinal\ncalcifications on the left. Visualized paranasal sinuses and \nmastoid air\ncells appear clear. No evidence of fracture or bone \ndestruction.\n \nIMPRESSION: \n \nFindings consistent with evolving infarcts within the right \nmiddle cerebral\nartery distribution. No evidence of acute hemorrhage.\n\n___ HEAD W/O CONTRAST\nCorresponding to area of hypodensity on prior CT, there is \nrestricted\ndiffusion with T2/FLAIR hyperintensity centered in the right \nlentiform nucleus\nwith central area of susceptibility compatible with an \nacute/subacute infarct\nwith hemorrhagic transformation. Additional areas of \nacute/subacute infarct\nseen involving the right caudate head, caudate body and regions \nof the right\ntemporal lobe. Degree of mass effect is marginally increased \nsince prior head\nCT with asymmetry of the right lateral ventricle and 4 mm of \nleftward midline\nshift. There is no underlying acute evolving hydrocephalus.\n \nPeriventricular and subcortical white matter T2/FLAIR \nhyperintensities are\nnonspecific but likely sequelae of chronic small vessel ischemic \ndisease.\n \nBoth orbits and globes are unremarkable. Paranasal sinuses and \nmastoid air\ncells are clear.\n \nIMPRESSION:\n \n \n1. Right MCA territory multifocal acute/early subacute \ninfarction with\nhemorrhagic transformation at right lentiform nucleus.\n2. There is a leftward midline shift by 4 mm with no acute \nevolving\nhydrocephalus.\n\n \nBrief Hospital Course:\nMr. ___ is a ___ year old man with history of childhood \nosteosarcoma in remission s/p chemotherapy c/b cardiomyopathy, \ndepression on venlafaxine, polysubstance use d/o on suboxone who \npresented with left-sided weakness, found to have a right MCA \nstroke. \n\n#R MCA stroke\nTransferred to ___ from ___ for thrombectomy on ___. ___ \nStroke Scale Score: 11 @ ___ 1530. There was TICI 3 \nreperfusion after 2 passes. Admitted to neuro ICU for \nrespiratory monitoring overnight as history of anaphylaxis to \ncontrast. Called out to ___ the day after thrombectomy. \nSubsequently, his exam improved from near plegic right side to \n___ strength in the left triceps and quadriceps but later \nstrength declined and his RUE remained plegic (___), Lower \nextremity strength at baseline. Etiology thought to be \ncardioembolic given severe non-ischemic cardiomyopathy vs \nundiagnosed atrial fibrillation. TTE negative for LV thrombus. \nMRI on ___ showed evolving RMCA multifocal infarction and \nsignificant hemorrhagic transformation in the right basal \nganglia with 4mm leftward stroke. Given the hemorrhage, \nanticoagulation was withheld and planned to start on ___. \nNeeds Non Con CT Head a day ___ and Please notify Dr. \n___/ ___ neurology team of the results prior to initiating \nWarfarin. He was started on aspirin 81 mg daily in the meantime. \nZio patch at discharge\n\n#Doxorubicin-induced non-ischemic cardiomyopathy \nPatient reports that his LVEF was as low as 15% in the past. \nPrior records were obtained that showed a LVEF of ___ in \n___. However, he notes that he has not been taking any \ngoal-directed heart failure therapy in over a year. He had \npersistently low blood pressures throughout his hospitalization. \nAttempted to initiated metoprolol tartrate 6.25 mg Q6H, but BP \ndid not tolerate this. Not on ACE inhibitor for the same reason.\n\n#Anxiety, Depression \n#History of opioid use disorder \nContinued home venlafaxine 225 mg daily and \nBuprenorphine-Naloxone Film (8mg-2mg) 1.5 FILM SL DAILY. Patient \ncomplained of additional anxiety related to his medical \nsituation and feeling trapped due to hemiparesis. He also \nexpressed hopelessness and depressed mood due to possibly not \nbeing able to return to playing guitar, which is his \"whole \nlife.\" Therefore, started mirtazapine \n\nTransitional Issues:\n- Continue Aspirin\n- Repeat Non contrast Head CT head on ___ ___ at ___ \n___, ___ building fourth floor)- to rule out worsening \nHemorrhage prior to switching Asa to Warfarin ( suspected \ncardioembolic stroke )\n- Zio Patch at discharge \n- Cardiology follow up with either patients cardiologist in \n___. Referral place to ___ cardiology prior to DC.\n- Continue ___\n\nNew medications:\n- Aspirin 81 Po daily\n- Mitrazepine 15 mg Po daily\n- MVI PO and Nicotine patch\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Venlafaxine XR 225 mg PO QAM \n2. Buprenorphine-Naloxone Film (8mg-2mg) 1.5 FILM SL DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Mirtazapine 15 mg PO QHS \n3. Multivitamins 1 TAB PO DAILY \n4. Nicotine Patch 21 mg/day TD DAILY \n5. Buprenorphine-Naloxone Film (8mg-2mg) 1.5 FILM SL DAILY \n6. Venlafaxine XR 225 mg PO QAM \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nAcute ischemic stroke\nChemotherapy-induced cardiomyopathy \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Bedbound.\n\n \nDischarge Instructions:\nDear Mr. ___,\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. 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. You had a procedure, called \nthrombectomy, to remove the clot from your brain. You were also \ntreated with aspirin. We plan to eventually starting warfarin. \nYou will Need a repeat CT Head on ___.\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:\n- Heart failure \n- High cholesterol \n\nWe are changing your medications as follows:\n- Started aspirin 81 mg daily\n- Plan to start warfarin on ___\n- Mitrazepine 15 mg PO At bedtime\n- Oral Multivitamin\n\nPlease take your other medications as prescribed.\n\nPlease follow up with Neurology and your primary care physician \nas 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", "I5022", "I427", "R29810", "R531", "R29711", "F329", "I110", "F1910", "F17200", "T451X5S", "F419", "G4700", "Z85830" ]

[ "I63411: Cerebral infarction due to embolism of right middle cerebral artery", "I5022: Chronic systolic (congestive) heart failure", "I427: Cardiomyopathy due to drug and external agent", "R29810: Facial weakness", "R531: Weakness", "R29711: NIHSS score 11", "F329: Major depressive disorder, single episode, unspecified", "I110: Hypertensive heart disease with heart failure", "F1910: Other psychoactive substance abuse, uncomplicated", "F17200: Nicotine dependence, unspecified, uncomplicated", "T451X5S: Adverse effect of antineoplastic and immunosuppressive drugs, sequela", "F419: Anxiety disorder, unspecified", "G4700: Insomnia, unspecified", "Z85830: Personal history of malignant neoplasm of bone" ]

[ "F329", "I110", "F419", "G4700" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nLisinopril / Penicillins / aspirin / birth control pill / \nnovacaine\n \nAttending: ___.\n \nChief Complaint:\nshortness of breath\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ y/o F with PMH significant for asthma, HTN, hypothyroidism, \nobesity presents with four days of fever, cough and shortness of \nbreath. \n\nShe has been previously health with well-controlled asthma (on \nQvar, but rarely uses albuterol, once a week at most) and no \nadmissions or intubations for her asthma. Her symptoms started \non ___ with fevers at home which were up to 103. She \ndescribed her dyspnea as difficulty getting air in and out. She \nalso notes a productive cough, no hemoptysis. She saw her PCP \nwho prescribed ___ Z-pak, which she has completed. She notes that \nher cough and fever have improved; however, her dyspnea has \nworsened and is not responsive to inhalers which led her to \npresentation to the ED. \n\nOtherwise, she denied leg swelling, no recent travel or surgery.\n\nIn the ED, initial vitals: 99.5, 103, 171/95, 28, 88% RA\n- Labs were notable for being positive Influenza A and a mild \nhyponatremia to 131. \n- CXR showed multifocal infiltrates\n- Patient was given: IVF, Duoneb and levofloxacin\n\nIn the ED, her oxygen requirements increased, so she was \nadmitted to the ICU.\nOn arrival to the MICU, she endorsed that her breathing had \nimproved on NRB. She denied any chest pain, abdominal pain, \nconstipation, diarrhea.\n\nROS: 10-point ROS negative except as noted above in HPI\n \nPast Medical History:\n- Asthma\n- Obesity\n- Hypothyroidism\n \nSocial History:\n___\nFamily History:\nMother, living, ENDOMETRIAL CANCER, DIABETES MELLITUS, ASTHMA, \nMORBID OBESITY, HYPERTENSION, HYPERLIPIDEMIA\n\nFather, living, DIABETES MELLITUS, ATRIAL FIBRILLATION, \nHYPERTENSION, HYPERLIPIDEMIA, COGNITIVE IMPAIRMENT\n\nMGM, deceased, MELANOMA\nMGF, deceased at ___, MYOCARDIAL INFARCTION\nPGF, deceased, CHRONIC OBSTRUCTIVE PULMONARY DISEASE\nPGM, deceased, LUNG CANCER\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n===========================\nGENERAL: Alert, oriented, slightly tachypneic on NRB. \nHEENT: Sclera anicteric, MM dry, oropharynx clear \nNECK: supple, JVP not elevated, no LAD \nLUNGS: On NRB, mild increased work of breathing, poor air \nexchange, no wheezes, rales or ronchi. \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 rashes or lesions noted. \nNEURO: CN II-XII intact, distal sensation intact, strength ___ \nin upper and lower extremities. \nACCESS: PIV \n\nDISCHARGE PHYSICAL EXAM:\n===========================\nVS: AF, 97.6, 123/69, 94, 18, 93% on 3L\nGEN: NAD, pleasant, comfortable in chair\nHEENT: anicteric, MMM\nNECK: supply\nCV: RRR, no murmur\nPULM: No wheeze, no crackles, some upper airway sounds\nABD: soft, NT, NABS\nEXT: Non-pitting edema\nSKIN: warm, dry, no obvious rashes\nNERUO: AAOX3, fluent speech\nPsych: Calm, appropriate\n \nPertinent Results:\nADMISSION LABS:\n___ 09:50AM BLOOD WBC-4.9 RBC-4.63 Hgb-11.9 Hct-37.3 \nMCV-81* MCH-25.7* MCHC-31.9* RDW-14.6 RDWSD-42.7 Plt ___\n___ 09:50AM BLOOD Neuts-70 Bands-2 ___ Monos-3* Eos-0 \nBaso-0 Atyps-1* ___ Myelos-0 Plasma-3* AbsNeut-3.53 \nAbsLymp-1.08* AbsMono-0.15* AbsEos-0.00* AbsBaso-0.00*\n___ 09:50AM BLOOD ___ PTT-34.3 ___\n___ 09:50AM BLOOD Glucose-140* UreaN-14 Creat-0.9 Na-131* \nK-3.9 Cl-95* HCO3-22 AnGap-18\n___ 09:50AM BLOOD ALT-38 AST-135* AlkPhos-90 TotBili-0.4\n___ 09:50AM BLOOD proBNP-65\n___ 09:50AM BLOOD cTropnT-<0.01\n___ 09:50AM BLOOD Albumin-3.4* Calcium-8.0* Phos-2.4* \nMg-1.9\n___ 09:58PM BLOOD Lactate-0.9\n___ 10:35AM URINE Color-Yellow Appear-Slcldy Sp ___\n___ 10:35AM URINE Blood-LG Nitrite-NEG Protein-100 \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-6.0 Leuks-NEG\n___ 10:35AM URINE RBC-4* WBC-4 Bacteri-FEW Yeast-NONE \nEpi-<1\n\nMICROBIOLOGY:\n___ 11:20AM OTHER BODY FLUID FluAPCR-POSITIVE * \nFluBPCR-NEGATIVE\n___ Blood cultures x 2 sets: No growth (FINAL)\n___ MRSA screen: NEGATIVE\n___ Urine Legionella antigen: NEGATIVE\n\nIMAGING:\n___ PA/LAT CXR\nIMPRESSION:\nDiffuse airspace opacities in bilateral lungs are concerning for \nwide spread multifocal pneumonia. Differential also includes \nmetastasis and sarcoidosis.\n\n___ PCXR\nIMPRESSION:\nMultifocal pulmonary consolidations have at additionally \nprogressed as compared to previous examination. It might \nrepresent progression of multifocal pneumonia but potentially \nand element of superimposed pulmonary edema cannot be excluded. \nCardiomediastinal silhouette is difficult to assess since \nobscured by the consolidations. Bilateral pleural effusion is \nmost likely present. No evidence of pneumothorax.\n\n___ CXR\nIMPRESSION:\nIn comparison with the study of ___, there has been \nsubstantial improvement in the diffuse bilateral pulmonary \nopacifications. The associated enlargement of the heart an the \ntime course suggests that most of this represented pulmonary \nedema and that this study is been performed following diuresis. \nNevertheless, in the appropriate clinical setting, some \nsuperimposed pneumonia would be difficult to unequivocally \nexclude.\nNo evidence of impression on the lower cervical trachea to \nradiographically indicate thyroid enlargement.\n\n___ Echocardiogram\nConclusions\nThe left atrium and right atrium are normal in cavity size. \nThere is mild symmetric left ventricular hypertrophy with normal \ncavity size and global systolic function (LVEF>55%). Due to \nsuboptimal technical quality, a focal wall motion abnormality \ncannot be fully excluded. The right ventricle is not well seen \nbut there appears to be normal free wall contractility. The \naortic arch is mildly dilated (may be overestimated because of a \nbranch vessel takeoff. At the isthmus aorta measures only 2.5cm \nwhich is normal). The aortic valve leaflets (3) appear \nstructurally normal with good leaflet excursion and no aortic \nstenosis or aortic regurgitation. The mitral valve leaflets are \nmildly thickened. There is no mitral valve prolapse. Trivial \nmitral regurgitation is seen. There is borderline pulmonary \nartery systolic hypertension. There is no pericardial effusion. \n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with \nnormal biventricular systolic function. No pathologic valvular \nflow.\nCompared with the report of the prior study (images unavailable \nfor review) of ___ mild left ventricular hypertrophy is now \npresent. Other findings do not appear to be significantly \nchanged.\n\nDISCHARGE LABS:\n___ 04:20AM BLOOD WBC-5.1 RBC-4.47 Hgb-11.5 Hct-37.5 MCV-84 \nMCH-25.7* MCHC-30.7* RDW-14.6 RDWSD-44.7 Plt ___\n___ 06:24AM BLOOD Glucose-133* UreaN-15 Creat-0.8 Na-141 \nK-3.6 Cl-96 HCO3-32 AnGap-17\n___ 06:24AM BLOOD ALT-124* AST-96* CK(CPK)-305* AlkPhos-83 \nTotBili-0.6\n___ 04:13PM BLOOD Calcium-9.1 Phos-3.4 Mg-2.___RIEF SUMMARY STATEMENT:\n=============================\nMs ___ is a ___ y/o F with asthma, HTN, hypothyroidism, and \nobesity, who presented with four days of fever, cough and \nshortness of breath at home, and was admitted to the ICU for \nacute hypoxemic respiratory failure in the setting of influenza \nand likely suprainfection with bacterial pneumonia.\n\nACTIVE ISSUES\n=============================\n# ACUTE HYPOXEMIC RESPIRATORY FAILURE\n# INFLUENZA A\n# MULTIFOCAL BACTERIAL PNEUMONIA\nPatient presented with ___ days of progressive dyspnea, as well \nas fevers and chills. On admission, VBG showed respiratory \nalkalosis. She was positive for influenza A, and had history of \nasthma. CXR on admission showed bibasilar opacities concerning \nfor a multifactorial pneumonia. Troponin negative, BNP only 65, \nand ECG with no signs of PE or acute MI. She was started on 5 \ndays of Tamiflu (Day 1; ___, and CTX/Levofloxacin (Day 1: \n___ for CAP, but then narrowed to just levofloxacin. She had a \nTTE which was unremarkable. She was diuresed. Her respiratory \nstatus slowly improved. She completed her antibiotic course \ninpatient. She received diuretics for mild volume overload (by \nexam). She was transferred from the ICU to the medical floor \nafter she was weaned from NRB to nasal cannula 4 liters on \n___. On the floor, she was further weaned to 3L NC. She is \nbeing discharged to home on supplemental O2. Blood cultures, \nUrine Legionella Ag and MRSA screen were NEGATIVE.\n\n# ASTHMA:\nPatient has history of asthma since childhood, never had any \nexacerbation, hospitalization or intubation. Controlled with \nQvar and only used albuterol when she is exposed to smog (works \noccasionally in ___). She was started on Ipratropium Q4H \nstanding with Albuterol Q2H prn dyspnea with Fluticasone \nPropionate 110mcg 2 PUFF IH BID while hospitalized. She will \nresume Qvar and PRN albuterol as an outpatient.\n\n# TRANSAMINITIS\n# RHABDOMYOLYSIS\nShe had a transaminitis and rhabdomyolysis. \n\nCHRONIC ISSUES\n=============================\n# Hypothyroidism: continued home dose levothyroxine\n\nTRANSITIONAL ISSUES:\n=============================\n1. Repeat LFT's at PCP ___\n2. Repeat CXR in ___ weeks to document resolution of pulmonary \ninfiltrates\n3. Wean supplemental O2\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Furosemide 20 mg PO DAILY:PRN leg swelling \n2. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea \n3. Azithromycin 250 mg PO Q24H \n4. Qvar (beclomethasone dipropionate) 80 mcg/actuation \ninhalation BID \n5. Levothyroxine Sodium 75 mcg PO DAILY \n\n \nDischarge Medications:\n1. Furosemide 20 mg PO DAILY:PRN leg swelling \n2. Levothyroxine Sodium 75 mcg PO DAILY \n3. Qvar (beclomethasone dipropionate) 80 mcg/actuation \ninhalation DAILY \n4. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nInfluenza\nPneumonia\nAsthma Flare\nHypoxemic respiratory failure\n\nTransaminitis (elevated liver tests)\nRhabdomyolysis (muscle breakdown)\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 shortness of breath and \nlow oxygen levels. You were found to have pneumonia and \ninfluenza infections. You were briefly admitted to the ICU due \nto high oxygen requirements. You improved with antibiotics and \nsupportive care. You have completed your antibiotic course, but \nyou will still require some oxygen at home.\n.\nYou will need to ___ with your PCP. We recommend that you \nhave your liver blood tests repeated at ___ with your PCP. \n We also recommend a ___ chest x-ray in approximately 4 \nweeks to document resolution of your chest infection.\n \nFollowup Instructions:\n___\n" ]

[ "J09X1", "J9601", "J159", "E873", "J811", "M6282", "E871", "J45901", "E861", "I10", "E039", "E669", "R740" ]

[ "J09X1: Influenza due to identified novel influenza A virus with pneumonia", "J9601: Acute respiratory failure with hypoxia", "J159: Unspecified bacterial pneumonia", "E873: Alkalosis", "J811: Chronic pulmonary edema", "M6282: Rhabdomyolysis", "E871: Hypo-osmolality and hyponatremia", "J45901: Unspecified asthma with (acute) exacerbation", "E861: Hypovolemia", "I10: Essential (primary) hypertension", "E039: Hypothyroidism, unspecified", "E669: Obesity, unspecified", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]" ]

[ "J9601", "E871", "I10", "E039", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \n___\n \nAttending: ___.\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\n___ - cardiac cath, radial access\n\n \nHistory of Present Illness:\n___ year old woman with PMH significant for hypertension, fall\nwith 6mm subdural hematoma, Afib who was recently discharged \nfrom\n___ on ___ who represents with chest pain. \n\nMs. ___ was initially ___ to ___ from ___ to ___nd was found to have 6mm subdural hematoma. Subdural\nhematoma was stable and she was discharged. She admitted to \n___\nfrom ___ after she represented on ___ to the ED with\nchest pain and was found to have recurrent afib with RVR. Her\natrial fibrillation was controlled with diltiazem and \nmetoprolol.\nShe was initiated on apixaban 2.5mg BID after consultation with\nneurosurgery with stable CT head after 3 doses of apixaban.\nDuring the admission she complained of chest pressure in the\nsetting of afib with RVR. EKG during episode demonstrated TWI in\nV1-V3 and troponin elevation to 0.07. She developed several\nepisodes of recurrent chest pain in the setting of hypertension\nand atrial fibrillation. Plan was made for outpatient stress\ntest. She was also treated during the hospitalization for UTI\nthat was positive for enterococcus and E. Coli. Patient \ndeveloped\nhyponatremia in the setting of treatment with Chlorthalidone, so\nthis was stopped. She was also placed on salt tablets with\nimprovement in hyponatremia to 131. \n\nPatient notes chest tightness that started at 2 AM with \nbilateral\narm numbness. Coincided with ambulation and perception of\ntacyhcardia. Improved when she was lying in bed. She also\ncomplains of anxiety that she thinks may be contributing to her\nsymptoms. Denies diaphoresis, palpitations, presycnope, syncope.\nComplains of ongoing productive cough since admission that is\nstable. She also endorses abdominal bloating/gas.\n\nIn the ED, \n\n- Initial vitals: T96.2 HR80 BP143/59 RR19 SpO297% RA \n\n- EKG: NSR at rate of 80. Normal axis. Diffuse T wave \nflattening.\nNo ST/TW changes. Unchanged from prior. \n\n- Labs/studies notable for: \n 11.3\n 12.1 >----< 329\n 35.4\n\n 134|96|15\n ---------< 145\n 4.9|27|0.6\n\n Trop < 0.01 x 2\n \n- Patient was given: \n+ Aspirin 162mg\n+ Nitro SL 0.4\n+ Simethicone 80mg PO\n\n- Vitals on transfer: \n \nOn the floor, patient notes that her chest pain has mostly\nresolved. Described discomfort that occurred with ambulation,\nnumbness in bilateral arms from elbows to shoulders associated\nwith fast heart rate. Feels better when lying in bed, but\ncomplains of anxiety. Also notes non-productive cough. Denies\nsyncope, pre-syncope, PND, orthopnea. Denies fever, chills, or\nnight sweats.\n \nREVIEW OF SYSTEMS: \nSee HPI. All other ROS negative. \n \nPast Medical History:\n1. CARDIAC RISK FACTORS \n- Diabetes: No\n- Hypertension: Yes\n- Dyslipidemia: Yes\n\n2. CARDIAC HISTORY \n- CABG: None \n- PERCUTANEOUS CORONARY INTERVENTIONS: None \n- PACING/ICD: None \n- New onset pAfib\n\n3. OTHER PAST MEDICAL HISTORY\nHypothyroidism\nGout\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or\nsudden cardiac death. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\nVITALS:\n___ 1051 Temp: 97.6 PO BP: 151/81 HR: 93 RR: 18 O2 sat: 99%\nO2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___ \nGENERAL: Lying comfortably in bed. \nHEENT: PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of\nthe oral mucosa. \nNECK: Supple with JVP of 8 cm. \nCARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. \nLUNGS: CTAB. No crackles, wheezes or rhonchi. \nABDOMEN: Soft, mild TTP in LLQ. \nEXTREMITIES: No c/c/e. \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \nPULSES: 2+ peripheral pulses. \n\nDISCHARGE PHYSICAL EXAM\nVITALS: \n24 HR Data (last updated ___ @ 1330)\n Temp: 98.1 (Tm 98.3), BP: 123/80 (100-135/68-81), HR: 85 \n(69-85), RR: 16 (___), O2 sat: 100% (93-100), O2 delivery: Ra, \nWt: 110.67 lb/50.2 kg \nFluid Balance (last updated ___ @ 1347) \n  Last 8 hours Total cumulative -650ml\n    IN: Total 300ml, PO Amt 300ml\n    OUT: Total 950ml, Urine Amt 950ml\n  Last 24 hours Total cumulative -1110ml\n    IN: Total 540ml, PO Amt 540ml\n    OUT: Total 1650ml, Urine Amt 1650ml \nGENERAL: Lying comfortably in bed. \nHEENT: PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of \nthe oral mucosa. Healing ecchymoxis on right maxilla\nNECK: Supple without visible JVP \nCARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. \nLUNGS: CTAB. No crackles, wheezes or rhonchi. \nABDOMEN: Soft, nontender, nondistended, normoactive bowel \nsounds. \nEXTREMITIES: No edema in the extremities.\nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \nPULSES: 2+ peripheral pulses. \n \nPertinent Results:\nADMISSION LABS\n\n___ 06:36AM BLOOD WBC-11.3* RBC-4.47 Hgb-11.8 Hct-37.0 \nMCV-83 MCH-26.4 MCHC-31.9* RDW-14.9 RDWSD-45.0 Plt ___\n___ 05:30AM BLOOD Neuts-81.1* Lymphs-10.0* Monos-7.2 \nEos-0.4* Baso-0.5 Im ___ AbsNeut-10.65* AbsLymp-1.32 \nAbsMono-0.95* AbsEos-0.05 AbsBaso-0.06\n___ 06:36AM BLOOD Glucose-148* UreaN-11 Creat-0.6 Na-131* \nK-5.6* Cl-94* HCO3-23 AnGap-14\n___ 01:05PM BLOOD CK-MB-2 cTropnT-<0.01\n___ 06:10AM BLOOD cTropnT-<0.01\n___ 05:30AM BLOOD cTropnT-<0.01\n___ 04:20AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.0\n\nDISCHARGE LABS\n\n___ 04:21AM BLOOD WBC-9.5 RBC-4.34 Hgb-11.4 Hct-36.2 MCV-83 \nMCH-26.3 MCHC-31.5* RDW-15.0 RDWSD-45.5 Plt ___\n___ 04:21AM BLOOD Glucose-169* UreaN-9 Creat-0.6 Na-137 \nK-4.5 Cl-98 HCO3-22 AnGap-17\n___ 04:21AM BLOOD Calcium-8.5 Phos-3.4 Mg-1.9\n \nBrief Hospital Course:\nSUMMARY STATEMENT\n___ with PMH significant for hypertension, fall with 6mm \nsubdural\nhematoma, Afib who was recently discharged from ___ on ___ \nwho\nrepresents with chest pain. ECG baseline, trop negative x2, \nnonobstructive CAD on coronary angiogram ___. Found to \nhave recurrent UTI, discharged on 7 day total course of \namoxicillin (last day ___.\n\n# CORONARIES: unknown\n# PUMP: EF 67%, mild MR\n# RHYTHM: pAF, now in NSR \n\n# Chest pain\nPatient had recently had intermittent chest pain at rest during \nlast admission during episodes of hypertension or afib. She \npresented with chest pain in the setting of negative biomarkers \nwith stable ECG. Coronary angiogram on ___ showed \nnonobstructive coronary artery disease. No interventions were \nperformed, and medical management was recommended. Continued \nAtorvastatin, metoprolol, amlodipine, sublingual nitro prn. \nD/C-ed aspirin given no obstructive CAD and started on apixaban \n2.5 BID for pAF.\n\n# UTI: On last admission had been treated for both E. Coli and \nEnterococcus UTI. Complained of mild dysuria, repeat UCx again \ngrew Enterococcus, sensitive to ampicillin. She was discharged \non amoxicillin to complete a total of 10 days of antibiotics\n\n# Cough: Unclear etiology. Initially felt potentially due to \n___ although persisted despite discontinuation of these \nmedications. Evaluated with CT chest which showed \"Tenuous \nground-glass opacities and distal mucus plugging can be \nattributable to inflammatory or infectious process, likely \naspiration.\" She had a bedside speech and swallow evaluation \nwhich did not reveal clinically apparent aspiration. Unclear \netiology of cough, although appeared to be improving prior to \ndischarge.\n\n# pAF: CHADS2Vasc 4. Recent admission for afib with rvr. In \nsinus rhythm this admission with no telemetry events. Episodes \nlikely precipitated by intracranial bleed. Metoprolol increased \nto 150 daily. Held then restarted apixaban without bridge given \nrecent hx of SDH.\n\n# HTN: Well-controlled BP. Amlodipine was continued.\n\n# Hyponatremia: Developed hyponatremia in setting of SIADH and \nChlorthalidone. Likely with ongoing SIADH in setting of \nintracranial bleed. Improved with nepro shakes, salt tabs, and \nfluid restriction, Na 137 on discharge. Observed off salt tabs \nfor 2 days without development of hyponatremia.\n\n# Subdural hematoma: Presented to the ED on ___ after a fall \nwhere she hit the right side of her head. Found to have right \ncerebral convexity acute subdural hematoma measuring up to 6-7 \nmm which was evaluated by serial CT images. Was started on \napixaban\n2.5mg BID with stable appearance of SDH.\n\n#Hyperlipidemia \nIncreased atorvastatin to 80 daily \n\n#Hypothyroidism \nContinued home levothyroxine 112 mcg daily\n\n#Gout \nContinued home allopurinol ___ MG daily\n\nTRANSITIONAL ISSUES:\n====================\n- Continue to monitor blood pressure with new antihypertensive \nregimen. ___ need to decrease as subdural hematoma resolves.\n\n- Please have patient see a cardiologist for management of \natrial fibrillation and coronary artery disease.\n\n- Follow up cough symptoms\n\n- 1.7 cm thyroid nodule seen on CT Chest without contrast ___\n\nNEW MEDICATIONS:\n[ ] Amoxicillin 500mg q12 until ___\n\nCHANGED MEDICATIONS: \n[ ] Atorvastatin changed from 40 mg po qhs to 80 mg po qhs\n[ ] Metoprolol succinate XL changed from 50 mg po daily to 150 \nmg po daily\n\nDISCONTINUED MEDICATIONS:\n[ ] Diltiazem 120 mg po daily\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. Docusate Sodium 100 mg PO DAILY \n5. Levothyroxine Sodium 112 mcg PO DAILY \n6. Albuterol Inhaler ___ PUFF IH Q4H:PRN cough/wheeze \n7. amLODIPine 10 mg PO DAILY \n8. Apixaban 2.5 mg PO BID \n9. Diltiazem Extended-Release 120 mg PO DAILY \n10. Metoprolol Succinate XL 50 mg PO Q24H \n11. Sodium Chloride 1 gm PO TID \n12. Potassium Chloride 10 mEq PO DAILY \n\n \nDischarge Medications:\n1. Amoxicillin 500 mg PO Q12H \nRX *amoxicillin 500 mg 1 capsule(s) by mouth twice a day Disp \n#*12 Capsule Refills:*0 \n2. Atorvastatin 80 mg PO QPM \n3. Metoprolol Succinate XL 150 mg PO DAILY \nRX *metoprolol succinate 100 mg 1 tablet(s) by mouth Daily Disp \n#*30 Tablet Refills:*3 \n4. Albuterol Inhaler ___ PUFF IH Q4H:PRN cough/wheeze \n5. Allopurinol ___ mg PO DAILY \n6. amLODIPine 10 mg PO DAILY \n7. Apixaban 2.5 mg PO BID \n8. Cyanocobalamin 1000 mcg PO DAILY \n9. Docusate Sodium 100 mg PO DAILY \n10. Levothyroxine Sodium 112 mcg PO DAILY \n11. Potassium Chloride 10 mEq PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\nCoronary artery disease\n\nSECONDARY DIAGNOSES:\nAtrial fibrillation\nHyponatremia\nHypertension\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\n It was a pleasure caring for you at ___. \n\n WHY WAS I IN THE HOSPITAL? \n ========================== \n - You were admitted because you had chest pain.\n \n WHAT HAPPENED IN THE HOSPITAL? \n ============================== \n - You had several tests which ruled out a heart attack. You \nalso had a coronary angiogram to look at the vessels which \nsupply blood to your heart. There were no blockages that were \nsignificant enough to perform any intervention. It was decided \nthat the best way to manage your mild heart disease is with \nmedications.\n\n WHAT SHOULD I DO WHEN I GO HOME? \n ================================ \n - Take all your medications exactly as prescribed.\n\n - You should follow up with your primary care physician \n(appointment listed below) and discuss your new diagnoses and \nmedications as well as obtaining a referral to cardiology to \nfollow up with your chest pain and new atrial fibrillation.\n\n - You were started on a blood thinner, so you should look for \nsigns of bleeding, including blood in your urine or stool. If \nyou notice these or other signs of excess bleeding you should \ncontact your primary care physician or go to the emergency room.\n\n Thank you for allowing us to be involved in your care, we wish \nyou all the best!\n\n Your ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "I25110", "I21A1", "N390", "E222", "E872", "I480", "I10", "B952", "R05", "E785", "E039", "M109", "I252" ]

[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "I21A1: Myocardial infarction type 2", "N390: Urinary tract infection, site not specified", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "E872: Acidosis", "I480: Paroxysmal atrial fibrillation", "I10: Essential (primary) hypertension", "B952: Enterococcus as the cause of diseases classified elsewhere", "R05: Cough", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "M109: Gout, unspecified", "I252: Old myocardial infarction" ]

[ "N390", "E872", "I480", "I10", "E785", "E039", "M109", "I252" ]

[]

[ " \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 ankle malunion, subtalar arthritis\n \nMajor Surgical or Invasive Procedure:\n___: Right ankle corrective osteotomy, subtalar arthrodesis \n(Dr. ___\n\n \nHistory of Present Illness:\n___ with right ankle malunion (equinovarus) and subtalar \narthritis now s/p RIGHT ankle osteotomy, subtalar arthrodesis \n(Dr. ___, ___.\n \nPast Medical History:\nRight ankle fusion\n \nSocial History:\n___\nFamily History:\nNoncontributory\n \nPhysical Exam:\nGeneral: Well-appearing, breathing comfortably\nRLE: Dressing c/d/i. Formal motor and sensory exam limited given \nnerve block is still in effect. Foot WWP.\n \nBrief Hospital Course:\nThe patient presented as a same day admission for surgery. The \npatient was taken to the operating room on ___ for Right \nankle corrective osteotomy and subtalar arthrodesis, 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 home 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. The patient is \nnonweightbearing in the right lower extremity, and will be \ndischarged on Aspirin for DVT prophylaxis. The patient will \nfollow up with Dr. ___ routine. A thorough discussion was \nhad with the patient regarding the diagnosis and expected \npost-discharge course including reasons to call the office or \nreturn to the hospital, and all questions were answered. The \npatient was also given written instructions concerning \nprecautionary instructions and the appropriate follow-up care. \nThe patient expressed readiness for discharge.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Docusate Sodium 100 mg PO BID \n3. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain \n5. Multivitamins 1 TAB PO DAILY \n6. Aspirin 325 mg PO daily x 3 weeks\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nRight ankle malunion, subtalar arthritis\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- Nonweightbearing 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 Aspirin 325mg daily for 3 weeks\n\nWOUND CARE:\n- Dressing must be left on until follow up appointment unless \notherwise instructed\n- Do NOT get dressing wet\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\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\nFOLLOW UP:\nPlease follow up as scheduled. You have an appointment with \n___, NP on ___ at 1pm in the ___ location. \nCall ___ if there are any changes to your schedule.\n\nPlease follow up with your primary care doctor regarding this \nadmission within ___ weeks and for and any new \nmedications/refills.\n \nFollowup Instructions:\n___\n" ]

[ "M13871", "M21541" ]

[ "M13871: Other specified arthritis, right ankle and foot", "M21541: Acquired clubfoot, right foot" ]

[]

[]

[ " \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:\nLLQ Pain \n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ female with remote history of left thigh STS s/p \nresection/XRT complicated by radiation osteitis, now s/p left \ntotal femur replacement by Dr. ___ on ___. She was \nre-admitted and underwent irrigation and debridement of a left \nthigh hematoma and ligation of an arteriole on ___. OR \ncultures grew MRSA and enterococcus and she was maintained on \nvancomycin per ID. She was discharged to rehab on ___. She was \nadmitted to an outside hospital with LLQ pain on ___. She was \ntreated with 3 days of IV cipro and flagyl. She was accepted in \ntransfer to ___ on ___ to facilitate multidisciplinary care.\n \nPast Medical History:\n-low back pain\n-hypercholesterolemia\n-hypertension\n-depression\n-osteomyelitis\n-sarcoma\n-___: Left leg high-grade soft tissue sarcoma s/p preop XRT\nand MAID chemotx and resection \n-___: pathologic fx Left femur s/p ORIF and bone graft, L total\nknee replacement\n-___: Broken screw removal with 1 screw replaced\n-___: ORIF with removal of hardware and replacement of femur\nnonunion with nail placement\n-___ Left thigh deep abscess hematoma and left hip abscess\ns/p I&D\n-___: bone bx: CoNS\n-___: reaccumulation of pus in thigh soft tissues\ncommunicating with intramedullary implant; washout and removal \nof 2 screws\n-resection of the entire left femur with total femur \nreplacement, hip hemiarthroplasty, and revision total knee \narthroplasty on ___\n-excision of benign pulmonary nodules on ___\n \nPhysical Exam:\nWell-appearing female in no acute distress.\nLLE: Incision c/d/i. \nJP intact with serosang output.\nMotor intact to ___. Sensation intact in saphenous,\nsural, SP, DP distributions. Palpable DP pulse. Skin warm and\nwell-perfused.\n \nPertinent Results:\n___ 06:21AM BLOOD WBC-3.4* RBC-2.89* Hgb-7.7* Hct-24.8* \nMCV-86 MCH-26.6 MCHC-31.0* RDW-16.9* RDWSD-53.1* Plt ___\n___ 06:21AM BLOOD Glucose-103* UreaN-4* Creat-0.8 Na-145 \nK-3.4 Cl-106 HCO3-29 AnGap-10\n___ 06:21AM BLOOD CRP-31.4*\n \nBrief Hospital Course:\nFollowing admission for diverticulitis at ___ \nfrom ___, the patient was transferred to ___ on ___ for \nconcern of left thigh wound infection. This wound had undergone \nsurgical debridement on ___ and OR cultures grew MRSA and \nenterococcus. She has been maintained on IV vancomycin since \nthat time. During this admission her wound was found to be \nbenign and well-healing. Her distal staples were removed and her \nproximal sutures were left in place. By the day of discharge, \nher left lower quadrant pain had resolved and she was cleared by \nphysical therapy for discharge home. She is continuing IV \nvancomycin therapy for a left thigh wound infection until \n___. \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n2. Acetaminophen 650 mg PO TID \n3. Atorvastatin 40 mg PO QPM \n4. Bisacodyl 10 mg PR QHS:PRN constipation \n5. Citalopram 20 mg PO DAILY \n6. Docusate Sodium 100 mg PO BID \n7. Enoxaparin Sodium 40 mg SC Q24H \n8. Lisinopril 5 mg PO DAILY \n9. Senna 17.2 mg PO QHS \n10. Miconazole Powder 2% 1 Appl TP TID:PRN rash \n11. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line \nflush \n12. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line \nflush \n13. TraZODone 25 mg PO QHS:PRN insomnia \n14. Vancomycin 750 mg IV Q 8H \n15. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n \nDischarge Medications:\n1. Acetaminophen 650 mg PO TID \n2. Atorvastatin 40 mg PO QPM \n3. Bisacodyl 10 mg PR QHS:PRN constipation \n4. Citalopram 20 mg PO DAILY \n5. Docusate Sodium 100 mg PO BID \n6. Enoxaparin Sodium 40 mg SC Q24H \n7. Lisinopril 5 mg PO DAILY \n8. Miconazole Powder 2% 1 Appl TP TID:PRN rash \n9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n10. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n11. Senna 17.2 mg PO QHS \n12. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line \nflush \n13. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line \nflush \n14. TraZODone 25 mg PO QHS:PRN insomnia \n15. Vancomycin 750 mg IV Q 8H \n16.wheelchair\nDx:Left total femur replacement \nPx: Good \nLength of need: 2 months \n20\" wheelchair with elevating leg rest \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\ndiverticulitis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nWBAT; Sutures to be removed in ___ days \nPhysical Therapy:\nActivity as tolerated Activity: Ambulate twice daily if patient \nable \nWith Assist: Walker\nLeft lower extremity: Full weight bearing\nNo active abduction, posterior hip precautions. \n\nTreatments Frequency:\n Wound care: \n Site: Incision \n Type: Surgical\n Dressing: Gauze - dry\n Comment: Change dressing as needed or leave open to air; \nsutures to be removed in ___ days\n \nFollowup Instructions:\n___\n" ]

[ "K5792", "D649", "E785", "F329", "Z85831", "Z86718", "I10" ]

[ "K5792: Diverticulitis of intestine, part unspecified, without perforation or abscess without bleeding", "D649: Anemia, unspecified", "E785: Hyperlipidemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "Z85831: Personal history of malignant neoplasm of soft tissue", "Z86718: Personal history of other venous thrombosis and embolism", "I10: Essential (primary) hypertension" ]

[ "D649", "E785", "F329", "Z86718", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nCiprofloxacin / Lipitor / Cortisone\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nNone\n\nattach\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 11:40AM BLOOD WBC-8.0 RBC-4.90 Hgb-15.1 Hct-44.8 MCV-91 \nMCH-30.8 MCHC-33.7 RDW-12.7 RDWSD-41.4 Plt ___\n___ 11:40AM BLOOD Neuts-80.8* Lymphs-9.5* Monos-8.4 \nEos-0.4* Baso-0.4 Im ___ AbsNeut-6.47* AbsLymp-0.76* \nAbsMono-0.67 AbsEos-0.03* AbsBaso-0.03\n___ 11:40AM BLOOD ___ PTT-28.0 ___\n___ 11:40AM BLOOD Glucose-138* UreaN-17 Creat-1.2 Na-139 \nK-4.3 Cl-100 HCO3-25 AnGap-14\n___ 11:40AM BLOOD proBNP-208\n___ 11:40AM BLOOD cTropnT-<0.01\n\nCTA CHEST ___\nLeft lower lobe segmental pulmonary embolism with associated \nleft lower lobe pulmonary infarct. No definite evidence of \nright heart strain, although echocardiogram is more sensitive. \n\nBILAT LOWER EXT VEINS Study Date of ___ \nNo evidence of deep venous thrombosis in the right or left lower \nextremity \nveins. \n\nCHEST (PORTABLE AP) Study Date of ___ \nLeft base opacity may be due to a combination of small pleural \neffusion and atelectasis, but consolidation due to infection is \nnot excluded. Consider dedicated PA and lateral views for \nbetter/further evaluation, if/when patient able. \n\nDISCHARGE LABS:\n===============\n___ 06:50AM BLOOD WBC-7.8 RBC-4.30* Hgb-13.5* Hct-39.2* \nMCV-91 MCH-31.4 MCHC-34.4 RDW-12.6 RDWSD-41.1 Plt ___\n___ 06:50AM BLOOD ___ PTT-71.6* ___\n___ 06:50AM BLOOD Glucose-152* UreaN-19 Creat-1.3* Na-137 \nK-4.7 Cl-103 HCO3-22 AnGap-12\n___ 06:50AM BLOOD Calcium-8.9 Phos-2.2* Mg-1.___RIEF HOSPITAL COURSE:\n====================\nMr. ___ is a ___ gentleman with history of DVT \nnot on AC, CAD s/p CABG ___, RCA stenting ___ c/b \nre-occlusion, PAD, HTN presents with acute on chronic SOB found \nto have segmental PE with LLL infarct. \n\nTRANSITIONAL ISSUES:\n====================\n[] Patient to continue on apixaban indefinitely given this is \nhis ___ unprovoked DVT. Please ensure that patient has ongoing \nprescriptions for this and clarify instructions for how to take \nthis medication properly. \n[] Ensure patient is up to date on age related cancer screening \n[] Hypercoagulability workup as an outpatient as this is his ___ \nunprovoked DVT/PE\n[] Re-assess patient's depression and anxiety. Consider starting \nan SSRI as outpatient rather than prn Ativan\n\nACUTE ISSUES:\n=============\n#Segmental pulmonary embolism\n#Hx DVT\nPresented with SOB and pleuritic chest pain with segmental PE on \nLLL. Negative CHF and ACS workup. Patient's pulmonary embolism \nseverity index (PESI) is low risk as he is hemodynamically \nstable, satting adequately on room air and is without chronic \ncardiopulmonary comorbidities. Interestingly, LENIs negative in\nED, and nothing in history pointing towards source of clots (no \ntrauma, recent surgery, immobilization). Unclear if he is up to \ndate about age-related cancer screening. Given prior history of \nDVT however, will likely need heparin transition to lifelong \noral anticoagulant as this is a second unprovoked thrombus. \nSuspect that DOAC may be better choice as patient was previously \non warfarin but may be difficult to adhere to.\n- Patient was started on heparin drip and transitioned to oral \napixaban. Started loading dose of apixaban on ___ - 10mg \nbid for 7 days, then maintenance dose of 5mg bid.\n- TI: ensure patient is up to date on age related cancer \nscreening \n- TI: hypercoagulability workup as outpatient as this is his ___ \nunprovoked DVT/PE\n\n#Depression/Anxiety\nRecent stressors include financial stress/access to food. Social \nwork was consulted but did not have time to meet with him prior \nto discharge. \n- Ativan 0.5mg QHS:prn for anxiety (home med confirmed via \n___ \n- TI: consider SSRI\n\nCHRONIC ISSUES:\n===============\n#CAD s/p CABG, PCI\n#PAD \n#HTN\n- continue home metoprolol tartrate 50 BID, lisinopril 40 QD\n- pt report not starting his statin. Restarted rosuvastatin 10 \nmg - gave him a physical script for this to refill this \nmedication\n- pt also not on aspirin. Restarted ASA 81mg and sent him home \nwith a physical script for this \n\n# GERD\n- continue home omeprazole\n\n# BPH\n- continue home finasteride\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Tartrate 50 mg PO BID \n2. Lisinopril 40 mg PO DAILY \n3. Omeprazole 20 mg PO DAILY \n4. Finasteride 5 mg PO DAILY \n5. LORazepam 0.5 mg PO QHS:PRN anxiety \n6. Sildenafil 50 mg PO PRN 1 hour before sex \n7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN cp \n\n \nDischarge Medications:\n1. Apixaban 10 mg PO BID Duration: 7 Days \nRX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth twice a day \nDisp #*70 Tablet Refills:*0 \n2. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*60 \nTablet Refills:*0 \n3. Rosuvastatin Calcium 10 mg PO QPM \nRX *rosuvastatin 10 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*2 \n4. Finasteride 5 mg PO DAILY \n5. Lisinopril 40 mg PO DAILY \n6. LORazepam 0.5 mg PO QHS:PRN anxiety \n7. Metoprolol Tartrate 50 mg PO BID \n8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN cp \n9. Omeprazole 20 mg PO DAILY \n10. Sildenafil 50 mg PO PRN 1 hour before sex \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\nSegmental pulmonary embolism complicated by left lower lobe lung \ninfarction \n\nSECONDARY DIAGNOSIS\nHistory of DVT\nDepression/Anxiety\nCAD, PAD\nHTN\nGERD\nBPH\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 privilege caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n- You were admitted to the hospital with shortness of breath.\n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- You had imaging of your chest which showed you had a blood \nclot in your lung arteries. This was likely what was causing \nyour shortness of breath and chest pain. This will take time to \nstart feeling better \n- You were started on a medication called apixaban to help \nprevent further clot formation which you need to take TWICE \nDAILY EVERYDAY! For the first week, please take 2 pills twice \ndaily. After the first week please take 1 pill twice a day.\n- It is very important that you continue on this medication for \nthe long term unless you are told to stop by another doctor.\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, \n\nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "I2693", "Z86718", "Z7902", "F3289", "F419", "I2510", "Z951", "I10", "N400", "T82855A", "Y831", "K219", "Z87891", "K589", "G8929" ]

[ "I2693: Single subsegmental pulmonary embolism without acute cor pulmonale", "Z86718: Personal history of other venous thrombosis and embolism", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "F3289: Other specified depressive episodes", "F419: Anxiety disorder, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "I10: Essential (primary) hypertension", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "T82855A: Stenosis of coronary artery stent, initial encounter", "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", "K219: Gastro-esophageal reflux disease without esophagitis", "Z87891: Personal history of nicotine dependence", "K589: Irritable bowel syndrome without diarrhea", "G8929: Other chronic pain" ]

[ "Z86718", "Z7902", "F419", "I2510", "Z951", "I10", "N400", "K219", "Z87891", "G8929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nHumira / Remicade / imuron\n \nAttending: ___.\n \nChief Complaint:\nFailure to thrive\n \nMajor Surgical or Invasive Procedure:\nileostomy reversal ___\n\n \nHistory of Present Illness:\n___ year old woman ___ UC s/p total abdominal colectomy w/ end\nileostomy, c/b incarcerated parastomal hernia s/p hernia repair,\nproctectomy, IPAA, diverting loop ileostomy, presenting now with\nfailure to thrive. Ms. ___ was recently discharged on ___\nafter a 2 week admission recovering from her last operation.\nSince returning home, she reports continued fatigue, poor PO\nintake, and feeling subjectively warm without objective fevers.\nShe states that she has had difficulty managing her ostomy\nappliance, which leaks frequently. She has developed significant\nlocal skin irritation as a result. She has also had difficulty\nmanaging her wound vac. She admits to not recording her \nileostomy\noutput, though she believes her oral intake has been inadequate\nto make up for her losses. She returns to ___ given the\ncombination of these complaints. Colorectal surgery was \nconsulted\nfor further care. \n\nUpon initial assessment by colorectal surgery, Ms. ___\ndenies shortness of breath, vomiting, chest pain, significant\nabdominal pain, or dysuria. She endorses subjective fevers, mild\nnausea, and small volume stool output per anus. \n\n \nPast Medical History:\nPMH: \n-Ulcerative Colitis, dx'd at age ___ yrs ago); intolerant to \nRemicade & Humira, off tx for ___ yrs until ___ when flared. \nPSH: \n-None \n\n \nSocial History:\n___ ___ ___, 4 small children at home, married/supportive \nhusband, supportive mother\n\n \nPhysical Exam:\nGEN: lying in bed, NAD, AOx3\nCV: RRR\nPULM: no respiratory distress\nABD: soft, mildly distended, mildly tender around incisions. \nwound vac in place.\nEXT: no edema\nNEURO: grossly intact\nWOUND: Regular VAC\n\n \nPertinent Results:\nAdmission\n\n___ 08:46PM BLOOD WBC-6.3 RBC-3.95# Hgb-9.9*# Hct-32.7*# \nMCV-83 MCH-25.1* MCHC-30.3* RDW-16.8* RDWSD-50.0* Plt ___\n___ 08:46PM BLOOD Neuts-76.7* Lymphs-11.4* Monos-8.1 \nEos-3.0 Baso-0.5 Im ___ AbsNeut-4.86 AbsLymp-0.72* \nAbsMono-0.51 AbsEos-0.19 AbsBaso-0.03\n___ 08:46PM BLOOD Glucose-130* UreaN-16 Creat-0.7 Na-133 \nK-5.1 Cl-93* HCO3-20* AnGap-20*\n___ 08:46PM BLOOD ALT-66* AST-60* AlkPhos-250* TotBili-0.7\n___ 08:46PM BLOOD Albumin-4.2 Calcium-9.6 Phos-5.5* Mg-1.9\n\nDischarge\n\n___ 06:05AM BLOOD WBC-5.3 RBC-3.26* Hgb-8.2* Hct-27.3* \nMCV-84 MCH-25.2* MCHC-30.0* RDW-16.1* RDWSD-49.4* Plt ___\n___ 06:05AM BLOOD Plt ___\n___ 06:05AM BLOOD Glucose-91 UreaN-10 Creat-0.6 Na-141 \nK-4.7 Cl-99 HCO3-25 AnGap-17*\n___ 06:05AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.7\n \nBrief Hospital Course:\nMrs. ___ is a ___ year old female with past medical history \nof ulcerative colitis s/p lap total abdominal colectomy w/ end \nileostomy and recent parastomal hernia repair, proctectomy, \nIPAA, diverting loop ileostomy. She was admitted due for \ndehydration and failure to thrive. Patient underwent a ileostomy \nreversal on ___. She tolerated the procedure well without \ncomplications (Please see operative note for further details). \nAfter a brief and uneventful stay in the PACU, the patient was \ntransferred to the floor for further post-operative management.\nNeuro: Pain was well controlled.\nCV: Vital signs were routinely monitored during the patient's \nlength of stay. \nPulm: The patient was encouraged to ambulate, sit and get out of \nbed, use the incentive spirometer, and had oxygen saturation \nlevels monitored as indicated.\nGI: The patient was initially kept NPO after the procedure. The \npatient was later advanced to and tolerated a regular diet at \ntime of discharge.\nGU: Patient had a Foley catheter that was removed at time of \ndischarge. Urine output was monitored as indicated. At time of \ndischarge, the patient was voiding without difficulty.\nID: The patient's vital signs were monitored for signs of \ninfection and fever. \nHeme: The patient had blood levels checked post operatively \nduring the hospital course to monitor for signs of bleeding. The \npatient had vital signs, including heart rate and blood \npressure, monitored throughout the hospital stay.\nOn ___, the patient was discharged to home. At discharge, \nshe was tolerating a regular diet, passing flatus, stooling, \nvoiding, and ambulating independently. She will follow-up in the \nclinic in ___ weeks. This information was communicated to the \npatient directly prior to discharge.\nPost-Surgical Complications During Inpatient Admission:\n[ ] Post-Operative Ileus resolving w/o NGT\n[ ] Post-Operative Ileus requiring management with NGT\n[ ] UTI\n[ ] Wound Infection\n[ ] Anastomotic Leak\n[ ] Staple Line Bleed\n[ ] Congestive Heart failure\n[ ] ARF\n[ ] Acute Urinary retention, failure to void after Foley D/C'd\n[ ] Acute Urinary Retention requiring discharge with Foley \nCatheter\n[ ] DVT\n[ ] Pneumonia\n[ ] Abscess\n[x] None\nSocial Issues Causing a Delay in Discharge:\n[ ] Delay in organization of ___ services\n[ ] Difficulty finding appropriate rehab hospital disposition.\n[ ] Lack of insurance coverage for ___ services\n[ ] Lack of insurance coverage for prescribed medications.\n[ ] Family not agreeable to discharge plan.\n[ ] Patient knowledge deficit related to ileostomy delaying \ndispo\n[x] No social factors contributing in delay of discharge.\n \nDischarge Medications:\n1. LOPERamide 2 mg PO Q12H \nYou may discontinue this medication if you become constipated or \nbloated. \nRX *loperamide [Anti-Diarrhea] 2 mg 1 tablet by mouth twice \ndaily Disp #*30 Tablet Refills:*0 \n2. LORazepam 1 mg PO ONCE Before VAC changes Duration: 1 Dose \nRX *lorazepam 1 mg 1 mg by mouth Once Disp #*12 Tablet \nRefills:*0 \n3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nDo not drive or operate heavy machinery while taking this \nmedication \nRX *oxycodone 5 mg ___ tablet(s) by mouth Every 4 hours Disp \n#*60 Tablet Refills:*0 \n4. Psyllium Wafer 2 WAF PO BID \nRX *psyllium 2 packet(s) by mouth Every 12 hours Disp #*30 \nPacket Refills:*0 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___:\nDehydration\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\nYou were admitted for dehydration and ultimately for reversal of \nyour ileostomy ___. Surgery was uncomplicated and you did \nwell. You had wound vac placed during surgery on your 4 \nabdominal wounds, and this was changed postoperatively on \n___. It will continue to be changed by the ___ 3x weekly. \n\nDiet: \nYou may resume your normal diet. It is important that you drink \nplenty of water to stay hydrated.\n\nWounds:\n___ nursing will continue 3X weekly vac changes for your 4 \nabdominal wounds. You should keep dry gauze in the crease above \nyour pubic region to prevent too much moisture from accumulating \nthere and causing a yeast infection.\n\nMedications:\nYou were given narcotic pain medications on your admission, and \nthese may be used postoperatively as needed for abdominal pain \nor pain associated with your vac changes. Do not drive or \noperate heavy machinery while taking these medications. \n\nYou were started on Imodium (Loperamide) during your admission \nto help slow down your bowel movements. If you become bloated or \nconstipated, or worry that you are not passing bowel movements \nfrequently enough, you may discontinue this medication.\n\nBowel Movements:\nYou may experience some frequency and watery bowel movements. \nThis is normal and expected after removal of your colon and an \nileo-anal pouch. You were given Imodium (Loperamide) as an \ninpatient to help slow these bowel movements down. If you feel \nthat your dose should be increased, please do not hesitate to \ncontact our clinic and we will provide further instructions. \n\nIf you experience any new symptoms that concern you, or have any \nquestions, please contact our clinic at ___. If you \nbelieve you have an emergency please seek emergent medical \nattention at the nearest Emergency Deparment.\n \nFollowup Instructions:\n___\n" ]

[ "K9419", "R627", "E860", "L989", "Y833", "Y929", "Z9049" ]

[ "K9419: Other complications of enterostomy", "R627: Adult failure to thrive", "E860: Dehydration", "L989: Disorder of the skin and subcutaneous tissue, unspecified", "Y833: Surgical operation with formation of external stoma 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", "Z9049: Acquired absence of other specified parts of digestive tract" ]

[ "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\n\"aches all over\"\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\nMr. ___ is a ___ male with history of IVDU including \nmethamphetamine use, cocaine use and opiate use disorder, \npresents with complaints of generalized aches and pains, fever, \nand cough.\n\nPatient has h/o IVDU for over ___ years. He has been in rehab \nbefore and relapsed. He has been evaluated in our ED for c/o SI \nand was seen by psych, but did not meet inpatient criteria at\nthat time. Patient continues to abuse drugs, and most recently \nused meth and IV heroine on the day prior to admission.\n\nHe is somewhat of a poor historian in the sense that he is not \ncooperative with answering questions, will offer little \nexplanation, and often refuses to elaborate. He does tell me \nthat\naprx 3 days prior to admission, he started noticing generalized \naches and pain, headache, chills and body sweats, and cough \nproductive of yellow nonbloody sputum. He also had 2 episodes of \nnonbloody loose stool over the last 24 hrs. He presented to the \nED for further evaluation.\n\nIn the ED: \n- He was febrile up to 100.8, tachycardic in the low 100s, \nnormotensive. Satting well on room air.\n- Labs remarkable for WBC 3.6, Hgb 13.1. Lactate 0.9. Urine \nbland. Flu screen negative \n- Serum aspirin, EtOH, seen medicine, tricyclics negative.\n- Urine tox screen positive for amphetamines.\nChest x-ray showed retrocardiac air bronchograms suggestive of \npossible pneumonia.\n- 3 sets of blood cultures were obtained as well as a urine \nculture. The patient was given vancomycin and cefepime, along \nwith 2 L IV fluids.\n- ___ medicine was asked to admit the patient for \nevaluation of sepsis due to possible pneumonia as well as \nconcern for bacteremia/endocarditis in the setting of IV drug \nuse.\n\nUpon my evaluation, patient describes events as noted above. He \nis complaining of generalized aches and pains all over, ongoing \nheadache. He denies any rash, chest pain or shortness of \nbreath, nuchal rigidity, urinary symptoms such as hematuria or \npain. He\ndid endorse a couple of loose bowel movements without blood. He \nendorses the ongoing cough occasionally productive of yellow \nnonbloody sputum. Has never had symptoms similar to this \nbefore.\n\nROS: Pertinent positives and negatives as noted in the HPI. All \nother systems were reviewed and are negative. \n \nPast Medical History:\nHepatitis C, diagnosed years ago, never been on treatment.\nPrior suicidal ideation, evaluated here by psych. \nMethamphetamine use disorder\nCocaine use disorder\nOpiate use disorder in early remission\nPosttraumatic stress disorder\nAntisocial personality disorder (per psych).\n \nSocial History:\n___\nFamily History:\nReviewed and found to be not relevant to this illness/reason for \nhospitalization.\n \nPhysical Exam:\nVITALS: Afebrile and vital signs stable\nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \n\nCV: rrr, no murmur, no S3, no S4. No JVD.\nRESP: trace crackles at bilateral bases, no increased work of \nbreathing.\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel \nsounds present. \nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, strength grossly full \nand symmetric bilaterally in all limbs\nSKIN: has multiple track marks ___ upper extremities. Has area of \nerythema with induration on R inner forearm, not sharply \ndemarcated, mildly tender to palpation.\nNEURO: Alert, face symmetric\nPSYCH: appropriate affect\n \nPertinent Results:\nWBC 3.6, Hgb 13.1, Plt 190\nNa 134, K 4.4, Cl 95, bicarb 27, BUN 11, Crt 0.6\nLactate 0.9. \nUrine bland.\nSerum aspirin, EtOH, seen medicine, tricyclics negative.\n\nUrine tox screen positive for amphetamines.\n\nMicro: \n___ BLOOD CULTURE Blood Culture, Routine-PENDING \nNGTD\n___ BLOOD CULTURE Blood Culture, Routine-PENDING \nNGTD\n___ BLOOD CULTURE Blood Culture, Routine-PENDING \nNGTD\n___ BLOOD CULTURE Blood Culture, Routine-PENDING \nNGTD\n___ BLOOD CULTURE Blood Culture, Routine-PENDING \nNGTD\n\n___ 1:50 am URINE\n\n URINE CULTURE (Preliminary): \n CORYNEBACTERIUM UREALYTICUM SP.. 10,000-100,000 CFU/mL. \n\n PRESUMPTIVE IDENTIFICATION. test result performed by \nSensititre. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n CORYNEBACTERIUM UREALYTICUM SP.\n | \nERYTHROMYCIN---------- =>8 R\nGENTAMICIN------------ <=2 S\nVANCOMYCIN------------ <=1 S\n\nCXR ___: There are retrocardiac air bronchograms which can be \nseen in the setting of an infectious consolidation, difficult to \ndiscern in the absence of a lateral view. \n\n___ 01:30PM BLOOD WBC-3.4* RBC-4.78 Hgb-13.2* Hct-40.0 \nMCV-84 MCH-27.6 MCHC-33.0 RDW-13.1 RDWSD-40.0 Plt ___\n___ 01:30PM BLOOD ___ PTT-30.2 ___\n___ 01:30PM BLOOD Glucose-96 UreaN-12 Creat-0.7 Na-137 \nK-4.3 Cl-96 HCO3-31 AnGap-10\n___ 01:30PM BLOOD ALT-41* AST-24 LD(LDH)-209 AlkPhos-61 \nTotBili-0.2\n___ 01:30PM BLOOD Albumin-3.6 Calcium-9.0 Phos-3.0 Mg-1.8\n___ 01:30PM BLOOD HCV VL-PND\n___ 03:20PM BLOOD HIV NUCLEIC ACID TEST (NAT)-PND\n \nBrief Hospital Course:\nMr. ___ is a ___ with a history of opiate abuse admitted with \nSSTI of the RUE. \n\n# Sepsis, secondary to RUE SSTI: Exam well appearing. Patient \nsays improving. No purulence. No e/o deep space infection of \nfluid collection on CT. CRP and ESR are within normal limits, \nmaking osteomyelitis unlikely. TTE without vegetations or\nvalvular issues. HR, fever, WBC now resolved. \n- Changed vanco/CefePIME to cephalexin and doxycycline (wound \nnot c/w MRSA, but at risk), plan for 5 more days for total of 7 \ndays\n\n# Mild hypochloremic hyponatremia: Resolved. \n\n# Mild normocytic anemia. Aprx at baseline (hgb 13.4 in ___. \nNo signs of active bleeding. Stable on serial crit testing.\n\n# Hepatitis C, reportedly diagnosed years ago, never been on \ntreatment: HCV Ab positive, added on HCV viral load which is \nstill pending at time of discharge\n\n# HIV discordant results - reactive but not positive. Notified \nby path lab that HIV testing is reactive, but not positive, as \nfirst test is weakly reactive, and confirmation test negative. \n___ be interference or cross reactively, per path resident. \nOptions are to repeat serology in ___ weeks or perform NAAT. \nGiven question of patient compliance, sent HIV PCR / NAT which \nis pending still at time of discharge.\n\n# Polysubstance abuse: Methamphetamine use, Cocaine use \ndisorder, Opiate use disorders. \n# Posttraumatic stress disorder\n# Antisocial personality disorder (per psych).\n- Completed methadone taper, last day ___.\n- Discussed addiction psych consult - patient is not interested \nin this or suboxone at this time. \n- Social work consult for assistance with discharge planning - \npatient declined this as well\n\nTransitional: \n[ ] HIV NAT testing pending at time of discharge. may benefit \nfrom repeat HIV testing in a few weeks. \n[ ] HCV viral load pending on discharge. will need referral \nafter discharge to discuss treatment options including for his \nopiate use disorder\n\n> 30 minutes spent on discharge planning, counseling and \ncoordination of care. \n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. Cephalexin 500 mg PO Q6H \nRX *cephalexin [Keflex] 500 mg 1 capsule(s) by mouth every six \n(6) hours Disp #*20 Capsule Refills:*0 \n2. Doxycycline Hyclate 100 mg PO Q12H \nRX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every twelve \n(12) hours Disp #*10 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nComplicated Cellulitis, Right Upper Extremity\nOpiate Use Disorder with opiate dependence\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 fevers and body aches. We \ntreated you for a complicated skin infection in your right arm. \nThis will require continued course of antibiotics on discharge \nas well as dressing changes and a check-in with your PCP for ___ \ndressing change before you've finished your course of \nantibiotics. \n\nWe have arranged for you to have a follow up appointment in \nPrimary Care clinic as below. It is important that you keep this \nappointment to follow up on:\n1. your skin infection, to make sure it's responding to \nantibiotics and hasn't developed into an abscess which would \nrequire drainage\n2. follow up on your HIV testing which was inconclusive but not \npositive. You will need repeat testing in a few weeks for this. \n3. follow up on your Hepatitis C. We have repeated your viral \nload test to check on how active it is, but the results are \nstill pending. You will need to discuss these results in clinic \nand discuss any treatment options if it is active. \n4. We encourage you to continue to seek out support for your \nopiate use disorder. There are treatment options available which \nwe urge you to re-explore with your doctor in primary care \nclinic. \n\nIt was a pleasure taking care of you. We wish you all the best!\n\nYour ___ team. \n \nFollowup Instructions:\n___\n" ]

[ "A419", "L03113", "E871", "F1120", "F1410", "F1510", "B182", "F4310", "F602", "D649", "R75", "F17210" ]

[ "A419: Sepsis, unspecified organism", "L03113: Cellulitis of right upper limb", "E871: Hypo-osmolality and hyponatremia", "F1120: Opioid dependence, uncomplicated", "F1410: Cocaine abuse, uncomplicated", "F1510: Other stimulant abuse, uncomplicated", "B182: Chronic viral hepatitis C", "F4310: Post-traumatic stress disorder, unspecified", "F602: Antisocial personality disorder", "D649: Anemia, unspecified", "R75: Inconclusive laboratory evidence of human immunodeficiency virus [HIV]", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]

[ "E871", "D649", "F17210" ]

[]

[ " \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:\nConfusion\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nIn brief, this is an ___ year old man with a PMH significant for \nhypothyroidism and recent surgery for spinal spinal stenosis on \n___ (c/b post-surgical pneumonia, for which he is currently \non a 5 day course of ciprofloxacin) who is presenting from his \nnursing home for concerns of hyponatremia and new onset tremors. \nBy report, the nursing facility noticed that his sodium labs \nwere downtrending ___ yesterday and 127 today) and some whole \nbody shaking that has since resolved. They also noted a low iron \nof 22. He is confused about why he is in the hospital, but \ndescribes that the shaking is a feeling of whole body weakness \nthat he has been having since his surgery. He denies headache, \nSOB, CP, abd pain, or feelings of weakness now. His family is \npresent and states that he is in the hospital today because he \nis confused and this is not his baseline. Report from nursing \nhome that he fell out of bed last night and was found by staff. \nThey do not know if he hit his head or lost consciousness \n\nThus far in hospitalization, patient has remained afebrile with \nnon-focal neuro exam. Sodium 125. Urine osm 387, Urine Na 84. CT \nhead with no acute intracranial process. CXR with no new \nconsolidation. \n\nOn the floor, patient denies any pain, shortness of breath, \ncough, or sputum production. He is alert and oriented to person, \nbut he believes that he is in the hospital for surgical \nfollow-up. He is intermittently agitated, and has pulled out his \nIV. \n\n \nPast Medical History:\n hypothyroidism \n BPH \n HTN, but not on any medications\n R hip replacement (___)\n \nSocial History:\n___\nFamily History:\n \n Father died during ___. Mother died of \nunclear causes. \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nVS - 98.4 155/73 83 18 100RA\nGeneral: Alert, oriented x2, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, \nneck supple, JVP not elevated, no LAD \nCV: Regular rate and rhythm, normal S1 + S2, ___ \ncrescendo-decrescendo murmur best heard at ___, no rubs or \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 \nBack: surgi-strips in place with no surround erythema or \ninduration or warmth around lumbar spine surgical site \nGU: foley \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nNeuro: CNIII-XII intact, ___ strength upper/lower extremities, \ngrossly normal sensation, 2+ reflexes bilaterally, gait \ndeferred. \n\nDISCHARGE PHYSICAL EXAM\n=======================\nVS - 98.4 98.3 | ___ | ___ | 20 | 98-100%RA\nGeneral: well appearing, NAD, AOx3 \nHEENT: MMM, EOMI \nNeck: no JVD, supple neck \nCV: rrr, ___ crescendo/decrescendo murmur heard best at the RUSB \n\nLungs: CTAB, breathing comfortably \nAbdomen: soft, nontender, nondistended, no HSM appreciated \nGU: no foley\nExt: warm and well perfused, no edema \nNeuro: grossly normal \nVS - 98.4 98.3 | ___ | ___ | 20 | 98-100%RA\nGeneral: well appearing, NAD, AOx3 \nHEENT: MMM, EOMI \nNeck: no JVD, supple neck \nCV: rrr, ___ crescendo/decrescendo murmur heard best at the ___ \n\nLungs: CTAB, breathing comfortably \nAbdomen: soft, nontender, nondistended, no HSM appreciated \nGU: no foley\nExt: warm and well perfused, no edema \nNeuro: grossly normal \n \nPertinent Results:\nADMISSION LABS\n===============\n___ 08:22PM BLOOD WBC-8.1 RBC-3.00* Hgb-9.5* Hct-28.6* \nMCV-95 MCH-31.7 MCHC-33.2 RDW-13.2 RDWSD-46.8* Plt ___\n___ 08:22PM BLOOD Neuts-55 Bands-0 ___ Monos-8 Eos-4 \nBaso-2* Atyps-2* ___ Myelos-0 AbsNeut-4.46 AbsLymp-2.51 \nAbsMono-0.65 AbsEos-0.32 AbsBaso-0.16*\n___ 08:22PM BLOOD Hypochr-NORMAL Anisocy-NORMAL \nPoiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL\n___ 08:22PM BLOOD Glucose-119* UreaN-12 Creat-0.6 Na-125* \nK-4.6 Cl-90* HCO3-25 AnGap-15\n___ 08:22PM BLOOD Calcium-8.7 Phos-3.1 Mg-2.0\n___ 08:22PM BLOOD TSH-2.2\n___ 08:22PM BLOOD Osmolal-259*\n___ 05:05AM BLOOD Cortsol-7.6\n\nMICRO\n===============\nBCx pending\nUCx negative\n\nSTUDIES\n===============\nCT Head non-contrast (___) \nNo acute intracranial process \n\nCXR ___\nIrregular left perihilar opacities are likely pneumonia given \nthe clinical symptoms, CT is recommended for further evaluation \n\nDISCHARGE LABS\n===============\n___ 05:55AM BLOOD WBC-10.6* RBC-3.15* Hgb-9.7* Hct-31.5* \nMCV-100* MCH-30.8 MCHC-30.8* RDW-13.5 RDWSD-49.7* Plt ___\n___ 05:55AM BLOOD Glucose-100 UreaN-21* Creat-0.6 Na-135 \nK-5.3* Cl-95* HCO3-29 AnGap-16\n___ 05:55AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.___RIEF SUMMARY STATEMENT:\nPatient is a ___ with a PMHx of hypothyroidism and recent \nposterior L4-L5 laminectomy and fusion complicated by PNA who \npresents from rehab with altered mental status and hyponatremia. \nLabs consistent wit SIADH, and given time frame, the likely \ncause was the recent spine surgery/PNA. Considered contribution \nof duloxetine to hyponatremia in this elderly man, but this \neffect of SSRIs tends to be found soon after initiation of \nmedication (and patient was started 6 months ago). Hyponatremia \n(and mental status) responded well to fluid restriction and \nincreased solute (Ensure shakes). Of note, he developed mild \nleukocytosis & thrombocytosis in the hospital, with CXR showing \ninfiltrate at left hilar region; patient was started on a 7-day \ncourse of Cefpodoxime / Azithromycin. At time of discharge, his \nbreathing was stable and his mental status was at baseline.\n\nACTIVE ISSUES:\n# HYPONATREMIA:\nWas likely SIADH in the setting of recent surgery & pneumonia. \nOn admission, Urine osm 387, urine Na 84, consistent with SIADH. \nHe was placed on a 1L fluid restriction & BID salt tabs, with \ngradual improvement in sodium & his mental status. Renal was \nconsulted, and recommended switching salt tabs to Ensure for \nbetter solute. Sodium normalized & fluid restriction was lifted. \nContinued home Duloxetine, although this has been known to cause \nSIADH in the elderly. At discharge, he was off salt tabs & fluid \nrestrictions, and was at baseline mental status. \n\n# Toxic metabolic encephalopathy \nOn admission, patient was confused, likely due to hyponatremia. \nNo initial sign of infection, no other medication changes or \ningestions. With urinary symptoms reported (and possible \ncontribution to altered mental status), sent UA and UCx, though \nlow clinical suspicion for infection. Urine culture was \nnegative. At time of discharge, mental status was at baseline. \n\n# Pneumonia \nDeveloped fever and consolidation during recent hospital stay \nand was started on a 7 day course of ciprofloxacin. Given \nclinical status currently (no fever, respiratory sx, \nleukocytosis, or CXR changes) along with possible contribution \nof cipro to change in mental status (as well as the relatively \npoor penetration of cipro for respiratory illnesses), stopped \ncipro on admission at this time. Portable CXR on ___ with \npersistent perihilar opacities, c/w pneumonia, but largely \nunchanged from prior imaging. Subjective cough, though \nunproductive and unchanged. No fever during admission. \nTechnically meets criteria for HCAP, but clinical picture does \nnot warrant empiric HCAP coverage at this time. Initiated CAP \nabx regimen on ___ and monitor clinically. Remained stable, so \nwas discharged on cefpodoxime 200mg daily x7days ___- ) & \nAzithromycin x5 days.\n\n# Tremor\nFine tremor of outstretched hands on exam, attributed to \npost-surgical weakness. Possible contribution from hyponatremia. \nNon-focal neuro exam otherwise. ___ evaluated and recommended \nrehab.\n\n# L5 cord compression secondary to disc herniation: Stable, no \nchanges made.\n\n# BPH: Urinary frequency and urgency reported. Continued Flomax \nand dutasteride \n\n# Hypothyroidism: Admission TSH wnl. Continued home \nlevothyroxine \n\n# ?Depression: Unclear if pt has diagnosis of depression, though \nhas duloxetine on home medication list. Possible contribution of \nduloxetine to SIADH, but has been on medication for ~6months, \nwhich does not fit with timeline of presentation. Continued home \nduloxetine and Na improved, as above.\n\n# Normocytic anemia: Stable from last discharge\n\nTransitional issues:\n# ANTIBIOTICS: Patient should complete 7-day course of \nCefpodoxime Proxetil 200 mg PO/NG Q12H (___) & complete \nAzithromycin course with 250mg daily on ___\n# HYPONATREMIA: Resolved. Recommend twice weekly lab draws to \nmonitor sodium. If within normal limits for 2 weeks, can resume \nregular schedule for follow-up appointments.\n# HYPERKALEMIA: K was 5.3 at time of discharge. Please recheck \nlytes within 5 days of discharge, and alert MD if ___. ___ be \nfrom Azithromycin\n# THROMBOCYTOSIS: Patient had platelets of 581 at time of \ndischarge. Please recheck within 5 days of hospital discharge, \nand notify MD if >600. Patient would need further outpatient \nevaluation if still elevated.\n# No need for ongoing fluid restriction, but would encourage \ndaily supplement shake (e.g Ensure)\n# SSRI's can cause hyponatremia, commonly in the elderly. Did \nnot initiate taper of duloxetine while Mr. ___ was \nhospitalized, though patient and family do not believe the \nmedicine is helpful. Would recommend outpatient provide revisit \nthe need for SSRI. \n# Patient was hypertensive during admission, and was started on \namlodipine 5mg daily. SBPs since starting amlodipine have ranged \n140s-160s. Antihypertensive regimen should be revisited by \noutpatient provider. \n# Pt should have repeat chest xray in 6 weeks to look for \nresolution of ?pneumonia. If perihilar opacities are still \npresent, would recommend CT imaging to further characterize. \nPatient aware of possible need for CT.\n\n#Full code\n#EMERGENCY CONTACT HCP: \n ___, Cell phone: ___ \n wife ___ is alt ___ \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Docusate Sodium 100 mg PO BID \n3. DULoxetine 60 mg PO DAILY \n4. dutasteride 0.5 mg oral DAILY \n5. Levothyroxine Sodium 75 mcg PO DAILY \n6. Tamsulosin 0.4 mg PO QHS \n7. Senna 8.6 mg PO BID:PRN constipation \n8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n9. Ciprofloxacin HCl 500 mg PO Q12H \n\n \nDischarge Medications:\n1. amLODIPine 5 mg PO DAILY \n2. Azithromycin 250 mg PO Q24H \n3. Cefpodoxime Proxetil 200 mg PO Q12H \n4. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever \n5. Docusate Sodium 100 mg PO BID \n6. DULoxetine 60 mg PO DAILY \n7. dutasteride 0.5 mg oral DAILY \n8. Levothyroxine Sodium 75 mcg PO DAILY \n9. Senna 8.6 mg PO BID:PRN constipation \n10. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis: Syndrome of Inappropriate Antidiuretic \nHormone\n\nSecondary Diagnoses: Tremor, Pneumonia, L5 cord compression, \nbenign prostatic hyperplasia, depression, normocytic anemia\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to ___ \nbecause your family was concerned that you were not behaving \nlike yourself. Your care team looked into many possible reasons \nwhy this might have happened. We believe that the reason this \nhappened is related to how your body processes salt. In some \npeople, major illness or surgery (like your spine surgery), \ncauses the hormone that controls salt and water levels to work \nincorrectly. The treatment for this is to limit the amount of \nwater that you drink. When we limited your water intake, your \nsalt returned to normal levels and your family reported that you \nwere back to yourself. We monitored your salt for one day \nwithout limiting your water intake, and your salt level remained \nnormal. \n\nYou also had a recurrence of your pneumonia, so you were started \non oral antibiotics to treat this.\n\nWe wish you all the best,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "E222", "J189", "G92", "E875", "D6959", "D649", "R251", "E039", "Z9181", "N401", "R350", "R3915", "Z96641", "Z981", "F329", "I10" ]

[ "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "J189: Pneumonia, unspecified organism", "G92: Toxic encephalopathy", "E875: Hyperkalemia", "D6959: Other secondary thrombocytopenia", "D649: Anemia, unspecified", "R251: Tremor, unspecified", "E039: Hypothyroidism, unspecified", "Z9181: History of falling", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "R350: Frequency of micturition", "R3915: Urgency of urination", "Z96641: Presence of right artificial hip joint", "Z981: Arthrodesis status", "F329: Major depressive disorder, single episode, unspecified", "I10: Essential (primary) hypertension" ]

[ "D649", "E039", "F329", "I10" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nDemerol / Penicillins / ampicillin / Iodine and Iodide \nContaining Products / pseudoephedrine / Gadavist / oxaliplatin\n \nAttending: ___.\n \nChief Complaint:\nOxliplatin desensitization\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ is a ___ year old woman with recurrent,\nmetastatic rectal adenocarcinoma sp resection of isolated\npulmonary met and hepatic mets, currently receiving adjuvant\nmodified FOLFOX who is admitted for oxaliplatin desensitization\nas part of C4D15 mFOLFOX. \n\nMrs ___ began adjuvant ___ with FOLFOX ___. She\ncompleted 4 cycles with oxaliplatin-induced neuropathy but no\nreactions. When she had progression of disease, she restarted\nFOLFOX ___. On C1D15 (___) she experienced sudden onset\nchest pain radiating to her back 4 hours after beginning\noxaliplatin. She received benadryl and hydrocortisone without\nsignificant improvement. Ativan and morphine were mildly \nhelpful.\nShe was sent to the ED. EKG/CTA were unrevealing. She observed\nfor a few hours and discharged. \n\nShe saw Dr ___ ___. Skin testing was positive for oxaliplatin\nhypersensitivity, so she was recommended for 12-step/3-bag\nprotocol. She received desensitization protocol with C2D1 \n(___),\nC2D15 (___), C3D1 (___), C3D15 (___), and C4D1 (___) which\nshe tolerated well. Please note, C4 was delayed a week due to\nthrombocytopenia and neuropathy. \n\nSince her last treatment she has been in her usual state of\nhealth. She alternates between constipation and diarrhea. Last\nloose stool, per ostomy, was last night. No abdominal pain or\nnausea and appetite is OK. She also notes persistent neuropathy,\nworsened right after ___. No FC. No URTI symptoms. No CP SOB \nor\ncough. No dysuria. No new rashes. She took cetirizine last night\nand this morning.\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:\nPAST ONCOLOGIC HISTORY:\nONCOLOGIC HISTORY:\n- ___: colonoscopy for workup of BRBPR revealed a rectal mass\nwhich was biopsied and revealed rectal adenocarcinoma, pMMR\n- ___: MRI of rectum showed a low to mid rectal tumor\nextending 4.8 cm with invasion through the muscularis propria \nand\nloss of the fat plane between the right lateral rectal wall and\nthe levator ani muscle which is asymmetric and thickened with\nenhancement. Reviewed in tumor board and thought to represent at\nleast T3 disease. Multiple (>4) enlarged mesorectal lymph nodes,\ncompatible with N2 disease. One of the lymph nodes on the right\nis less than 1 mm from the mesorectal fascia, compatible with\npositive circumferential resection margin. Single enlarged lymph\nnode in the right hemipelvis measuring 6 mm in short axis\ndiameter located just outside the mesorectal fascia - at the\nposterolateral corner of the urinary baldder. \n- ___: Re-demonstration of rectal wall thickening\ncompatible with known carcinoma as well as enlarged mesorectal\nlymph nodes. No evidence of metastatic disease within the \nabdomen\nor pelvis. \n- ___: CT chest- No evidence of intrathoracic malignancy \nor\ninfection. Mild biapical bronchiolar inflammation.\n- ___: iliac lymph node fiducial placement \n- ___: Neoadjuvant C1D1 continuous infusion ___ + XRT\n- ___: end of XRT and ___\n- ___: laparoscopic, robotic-assisted abdominoperineal\nresection with permanent end colostomy. Pathology revealed\nadenocarcinoma, tumor size 3.2 cm, no macroscopic tumor\nperforation, low-grade, pT3, 0 out of 12 lymph nodes involved, +\ntumor deposits present (pN1c), intramural lymphovascular\ninvasion, no perineural invasion, negative margins\n- ___: C1D1 of adjuvant FOLFOX\nC1D15 delayed by 1 day -> ___ bolus discontinued to reduce risk\nof stomatitis & diarrhea; extended the infusion duration of\noxaliplatin to 4 hours to reduce acute neurotoxicity.\n- ___: C1D15 FOLFOX\n- ___: C2D1 FOLFOX (zofran replaced by palonosetron)\n- ___: C2D15 FOLFOX\n- C3D1 delayed by 1 week due to thrombocytopenia -> 5- ___\ninfusion dose reduced by 25% to 900 mg/m2 (from 1200 mg/m2)\n- ___: C3D1 FOLFOX\n- ___: C3D15 FOLFOX \n- ___: DELAYED C4 FOLFOX due to thrombocytopenia -> ___\ninfusion dose reduced by total of 35% to 780 mg/m2; and\noxaliplatin dose reduced by 20% to 68 mg/m2\n- ___: C4D1 FOLFOX \n- C4D15 delayed ___ thrombocytopenia & then, cellulitis over \nport\nsite\n- ___: C4D15 FOLFOX\n- ___: CT chest/MRI a/p with ___.\n- ___: Colonoscopy via the stoma normal (plan to repeat \nevery\n___ years).\n- ___ CEA 4.8\n- ___ CEA 6.0\n- ___ CT torso suggested one liver lesion in segment 8\nmeasuring less than 1 cm, and 2 right lower lobe pulmonary\nnodules. \n- ___: ___ PET revealed 2 avid right lower lobe pulmonary\nnodules, consistent with metastatic disease. Additional sub 3 \nmm\npulmonary nodules are too small to characterize FDG avidity.\nMultiple previously seen hypoattenuating lesions \nthroughout the liver, some of which are cysts while the others\nare hemangiomas, not well visualized on today's exam. The new\nhepatic segment VIII 0.7 hypoattenuating lesion seen on recent \nCT\nfrom ___ is also not well visualized but probably\ncorresponds to a small focus of relatively increased FDG \nuptake compared to background liver parenchyma with SUV max of\n4.9. \n- ___ Liver MRI demonstrated the single segment 8 likely\nmetastatic focus, and no other concerning liver lesions they \nalso\npointed out a right-sided T12 lesion that had been seen\npreviously that likely reflected a stable hemangioma but\nrecommend close attention on follow-up imaging.\n- ___ CT torso demonstrated no evidence of disease\nprogression at other sites; her CEA rose to approximately 20.\n- ___ Max CEA of 27.1 \n- ___: Right lower lobe thoracic wedge resection. The\npathology showed 2 foci of metastatic adenocarcinoma consistent\nwith rectal primary. \n- ___ Resection of the segment VIII hepatic met was done on\n___ Dr. ___. Post operative \nCEA\n2.9. Final path revealed \nLiver, right anterior, resection:\n-Metastatic adenocarcinoma (1.3 cm), morphologically consistent\nwith colorectal origin. \n-Lateral parenchymal margin is positive for adenocarcinoma.\nMedial margin is negative.\n-Focal nodular hyperplasia (0.9 cm); immunostains for serum\namyloid A and glutamine synthetaseexamined ans support this\ndiagnosis. \n-Nonlesional liver parenchyma with pericentric and lobular\nneutrophilic inflammation, likely secondary to surgical\nprocedure. \n-No steatosis or fibrosis (trichrome and reticulin stains\nexamined).\n- Iron stain shows no stainable \n\nWe discussed the \"positive margin\" at ___ tumor board. \n___ impression is that the use of the device to achieve\nhemostasis at the surgical bed achieved a 5-8 mm border of\nadditional coagulative necrosis and therefore he feels that it \nis\nhighly unlikely that there are even microscopic tumor cells\nremaining at this margin. When Dr. ___ her path as\nwell and felt that the entire metastasis had been surrounded by\napparently morphologically normal liver parenchyma, and she felt\npositive margin was an artifact of sectioning. Neither surgeon\nfelt there was a need for additional local therapy clean up any\nresidual disease at any margin. \n\n- ___ Port placed and complicated by post procedural PTX\n- ___ C1D1 adjuvant FOLFOX (no ___ bolus ___ past\ncytopenias, oxaliplatin 68 ___ prolonged\nthrombocytopenia/neuropathy)\n- ___ C1D15 FOLFOX (no ___ bolus ___ cytopenias, \noxaliplatin\n___ 30% ___ neuropathy, infusional ___ ___ 10% ___ mucositis).\nFosaprepitant was added to the regimen because of delayed nausea\nand vomiting. She experienced sudden chest pain that radiated to\nher back ___ way through her oxaliplatin infusion. ADR kit was\ngiven without improvement of symptoms. Lorazepam and morphine IV\nwas additionally given without much effect. EKG was difficult to\nobtain ___ motion artifact so she was transport to ED to r/o\ncardiac etiology (concern for aortic dissection or PE). CTA \nchest\nwas negative and her symptoms improved with additional morphine\nIV administration. She was also diagnosed with an asymptomatic\nUTI during her ED stay and completed a 7 day course of Bactrim\nfor this.\n\n- ___: Seen by allergy/immunology (Dr ___ with a\npositive skin test for oxaliplatin hypersensitivity.\n- ___: Admitted for C2D1 oxaliplatin with inpatient\ndesensitivitation protocol. Received ___ and LV on ___. Dose\nreductions were additionally made in oxaliplatin (increased to\n30% because of neuropathy) and infusional ___ (10%) due to\nthrombocytopenia.\n- ___: C3D1 FOLFOX with 3 bag desensitization (oxaliplatin\n___ 30%, infusional ___ ___ 10%)\n___: C3D15 FOLFOX with 3 bag desensitization (oxaliplatin \n___\n30%, infusional ___ ___ 10%)\n- ___: C4D1 FOLFOX with 3 bag desensitization (oxaliplatin\n___ %, infusional ___ ___ %)\n\n \nPAST MEDICAL HISTORY: \n- Oligometastatic rectal cancer\n\n \nSocial History:\n___\nFamily History:\nNo known family history of cancer.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVS: T 97.9 HR 59 BP 113/70 RR 18 SAT 97% O2 on RA\nGENERAL: Pleasant, lying in bed comfortably\nEYES: Anicteric sclerea, PERLL, EOMI; \nENT: Oropharynx clear without lesion, JVD not elevated \nCARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or\ngallops; 2+ radial pulses\nRESPIRATORY: Appears in no respiratory distress, clear to\nauscultation bilaterally, no crackles, wheezes, or rhonchi\nGASTROINTESTINAL: Normal bowel sounds; nondistended; soft,\nnontender without rebound or guarding; no hepatomegaly, no\nsplenomegaly\nMUSKULOSKELATAL: Warm, well perfused extremities without lower\nextremity edema; Normal bulk \nNEURO: Alert, oriented, CN III-XII intact, motor and sensory\nfunction grossly intact\nSKIN: No significant rashes\nLYMPHATIC: No cervical, supraclavicular, submandibular\nlymphadenopathy. No significant ecchymoses\n\nDISCHARGE EXAM\n- No significant change\n \nPertinent Results:\nLABS: \n___ 12:46PM BLOOD WBC: 4.6 RBC: 4.19 Hgb: 13.0 Hct: 39.8\nMCV: 95 MCH: 31.0 MCHC: 32.7 RDW: 15.9* RDWSD: 54.7* Plt Ct: \n118*\n\n___ 12:46PM BLOOD Neuts: 63.2 Lymphs: ___ Monos: 15.7* \nEos:\n1.1 Baso: 0.6 Im ___: 0.2 AbsNeut: 2.93 AbsLymp: 0.89* AbsMono:\n0.73 AbsEos: 0.05 AbsBaso: 0.03 \n___ 12:46PM BLOOD UreaN: 9 Creat: 0.6 Na: 141 K: 4.3 Cl: \n107\nHCO3: 24 AnGap: 10 \n___ 12:46PM BLOOD ALT: 82* AST: 81* AlkPhos: 317* TotBili:\n0.6 \n___ 12:46PM BLOOD Calcium: 9.6 Phos: 3.6 Mg: 2.3 \n___ 12:46PM BLOOD CEA: 4.3* \n\nMICROBIOLOGY: None new\n \nIMAGING: \n___ Imaging MRI (ABDOMEN & PELVIS) \n1. No evidence of new abdominopelvic metastases. However, as \nthe\nsuperior portion of the liver was not captured on the current\nexam, the patient will be called back for repeat imaging of the\nliver at no additional cost to the patient. \n2. Postsurgical changes after interval right lower lobe wedge\nresection, and right anterior sectionectomy (segments 5 and 8),\nwith a new 11.2 cm hematoma along the hepatic resection cavity. \n\n \nBrief Hospital Course:\nPRINCIPLE REASON FOR ADMISSION:\n___ is a ___ year old woman with recurrent, \nmetastatic rectal adenocarcinoma sp resection of isolated \npulmonary met and hepatic mets, currently receiving adjuvant \nmodified FOLFOX who is admitted for oxaliplatin desensitization \nas part of C4D15 mFOLFOX. \n\n# Oxaliplatin hypersensitivity\n# Encounter for chemotherapy\nPatient underwent 3 bag oxaliplatin desensitization per OMS \nprotocol. She was premedicated with 10mg po cetirizine, 25mg IV \ndiphenhydramine,\n40mg po famotidine, 12mg IV dexamethasone. She also had 150mg IV \nfosaprepitant and 0.25mg IV palonosetron prior\nto infusion. She tolerated well without incident. She also \nreceived 1g Calcium gluconate and 1g IV magnesium prior to and \nafter infusion. She will follow up in clinic tomorrow for her \nnext treatment.\n\n# Oligometastatic rectal cancer\n- CEA mildly rising; defer to outpatient team\n- Will need to trend closely; consider restaging imaging\n- Supportive therapy with dexamethasone 2mg bid x3 days after\nchemotherapy; lorazepam prn, Compazine prn\n\n# Thrombocytopenia: \n- Moderate, should continue to monitor as outpatient; OK for\ntreatment today\n\nTRANSITIONAL ISSUES:\n- Return to clinic on ___ for remainder of mFOLFOX \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Cetirizine 10 mg PO 1 TABLET BY MOUTH NIGHT BEFORE AND DAY OF \nDESENSITIZATION \n2. LORazepam 0.5 mg PO Q8H:PRN nausea/vomiting \n3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n4. Omeprazole 20 mg PO DAILY \n5. PredniSONE 50 mg PO ONE TABLET(S) BY MOUTH 13 HOURS, 7 HOURS, \nAND ONE HOUR BEFORE MRI SCAN \n6. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second \nLine \n7. Dexamethasone 2 mg PO 1 TABLET(S) BY MOUTH BID X 3 DAYS AFTER \nCHEMOTHERAPY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Cetirizine 10 mg PO 1 TABLET BY MOUTH NIGHT BEFORE AND DAY \nOF DESENSITIZATION \n3. Dexamethasone 2 mg PO 1 TABLET(S) BY MOUTH BID X 3 DAYS \nAFTER CHEMOTHERAPY \n4. LORazepam 0.5 mg PO Q8H:PRN nausea/vomiting \n5. Omeprazole 20 mg PO DAILY \n6. PredniSONE 50 mg PO ONE TABLET(S) BY MOUTH 13 HOURS, 7 \nHOURS, AND ONE HOUR BEFORE MRI SCAN \n7. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second \nLine \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\n# Oxaliplatin hypersensitivity\n# Encounter for chemotherapy\n# Metastatic rectal 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 ___ \n___. You were admitted for your scheduled \nchemotherapy, which you tolerated well. Please follow up in \nclinic for the remainder of your treatment.\n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C20", "Z85118", "Z8505", "Z933", "D696" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C20: Malignant neoplasm of rectum", "Z85118: Personal history of other malignant neoplasm of bronchus and lung", "Z8505: Personal history of malignant neoplasm of liver", "Z933: Colostomy status", "D696: Thrombocytopenia, unspecified" ]

[ "D696" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nsulfadimethoxine / lisinopril / codeine / Biaxin / yellow \njackets bee stings\n \nAttending: ___.\n \nChief Complaint:\nLower extremity weakness\n \nMajor Surgical or Invasive Procedure:\n___: XRT to T7 and L2 \n\n \nHistory of Present Illness:\nMr. ___ is a ___ man with T2DM, HTN, PE/DVT s/p\nIVC filter, seizure disorder, neurofibroma/acoustic neuroma s/p\nresection in ___, and metastatic cecal adenocarcinoma (MSS, \nKRAS\nmutated) s/p right hemicolectomy in ___ and right hepatic\nlobectomy in ___ s/p multiple rounds of chemotherapy\ncomplicated by thrombocytopenia and brain metastases s/p SRS who\npresents to ED from ___ clinic with weakness and concern \nfor\ncord compression.\n\nHe was at his oncologist and it was thought he potentially has a\nnew cerebellar lesion because of his issues with balance over \nthe\npast several weeks. He reports that he was going to be started \non\na new chemotherapy pill, but today he had a severe weakness, and\nwas unable to stand even with his walker. \n\nHe does not think it is necessarily dizzy but more of just a\ngeneral weakness. He denies any fevers or chills. No nausea or\nvomiting. He reports that appetite is somewhat poor but he has\nbeen drinking liquids. He also reports that he had an MRI \nseveral\ndays ago but is not quite sure of the results.\n\nHe was referred to radiation oncology for consideration of\nradiation to the T7 vertebral lytic lesion which appears to be\nsymptomatic.\n\nExam was notable for normal lower extremity strength. Labs were\nnotable for WBC 3.6, H/H 9.9/30.3, Plt 51, Na 136, K 3.9, BUN/Cr\n___, ALT 19, aST 45, ALP 358, and trop T < 0.03. \n\nA code cord was called. MRI was obtained, showing diffuse\ninfiltration of the T7 vertebral body and possible superimposed\nacute \nfracture. No definite spinal cord signal abnormality. There was\nalso a rounded, T1 hypointense lesion in the T12 vertebral body,\nsuggestive of additional metastatic focus. \n\nSpine was consulted. Recommended\n- TLSO ___ put on edge of bed. \n- Recommend radiation oncology consult given the fact that he\n[...] already started radiation therapy \n- Please continue to\n\nOn arrival to the floor, patient somewhat unclear historian.\nStates that he had a mechanical fall last week but otherwise no\nincreased weakness or dizziness. He does have back pain, ___,\nimproved with oxycodone. No numbness or tingling in lower\nextremities.\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\n- ___: s/p laparoscopic right hemicolectomy with\nreanastomosis. Pathology was pT3N1b cM1 given several liver\nlesions noted on imaging, KRAS mutated, MSS\n- 6 cycles FOLFOX\n- ___: s/p partial hepatectomy for liver metastasis and RFA\nof remaining lesion\n- ___: Admission for neutropenic fever, pancytopenia,\npneumonia\n- Irinotecan/Avastin, recently irinotecan held for counts\n- ___: PET showed retroperitoneal lymph nodes of concern \nfor\na secondary process versus potential low-grade lymphoma. Recent\nliver Bx confirmed recurrent metastatic disease to the liver,\nretroperitoneal nodes were not able to be accessed.\n- Capecitabine/Avastin, recently held for counts\n- ___: MRI with increasing disease burden in liver\n- ___: Yttrium 90 radioembolization at ___\n- ___: ED visit with dizziness, sinus congestion and\nheadache\n- ___: ___ CT showed right occipital and right parietal\nlesions\n- ___: Brain MRI showed right occipital and right parietal\nlesions\n- ___: SRS to right posterior parietal and right occipital\n22 Gy by Dr. ___\n- ___: Brain MRI showed left cerebellar mass\n- ___: SRS to left cerebellum\n\nPAST MEDICAL HISTORY:\n- Metastatic Colon Cancer, as above\n- Pulmonary Embolism in ___\n- Right Femoral and Popliteal DVT in ___ s/p IVC filter\n- Type II Diabetes Mellitus\n- Hypertension\n- Dyslipidemia\n- Seizure Disorder\n- Kidney Stones\n- Neurofibroma s/p craniotomy and resection in ___\n- Secondary Acoustic Neuroma s/p resection\n- Depression\n- Deviated Septum s/p sinus surgery\n- s/p cholecystectomy\n- s/p adenoidectomy\n\n \nSocial History:\n___\nFamily History:\nMother with breast cancer. Father had diabetes.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVS: 97.9 146/81 98 18 97RA \nGENERAL: Pleasant man, in no distress, lying in bed comfortably;\npoor dentition \nHEENT: Anicteric, PERLL, OP clear.\nCARDIAC: RRR, ___ systolic murmur at RUSB\nLUNG: Appears in no respiratory distress, clear to auscultation\nbilaterally\nABD: Soft, non-tender, non-distended\nEXT: Warm, well perfused, no lower extremity edema\nNEURO: A&Ox3, good attention and linear thought, CN II-XII\nintact. Strength full throughout including ___ strength in all\nmuscle groups of lower extremities bilaterally. Sensation to\nlight touch\nintact.\nSKIN: No significant rashes.\nACCESS: Port\n\nDISCHARGE PHYSICAL EXAM:\n========================\n24 HR Data (last updated ___ @ 339)\n Temp: 98.9 (Tm 99.1), BP: 111/62 (111-124/57-74), HR: 80\n(80-90), RR: 18 (___), O2 sat: 95% (94-96), O2 delivery: RA \nGENERAL: M in NAD, lying in bed; poor dentition. Tearful.\nCV: RRR\nLUNG: No increased WOB on room air. CTABL \nABD: Obese abdomen, softly distended, non-tender \nEXT: no ___ edema\nNEURO: A&Ox3, right sided facial droop/weakness at baseline due\nto prior acoustic neuroma, unchanged. Strength ___ in UE and \nLLE,\n4+/5 in RLE, stable. \nSKIN: No significant rashes.\nACCESS: POC\n\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 11:43PM GLUCOSE-79 UREA N-13 CREAT-0.6 SODIUM-139 \nPOTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-21* ANION GAP-16\n___ 11:43PM estGFR-Using this\n___ 11:43PM WBC-3.5* RBC-2.91* HGB-9.4* HCT-29.0* \nMCV-100* MCH-32.3* MCHC-32.4 RDW-16.9* RDWSD-61.8*\n___ 11:43PM NEUTS-58.1 LYMPHS-15.1* MONOS-14.8* EOS-11.1* \nBASOS-0.6 IM ___ AbsNeut-2.05 AbsLymp-0.53* AbsMono-0.52 \nAbsEos-0.39 AbsBaso-0.02\n___ 11:43PM PLT COUNT-47*\n___ 11:43PM ___ PTT-24.9* ___\n\nOTHER LABS/MICRO:\n=================\n___ 05:04AM BLOOD calTIBC-218* Ferritn-131 TRF-168*\n___ 04:40AM BLOOD VitB12-364 Folate-9 Hapto-85\n\n___ 6:04 am URINE Source: ___. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n STAPH AUREUS COAG +. >100,000 CFU/mL. \n Staphylococcus species may develop resistance during \nprolonged\n therapy with quinolones. Therefore, isolates that are \ninitially\n susceptible may become resistant within three to four \ndays after\n initiation of therapy. Testing of repeat isolates may \nbe\n warranted. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n STAPH AUREUS COAG +\n | \nGENTAMICIN------------ <=0.5 S\nLEVOFLOXACIN---------- 0.25 S\nNITROFURANTOIN-------- <=16 S\nOXACILLIN-------------<=0.25 S\nTETRACYCLINE---------- <=1 S\nTRIMETHOPRIM/SULFA---- <=0.5 S\n\nIMAGING:\n========\n___ MRI Spine\nIMPRESSION: \n1. Diffuse marrow replacement in tumor infiltration of the T7 \nvertebral body with retropulsion of the posterior cortex and \nsoft tissue epidural extension resulting in severe spinal canal \nnarrowing without cord signal abnormalities. \n2. Severe neural foraminal narrowing at T7-T8, left greater than \nright, due to tumor infiltration. \n3. Multiple other probable metastatic lesions at T12 and L2. \n4. There is loss of vertebral body height spanning L3 through L5 \nwith superior endplate signal abnormality as well as more \ndiffuse infiltrative signal in of the L5, concerning for \npathologic compression fractures. Infectious etiology is \nconsidered less likely. \n5. Additional findings as described above, including metastatic \nlesions to the posterior fossa and bilateral adrenal glands. \n\n___ CT A/P:\nIMPRESSION: \n1. Compared with ___, there has been interval \nprogression of disease with increase in size and number of \nhepatic metastases, increase in size of bilateral adrenal \nmetastases, slight increase in lymphadenopathy and size of a \nright lower quadrant soft tissue nodule, and findings concerning \nfor new osseous metastases in the lumbar spine with associated \nmild compression deformities, as seen on recent spine MRI. \n2. New 2.7 cm hypodensity along the left prostate, with \nasymmetric enlargement of the left seminal vesicle, may reflect \na prostatic abscess. \n3. Please refer to separate report of CT chest performed on the \nsame day for description of the thoracic findings. \n\n___ CT Chest:\nIMPRESSION: \n1. No evidence of pneumonia. \n2. Increased size of multiple pulmonary nodules concerning for \ndisease \nprogression. \n3. Increased soft tissue rind along the right hemidiaphragm \nconcerning for disease progression. \n4. T7 vertebral body sclerotic lesion remains concerning for \nmetastatic \ndisease with mild loss of vertebral body height suggesting mild \npathologic \nfracture. \n\n___ MR ___\nIMPRESSION: \n1. Mixed response with the right parietal and right occipital \nlesions \nunchanged in size with increasing surrounding edema, which may \nreflect post treatment changes. New right temporal lobe lesion. \n Decreased size of the left cerebellar lesion. \n2. Unchanged area of enhancement in the right internal auditory \ncanal near the fundus, which may be postsurgical given the prior \nright suboccipital \ncraniectomy. \n3. No findings to suggest infarction or hemorrhage. \n \n___ CT A/P\nIMPRESSION: \n1. Interval decrease in the size of the left prostatic \nhypodensity, measuring 1.7 cm x 1.5 cm x 1.8 cm, previously 2.7 \ncm x 1.7 cm x 2.2 cm, which may represent a prostate abscess. \n2. Metastatic disease within the abdomen, which is unchanged \ncompared to prior study. \n3. New small left pleural effusion. \n\n___ TTE\nIMPRESSION: Suboptimal image quality. No mitral valve \nmass/vegetation seen. Aortic and tricuspid valves poorly \nvisualized. No gross valvular pathology or pathologic flow, but \nendocarditis cannot be excluded on the basis of this study \nalone. TEE recommended if clinical suspicion\ndictates. Mild symmetric left ventricular hypertrophy with \nnormal cavity size and regional/global biventricular systolic \nfunction.\n\nDISCHARGE LABS:\n===============\n___ 05:02AM BLOOD WBC-2.2* RBC-2.43* Hgb-7.7* Hct-24.4* \nMCV-100* MCH-31.7 MCHC-31.6* RDW-19.4* RDWSD-68.6* Plt Ct-33*\n___ 05:02AM BLOOD Glucose-86 UreaN-12 Creat-0.5 Na-138 \nK-4.0 Cl-107 HCO3-21* AnGap-10\n___ 05:02AM BLOOD Calcium-7.8* Phos-2.8 Mg-1.___RIEF HOSPITAL SUMMARY:\n=======================\nMr. ___ is a ___ man with T2DM, HTN, PE/DVT s/p \nIVC filter, seizure disorder, neurofibroma/acoustic neuroma s/p \nresection in ___, and metastatic cecal adenocarcinoma (MSS, \nKRAS mutated) s/p right hemicolectomy in ___ and right \nhepatic lobectomy in ___ s/p multiple rounds of chemotherapy \ncomplicated by\nthrombocytopenia and brain metastases s/p SRS who presents to ED \nfrom ___ clinic with weakness and concern for cord \ncompression.\n\nTRANSITIONAL ISSUES:\n====================\n[] TLSO brace to be worn at all times when out of bed.\n[] levaquin 750 qd for 6 week course to treat prostate abscess, \nto complete ___. \n[] Discharged on opioids with aggressive bowel regimen \n[] f/u partially imaged bilateral lower lobe pulmonary \nmetastasis, new compared to ___ on ___ CT T spine, \nif within goals of care.\n[] Discharged on dexamethasone 1mg daily for treatment of \nlower-extremity numbness, should be discontinued in 4 days (end \ndate ___. If recurrent numbness, can restart dexamethasone 2mg \ndaily.\n\nACTIVE ISSUES\n=============\n# RLE weakness \n# Metastatic T7 spine lesion: Patient with known T7 disease \ninitially presented with slight RLE weakness stable on exam. MR \nwith evidence of canal narrowing but no cord compression. \nPatient was seen by spine surgery team who recommended TLSO to \nbe worn at all times when out of bed. CT T spine with T7 \ncompression fracture. Radiation oncology was consulted and \ninitially deferred XRT, but subsequently pursued 5 fractions to \nT7 and L2 given continued admission. He was noted to have new \nnumbness in right L2 dermatome on ___, without incontinence or \nsaddle anesthesia. He was started on dexamethasone which was \ntapered to 1mg, and will be discontinued in 4 days. \n\n# Colon cancer w/ mets to liver, adrenal glands, spine: \nOncologist Dr. ___ at ___. Last chemo ___. Per notes, \nplan had been to try Capecitabine 500 mg PO BID but delayed \ngiven acute issues including cord involvement. Note that \nsystemic treatment over the past few months has been limited by \nthrombocytopenia, and oncology considered NPlate (not covered by \ninsurance) vs partial splenic embolization. CT torso and MRI \nbrain with evidence of progression of disease. There are \nunfortunately no chemotherapy options given profound \npancytopenia. Palliative care was consulted. Oxycontin and PRN \noxycodone was titrated and gabapentin was started. Patient \nopting to pursue SNF to try to regain some strength and \nindependence, likely followed by hospice. \n\n# MSSA prostate abscess: Patient with fevers without localizing \ninfectious symptoms. Infectious workup only notable for MSSA in \nurine and prostate abscess on CT A/P. Received vanc and then \nnafcillin for presumed abscess. Prostate abscess drainage or \ntrans-rectal ultrasound was not pursued given GOC. Patient began \nspiking fevers despite nafcillin. Again broad infectious workup \nunremarkable except for decreasing size of prostate abscess. \nSwitched to levaquin given concern for Beta-lactam drug fever. \nPlan for total 6 week course of antibiotics, to complete on \n___. \n\n#Pancytopenia: Patient with known thrombocytopenia after chemo \nand iso splenomegaly now s/p partial splenic embolization. \nProfound pancytopenia concerning for possible disease \ninvolvement of the marrow vs concurrent MDS maybe ___ prior \nchemotherapy. On review of OSH records, has been stable for at \nleast 6 months. Haptoglobin, folate, and B12 all wnl. Notably \niron deficient. Transfused for Hb <7, platelets <10.\n\n#Constipation: in setting of opioid use. Titrated bowel regimen \nas needed. Will be discharged on bowel regimen in setting of \nopioids. \n\n#Moderate malnutrition: supplemented with ensure enlive TID and \nMVI with minerals.\n\nCHRONIC ISSUES\n==============\n# DM2: Home metformin and Januvia held. ISS while hospitalized. \n\n# Epilepsy: Last seizure > ___ years ago described as tunneled \nvision. EEG negative last hospitalization. Continued Dilantin at \ncurrent dose of 200mg bid. \n\n# History of DVT/PE: s/p IVC filter. Received SQH ppx, held for \nplatelets <50.\n\n# HLD: continued atorvastatin\n\n# Depression: continued citalopram\n\n# HTN: hold losartan and metoprolol, restart if HTN\n\n#CODE: DNR/DNI\n#EMERGENCY CONTACT HCP: ___ (sister-in-law) \n___\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. Atorvastatin 20 mg PO QPM \n2. Citalopram 40 mg PO DAILY \n3. Losartan Potassium 50 mg PO DAILY \n4. Metoprolol Succinate XL 25 mg PO DAILY \n5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate \n\n6. Phenytoin Sodium Extended 200 mg PO BID \n7. Lantus Solostar U-100 Insulin (insulin glargine) 16 units \nsubcutaneous QAM \n8. Lantus Solostar U-100 Insulin (insulin glargine) 8 units \nsubcutaneous QHS \n9. HumaLOG KwikPen Insulin (insulin lispro) 4 units subcutaneous \nTID W/MEALS \n10. MetFORMIN (Glucophage) 1000 mg PO BID \n11. Capecitabine 500 mg PO BID \n12. Januvia (SITagliptin) 50 mg oral DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \n2. Bisacodyl 10 mg PO DAILY \n3. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity \n4. Dexamethasone 1 mg PO DAILY Duration: 4 Days \n5. Gabapentin 300 mg PO QHS \n6. Gabapentin 300 mg PO QAM \n7. Lactulose 30 mL PO Q6H:PRN Constipation - Third Line \n8. LevoFLOXacin 750 mg PO Q24H Duration: 25 Days \n9. Loratadine 10 mg PO DAILY \n10. OxyCODONE SR (OxyCONTIN) 30 mg PO Q12H \nRX *oxycodone [OxyContin] 30 mg 1 (One) tablet(s) by mouth twice \na day Disp #*10 Tablet Refills:*0 \n11. Polyethylene Glycol 17 g PO BID \n12. Senna 8.6 mg PO BID \n13. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *oxycodone 5 mg ___ capsule(s) by mouth every four (4) hours \nDisp #*10 Capsule Refills:*0 \n14. Atorvastatin 20 mg PO QPM \n15. Citalopram 40 mg PO DAILY \n16. HumaLOG KwikPen Insulin (insulin lispro) 4 units \nsubcutaneous TID W/MEALS \n17. Januvia (SITagliptin) 50 mg oral DAILY \n18. Lantus Solostar U-100 Insulin (insulin glargine) 16 units \nsubcutaneous QAM \n19. Lantus Solostar U-100 Insulin (insulin glargine) 8 units \nsubcutaneous QHS \n20. MetFORMIN (Glucophage) 1000 mg PO BID \n21. Phenytoin Sodium Extended 200 mg PO BID \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n#Metastatic colon cancer\n#T7 spine lesion\n#MSSA prostate abscess\n#Pancytopenia \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 Mr. ___,\n \nIt was a pleasure caring for you at ___ \n___. \n \nWHY WAS I IN THE HOSPITAL? \n - You were admitted for concern for cord involvement of your \ncancer. \n \nWHAT HAPPENED TO ME IN THE HOSPITAL? \n - You receive radiation to your spine to help relieve some of \nyour symptoms.\n - You were having fevers while in the hospital. A full \ninfectious workup revealed a possible abscess in your prostate. \nYou received antibiotics to treat this infection. \n - Your pain medication regimen was altered to help relieve your \npain. \n \nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n - Continue to take all your medicines and keep your \nappointments. \n \nWe wish you the best! \n \nSincerely, \nYour ___ Team \n\n \nFollowup Instructions:\n___\n" ]

[ "C7951", "C7949", "C7972", "C7971", "C7931", "C787", "C7802", "C7801", "C7889", "M8458XA", "N412", "D61818", "G40919", "E440", "J90", "Z85038", "R531", "B9561", "R8271", "Z66", "E119", "Z794", "I10", "Z86711", "Z86718", "Z95828", "Z9181", "F329", "Z803", "Z833", "R29810", "R200", "K5903", "T402X5A", "Y92230", "Z6828", "E7849", "G620", "T451X5A" ]

[ "C7951: Secondary malignant neoplasm of bone", "C7949: Secondary malignant neoplasm of other parts of nervous system", "C7972: Secondary malignant neoplasm of left adrenal gland", "C7971: Secondary malignant neoplasm of right adrenal gland", "C7931: Secondary malignant neoplasm of brain", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C7802: Secondary malignant neoplasm of left lung", "C7801: Secondary malignant neoplasm of right lung", "C7889: Secondary malignant neoplasm of other digestive organs", "M8458XA: Pathological fracture in neoplastic disease, other specified site, initial encounter for fracture", "N412: Abscess of prostate", "D61818: Other pancytopenia", "G40919: Epilepsy, unspecified, intractable, without status epilepticus", "E440: Moderate protein-calorie malnutrition", "J90: Pleural effusion, not elsewhere classified", "Z85038: Personal history of other malignant neoplasm of large intestine", "R531: Weakness", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere", "R8271: Bacteriuria", "Z66: Do not resuscitate", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "I10: Essential (primary) hypertension", "Z86711: Personal history of pulmonary embolism", "Z86718: Personal history of other venous thrombosis and embolism", "Z95828: Presence of other vascular implants and grafts", "Z9181: History of falling", "F329: Major depressive disorder, single episode, unspecified", "Z803: Family history of malignant neoplasm of breast", "Z833: Family history of diabetes mellitus", "R29810: Facial weakness", "R200: Anesthesia of skin", "K5903: Drug induced constipation", "T402X5A: Adverse effect of other opioids, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "Z6828: Body mass index [BMI] 28.0-28.9, adult", "E7849: Other hyperlipidemia", "G620: Drug-induced polyneuropathy", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter" ]

[ "Z66", "E119", "Z794", "I10", "Z86718", "F329", "Y92230" ]

[]

[ " \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:\nB/l Lower extremity swelling and pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ MEDICINE ATTENDING ADMISSION NOTE .\n.\nDate: ___\nTime: 0030 pm\n.\n_\n________________________________________________________________\nPCP: PCP: None at moment ___, MD to take over). \nCHIEF COMPLAINT: Leg Swelling. \n\nHPI: Ms. ___ is a ___ year old female, with past history of TBI \n___ to ___ with residual right sided hemiparesis, dysarthria, \nwho is wheelchair bound, presenting with right lower extremity \nswelling and pain. \n\nPatient reports that her friend, ___, had previously \nvisited her about 4 days ago, and had noticed that she had \nincreased bilateral leg swelling, and some redness. The patient \nstates that she has had swelling in her legs for months. She put \noff coming because she does not have anyone to care for her cat. \nThe pain in her leg worsened such that she came to the ER. \nPatient also was noted to have an open sore on the left lower \nextremity, and states that her legs had been painful. Patient \nreports that her swelling and redness in her legs has been quite \nworse, especially L > R. She denies any fevers, chills, \nsensation changes that are new compared to her previous right \nsided hemiparesis. She denies any dyspnea, chest pain, \nlightheadedness, fevers, chills, nausea, or vomiting. Patient \nthen called ___ for triage, and patient has been having these \nsymptoms for several weeks however did not want to leave home as \nshe did not have a cat sitter.\n\nOf note, patient is a new patient to the ___ practice for the \npast ___ years. She has not had any of these symptoms previously. \nHer previous care was at the ___. Initially patient was to be \nseen at the ___ clinic practice for an episodic visit, however \nthis was deferred and an ambulance was arranged. \n\nUpon arrival to the ___ ED, patient was found to have \nbilateral lower extremity edema, with right sided weakness \nconsistent with prior diagnosis. \n\nIn the ED, initial vital signs were: 96.8 77 130/70 16 100% RA \n- Exam was notable for: 2+ bilateral pitting edema, with left \nleg dry skin callus, hyper pigmented skin, and painful leg. No \npalpable abscess. \n- Labs were notable for: WBC 7.3, Hgb 12.9, Platelet 215. BNP \n55. Electrolytes wnl. U/A remarkable for trace protein, 10 \nketones, RBC 12, WBC 6. UCG negative. Lactate 1.1. \n- Imaging: Bilateral lower extremity ultrasound ordered. \n- The patient was given:\n___ 19:21 IV Vancomycin 1000 mg ___ \nVitals prior to transfer were: 96.8 77 130/70 16 100% RA \n \nREVIEW OF SYSTEMS:\n CONSTITUTIONAL: As per HPI\n HEENT: [X] All normal\n RESPIRATORY: [X] All normal\n CARDIAC: [X] All normal\n GI: As per HPI\n GU: [X] All normal\n SKIN: [X] All normal\n MUSCULOSKELETAL: [X] All normal\n NEURO: [X] All normal\n ENDOCRINE: [X] All normal\n HEME/LYMPH: [X] All normal\n PSYCH: [X] All normal\n\nAll other systems negative except as noted above\n \nPast Medical History:\nPAST MEDICAL HISTORY:\n1. Neurologic Deficit: s/p MVA in ___ with head injury, coma \nfor 6 months with subsequent. Slowed speech and now wheelchair \nbound. Patient was hit on ___ by a Coke truck while \ncorssing the street. \n2. Onychomycosis\n3. Vitamin D Deficiency\n4. Osteopenia. \n\nPAST SURGICAL HISTORY: \n1. Right shoulder surgery, ___\n2. Left Hand Surgery, ___. \n\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY:\nMother: ___, age ___ with Lymphoma\nFather: Unknown\nBrother: Living, healthy ___\n\n \nPhysical Exam:\n Vitals: T 97.8 P 72 BP 132/56 RR 20 SaO2 95% RA\n GEN: NAD, comfortable appearing \n HEENT: ncat anicteric MMM \n NECK: supple \n CV: s1s2 rr no m/r/g \n RESP: b/l ae no w/c/r \n ABD: +bs, soft, NT, ND, no guarding or rebound \nEXTR: L ___ with increased swelling and warmth with verrucus \nswelling present close to L medial malleolus. + pressure with \npus expressed. RLE with erythema and edema but < than L\n DERM: no rash \n NEURO: L sided facial droop. + dysphagia\nABle to lift b/l legs off the bed and L arm. Weakness in RUE \nnoted\n PSYCH: calm, cooperative \n \nPertinent Results:\n___ 06:19PM URINE HOURS-RANDOM\n___ 06:19PM URINE HOURS-RANDOM\n___ 06:19PM URINE UCG-NEGATIVE\n___ 06:19PM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 06:19PM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 06:19PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR \nGLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 \nLEUK-NEG\n___ 06:19PM URINE RBC-12* WBC-6* BACTERIA-NONE YEAST-NONE \nEPI-1\n___ 06:19PM URINE AMORPH-RARE CA OXAL-RARE\n___ 06:19PM URINE MUCOUS-RARE\n___ 02:50PM LACTATE-1.1\n___ 02:44PM GLUCOSE-79 UREA N-16 CREAT-0.6 SODIUM-142 \nPOTASSIUM-4.6 CHLORIDE-108 TOTAL CO2-25 ANION GAP-14\n___ 02:44PM estGFR-Using this\n___ 02:44PM proBNP-55\n___ 02:44PM WBC-7.3 RBC-3.80* HGB-12.9 HCT-38.9 MCV-102* \nMCH-33.9* MCHC-33.2 RDW-11.6 RDWSD-43.3\n___ 02:44PM NEUTS-64.8 ___ MONOS-6.7 EOS-1.5 \nBASOS-1.4* IM ___ AbsNeut-4.71 AbsLymp-1.84 AbsMono-0.49 \nAbsEos-0.11 AbsBaso-0.10*\n___ 02:44PM PLT COUNT-215\n=================================\n \nBrief Hospital Course:\nASSESSMENT & PLAN: Ms. ___ is a ___ year old female, with past \nhistory of traumatic brain injury ___ MVA with residual \nneurologic deficts, disabled but independently living utilizing \na wheelchair, presenting with leg pain, swelling and redness \nconsistent with cellulitis. There was no radiographic evidence \nof DVT, abscess, or osteomyelitis. There was a dried scab over \nher left lateral malleolus, as well as a superficial curvilinear \nlaceration over her left shin, that may have served as portals \nof entry for infection. Her cellulitis improved with \nintravenous vancomycin, and continued to improve with transition \nto Bactrim/Keflex. She had no evidence of significant systemic \nseptic complications. She was thus discharged to home in stable \ncondition, with instructions to follow-up in HCA to ensure \nappropriate resolution.\n\n \nMedications on Admission:\nNone\n \nDischarge Medications:\n1. Cephalexin 500 mg PO Q6H \nRX *cephalexin 500 mg 1 capsule(s) by mouth every 6 hours Disp \n#*20 Capsule Refills:*0\n2. Sulfameth/Trimethoprim DS 1 TAB PO BID \nRX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 \ntablet(s) by mouth twice daily Disp #*10 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nLeft lower leg cellulitis\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:\nPlease take antibiotics as prescribed\nElevate your left leg when possible\n \nFollowup Instructions:\n___\n" ]

[ "L03116", "G8191", "R471", "Z87820", "E559", "D7589", "Z993", "V0929XS", "M8580", "F17200" ]

[ "L03116: Cellulitis of left lower limb", "G8191: Hemiplegia, unspecified affecting right dominant side", "R471: Dysarthria and anarthria", "Z87820: Personal history of traumatic brain injury", "E559: Vitamin D deficiency, unspecified", "D7589: Other specified diseases of blood and blood-forming organs", "Z993: Dependence on wheelchair", "V0929XS: Pedestrian injured in traffic accident involving other motor vehicles, sequela", "M8580: Other specified disorders of bone density and structure, unspecified site", "F17200: Nicotine dependence, unspecified, uncomplicated" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nCephalosporins / Bactrim / Rocephin\n \nAttending: ___.\n \nChief Complaint:\nshortness of breath\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ yo gentleman with PMH of HTN, HLD, OSA, prior\nalcohol use disorder, morbid obesity, DM2, and prostate cancer\n(getting radiation therapy) who is presenting with worsening\nshortness of breath. \n\nThe patient notes that this has been acutely worsening over the\nlast ___ weeks. He has always had shortness of breath and \nthought\nthat it was \"part of being a morbidly obese ___, but it has\nstarted to worsen. He notes that he used to be able to walk from\nhis care to his radiation appointments by stopping at benches\nalong the way. Now he has to stop in between each bench, breath,\nstop wheezing, and continue on. He has no cough. He Says that he\nhas had more episodes at night that feel like he has to catch \nhis\nbreath. He wears a CPAP machine and he says it feels like his\nsleep apnea. He checks his saturation and says it has been ok. \nHe\nhas never been able to lay flat effectively because of his\nweight. He says he has some increased abdominal fullness. He \nalso\nnotes increased swelling in his legs. He takes 20 mg of\nfurosemide at home. This was started because of leg swelling\npreviously. He notes he has been urinating less frequently than\nbefore. No burning w/ urination. \n\nHe notes that he has had some chest tightness associated with \nthe\nincreasing shortness of breath when he gets very wheezy. No\npressure, no radiation of the pain. He has been working on his\ndiet. He had actually presented to ___ with the complaint of\nSOB last week and they were planning a P-MIBI to evaluate\nfurther. He had an ECHO in ___ with low normal EF and poor\nwindows. It was felt at that time he may have alcohol related\ncardiomyopathy as he had been drinking heavily. He has been \nsober\nfor the last ___ years. In the ED the patient had a CXR that\nshowed bilateral pleural effusions. He had lab findings with an\nelevated proBNP. Troponins were negative x2. He was given 40 mg\nIV Lasix. Cardiology saw the patient and recommended medicine\nadmission as he has not previously established with ___\nCardiology. \n\nOtherwise, his only other acute change is swelling and pain on\nhis right lower jaw that started last week. He says so much has\nbeen going on in his life he has not gotten to the dentist for\nevaluation but is concerned that he has a tooth infection. He \nhas\nhad no fevers, no chills. It has given him a headache. \n\nOf note, the patient had called in reporting bloody stools to\nnursing at ___. He is getting active radiation treatments to\nhis prostate. He denied bloody stools when questioned. His Hgb\n___ was 13.3.\n\nThe patients ROS is otherwise negative for dizziness,\nlightheaded, chest pain/pressure, palpitations, nausea, \nvomiting,\ndiarrhea, constipation. \n\nREVIEW OF SYSTEMS: \nA 10-point ROS was taken and is negative except otherwise stated\nin the HPI. \n\n \nPast Medical History:\nHTN\nHLD\nOSA\nAlcohol use disorder\nDM2\nProstate cancer\nCVA (no residual deficits) \ncolonic polyps \n \nSocial History:\n___\nFamily History:\nNo family history of heart failure or MIs \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVITALS: 24 HR Data (last updated ___ @ 302)\n Temp: 97.8 (Tm 97.8), BP: 161/73, HR: 52, RR: 20, O2 sat:\n96%, O2 delivery: 2L NC \nGeneral: Alert, oriented, no acute distress \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,\nneck supple, JVP to 10 cm, no LAD. small 1 cm hard, tender mass\non right lower mandible \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops \nLungs: Clear to auscultation bilaterally, no wheezes, rales,\nrhonchi \nAbdomen: Soft, obese, non-tender, non-distended, bowel sounds\npresent, no organomegaly, no rebound or guarding \nGU: No foley \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+\nedema to the quads. \nSkin: Warm, dry, no rashes or notable lesions. \nNeuro: CNII-XII intact, ___ strength upper/lower extremities,\ngrossly normal sensation \n\nDISCHARGE PHYSICAL EXAM:\n========================\nVITALS: \n24 HR Data (last updated ___ @ 736)\n Temp: 98.4 (Tm 98.4), BP: 129/66 (90-154/51-82), HR: 53\n(48-61), RR: 16 (___), O2 sat: 94% (92-95), O2 delivery: RA \nFluid Balance (last updated ___ @ 616) \n Last 24 hours Total cumulative 1868.4ml\n IN: Total 2768.4ml, PO Amt 2740ml, IV Amt Infused 28.4ml\n OUT: Total 900ml, Urine Amt 900ml \n\nGeneral: Alert, oriented, no acute distress \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, OP\nClear\nCV: RRR, normal S1 + S2, no murmurs, rubs, gallops \nLungs: CTAB with diminished breath sounds at bilateral bases, no\nwheezes, rales, rhonchi \nAbdomen: Soft, obese, non-tender, non-distended\nGU: No foley \nExt: WWP, 2+ pulses, no clubbing, cyanosis. 1+ ___ edema\nbilaterally\nSkin: L shin with improving area of erythema/warmth surrounding\nskin excoriations. No purulence or fluctuance\nNeuro: CNII-XII intact, ___ strength upper/lower extremities,\ngrossly normal sensation \n \nPertinent Results:\nADMISSION LABS:\n===============\n\n___ 06:10PM BLOOD WBC-5.7 RBC-4.32* Hgb-11.5* Hct-36.1* \nMCV-84 MCH-26.6 MCHC-31.9* RDW-15.7* RDWSD-46.5* Plt ___\n___ 06:10PM BLOOD Neuts-76.8* Lymphs-9.2* Monos-10.6 \nEos-2.5 Baso-0.4 Im ___ AbsNeut-4.35 AbsLymp-0.52* \nAbsMono-0.60 AbsEos-0.14 AbsBaso-0.02\n___ 06:10PM BLOOD ___ PTT-26.7 ___\n___ 06:10PM BLOOD Glucose-108* Creat-0.9 Na-140 K-3.8 \nCl-105 HCO3-23 AnGap-12\n___ 10:09PM BLOOD ALT-13 AST-12 LD(LDH)-167 CK(CPK)-28* \nAlkPhos-91 TotBili-1.0\n___ 06:10PM BLOOD CK-MB-1 proBNP-1828*\n___ 06:10PM BLOOD cTropnT-<0.01\n___ 10:09PM BLOOD cTropnT-<0.01\n___ 06:10PM BLOOD Calcium-9.2 Phos-4.5 Mg-1.9\n___ 10:09PM BLOOD Iron-60\n___ 10:09PM BLOOD calTIBC-276 Ferritn-295 TRF-212\n___ 06:16PM BLOOD Glucose-107* Creat-0.8 Na-141 K-3.3* \nCl-108 calHCO3-24\n___ 06:16PM BLOOD Hgb-12.2* calcHCT-37\n___ 06:10PM URINE Color-Yellow Appear-Clear Sp ___\n___ 06:10PM URINE Blood-NEG Nitrite-NEG Protein-30* \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG\n___ 06:10PM URINE RBC-<1 WBC-2 Bacteri-FEW* Yeast-NONE \nEpi-0\n___ 06:10PM URINE CastHy-2*\n___ 06:10PM URINE Mucous-OCC*\n\nDISCHARGE LABS:\n===============\n___ 05:35AM BLOOD WBC-6.5 RBC-4.90 Hgb-13.0* Hct-41.5 \nMCV-85 MCH-26.5 MCHC-31.3* RDW-15.4 RDWSD-47.0* Plt ___\n___ 01:00PM BLOOD Glucose-110* UreaN-26* Creat-0.9 Na-144 \nK-4.0 Cl-99 HCO3-30 AnGap-15\n___ 01:00PM BLOOD Calcium-10.3 Phos-4.4 Mg-2.3\n\nMICROBIOLOGY:\n=============\n___ 6:16 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH.\n\n \n \n___ 6:10 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH. \n\nIMAGING/REPORTS:\n================\n___ CXR:\nIMPRESSION: \n \nBilateral pleural effusions and bibasilar consolidations, both \nleft greater than right. No pulmonary edema. \n\nCT Neck ___\nIMPRESSION: \n1. Periapical lucency ___ 31 without cortical dehiscence; \nplease correlate clinically regarding the possibility of active \ndental infection. Mild edema in the adjacent buccal soft \ntissues without evidence for an abscess. \n2. 4 mm stone in the distal right submandibular duct and 3 mm \nstone in the \ndistal left submandibular duct, without submandibular duct \ndilatation. No \nevidence for stones, intraglandular ductal dilatation, or \ninflammatory changes in the submandibular glands. \n3. No evidence for stones, masses, or inflammatory changes in \nthe parotid \nglands. \n4. Mildly enlarged, morphologically normal 2 cm right level 1B \nlymph node, \nlikely reactive. \n5. Multilevel degenerative changes in the cervical spine, \nincompletely \nevaluated. Spinal canal stenosis appears moderate to severe at \nC4-C5, at \nleast moderate at C5-C6 and C6-C7. \n\nTTE ___:\nIMPRESSION: Poor image quality. Mild symmetric left ventricular \nhypertrophy with normal global systolic function. Right \nventricular cavity dilation with preserved free wall motion. No \nvalvular pathology or pathologic flow identified. Normal \npulmonary artery systolic pressure.\nBiatrial enlargement.\n\nCTA ___:\nIMPRESSION: \nNo evidence of pulmonary embolism or aortic abnormality. \nMild cardiomegaly with no current evidence of pulmonary edema or \npleural \neffusions. \nMild bilateral atelectasis noted in both lower lobes, left \ngreater than right. \n\nCXR ___:\nIMPRESSION: \n \nIn comparison with the study of ___, the cardiomediastinal \nsilhouette is stable. Mild if any pulmonary vascular \ncongestion. Bibasilar opacifications with poor definition of the \nhemidiaphragms, more \nprominent on the left, is consistent with layering pleural \neffusions and \nunderlying compressive atelectasis. \n\n \nBrief Hospital Course:\nSUMMARY:\n========\n___ with PMHx of HTN, HLD, OSA, prior alcohol use disorder, \nmorbid obesity, DM2, and prostate cancer (getting radiation \ntherapy) who presented with worsening DOE, labs and CXR \nconsistent with CHF exacerbation. CTA Chest negative for PE or \nother obvious cause of his symptoms. TTE revealed preserved EF. \nWas diuresed with IV Lasix and transitioned to Torsemide 60mg po \nBID before discharge. During hospitalization, telemetry \nmonitoring revealed a high PVC burden with bradycardia. Beta \nblocker therapy was changed from atenolol to metoprolol and dose \ntitrated to attempt to suppress some ectopy without Bradycardia \nand pt improved. He also had night time desaturations and \nawakenings were felt to be more likely due to poorly titrated \nCPAP vs PND He developed tooth pain and was evaluated by our \ndental service who felt there was a possible infection in tooth \n31 and should get further evaluation as an outpatient. Patient \ndeveloped cellulitis of his left leg and was treated initially \nwith Vancomycin then transitioned to amoxicillin and \ndoxycycline. \n\nTRANSITIONAL ISSUES:\n====================\n- New Medications: Metoprolol Succinate 50mg Daily, Torsemide \n60mg BID, Doxycycline 100mg Q12H, Amoxicillin 500mg Q8H, \nAtorvastatin 80mg Daily\n- Held Medications: Atenolol 50mg Daily, Furosemide 20mg Daily\n- Follow Up Appointments: PCP, ___\n- ___ Up Labs: Should have chem panel checked within 1 week \nto ensure stable electrolytes and renal function. BNP to \nestablish baseline level when not fluid overloaded\n[] LLL Cellulitis: Doxycycline 100mg Q12H, Amoxicillin 500mg Q8 \nx7d (last dose ___\n[] Will need holter monitor, nuclear stress as outpatient\n[] Discharge Hgb 13.0, Cr 1.1, Weight 326.7lbs\n[] R side submandibular salivary duct stone identified on CT\n[] Tooth #31 - can not rule out necrotic pulp on panorex. Will \nneed dental evaluation as outpatient with focus to test vitality \non tooth #31.\n[] Noted to have night-time desaturations. Should have sleep \nstudy as outpatient\n\nACUTE ISSUES:\n=============\n# New acute HFpEF:\nPatient presented with dyspnea on exertion, likely paroxysmal \nnocturnal dyspnea. On admission he was volume overload on exam \nwith BNP 1800, and CXR consistent with CHF. TTE was obtained \nshowing preserved EF, no wall motion abnormalities. ACS ruled \nout on admission with two negative troponins. Patient was \ndiuresed with bolus and continuous IV furosemide. As he \napproached euvolemia he was transitioned to po regimen of \ntorsemide 60mg BID. Ambulatory sat was obtained and was 95% on \nroom air. He has a nuclear stress test for further workup and \ncardiology appointment scheduled at time of discharge. Atrius \ncardiology followed patient while admitted.\n\n# Asymptomatic Bradycardia\n# Frequent PVCs\nPatient noted to have frequent PVCs on telemetry, mostly in \nbigeminy pattern. Asymptomatic. Home atenolol switched to metop \nto attempt to suppress PVCs, which was successful but then \npatient experienced bradycardia with heart rates in ___. \nCardiology was consulted who recommended decreasing metoprolol \ntartrate to 12.5mg Q6H. He was transitioned to metoprolol \nsuccinate 50mg Daily prior to discharge. \n\n# LLE Cellulitis:\nArea on left shin with growing area of erythema/warmth \nsurrounding skin\nexcoriations consistent with cellulitis first noted on ___. No \npurulence or fluctuance to\nsuggest abscess on exam. Initially treated with vancomycin then \ntransitioned to po regimen of amoxicillin and doxycycline to \ncomplete ___nded ___.\n\n# HTN:\nHome lisinopril was continued. Home atenolol was held and \nchanged to metoprolol as above. Patient would benefit from \nongoing antihypertensive medication titration as outpatient. \n\n# Anemia\nHgb noted to last be 13.3 as outpatient, down to ___ on \nadmission. Patient reported possible bloody stools since \nstarting radiation therapy. Hgb noted to be uptrending since \nadmission and stabilized at his baseline in ___. \n\n# Tooth pain\nPatient complaining of face/tooth pain on admission. CT face \nobtained revealing right submandibular duct stone, lucency in \n___ 31. Panorex obtained to further evaluate tooth showing area \nof concern for possible infection/necrosis in tooth. Dental \nconsult recommended outpatient followup. Pain improved after \nstarting antibiotics for cellulits as above.\n\nCHRONIC ISSUES:\n===============\n#HLD\n- Continued atorvastatin 80 mg daily\n\n#Depression\n- Continued home fluoxetine \n\n#DM\nLast HA1c 7.1\nHome metformin held during admission and patient placed on \ninsulin sliding scale. Metformin restarted at discharge.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n2. MetFORMIN XR (Glucophage XR) 1000 mg PO BID \n3. Lisinopril 40 mg PO DAILY \n4. Atenolol 50 mg PO DAILY \n5. Furosemide 20 mg PO DAILY \n6. Cyanocobalamin 1000 mcg PO DAILY \n7. FLUoxetine 20 mg PO DAILY \n8. Vitamin D 1000 UNIT PO DAILY \n9. bicalutamide 50 mg oral unknown \n\n \nDischarge Medications:\n1. Amoxicillin 500 mg PO Q8H \nRX *amoxicillin 500 mg 1 tablet(s) by mouth every eight (8) \nhours Disp #*5 Tablet Refills:*0 \n2. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n3. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0 \n4. Doxycycline Hyclate 100 mg PO Q12H \nRX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day \nDisp #*5 Tablet Refills:*0 \n5. Metoprolol Succinate XL 50 mg PO DAILY \nRX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*0 \n6. bicalutamide 50 mg oral unknown \n7. Cyanocobalamin 1000 mcg PO DAILY \n8. FLUoxetine 20 mg PO DAILY \n9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n10. Lisinopril 40 mg PO DAILY \n11. MetFORMIN XR (Glucophage XR) 1000 mg PO BID \n12. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n==================\nAcute HFpEF\nVentricular Ectopy\nOSA\nProstate Cancer\n\nSECONDARY DIAGNOSIS\n===================\nHTN\nAnemia\nTooth Pain\nHLD\nDepression\nType 2 Diabetes\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 at ___. \n\nWHY WERE YOU IN THE HOSPITAL? \n- You were admitted to the hospital for shortness of breath\n\nWHAT HAPPENED WHEN YOU WERE IN THE HOSPITAL? \n-An x-ray on admission was suggestive of you having too much \nfluid in and around your lungs which was likely contributing to \nyour shortness of breath. A lab test we obtained suggested that \nthis fluid was building up because your heart was not pumping \nblood as efficiently as normal. A CT scan was performed of your \nchest to rule out other causes of shortness of breath such as a \nblood clot or pneumonia and did not show and other potential \ncauses. You were given a medication through your IV to help you \nurinate out this extra fluid and you improved. The cardiology \nteam from your outpatient cardiology office evaluate you while \nyou were admitted to help us guide your treatment.\n-You were experiencing night time awakenings feeling short of \nbreath. This was felt to be possibly related to either the extra \nfluid in your body or to imperfectly titrated CPAP settings.\n-You continued to go to your radiation therapy appointments for \nyour prostate cancer\n-We monitored your heart continuously while you were admitted \nand saw that you were having frequent extra heart beats. We \nchanged one of your medications (atenolol changed to metoprolol) \nto help with this. \n- An area of redness appeared on your left leg which was felt to \nbe an infection. You were started on antibiotics to treat this.\n- You were having pain in your tooth and we found that there was \na possible infection there. The antibiotics for your leg likely \ntreated this infection as well. You will need to follow up with \nyour dentist to further evaluate this.\n\nWHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL? \n- Continue to take all your medicines as prescribed below. \n- Show up to your appointments as listed below.\n- Weigh yourself every morning in light loose fitting clothing \nafter using the bathroom. Call your doctor if your weight \nincreases by more than 3lbs in a day or 5lbs in a week.\n- Please limit the sodium in your diet to 2g daily\n\nWe wish you the best! \n\nSincerely, \n\nYour ___ Team\n\n \nFollowup Instructions:\n___\n" ]

[ "I110", "I5031", "Z6841", "L03116", "E785", "G4733", "F1021", "E6601", "E119", "Z86010", "D649", "F329", "C61", "Z9221", "K115", "K041", "Z7984", "I493", "K047", "Z8673", "F1290" ]

[ "I110: Hypertensive heart disease with heart failure", "I5031: Acute diastolic (congestive) heart failure", "Z6841: Body mass index [BMI]40.0-44.9, adult", "L03116: Cellulitis of left lower limb", "E785: Hyperlipidemia, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "F1021: Alcohol dependence, in remission", "E6601: Morbid (severe) obesity due to excess calories", "E119: Type 2 diabetes mellitus without complications", "Z86010: Personal history of colonic polyps", "D649: Anemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "C61: Malignant neoplasm of prostate", "Z9221: Personal history of antineoplastic chemotherapy", "K115: Sialolithiasis", "K041: Necrosis of pulp", "Z7984: Long term (current) use of oral hypoglycemic drugs", "I493: Ventricular premature depolarization", "K047: Periapical abscess without sinus", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "F1290: Cannabis use, unspecified, uncomplicated" ]

[ "I110", "E785", "G4733", "E119", "D649", "F329", "Z8673" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nDarvocet-N 100 / Rocephin / Dilaudid / celecoxib\n \nAttending: ___.\n \nChief Complaint:\nL knee OA\n \nMajor Surgical or Invasive Procedure:\n___: L TKA\n\n \nHistory of Present Illness:\n___ s/p L TKA ___ Dr. ___\n \nPast Medical History:\nPMH: blood transfusions, crohn's disease, depression/anxiety, \nDJD lumbar spine, dysphagia, dyspnea, fibromyalgia, GERD, \n___'s Thyroiditis, HRT, HTN, knee OA, pernicious anemia, \ntemporal lobe seizures, R TKR ___, vaginal hysterectomy, \nhyponatremia, adrenal insufficiency, low back pain, \nblepharitis,shingles, \n\nPSH:L hip replacement ___, h/o alcohol abuse; ___, lumbar \nbilateral laminectomies with foraminotomies at L4, L5 and S1 \ndecompression, Bilateral reduction mammoplasty and left temporal \nartery biopsy and\ncataract surgery\n\n \nSocial History:\n___\nFamily History:\n# Mother: ___ cancer, hypertension \n# Father: ASthma on his side of family \n# Children: Four healthy children. Son died from glioblastoma \nmultiforme. \n\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* Incision healing well with staples\n* Thigh full but soft \n* No calf tenderness \n* ___ strength \n* SILT, NVI distally \n* Toes warm\n\n \nPertinent Results:\n___ 07:18AM BLOOD WBC-6.2 RBC-2.56* Hgb-7.4* Hct-24.9* \nMCV-97 MCH-28.9 MCHC-29.7* RDW-15.0 RDWSD-53.4* Plt ___\n___ 07:05AM BLOOD WBC-5.9 RBC-2.50* Hgb-7.5* Hct-24.4* \nMCV-98 MCH-30.0 MCHC-30.7* RDW-15.0 RDWSD-54.1* Plt ___\n___ 06:00AM BLOOD WBC-9.8 RBC-2.76* Hgb-8.2* Hct-26.9* \nMCV-98 MCH-29.7 MCHC-30.5* RDW-14.6 RDWSD-51.8* Plt ___\n___ 06:17AM BLOOD WBC-7.9 RBC-2.73* Hgb-8.1* Hct-26.7* \nMCV-98 MCH-29.7 MCHC-30.3* RDW-14.8 RDWSD-53.0* Plt ___\n___ 06:30AM BLOOD WBC-10.9* RBC-2.76* Hgb-8.3* Hct-27.5* \nMCV-100* MCH-30.1 MCHC-30.2* RDW-14.8 RDWSD-54.1* Plt ___\n___ 05:30AM BLOOD WBC-9.1 RBC-3.02* Hgb-9.1* Hct-29.5* \nMCV-98 MCH-30.1 MCHC-30.8* RDW-14.4 RDWSD-52.0* Plt ___\n___ 07:05AM BLOOD Glucose-96 UreaN-15 Creat-0.8 Na-143 \nK-4.4 Cl-104 HCO3-25 AnGap-14\n___ 10:10AM BLOOD Glucose-109* UreaN-15 Creat-0.8 Na-141 \nK-4.1 Cl-103 HCO3-26 AnGap-12\n___ 09:53AM BLOOD Glucose-109* UreaN-13 Creat-0.9 Na-138 \nK-3.8 Cl-102 HCO3-26 AnGap-10\n___ 05:30AM BLOOD Glucose-90 UreaN-19 Creat-0.8 Na-141 \nK-4.4 Cl-102 HCO3-26 AnGap-13\n___ 07:10PM BLOOD cTropnT-<0.01 proBNP-1649*\n___ 07:05AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.3\n___ 10:10AM BLOOD Calcium-8.2* Phos-2.1* Mg-2.2\n___ 09:53AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.2\n___ 06:30AM BLOOD Mg-2.2\n___ 05:30AM BLOOD Calcium-8.4 Phos-3.9 Mg-1.7\n___ 09:53AM BLOOD Cortsol-10.2\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's magnesium was 1.7 and this was repleted. \nPatient was noted to be drowsy on increased dose of Oxycodone \n15mg and this was decreased to ___ Q4 PRN. Gabapentin was \nalso decreased from 300mg to 100mg TID.\nPOD #2, patient reported inadequate pain control and Gabapentin \nwas increased back to 300mg TID with adequate relief and no \nreport of further sedation.\nPOD #3, patient reported dizziness with SBP in the ___. Patient \nwas administered 500ml IV fluid bolus and BPs improved to 100s. \nPatient resumed home dose Hydrocortisone 5mg BID given history \nof adrenal insufficiency. Endocrinology was consulted for \nfurther medication management and they recommended 1x dose of IV \nHydrocortisone 100mg. PO Hydrocortisone was also increased to \n15mg with taper plan ordered per Endocrine.\nPOD #4, patient received 30mg hydrocortisone BID per endocrine. \nPatient reported a cough with green sputum production. A chest \nx-ray was performed which showed vascular congestion but no \novert pulmonary edema. \nBasal consolidation, most likely infection. Followup of the \npatient 4 weeks after completion of antibiotic therapy is \nrecommended. Increase cardiac silhouette, please consider \nechocardiography to exclude the possibility of pericardial \neffusion. Nonspecific interstitial changes. For pre size \ncharacterization consider assessment with chest CT after \ntreatment of current infectious process. Medicine was consulted \nand recommended starting Levaquin 750mg daily x 5 days.\n\nPOD #5, Endocrine recommended continuing Hydrocortisone taper as \nfollows: \nHydrocortisone 20 mg BID starting on ___ x 3 days, then 10 mg \nBID x 3 days then home dose of 5mg BID. Give BID doses at 8AM \nand 3PM. Patient continues to report dyspnea with o2 sats within \nnormal limits > 94% on room air. Medicine recommended standing \nDuoNeb treatments and starting Guaifenasin PRN.\n\nPOD #6, patient was cleared for discharge per Medicine and \nEndocrinology with taper plan as above. Patient will not require \nIVIG infusion for at least 2 weeks post-op and until she is \ndischarged from rehab facility.\n\nOtherwise, pain was controlled with a combination of IV and oral \npain medications. The patient received Aspirin 325 BID for DVT \nprophylaxis starting on the morning of POD#1. The foley was \nremoved and the patient was voiding independently thereafter. \nThe surgical dressing was changed on POD#2 and the surgical \nincision was found to be clean and intact without erythema or \nabnormal drainage. The patient was seen daily by physical \ntherapy. Labs were checked throughout the hospital course and \nrepleted accordingly. At the time of discharge the patient was \ntolerating a regular diet and feeling well. The patient was \nafebrile with stable vital signs. The patient's hematocrit was \nacceptable and pain was adequately controlled on an oral \nregimen. The operative extremity was neurovascularly intact and \nthe wound was benign. \n\nThe patient's weight-bearing status is weight bearing as \ntolerated on the operative extremity.\n \nMs. ___ is discharged to rehab in stable condition.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild \n2. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheez, SOB \n3. ALPRAZolam 1 mg PO QHS \n4. amLODIPine 5 mg PO TID \n5. ARIPiprazole 2 mg PO DAILY \n6. Aspirin 81 mg PO DAILY \n7. Vitamin D 1000 UNIT PO DAILY \n8. Citalopram 40 mg PO BID \n9. Estrogens Conjugated 0.3 mg PO DAILY \n10. Hydroxocobalamin 2 g IV WEEKLY \n11. Amphetamine-Dextroamphetamine 7.5 mg PO BID \n12. Estrogens Conjugated 1 gm VG DAILY \n13. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID:PRN \nWheez SOB \n14. FoLIC Acid 1 mg PO BID \n15. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain \n- Severe \n16. Hydrocortisone 5 mg PO BID \n17. Immune Globulin Intravenous (Human) unknown IV Frequency is \nUnknown \n18. LamoTRIgine 100 mg PO BID \n19. Levothyroxine Sodium 112 mcg PO DAILY \n20. Mesalamine Enema ___ID \n21. Mesalamine ___ 4.8 Gr PO DAILY \n22. Metoprolol Tartrate Dose is Unknown PO Frequency is Unknown \n\n23. Miconazole 2% Cream 1 Appl TP BID \n24. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY \n25. Omeprazole 40 mg PO BID \n26. GuaiFENesin ER 600 mg PO Q12H \n27. Rosuvastatin Calcium 40 mg PO QPM \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \n2. Gabapentin 300 mg PO TID \n3. Levofloxacin 750 mg PO DAILY Duration: 5 Days \nStart date: ___ \n4. Morphine Sulfate ___ 7.5 mg PO Q4H:PRN Pain - Severe \n5. Senna 8.6 mg PO BID \n6. Acetaminophen 1000 mg PO Q8H \n7. ALPRAZolam 1 mg PO QHS:PRN insomnia \n8. Aspirin 325 mg PO BID Duration: 30 Days \n9. Hydrocortisone 20 mg PO BID Duration: 3 Days \n20 mg BID starting on ___ x 3 days, then 10 mg BID x 3 days then \nhome dose of 5mg BID. \n10. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheez, SOB \n11. amLODIPine 5 mg PO TID \n12. Amphetamine-Dextroamphetamine 7.5 mg PO BID \n13. ARIPiprazole 2 mg PO DAILY \n14. Citalopram 40 mg PO BID \n15. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID:PRN \nWheez SOB \n16. FoLIC Acid 1 mg PO BID \n17. GuaiFENesin ER 600 mg PO Q12H \n18. Hydroxocobalamin 2 g IV WEEKLY \n19. LamoTRIgine 100 mg PO BID \n20. Levothyroxine Sodium 112 mcg PO DAILY \n21. Mesalamine ___ 4.8 Gr PO DAILY \n22. Mesalamine Enema ___ID \n23. Miconazole 2% Cream 1 Appl TP BID \n24. Nitrofurantoin Monohyd (MacroBID) 100 mg PO DAILY \n25. Omeprazole 40 mg PO BID \n26. Rosuvastatin Calcium 40 mg PO QPM \n27. Vitamin D 1000 UNIT PO DAILY \n28. HELD- Estrogens Conjugated 0.3 mg PO DAILY This medication \nwas held. Do not restart Estrogens Conjugated until you've been \ncleared by your surgeon\n29. HELD- Estrogens Conjugated 1 gm VG DAILY Duration: 3 Weeks \nThis medication was held. Do not restart Estrogens Conjugated \nuntil you've been cleared by your surgeon\n30. HELD- Immune Globulin Intravenous (Human) unknown IV \nFrequency is Unknown This medication was held. Do not restart \nImmune Globulin Intravenous (Human) until you've been cleared by \nyour surgeon\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nleft knee osteoarthritis\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. You may wrap the knee with an ace bandage \nfor added compression. Please DO NOT take any non-steroidal \nanti-inflammatory medications (NSAIDs such as Celebrex, \nibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by \nyour physician.\n \n8. ANTICOAGULATION: Please continue your Aspirin 325 mg twice \ndaily for four (4) weeks to help prevent deep vein thrombosis \n(blood clots). If you were taking aspirin prior to your \nsurgery, it is OK to continue at your previous dose after the \nfour weeks is completed. \n \n9. WOUND CARE: Please keep your incision clean and dry. It is \nokay to shower five days after surgery but no tub baths, \nswimming, or submerging your incision until after your four (4) \nweek checkup. Please place a dry sterile dressing on the wound \neach day if there is drainage, otherwise leave it open to air. \nCheck wound regularly for signs of infection such as redness or \nthick yellow drainage. Staples will be removed at your follow-up \nappointment in two weeks.\n \n10. ___ (once at home): Home ___, dressing changes as \ninstructed, wound checks.\n \n11. ACTIVITY: Weight bearing as tolerated on the operative \nextremity. Mobilize. ROM as tolerated. No strenuous exercise or \nheavy lifting until follow up appointment.\n\nPhysical Therapy:\nWBAT\nROMAT\nWean assistive device as able (i.e. 2 crutches or walker)\nMobilize frequently \nTreatments Frequency:\ndaily dressing changes as needed for drainage\nwound checks daily\nice\nstaple removal and replace with steri-strips at follow up visit \nin clinic\n \nFollowup Instructions:\n___\n" ]

[ "M1712", "J189", "E2740", "I9581", "D801", "K5090", "I10", "G4700", "M315", "J449", "F909", "Z96651", "Z96642", "Z87891" ]

[ "M1712: Unilateral primary osteoarthritis, left knee", "J189: Pneumonia, unspecified organism", "E2740: Unspecified adrenocortical insufficiency", "I9581: Postprocedural hypotension", "D801: Nonfamilial hypogammaglobulinemia", "K5090: Crohn's disease, unspecified, without complications", "I10: Essential (primary) hypertension", "G4700: Insomnia, unspecified", "M315: Giant cell arteritis with polymyalgia rheumatica", "J449: Chronic obstructive pulmonary disease, unspecified", "F909: Attention-deficit hyperactivity disorder, unspecified type", "Z96651: Presence of right artificial knee joint", "Z96642: Presence of left artificial hip joint", "Z87891: Personal history of nicotine dependence" ]

[ "I10", "G4700", "J449", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nTegaderm / erythromycin base / gentamicin / Penicillins / \ntetracycline\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ h/o EtOH cirrhosis s/p FEVAR with bilateral renal stents\n___, ___ c/b ruptured left groin pseudoaneurysm s/p\nleft groin cutdown with primary closure of left CFA ___,\n___ admitted from ___ to ___ for fevers. \n\nPer the patient's daughter, she had increasing abdominal and \nback\npain from her baseline that was persistent. She was therefore\ntaken to ___ where she was found to have a \ntype\nB dissection. She was ___ transferred to ___ for \nfurther\nevaluation.\n\nPatient appeared somnolent on initial presentation. Her daughter\nnotes that she was given morphine prior to transfer and that\notherwise, she has had no mental status changes. She denies\nnumbness, tingling, or weakness in her extremities. \n\n \nPast Medical History:\nHLD \nOvarian Cyst\nArthritis \nAlcohol Abuse \nHypertension\nBreast Cancer\nCirrhosis\nTubular adenomas of colon\nAnxiety\nDepression\n \nSocial History:\n___\nFamily History:\nNoncontributory\n \nPhysical Exam:\nAdmission Physical Exam \n=======================\nPhysical Exam\nVitals: 97.8 68 169/80 16 98% RA \nGEN: A&Ox2, somnolent\nCV: Regular rate, regular rhythm\nPULM: CTAB\nABD: soft, non-tender at this time\nExt: WWP, motor and sensory intact, left groin with 2 open areas\nsuperficially <5mm each, no drainage, no erythema\nPulse exam: \nUE: b/l palp radial \n___: b/l pop, DP, and ___ palpable. Right fem palpable, Left fem\nDopplerable\n\nDischarge Physical Exam \n=======================\n___ ___ Temp: 98.1 PO BP: 134/65 HR: 69 RR: 18 O2 sat: 95%\nO2 delivery: ra \nGENERAL: No acute distress, pleasant \nCV: RRR \nPULM: CTA b/l, no respiratory distress \nABD: Soft, non-tender, nondistended. Left groin with 2 \nsuperficial wounds, no drainage, no erythema, no clinical signs \nof infection\nEXTREMITIES: Unable to flex right third digit, no pain with \nexamination, sensation to light touch in tact \n \nPertinent Results:\nLab results \n===========\n___ 05:36AM BLOOD WBC-5.6 RBC-2.79* Hgb-8.2* Hct-25.5* \nMCV-91 MCH-29.4 MCHC-32.2 RDW-17.4* RDWSD-55.5* Plt Ct-55*\n___ 06:15AM BLOOD WBC-8.0 RBC-2.74* Hgb-8.0* Hct-25.4* \nMCV-93 MCH-29.2 MCHC-31.5* RDW-17.4* RDWSD-56.3* Plt Ct-57*\n___ 06:56AM BLOOD WBC-11.0* RBC-2.93* Hgb-8.5* Hct-26.7* \nMCV-91 MCH-29.0 MCHC-31.8* RDW-16.8* RDWSD-54.5* Plt Ct-90*\n___ 04:21AM BLOOD WBC-9.3 RBC-3.07* Hgb-8.8* Hct-28.4* \nMCV-93 MCH-28.7 MCHC-31.0* RDW-16.7* RDWSD-54.9* Plt Ct-82*\n\n___ 05:36AM BLOOD Glucose-90 UreaN-13 Creat-0.4 Na-138 \nK-3.6 Cl-106 HCO3-22 AnGap-10\n___ 06:15AM BLOOD Glucose-101* UreaN-14 Creat-0.5 Na-135 \nK-3.3* Cl-104 HCO3-21* AnGap-10\n___ 06:56AM BLOOD Glucose-96 UreaN-11 Creat-0.5 Na-132* \nK-3.6 Cl-100 HCO3-23 AnGap-9*\n___ 02:51AM BLOOD Glucose-106* UreaN-11 Creat-0.5 Na-132* \nK-3.4* Cl-98 HCO3-24 AnGap-10\n\n___ 02:51AM BLOOD ALT-20 AST-43* AlkPhos-99 TotBili-3.1*\n\n___ 02:51AM BLOOD cTropnT-<0.01\n\n___ 05:36AM BLOOD Calcium-8.0* Phos-1.9* Mg-1.8\n___ 06:15AM BLOOD Calcium-7.8* Phos-2.5* Mg-2.2\n___ 06:56AM BLOOD Calcium-8.0* Phos-2.0* Mg-1.4*\n\nImaging \n=======\nCT TORSO ___ \n\nTTE ___\nCONCLUSION:\nThe left atrial volume index is normal. The right atrium is\nmoderately enlarged. There is normal left ventricular\nwall thickness with a normal cavity size. There is normal\nregional and global left ventricular systolic function.\nQuantitative 3D volumetric left ventricular ejection fraction is\n59 %. Left ventricular cardiac index is\nnormal (>2.5 L/min/m2). There is no resting left ventricular\noutflow tract gradient. Normal right ventricular\ncavity size with normal free wall motion. The aortic sinus\ndiameter is normal for gender with normal ascending\naorta diameter for gender. The aortic arch is mildly dilated \nwith\na mildly dilated descending aorta. There is no\nevidence for an aortic arch coarctation. No aortic dissection is\nseen (best excluded TEE or thoracic CT/MRI).\nThe aortic valve leaflets (3) appear structurally normal. There\nis no aortic valve stenosis. There is no aortic\nregurgitation. The mitral valve leaflets appear structurally\nnormal with no mitral valve prolapse. There is trivial\nmitral regurgitation. The tricuspid valve leaflets appear\nstructurally normal. There is mild [1+] tricuspid\nregurgitation. There is mild pulmonary artery systolic\nhypertension. There is a trivial pericardial effusion.\nIMPRESSION: Mildly dilated aortic arch and descending thoracic\naorta. Normal left ventricular wall\nthickness and biventricular cavity\n\nHAND (PA,LAT & OBLIQUE) RIGHT Study Date of ___ 3:30 ___ \nIMPRESSION: \n1. Moderate to severe arthritis involving the second through\nfifth distal interphalangeal joints with cecal type pattern of\nnarrowing which has been described in erosive osteoarthritis. \n2. Severe degenerative changes involving the first\ncarpometacarpal and triscaphe joints. \n\n___ - CT TORSO SECOND READ \nIMPRESSION: \n1. Type B aortic dissection from the aortic arch to just above\nthe abdominal aortic aneurysm repair without evidence of\ncomplications. \n2. Stable abdominal aortic aneurysm repair without evidence of\nenlargement. \n3. Pulmonary nodules in the right lung measuring 5 mm and 6 mm. \n\nMR HEAD W & W/O CONTRAST Study Date of ___ 9:42 AM \nIMPRESSION: \n1. Within the confines of a mildly motion degraded exam, no\nevidence of acute infarct or intracranial abnormality. \n2. Likely chronic microhemorrhage of the right parietooccipital\nlobe. \n\n \nBrief Hospital Course:\n Neuro: Abdominal pain resolved within admission. Back pain \nwell controlled with lidocaine patches, low dose po oxycodone. \n CV: Vital signs were routinely monitored during the patient's \nlength of stay. Goal systolic blood pressure <120 mmHg. \nVascular medicine was consulted within admission, and their \nfinal recommendations included 25mg po losartan QD, as well as \n18.75 mg carvedilol BID. \n Pulm: The patient was encouraged to ambulate, sit and get out \nof bed, use the incentive spirometer, and had oxygen saturation \nlevels monitored as indicated. \n GI: The patient tolerated a regular diet at time of discharge. \n GU: Patient had a Foley catheter that was removed at time of \ndischarge. Urine output was monitored as indicated. At time of \ndischarge, the patient was voiding without difficulty. \n ID: The patient's vital signs were monitored for signs of \ninfection and fever. The patient was continued on her cipro \ncourse (end date ___ \n Heme: The patient had blood levels checked post operatively \nduring the hospital course to monitor for signs of bleeding. The \npatient had vital signs, including heart rate and blood \npressure, monitored throughout the hospital stay. \n \nDischarge Medications:\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nMrs. ___ is a ___ with ETOH cirrhosis, former smoker, and \nrecent fEVAR c/b left CFA pseudoaneurysm and hematoma s/p left \ngroin exploration and primary repair. Presented with type B \naortic dissection, being managed with blood pressure control. \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 ___ for a \ntype B dissection following treatment of your left groin \npsuedoaneurysm. You are ready to be discharged to home. Please \nfollow the instructions below to continue your recovery: \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 slight swelling of the legs. \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 full strength (325mg) enteric coated aspirin daily, \nunless otherwise directed \n\nACTIVITIES: \n• No driving until post-op visit and you are no longer taking \npain 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\nCALL THE OFFICE FOR : ___ \n• Redness that extends away from your incision \n• A sudden increase in pain that is not controlled with pain \nmedication \n• A sudden change in the ability to move or use your leg or the \nability to feel your leg \n• Temperature greater than 101.5F for 24 hours \n• Bleeding from incision \n• New or increased drainage from incision or white, yellow or \ngreen drainage from incisions \n \nFollowup Instructions:\n___\n" ]

[ "I7101", "C228", "I10", "E785", "F329", "F419", "Z87891", "K7030", "M6281" ]

[ "I7101: Dissection of thoracic aorta", "C228: Malignant neoplasm of liver, primary, unspecified as to type", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "Z87891: Personal history of nicotine dependence", "K7030: Alcoholic cirrhosis of liver without ascites", "M6281: Muscle weakness (generalized)" ]

[ "I10", "E785", "F329", "F419", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROSURGERY\n \nAllergies: \nlactose intolerance / gluten\n \nAttending: ___.\n \nChief Complaint:\nGradual cognitive decline and new-onset seizures in the presence \nof hippocampal lesion \n\n \nMajor Surgical or Invasive Procedure:\n___ right craniotomy for right temporal lobectomy and \nresection of brain lesion \n\n \nHistory of Present Illness:\nPatient was seen in ___ clinic for evaluation of R \nhippocampal lesion. She developed with new-onset piloerectile \nseizures on top of a gradual cognitive decline, mainly memory \nrelated. The seizures are described as chill which radiates down \nher right arm with goose bumps, and associated tingling and \nnausea that lasts for ___ minutes. \nEpileptic activity was confirmed on recent EEG and patient was \nput on oxcarbazepine. She hasn't had similar episodes since and \nshe is neurologically intact on today's exam. Recent MRI has \ndemonstrated a new FLAIR hyperintense hippocampal lesion which \nis also mildly enhanced. This finding is new compared to \nprevious MRI from ___ (the year when her cognitive difficulties \nstarted).\n \nPast Medical History:\n-R Bell's palsy (resolved)\n-depression and anxiety \n-cognitive decline-memory/attention (since ___\n-piloerectile seizure\n-migraines\n-remote history of concussion \n \nSocial History:\n___\nFamily History:\nHer mother passed away at age ___ and had a mixed dementia and \nlater developed seizures and also had a history of colorectal \ncancer. \nHer father died at age ___ from prostate cancer and had \ndepression. She has two brothers who are in good health. One \nmaternal aunt has MS. \n\n \n___ Exam:\n------------\non admission:\n------------\nPHYSICAL EXAM:\nVital Signs sheet entries for ___: \nBP: 102/66.\nGen: WD/WN, comfortable, NAD.\nHEENT: normal Pupils: PERRL EOMs: normal\nNeck: Supple.\nLungs: CTA bilaterally.\nCardiac: RRR. S1/S2.\nAbd: Soft, NT, BS+\nExtrem: Warm and well-perfused.\nNeuro:\nMental status: Awake and alert, cooperative with exam, normal \naffect.\nOrientation: Oriented to person, place, and date.\nRecall: ___ objects at 5 minutes.\nLanguage: Speech fluent with good comprehension and repetition.\nNaming intact. No dysarthria or paraphasic errors.\n\nCranial Nerves:\nI: Not tested\nII: Pupils equally round and reactive to light, 3 to 2 mm \nbilaterally. Visual fields are full to confrontation.\nIII, IV, VI: Extraocular movements intact bilaterally without \nnystagmus.\nV, VII: Facial strength and sensation intact and symmetric.\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\nCoordination: normal on finger-nose-finger, rapid alternating \nmovements\n\nGait: stable, including Tandem's. Romberg's neg.\n\n------------\nat discharge:\n------------\nAwakes to name, oriented to self, place, and date. Face symm, \ntongue midline. MAE full motor. Incision C/D/I. \n \nPertinent Results:\nCT HEAD W/O CONTRAST ___ 2:42 ___\nThe patient is status post partial right temporal lobectomy with \nexcision of the previously seen right hippocampal lesion. \nThere are expected \npostoperative changes including pneumocephalus and a small \namount of blood \nproducts in the resection cavity. The right choroidal fissure \ncyst is again seen and appears stable. There is no evidence of \nhemorrhage, infarction, or mass effect. \n\nMR HEAD W & W/O CONTRAST:\n1. Incomplete study with severe patient motion artifact \ndegrading image \nquality and limiting evaluation. \n2. Status post right temporal lobe craniotomy with expected \npostsurgical \nchanges as described above. \n3. No abnormal enhancement to suggest residual disease. However, \nplease note, FLAIR images are non-diagnostic, limiting direct \ncomparison with the prior study. \n4. Postoperative ischemia adjacent to the resection cavity \nwithin the right temporal lobe. \n\n \nBrief Hospital Course:\n# Brain Tumor\nMs. ___ was taken to the operating room on ___ for right \ncraniotomy for right temporal lobectomy and tumor resection. \nProcedure was uncomplicated. She was extubated and transferred \nto the PACU for close monitoring. Postop head CT showed postop \nchanges including pneumocephalus and small amount of hemorrhage \nalong the resection cavity. The patient was transferred to the \nfloor on ___. Her hospital course was complicated by delirium \nand confusion. A post-op MRI could rule out ischemia adjacent to \nthe resection bed vs. post-operative changes, there did not \nappear to be any residual tumor. \n\n# Delirium\nOn ___, the patient received Benadryl for insomnia and \nagitation. A code purple was called after patient continued to \nbe acutely agitated. A Veil bed ordered was ordered and her \nmedications were adjusted to decrease her delirium. Her \nBenadryl, scopolamine patch, and famotidine were discontinued \nand a Decadron wean was started. \nThe ___ bed was discontinued on ___. Mental status continued \nto improve through admission. Patient still slightly confused \nre: location of hospital. ___ evaluated and determined \ndischarge to rehab was appropriate. Patient expressed \nunderstanding and agreement.\n\nShe was discharged to rehab on ___.\n\n \nMedications on Admission:\nFLUOXETINE - 20mg daily\nOXCARBAZEPINE - 150 mg tablet. 1 tablet(s) by mouth bid\nEye-Drops -\n \nDischarge Medications:\n1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Pain - \nModerate \n2. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain \n3. Dexamethasone 2 mg PO Q12H Duration: 6 Doses \nThis is dose # 2 of 3 tapered doses\nTapered dose - DOWN \n4. Dexamethasone 2 mg PO DAILY Duration: 1 Dose \nThis is dose # 3 of 3 tapered doses\nTapered dose - DOWN \n5. Docusate Sodium 100 mg PO BID \n6. Heparin 5000 UNIT SC BID \n7. Pantoprazole 40 mg PO Q24H \n8. Senna 17.2 mg PO QHS \n9. CYCLOSPORINE 0.05% OPHTH EMULSION 1 DROP ___ BID \n10. FLUoxetine 20 mg PO DAILY \n11. OXcarbazepine 150 mg PO BID \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nBrain Tumor\n\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDischarge Instructions\nBrain Tumor\n\nSurgery\n· You underwent surgery to remove a brain lesion from your \nbrain.\n \n· Please keep your incision dry until your sutures/staples are \nremoved. \n\n· You may shower at this time but keep your incision dry.\n\n· It is best to keep your incision open to air but it is ok \nto cover it when outside. \n\n· Call your surgeon if there are any signs of infection like \nredness, fever, or drainage. \n\n \n\nActivity\n\n· We recommend that you avoid heavy lifting, running, \nclimbing, or other strenuous exercise until your follow-up \nappointment.\n\n· You make take leisurely walks and slowly increase your \nactivity at your own pace once you are symptom free at rest. \n___ try to do too much all at once.\n\n· No driving while taking any narcotic or sedating \nmedication. \n\n· If you experienced a seizure while admitted, you are NOT \nallowed to drive by law. \n\n· No contact sports until cleared by your neurosurgeon. You \nshould avoid contact sports for 6 months. \n\n \nMedications\n\n· You have been discharged on your home dose of \noxcarbazepine. This medication helps to prevent seizures. Please \ncontinue this medication as indicated on your discharge \ninstruction. It is important that you take this medication \nconsistently and on time. \n\n· You may use Acetaminophen (Tylenol) for minor discomfort \nif you are not otherwise restricted from taking this medication.\n\n \nWhat You ___ Experience:\n\n· You may experience headaches and incisional pain. \n\n· You may also experience some post-operative swelling \naround your face and eyes. This is normal after surgery and most \nnoticeable on the second and third day of surgery. You apply \nice or a cool or warm washcloth to your eyes to help with the \nswelling. The swelling will be its worse in the morning after \nlaying flat from sleeping but decrease when up. \n\n· You may experience soreness with chewing. This is normal \nfrom the surgery and will improve with time. Softer foods may be \neasier during this time. \n\n· Feeling more tired or restlessness is also common.\n\n· Constipation is common. Be sure to drink plenty of fluids \nand eat a high-fiber diet. If you are taking narcotics \n(prescription pain medications), try an over-the-counter stool \nsoftener.\n\n \nWhen to Call Your Doctor at ___ for:\n\n· Severe pain, swelling, redness or drainage from the \nincision site. \n\n· Fever greater than 101.5 degrees Fahrenheit\n\n· Nausea and/or vomiting\n\n· Extreme sleepiness and not being able to stay awake\n\n· Severe headaches not relieved by pain relievers\n\n· Seizures\n\n· Any new problems with your vision or ability to speak\n\n· Weakness or changes in sensation in your face, arms, or \nleg\n\n \n\nCall ___ and go to the nearest Emergency Room if you experience \nany of the following:\n\n· Sudden numbness or weakness in the face, arm, or leg\n\n· Sudden confusion or trouble speaking or understanding\n\n· Sudden trouble walking, dizziness, or loss of balance or \ncoordination\n\n· Sudden severe headaches with no known reason\n \nFollowup Instructions:\n___\n" ]

[ "D496", "G40109", "F05", "G40909", "F419", "F329", "K900", "G4700", "Z87891", "T450X5A", "T443X5A", "T470X5A", "Y92230" ]

[ "D496: Neoplasm of unspecified behavior of brain", "G40109: Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with simple partial seizures, not intractable, without status epilepticus", "F05: Delirium due to known physiological condition", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "K900: Celiac disease", "G4700: Insomnia, unspecified", "Z87891: Personal history of nicotine dependence", "T450X5A: Adverse effect of antiallergic and antiemetic drugs, initial encounter", "T443X5A: Adverse effect of other parasympatholytics [anticholinergics and antimuscarinics] and spasmolytics, initial encounter", "T470X5A: Adverse effect of histamine H2-receptor blockers, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]

[ "F419", "F329", "G4700", "Z87891", "Y92230" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROLOGY\n \nAllergies: \nPenicillins\n \nAttending: ___.\n \nChief Complaint:\nStroke\n \nMajor Surgical or Invasive Procedure:\nAttempted mechanical thrombectomy for right proximal middle \ncerebral artery occlusion. \n \nHistory of Present Illness:\nMs. ___ is an ___ year old woman with a past medical history of\nafib not on anticoagulation who presented with left weakness.\n\nPer report, was sitting in a chair at home at 1:50pm when she\nslumped. Husband tried to sit her up and could not, called ___.\nWhen EMS arrived she was noted to have a complete left\nhemiparesis, \"garbled\" speech and right gaze deviation. FSBG\n130s. She was brought to ___ where she was given tPA for\nNIHSS 24 at 2:55pm and then medflighted to ___ ED.\n\nOn transport, neurologic exam reportedly stable, asking for\nhusband ___ and following commands. BPs in the 150s.\n\nOn arrival to ___ ED stroke scale 18. Taken for CT/CTA which\nshowed R M1 cutoff, she was taken directly to angio.\n\nROS not obtained.\n\n \nPast Medical History:\n- afib\n- HTN\n- DM\n- stroke\n \nSocial History:\n___\nFamily History:\nUnknown\n \nPhysical Exam:\n==============\nADMISSION EXAM\n==============\n\nVitals: 94 ___ 99% RA \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 C/C/E bilaterally, 2+ radial, DP pulses\nbilaterally.\nSkin: no rashes or lesions noted.\n\nNeurologic:\n\n-Mental Status: Alert, awake. Gaze to right with profound left\nneglect. Speech dysarthric. Follows simple commands - shows her\nright thumb. Able to state name. Says month is ___. Says she is\n___. Repeatedly asks for her husband, ___.\n\n-Cranial Nerves:\nI: Olfaction not tested.\nII: PERRL 3 to 2mm and brisk. Does not blink to threat on the\nleft. Blinks to threat on the right.\nIII, IV, VI: Right gaze deviation, does not cross midline. Gaze\nconjugate.\nV: Facial sensation intact to light touch.\nVII: Severe left lower facial droop.\nVIII: Hearing grossly intact.\nIX, X: Not tested.\nXI: Not tested\nXII: Tongue protrudes in midline.\n\n-Motor: Decreased tone on in the left arm and leg. No pronator\ndrift bilaterally. No adventitious movements, such as tremor,\nnoted. No asterixis noted.\n\nNo drift in the right arm or leg. Left arm moves in the plane of\nthe bed to noxious stim, left leg with minimal movement to\nnoxious stim.\n\n-Sensory: Responds to nox throughout as above.\n\n-DTRs: ___ on the left.\n\n-Coordination: No dysmetria on the right, unable to test on the\nleft.\n\n-Gait: Deferred\n\n==============\nDISCHARGE EXAM\n==============\n\nAwake, unresponsive. LT plegia.\n\n \nPertinent Results:\n====\nLABS\n====\n___ 03:11AM BLOOD WBC-11.1* RBC-3.17* Hgb-8.4* Hct-27.0* \nMCV-85 MCH-26.5 MCHC-31.1* RDW-16.2* RDWSD-49.7* Plt ___\n___ 01:44AM BLOOD WBC-8.6 RBC-2.70* Hgb-7.2* Hct-23.6* \nMCV-87 MCH-26.7 MCHC-30.5* RDW-17.1* RDWSD-53.3* Plt ___\n___ 06:58AM BLOOD WBC-9.1 RBC-2.82* Hgb-7.5* Hct-24.7* \nMCV-88 MCH-26.6 MCHC-30.4* RDW-16.6* RDWSD-51.5* Plt ___\n___ 05:00AM BLOOD WBC-9.7 RBC-2.78* Hgb-7.3* Hct-24.0* \nMCV-86 MCH-26.3 MCHC-30.4* RDW-17.0* RDWSD-51.8* Plt ___\n___ 03:11AM BLOOD ___ PTT-25.0 ___\n___ 03:11AM BLOOD Plt ___\n___ 01:44AM BLOOD ___ PTT-26.8 ___\n___ 01:44AM BLOOD Plt ___\n___ 09:05PM BLOOD ___ PTT-25.5 ___\n___ 09:05PM BLOOD Plt ___\n___ 06:58AM BLOOD Plt ___\n___ 05:00AM BLOOD Plt ___\n___ 03:11AM BLOOD Glucose-206* UreaN-27* Creat-0.9 Na-140 \nK-4.3 Cl-106 HCO3-22 AnGap-16\n___ 01:44AM BLOOD Glucose-200* UreaN-25* Creat-0.9 Na-139 \nK-4.0 Cl-107 HCO3-24 AnGap-12\n___ 09:05PM BLOOD Glucose-219* UreaN-23* Creat-0.8 Na-142 \nK-4.1 Cl-108 HCO3-23 AnGap-15\n___ 06:58AM BLOOD Glucose-176* UreaN-21* Creat-0.7 Na-141 \nK-3.9 Cl-110* HCO3-25 AnGap-10\n___ 05:00AM BLOOD Glucose-193* UreaN-25* Creat-0.7 Na-139 \nK-4.2 Cl-106 HCO3-22 AnGap-15\n___ 04:00PM BLOOD ALT-14 AST-34 AlkPhos-35 TotBili-0.8\n___ 03:11AM BLOOD ALT-7 AST-12 AlkPhos-32* TotBili-0.8\n___ 04:00PM BLOOD Lipase-37\n___ 04:00PM BLOOD Albumin-3.9 Calcium-9.5 Phos-4.9* Mg-1.6\n___ 03:11AM BLOOD Albumin-3.6 Calcium-8.6 Phos-4.3 Mg-1.4* \nCholest-95\n___ 01:44AM BLOOD Calcium-8.0* Phos-3.8 Mg-2.1\n___ 09:05PM BLOOD Calcium-8.3* Phos-2.8 Mg-2.0\n___ 06:58AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.9\n___ 05:00AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.8\n___ 03:11AM BLOOD %HbA1c-6.7* eAG-146*\n___ 03:11AM BLOOD Triglyc-85 HDL-39 CHOL/HD-2.4 LDLcalc-39\n___ 03:11AM BLOOD TSH-1.3\n___ 04:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-9* \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 12:47PM URINE Blood-NEG Nitrite-NEG Protein-TR \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-7.0 Leuks-NEG\n___ 12:47PM URINE Color-Yellow Appear-Hazy Sp ___\n___ 12:47PM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0\n=======\nIMAGING\n=======\n\nCTA HEAD & NECK ___:\n1. Abrupt cut off of the right M1 segment, with sulcal \neffacement within the right insular cortex, representing \nthrombosis and an early acute right MCA stroke. \n2. Chronic left PCA infarct. \n3. No evidence of hemorrhage or midline shift. \n4. Severe atherosclerotic narrowing at the origin of the left \nvertebral \nartery. \n5. Multifocal atherosclerotic calcified and non-calcified \nplaques, but no other evidence of stenosis or occlusion. \n6. Enlarged aorto-pulmonary window lymph nodes measuring up to \n2.0 cm of \nunclear etiology. \n\nPROCEDURE ___: Attempted mechanical thrombectomy for right \nproximal middle cerebral artery occlusion. \n \nFINDINGS: \nRight carotid artery: The right carotid bifurcation is well \nvisualized and does not show signs of stenosis or \narteriosclerotic changes. The right anterior intracranial \ncirculation is notable for an abrupt cut off of the right M1 \nsegment of the middle cerebral artery past the majority of the \nlateral lenticulostriate perforators. With the micro catheter \npositioned past the occluded segment there was good filling of \nthe distal middle cerebral artery. Despite one attempt using \nthey stent retriever we were unable to reopen the artery \nconsistent with TICI0. \n\nECHO ___:\nIMPRESSION: Suboptimal image quality. Normal global \nbiventricular systolic function, chamber size and wall \nthickness. At least moderate tricuspid regurgitation. Moderate \npulmonary artery systolic hypertension. \n\nMRI BRAIN W/O CONTRAST ___:\n1. Please note the study is moderately degraded by motion. \n2. Large subacute infarction of the right MCA territory with no \ndefinite \nevidence for hemorrhage and no midline shift. \n3. Questionable acute infarctions in the bilateral cerebellar \nhemispheres, \ndifficult to definitively evaluate given motion artifact. \n4. White matter signal abnormality, likely secondary to chronic \nmicrovascular ischemic changes. \n\nCXR ___:\nA nasogastric tube extends to at least the level the stomach, \nwith the tip \nexcluded from the field-of-view. The heart size is top-normal. \nThere is new central pulmonary vascular congestion with mild \npulmonary edema. There is no pneumothorax or focal \nconsolidation. Trace bilateral pleural effusions are new. \n\n___ ___: \nVasogenic edema in the right frontoparietal region along the \nright MCA \nterritory compatible with patient's known recent MCA infarct. \nMild effacement of the right lateral ventricle, sulcal \neffacement. and 3 mm \nof leftward shift of normally midline structures, all which are \nnew since CTA head and neck ___. No intracranial \nhemorrhage. \n\nVIDEO SWALLOW EVAL:\nAspiration with nectar and honey liquids.\n \nBrief Hospital Course:\nMs. ___ is an ___ year old woman with a past medical history of \nafib not on anticoagulation and prior stroke who presented with \nleft sided weakness, found to have R MCA stroke with R M1 \ncutoff. Etiology of stroke is likely cardioembolic due to atrial \nfibrillation not on anticoagulation. The patient was taken \nquickly to angio however clot retrieval was unsuccessful. She \nwas admitted to the neuro ICU for post-tPA care. Her 24 hour \nscan did not show any evidence of hemorrhage and she was sent to \nthe floor. \n\nHospital course by system:\n\n#NEUROLOGY\nLarge RT MCA territory infarct as documented on MRI. Etiology \nlikely due to afib not on anticoagulation. Initially allowed for \nblood pressure autoregulation. Resumed home antihypertensies \nwith atenolol and lisinopril 5mg. She was also given ASA 81mg. \nThen after repeat NCHCT was stable without bleed on ___, she \nwas started on apixaban 2.5mg PO BID. Stroke risk factors were \nassessed with Lipid panel (LDL 39), TSH (1.3), HbA1c (6.7).\n\n#CV\nOn admission found to be in atrial fibrillation. Monitored on \ntelemetry while on the floor which was also consistent with \nafib. Cardiac enzymes were negative. TTE showed normal global \nbiventricular systolic function, chamber size and wall \nthickness. At least moderate tricuspid regurgitation and \nmoderate pulmonary artery systolic hypertension. CXR ___ \nwith increased congestion since admission. \n\n#ID: \nNo evidence of infection on u/a, urine culture or CXR. \n\n#ENDO:\nA1C was 6.7%. ___ service consulted and made insulin \nrecommendations. \n \n#FEN:\nInitially evaluated by speech and swallow service who \nrecommended NGT for all nutrition and medication. Swallow \nevaluation ___ improved, so recommended for video swallow \n___ which showed aspiration of all consistencies.\n\n#TOX/METAB:\nLFTs were assessed on admission and unremarkable.\n\n===================\nTransitional Issues\n===================\n1. Goals of care discussion led to family making patient CMO. \nAll heroic measures were withheld. She will be discharged to \nHospice. \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 \n2. DVT Prophylaxis administered? (x) Yes - () No \n3. Antithrombotic therapy administered by end of hospital day 2? \n(x) Yes - () No \n4. LDL documented? (x) Yes (LDL= 39) - () No \n5. Intensive statin therapy administered? (simvastatin 80mg, \nsimvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, \nrosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if \nLDL >100, reason not given: ] \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 (verbally or \nwritten)? (x) Yes - () No \n8. Assessment for rehabilitation or rehab services considered? \n(x) Yes - () No \n9. Discharged on statin therapy? (x) Yes - () No [if LDL >100, \nreason not given: ] \n10. Discharged on antithrombotic therapy? () Yes [Type: () \nAntiplatelet - () Anticoagulation] - (x) No \n11. Discharged on oral anticoagulation for patients with atrial \nfibrillation/flutter? (x) Yes - () No - () N/A \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Cyanocobalamin Dose is Unknown IM/SC MONTHLY \n2. Vitamin D Dose is Unknown PO WEEKLY \n3. Atenolol 50 mg PO DAILY hypertension \n4. Lisinopril 10 mg PO DAILY \n5. Furosemide 20 mg PO DAILY \n6. MetFORMIN (Glucophage) 500 mg PO TID \n7. Clopidogrel 75 mg PO DAILY \n8. Atorvastatin 80 mg PO QPM \n9. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen IV 1000 mg IV Q6H:PRN pain Duration: 24 Hours \n2. Glycopyrrolate 0.2 mg IV Q6H:PRN secretions \n3. Lidocaine 5% Patch 1 PTCH TD QAM \n4. Lidocaine Viscous 2% 15 mL PO TID:PRN sore throat \n5. LORazepam 0.5-1 mg IV Q2H:PRN agitation \n6. Morphine Sulfate 0.5-10 mg IV Q1H:PRN pain \n7. Scopolamine Patch 1 PTCH TD Q72H secretions Duration: 72 \nHours \n8. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary:\nRight MCA stroke\n\nSecondary: \n- Atrial fibrillation\n- HTN\n- DM\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Lethargic but arousable.\nActivity Status: Bedbound.\n\n \nDischarge Instructions:\nDear ___, \n\nYou were admitted to the hospital with symptoms of left side \nweakness and difficulty speaking resulting from an acute \nIschemic Stroke. We have imaged your brain and vessels with a \nCT/CTA/MRI which confirmed a stroke due to a clot in one of your \nright brain vessels. We attempted a procedure to take out the \nclot but this was not possible. \n\nAfter much discussion we gave you a clot busting medication with \nmoderate effect. We think your clot was caused by an abnormal \nheart rhythm called atrial fibrillation. We assessed your stroke \nrisk factors with a lipid panel and a glycated hemoglobin test, \nwhich were well controlled. We gave you an anticoagulant \nmedication to prevent further strokes. We had our swallow \nspecialists evaluate you on multiple occasions. However, your \nswallowing process continued to be disrupted. We placed a \ntemporary feeding tube for nutrition. We asked your family what \nthey think you would want in this condition. The let us know you \nwould not want any feeding tubes placed in your body. We have \narranged it so that you were made as comfortable as possible. \nYou will be discharged with hospice assistance for end of life \ncare. \n\nIt has been an honor to care for you and your lovely family. \nPlease do not hesitate to contact us with questions or concerns.\n\nSincerely,\n\nYour ___ Stroke neurology team.\n \nFollowup Instructions:\n___\n" ]

[ "I6349", "G8194", "I272", "I4891", "E119", "R414", "I10", "I361", "R471", "E861", "E785", "Z9282", "Z8673", "Z515", "Z66" ]

[ "I6349: Cerebral infarction due to embolism of other cerebral artery", "G8194: Hemiplegia, unspecified affecting left nondominant side", "I272: Other secondary pulmonary hypertension", "I4891: Unspecified atrial fibrillation", "E119: Type 2 diabetes mellitus without complications", "R414: Neurologic neglect syndrome", "I10: Essential (primary) hypertension", "I361: Nonrheumatic tricuspid (valve) insufficiency", "R471: Dysarthria and anarthria", "E861: Hypovolemia", "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", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z515: Encounter for palliative care", "Z66: Do not resuscitate" ]

[ "I4891", "E119", "I10", "E785", "Z8673", "Z515", "Z66" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNitrate Analogues / metolazone\n \nAttending: ___.\n \nChief Complaint:\nSOB\n \nMajor Surgical or Invasive Procedure:\nThoracentesis and pigtail catheter placement ___\n\n \nHistory of Present Illness:\n___ with h/o HFpEF, CAD s/p 3-vessel CABG (___) and PCI (___),\natrial fibrillation on apixaban, HTN, HLD, and CKD who was\nrecently discharged ___ for multiple complaints including a\nCHF exacerbation, UGIB secondary to gastric AVM, and had a \nstress\ntest indicated of ischemia with plans for outpatient\ncatheterization. He presented today after he had persistent\nweight gain and shortness of breath at home. Denies CP. When EMS\narrived they found the patient hypoxic with improvement on 3L \nNC.\n\nIn the ED initial vitals were: 96.5 70 152/64 32 91% 4L NC.\nPatient was hypoxic to ___ despite 4L NC. Placed on NRB with\nimprovement to SpO2 100%. \n\nCXR remarkable for Small to moderate partially loculated right\npleural effusion, new from prior radiograph. Small left pleural\neffusion, unchanged. New patchy opacification in the right upper\nlobe may reflect infection or aspiration. Mild pulmonary edema.\n\nGiven poor respiratory status and new pleural effusion, a right\npigtail catheter was placed in the ED. 950cc of serosanguinous\npleural fluid was drained. Antibiotics were also started. He was\nsubsequently weaned to 3L NC. Repeat CXR demonstrated pigtail\ncatheter w/ correct positioning w/ interval decrease in size of \nR\npleural effusion, continued opacity in RUL c/f infection.\n\nExam notable for: \nRespiratory distress, appears unwell\nTachycardic, no murmur\nDiminished breath sounds bilaterally, no crackles or wheezing\nAbdominal retractions, obese, abdomen is soft and non-tender\nBilateral peripheral pitting edema\n \nEKG: Afib, LBBB\n\nLabs/studies notable for: Cr 2.9. proBNP 2874. WBC 12.1. trop\n0.04. VBG 7.30/36, lactate 1.0.\n \nPatient was given: IV cefepime, vancomycin\n\nVitals on transfer: 98.0 78 139/87 20 98% 3L NC \n\nOn the floor, patient is interviewed with phone ___\ninterpreter. Given language barrier and significant SOB w/\nspeaking, history taking was not ideal. However, endorsed SOB,\ndenied CP, lightheadedness, bloody or black stools since last\ndischarge. Unclear whether he was having fevers or chills at\nhome. \n\n \nPast Medical History:\n1. CAD\n2. Hypertension\n3. Dyslipidemia\n4. AF, on apixaban/BB\n5. Type 2 diabetes\n6. Gout\n7. Asthma\n8. H/o of rectal cancer\n9. CKD\n\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or\nsudden cardiac death. \n \nPhysical Exam:\nPHYSICAL EXAMINATION: \n======================= \nVS: 97.3PO 130 / 48L Lying 67 16 99 3L \nGENERAL: speaking in short sentences, using accessory muscles to\nbreathe, lethargic, AOx3 \nHEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. \nNECK: JVP above mandible at 45 degrees\nCARDIAC: irregularly irregular, distant heart sounds, normal \nrate\nLUNGS: crackles diffusely, decreased breath sounds at b/l bases,\nno wheezing\nABDOMEN: s/nd/nt, bowel sounds present \nEXTREMITIES: lukewarm on exam. significant 3+ b/l ___ pitting\nedema. no cyanosis.\nSKIN: No significant skin lesions or rashes. \nPULSES: Distal pulses not palpable, but obtain via Doppler.\n\nDISCHARGE EXAM:\n===============\nGENERAL: In mild distress, intermittently oriented, alert\nHEENT: Oropharynx with apthous ulcers\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 09:47AM BLOOD WBC-12.1* RBC-2.52* Hgb-7.9* Hct-25.0* \nMCV-99* MCH-31.3 MCHC-31.6* RDW-16.1* RDWSD-56.6* Plt ___\n___ 09:47AM BLOOD Neuts-68.5 Lymphs-13.0* Monos-15.5* \nEos-1.7 Baso-0.6 Im ___ AbsNeut-8.28* AbsLymp-1.57 \nAbsMono-1.88* AbsEos-0.21 AbsBaso-0.07\n___ 09:47AM BLOOD ___ PTT-28.3 ___\n___ 09:47AM BLOOD Glucose-137* UreaN-76* Creat-2.9* Na-135 \nK-5.6* Cl-104 HCO3-16* AnGap-15\n___ 09:47AM BLOOD ALT-27 AST-21 LD(LDH)-230 CK(CPK)-60 \nAlkPhos-88 TotBili-0.4\n___ 09:47AM BLOOD Lipase-22\n___ 09:47AM BLOOD CK-MB-2 proBNP-2874*\n___ 09:47AM BLOOD cTropnT-0.04*\n___ 04:30PM BLOOD CK-MB-2 cTropnT-0.05*\n___ 09:47AM BLOOD TotProt-6.8 Albumin-3.6 Globuln-3.2 \nCalcium-8.6 Phos-3.5 Mg-2.8*\n___ 09:55AM BLOOD ___ pO2-41* pCO2-36 pH-7.30* \ncalTCO2-18* Base XS--7\n___ 09:55AM BLOOD O2 Sat-66\n___ 09:55AM BLOOD Lactate-1.0\n\nRELEVANT LABS:\n==============\n___ 09:47AM BLOOD cTropnT-0.04*\n___ 04:30PM BLOOD CK-MB-2 cTropnT-0.05*\n___ 12:00PM PLEURAL TotProt-2.2 Glucose-147 LD(LDH)-102 \nAmylase-36 Albumin-1.3\n___ 12:00PM PLEURAL TNC-319* RBC-6837* Polys-34* Lymphs-41* \n___ Macro-25*\n\nIMAGING:\n========\nCXR ___:\nThere are postsurgical changes from CABG. There has been \ninterval removal of the right basilar chest tube. \n \nThere is a small apical right pneumothorax. Mild blunting of \nthe bilateral costophrenic angles most likely represents trace \npleural effusions. A new retrocardiac opacity most likely \nrepresents subsegmental atelectasis. The cardiac silhouette is \nstable in appearance. Mild pulmonary edema is unchanged. There \nare no acute osseous abnormalities.\n\nDISCHARGE LABS:\n==============\nNone \n\n \n\n \nBrief Hospital Course:\nInformation for Outpatient Providers: BRIEF HOSPITAL COURSE:\n=====================\n___ with h/o HFpEF, CAD s/p 3-vessel CABG (___) and PCI (___),\natrial fibrillation on apixiban and CKD who presents \nw/multifactorial SOB after recent discharge for CHF \nexacerbation. Patient was started on IV diuresis and had an \nepisode of sustained Vtach which lead to one chest compression \nprior to flipping back to afib. Family meeting was held and \npatient was transitioned to CMO. \n\nCORONARIES: Multivessel disease s/p 3-vessel CABG (precise\nanatomy uncertain, records not available)\nPUMP: EF 50-55%\nRHYTHM: a-fib\n\n=============== \nACTIVE ISSUES: \n=============== \n#Goals of care \n#Comfort measures only\nFamily meeting with Dr. ___. Family and patient expressed\ndifficulty with quality of life and patient described not \nwanting\nto suffer any more. Given the poor prognosis with his heart\nfailure, multiple admissions, and episode of Vtach with a \nthready pulse,\nthe family and patient decided on DNR/DNI and CMO with goal to\ntransition to inpatient hospice given that his wife cannot care \nfor\nhim at home. Patient was continued on maintenance diuretic. \nPatient with throat pain, heel pain, and chest pain with \nincrease in pain requirements to IV dilaudid, in addition to PRN \noxycodone and SL morphine. He also received gabapentin for \nneuropathic pain in his heels. \n\n# HFpEF exacerbation: \nPatient was recently admitted for HF exacerbation ___ poorly \ncontrolled HTN and increased fluid intake. Likely ischemic \ncardiomyopathy given p-MIBI positive for reversible ischemia in \nanterolateral and inferolateral walls. During the previous \nadmission, he was diuresed w/ IV Lasix gtt c/b ___ so PO \ndiuretic was\nheld at discharge. Patient re-presented with volume overload \nlikely from holding diuretics. Patient started with diuresis \nwith IV boluses but complicated by sustained Vtach described \nbelow. Given multiple recent admissions and poor prognosis, \nfamily meeting was held and patient was transitioned to CMO. Was \ncontinued on torsemide 100mg daily for maintenance and other HF \nmeds including amlodipine and beta blocker were stopped.\n\n#Ventricular tachycardia on amiodarone load\nOn ___, the patient developed sustained ventricular tachycardia \nthat lasted for around 3 minutes. Had a thread pulse throughout, \nbut a code blue was called. Patient had 1 chest compression and \nconverted back to baseline afib with LBBB. Patient was loaded \nwith amiodarone and empirically repleted Mag, but given GOC and \nprognosis, patient was made DNR/DNI and CMO. \n\n#Pleural effusions\n#Small apical pneumothorax: \nOn admission, the patient had a chest pigtail catheter for large \nR pleural effusion found to be transudative likely ___ CHF. \nPigtail removed on ___ complicated by small apical pneumothorax \nthat has resolved. Removal was complicated by bleeding and \napixaban was held and discontinued given GOC. \n\nTRANSITIONAL ISSUES:\n====================\n[] Continue pain control - initiated on IV dilaudid boluses \nprior to discharge now with transition to PCA\n[] Continue dyspnea control with Torsemide for pulmonary edema \nand opiates\n[] Continue Torsemide 100mg daily for volume management. Can \nuptitrate for comfort. \n# LANGUAGE: ___\n# CODE STATUS: DNR/DNI, CMO\n# CONTACT: Gouta ___ (HCP, wife) ___ \n___, daughter, ___ is alternate \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Apixaban 2.5 mg PO BID \n3. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry \neyes \n4. Aspirin 81 mg PO DAILY \n5. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID \n6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID \n7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n8. Gabapentin 100 mg PO DAILY \n9. Rosuvastatin Calcium 10 mg PO QPM \n10. Tiotropium Bromide 1 CAP IH DAILY \n11. amLODIPine 10 mg PO DAILY \n12. Pantoprazole 40 mg PO Q12H \n13. melatonin 3 mg oral QHS \n14. Repaglinide 0.5 mg PO TIDAC \n15. Torsemide 100 mg PO DAILY \n16. Ferrous Sulfate 325 mg PO EVERY 3 DAYS \n17. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN sore throat \n18. Senna 17.2 mg PO BID \n19. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n2. Lidocaine 5% Patch 1 PTCH TD QPM heel \n3. Lidocaine 5% Patch 1 PTCH TD QPM other heel \n4. Lidocaine Viscous 2% 15 mL PO TID:PRN throat pain \n5. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain \n6. Ramelteon 8 mg PO QHS:PRN insomnia \nShould be given 30 minutes before bedtime \n7. TraZODone 50 mg PO QHS:PRN second line insomnia \nRX *trazodone 50 mg 1 tablet(s) by mouth at bedtime Disp #*3 \nTablet Refills:*0 \n8. Gabapentin 100 mg PO QAM \nRX *gabapentin 100 mg 1 capsule(s) by mouth qAM Disp #*3 Capsule \nRefills:*0 \n9. Gabapentin 300 mg PO QHS \nRX *gabapentin 300 mg 1 capsule(s) by mouth at bedtime Disp #*3 \nCapsule Refills:*0 \n10. Senna 8.6 mg PO BID:PRN Constipation - Second Line \n11. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry \neyes \n12. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID \n13. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP LEFT EYE BID \n14. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n15. Torsemide 100 mg PO DAILY \nRX *torsemide 100 mg 1 tablet(s) by mouth daily Disp #*3 Tablet \nRefills:*0 \n16.Hydromorphone PCA\nhydromorphone 10 mg/mL PCA, Route: IV\nBolus: 0.05 mg q20min (3x/hr)\nContinuous: 0 mg/hr\nDispense 2 (two) 100 mL cassettes\n\n \nDischarge Disposition:\nExtended Care\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n==================\nAcute on chronic diastolic heart failure \nVentricular tachycardia\n\nSECONDARY DIAGNOSIS\n=====================\nPleural effusion\nPneumothorax \nAcute on chronic kidney injury \nCoronary artery disease \nAtrial fibrillation\nDiabetes mellitus \nHyperkalemia \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:\n====================== \nDISCHARGE INSTRUCTIONS \n====================== \nDear Mr. ___, \n\nIt was a privilege caring for you at ___. \n\nWHY WAS I IN THE HOSPITAL? \n- You came to the hospital after developing shortness of breath \nrequiring oxygen and increasing weight consistent with a heart \nfailure exacerbation.\n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- You were initially given medications to help with removing \nfluid from the body. \n- You had a chest tube placed to remove fluid from the right \nlung.\n- You had an event where your heart was moving very quickly and \nyou had almost lost a pulse.\n- Given the prognosis of your heart failure and your wish to \nfocus on comfort focused care, we continued medications to help \nyou stay comfortable without plans to escalate care. \n- You will be transitioned to ___ Hospice house where they \nwill make you more comfortable when it comes to your pain.\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? \n- Continue to take all your medicines and keep your \nappointments. \n\nWe wish you the best! \n\nSincerely,\n \nYour ___ Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I130", "I5033", "I472", "N179", "J918", "L7622", "N189", "E1122", "I255", "Z66", "Z515", "Y848", "Y92239", "E875", "D509", "T501X5A", "M109", "R0902", "E1140", "R070", "J45909", "I4891", "Z7901", "Z85048", "I2510", "Z951", "Z87891", "K259", "Y92230", "I447" ]

[ "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", "I472: Ventricular tachycardia", "N179: Acute kidney failure, unspecified", "J918: Pleural effusion in other conditions classified elsewhere", "L7622: Postprocedural hemorrhage of skin and subcutaneous tissue following other procedure", "N189: Chronic kidney disease, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I255: Ischemic cardiomyopathy", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "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", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "E875: Hyperkalemia", "D509: Iron deficiency anemia, unspecified", "T501X5A: Adverse effect of loop [high-ceiling] diuretics, initial encounter", "M109: Gout, unspecified", "R0902: Hypoxemia", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "R070: Pain in throat", "J45909: Unspecified asthma, uncomplicated", "I4891: Unspecified atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "Z85048: Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "Z87891: Personal history of nicotine dependence", "K259: Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "I447: Left bundle-branch block, unspecified" ]

[ "I130", "N179", "N189", "E1122", "Z66", "Z515", "D509", "M109", "J45909", "I4891", "Z7901", "I2510", "Z951", "Z87891", "Y92230" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROSURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nreplacement of bone\n \nMajor Surgical or Invasive Procedure:\n___ Right Cranioplasty, Dr. ___ \n\n \n___ of Present Illness:\nMr. ___ is a ___ right-handed young man with hx \nof R frontal-parietal GBM s/p R craniectomy and removal of \nlesion on ___ post-operatively complicated by wound \ninfectionand underwent craniectomy and wound washout on \n___. Patient returns for cranioplasty. \n \nPast Medical History:\n- Right craniotomy for resection of brain tumor ___\n- Right craniectomy/wound washout for wound infection ___\n- Varicose vein repair in bilateral lower extremity \n\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nON DISCHARGE:\nPatient is alert and oriented x 3, pearl. Speech is clear and \nappropriate, follows commands in all extremities. ___ strengths \nthroughout. face is symmetric, tongue midline, no pronator \ndrift. \nIncision: craniotomy site with dressing that is clean/dry/intact\n\n \nPertinent Results:\n___ CT HEAD W/O CONTRAST\n \n1. Postoperative changes related to interval right frontal \ncranioplasty as \ndescribed. \n2. Evolving postsurgical changes related to patient's right \nfrontal glioma \nresection. \n\n \nBrief Hospital Course:\nMr. ___ is a ___ right-handed young man with hx \nof R frontal-parietal GBM s/p R craniotomy and removal of \nlesion on ___ post-operatively complicated by wound \ninfection and underwent craniectomy and wound washout on \n___. Patient returns electively for cranioplasty. OR was \nuneventful, patient was extubated in the OR and brought to the \nPACU for immediate post-operative care. Post-op CT Head with \nexpected post-operative changes, no hemorrhage. On ___, patient \nis neurologically and hemodynamically stable. Patient ambulating \nwithout assistance and complains of minimal headache; patient \ndischarged home. \n \nMedications on Admission:\nMultivitamin\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild \n2. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hrs as needed \nfor pain Disp #*20 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nprimary: \nBrain Tumor\n\nsecondary:\ninfection\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nSurgery\n\n· You underwent surgery to have your skull bone (or an \nartificial bone) placed back on. \n\n· Please keep your staples along your incision dry until they \nare removed.\n\n· It is best to keep your incision open to air but it is ok to \ncover it when outside. \n\n· Call your surgeon if there are any signs of infection like \nredness, fever, or drainage. \n\nActivity\n\n· We recommend that you avoid heavy lifting, running, climbing, \nor other strenuous exercise until your follow-up appointment.\n\n· You make take leisurely walks and slowly increase your \nactivity at your own pace once you are symptom free at rest. \n___ try to do too much all at once.\n\n· No driving while taking any narcotic or sedating medication. \n\n· If you experienced a seizure while admitted, you are NOT \nallowed to drive by law. \n\n· No contact sports until cleared by your neurosurgeon. You \nshould avoid contact sports for 6 months. \n\nMedications\n\n· Please do NOT take any blood thinning medication (Aspirin, \nIbuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. \n\n· You may use Acetaminophen (Tylenol) for minor discomfort \nif you are not otherwise restricted from taking this medication.\n\n \nWhat You ___ Experience:\n\n· Headache or pain along your incision. \n\n· You may also experience some post-operative swelling around \nyour face and eyes. This is normal after surgery and most \nnoticeable on the second and third day of surgery. You apply \nice or a cool or warm washcloth to your eyes to help with the \nswelling. The swelling will be its worse in the morning after \nlaying flat from sleeping but decrease when up. \n\n· You may experience soreness with chewing. This is normal from \nthe surgery and will improve with time. Softer foods may be \neasier during this time. \n\n· Constipation is common. Be sure to drink plenty of fluids and \neat a high-fiber diet. If you are taking narcotics (prescription \npain medications), try an over-the-counter stool softener.\n\nWhen to Call Your Doctor at ___ for:\n\n· Severe pain, swelling, redness or drainage from the incision \nsite. \n\n· Fever greater than 101.5 degrees Fahrenheit\n\n· Nausea and/or vomiting\n\n· Extreme sleepiness and not being able to stay awake\n\n· Severe headaches not relieved by pain relievers\n\n· Seizures\n\n· Any new problems with your vision or ability to speak\n\n· Weakness or changes in sensation in your face, arms, or leg\n\nCall ___ and go to the nearest Emergency Room if you experience \nany of the following:\n\n· Sudden numbness or weakness in the face, arm, or leg\n\n· Sudden confusion or trouble speaking or understanding\n\n· Sudden trouble walking, dizziness, or loss of balance or \ncoordination\n\n· Sudden severe headaches with no known reason\n\n \nFollowup Instructions:\n___\n" ]

[ "Z481" ]

[ "Z481: Encounter for planned postprocedural wound closure" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \natenolol / lisinopril / Cephalexin / Sulfa (Sulfonamide \nAntibiotics) / Tetracycline / hydroxyzine / hydroxyzine pamoate \n/ promethazine / meperidine / erythromycin base / aspirin / \nnifedipine / pneumococcal vaccine / Celexa / Vicodin / \nhydrocodone / magnesium citrate / Tetracyclines / cefoxitin / \nmetformin / amitriptyline / metoprolol / Opioids-Meperidine & \nRelated / simvastatin / trimethoprim / pentoxifylline / \nduloxetine / codeine\n \nAttending: ___.\n \nChief Complaint:\nRUQ pain, post-ERCP\n \nMajor Surgical or Invasive Procedure:\nERCP\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old woman with a history of APL s/p \nATRA and arsenic trioxide with sustained complete response, NASH \ncirrhosis, DM2, hypertension, recent salpingo-oopherectomy \n___ for ovarian mass, pathology benign), s/p CCY, who \npresents for monitoring after planned ERCP to evaluate for \nsource of RUQ pain after recent admission to ___.\n\nPatient was recently at ___ for the 5 days prior to \nadmission after presenting with RUQ pain. She had stable LFTs \nand unrevealing ultrasound, CT, MRI and endoscopy. No definitive \ndiagnosis was given for her pain. On the day of discharge her \ndiet was advanced and she was told to follow-up with her \noutpatient gastroenterologist.\n\nShe presented on ___ to Dr. ___, who scheduled her for \nERCP for further evaluation of her RUQ pain. ERCP was performed, \nwhich showed no filling defects or strictures. A mild restenosis \nwas noted at the ampulla, for which balloon sphincteroplasty was \nperformed. There was a small amount of sludge. She was admitted \nfor post-ERCP monitoring.\n\nOn arrival to the floor she reports improvement in her abdominal \npain. She says she feels that it was due to receiving IV \ndilaudid after the ERCP. She says she has been taking her home \ndilaudid 4mg q6h with minimal relief. She reports some nausea \nover the past few weeks, but no vomiting. She has decreased \nappetite but has been able to keep her meals down.\n\n \nPast Medical History:\n- APL s/p ATRA and arsenic trioxide with sustained complete \nresponse\n- Osteoporosis\n- Multiple bone fractures\n- Diabetes, type 2\n- NASH cirrhosis\n- Portal hypertension\n- Hypertension\n- Anxiety\n- S/p CCY\n- Salpingo-oopherectomy ___ for ovarian mass, pathology \nbenign)\n \nSocial History:\n___\nFamily History:\nmother with lung cancer, DM2, CAD\nfather ___, HTN, DM2, hypothyroid\n \nPhysical Exam:\nADMISSION EXAM:\nVital signs: T 97.6, BP 105/63, P 7, RR 18, O2 93 RA \nGen: Well appearing, in no apparent distress\nHEENT: NCAT, oropharynx clear\nLymph: no cervical lymphadenopathy\nCV: No JVD present, regular rate and rhythm, no murmurs \nappreciated\nResp: CTA bilaterally in anterior and posterior lung fields, no\nincreased work of breathing\nGI: Diffuse tenderness to palpation, however she is distractible \nand does not react with palpation using stethoscopy\nExtremities: no clubbing, cyanosis, or edema\nNeuro: no focal neurologic deficits appreciated. Moves all 4\nextremities purposefully and without incident, no facial droop.\nPsych: Euthymic, speech non-tangential, appropriate\n \nPertinent Results:\nCBC:\n6.0 > 14.4/41.8 < 108\n\nBMP:\n144 | 99 | 11 \n---------------< \n3.0 | 26 | 0.9 \n\nALT: 27 AP: 182 Tbili: 0.8 \nAST: 47 \n___: 38 Lip: 20 \n\nDischarge Labs:\n\nIMAGING: \nERCP (___):\nImpression: •Limited exam of the esophagus was normal\n•Limited exam of the stomach was normal\n•Limited exam of the duodenum was normal\n•The scout film revealed surgical clips in the RUQ. \n•There was evidence of previous sphincterotomy at the major \npapilla. \n•The CBD was successfully cannulated with the Hydratome \nsphincterotome preloaded with a 0.035in guidewire. \n•The guidewire was advanced into the intrahepatic biliary tree. \n•Contrast injection revealed a CBD of approximately 10mm in \ndiameter and normal intrahepatic biliary tree. \n•No discrete filling defects or strictures were noted. \n•The CBD was swept several times with successful removal of \nsmall amounts of sludge material. \n•Mild resistance to balloon sweep was noted at the level of the \nampulla suggesting mild restenosis. \n•Balloon sphincteroplasty was then successfully performed with a \n8-10mm CRE balloon dilator. \n•No post sphincteroplasty bleeding was noted. \n•There was excellent spontaneous drainage of bile and contrast \nat the end of the procedure.\n•The PD was not injected or cannulated. \n \nRecommendations: •Admit to hospital for monitoring\n•NPO overnight with aggressive IV hydration with LR at 200 cc/hr\n•If no abdominal pain in the morning, advance diet to clear \nliquids and then advance as tolerated\n•Continue with antibiotics - Ciprofloxacin 500mg BID x 5 days.\n•Follow up with Dr. ___.\n•Follow for response and complications. If any abdominal pain, \nfever, jaundice, gastrointestinal bleeding please call ERCP \nfellow on call ___\n\n \nBrief Hospital Course:\nASSESSMENT/PLAN:\nMs. ___ is a ___ year old woman with a history of APL s/p \nATRA and arsenic trioxide with sustained complete response, NASH \ncirrhosis, DM2, hypertension, recent salpingo-oopherectomy \n___ for ovarian mass, pathology benign), s/p CCY, who \npresents for monitoring after planned ERCP to evaluate for \nsource of RUQ pain after recent admission to ___.\n\n# RUQ PAIN,\n# S/P ERCP:\nERCP without any clear source for patient's RUQ pain. Also had \nextensive evaluation during recent ___ admission (CT, \nultrasound, EGD, MRI). Given that symptoms started after recent \nsalpingo-oopherectomy, certainly her pain may be related. \nShe had new pain as well as nausea after her ERCP accompanied by \nsome hypotension, so she was observed on fluids and started on \nmetoclopromide. It is possible that her new pain was due to \npost ERCP pancreatitis vs from the ERCP itself vs gastroparesis. \n She was treated supportively with gradual improvement. Zofran \nand Reglan were utilized. SHe was tolerating orals well on \ndischarge. Close follow up was recommended. The antiemetic \ncourse was limited to one week with instructions to re-assess. \nSide effects were explained. Her LFTs were improving on DC.\n\n# CHRONIC ISSUES:\n- APL: In remission. F/u with outpatient providers.\n- DM2: Continued lantus, dose reduced to 50% home dose that she \nwas NPO for nearly two days\n- CIRRHOSIS: Continue rifaximin. Diuretics held while \nhospitalized as she was NPO for nearly two days. Can resume \nonce taking normal POs\n- PSYCH: Continue buspirone, sertraline.\n- CHRONIC PAIN: Continue home Dilaudid, gabapentin. Takes for \nneck and back pain as well as neuropathy.\n- GERD: Continue pantoprazole, sucralfate.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q8H \n2. BusPIRone 10 mg PO QID \n3. Furosemide 40 mg PO DAILY \n4. Gabapentin 800 mg PO TID \n5. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Severe \n6. Glargine 22 Units Breakfast\nGlargine 42 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n7. Ondansetron 4 mg PO Q8H:PRN nausea \n8. Pantoprazole 40 mg PO DAILY \n9. Rifaximin 550 mg PO BID \n10. Sertraline 200 mg PO QHS \n11. Spironolactone 100 mg PO DAILY \n12. Sucralfate 1 gm PO QID \n13. Senna 17.2 mg PO QHS \n14. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild \n15. Vitamin D ___ UNIT PO DAILY \n16. Docusate Sodium 100 mg PO BID \n17. Lidocaine 5% Patch 1 PTCH TD QAM apply to shoulder/back \n18. Multivitamins 1 TAB PO DAILY \n19. Systane Liquid Gel (peg 400-propylene glycol) 0.4-0.3 % \nophthalmic BID \n\n \nDischarge Medications:\n1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Doses \n\nRX *amoxicillin-pot clavulanate 875 mg-125 mg 1 Tablet by mouth \ntwice a day Disp #*5 Tablet Refills:*0 \n2. Metoclopramide 5 mg PO QIDACHS \nRX *metoclopramide HCl 5 mg 1 Tablet by mouth TID with meals \nDisp #*21 Tablet Refills:*0 \n3. Glargine 10 Units Breakfast\nGlargine 20 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n4. Ondansetron 8 mg PO Q8H:PRN nausea \nRX *ondansetron [Zofran ODT] 8 mg 1 tablet(s) by mouth three \ntimes a day Disp #*30 Tablet Refills:*0 \n5. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild \n6. Acyclovir 400 mg PO Q8H \n7. BusPIRone 10 mg PO QID \n8. Docusate Sodium 100 mg PO BID \n9. Furosemide 40 mg PO DAILY \n10. Gabapentin 800 mg PO TID \n11. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN Pain - Severe \n12. Lidocaine 5% Patch 1 PTCH TD QAM apply to shoulder/back \n13. Multivitamins 1 TAB PO DAILY \n14. Pantoprazole 40 mg PO DAILY \n15. Rifaximin 550 mg PO BID \n16. Senna 17.2 mg PO QHS \n17. Sertraline 200 mg PO QHS \n18. Spironolactone 100 mg PO DAILY \n19. Sucralfate 1 gm PO QID \n20. Systane Liquid Gel (peg 400-propylene glycol) 0.4-0.3 % \nophthalmic BID \n21. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n1. Chronic abdominal pain\n2. Cirrhosis\n3. APML\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 an ERCP. We did not find a cause for your \nabdominal pain. You had slightly worse pain after your \nprocedure and had difficulty eating so you had to be observed in \nthe hospital. You have improved with supportive treatment. \nPlease take all medications as prescribed and stop the \nanti-nausea medications as soon as you can. Please follow up \nwith your PCP ___ 1 week. \n\nPlease note that your insulin has been decreased until you start \neating normally again. Your diuretics have also been held until \nyou are eating/drinking more normally\n \nFollowup Instructions:\n___\n" ]

[ "R1011", "K831", "I9589", "C9241", "K7581", "E1140", "I10", "M810", "F419", "Z794", "G8929", "M549", "M542", "K219" ]

[ "R1011: Right upper quadrant pain", "K831: Obstruction of bile duct", "I9589: Other hypotension", "C9241: Acute promyelocytic leukemia, in remission", "K7581: Nonalcoholic steatohepatitis (NASH)", "E1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecified", "I10: Essential (primary) hypertension", "M810: Age-related osteoporosis without current pathological fracture", "F419: Anxiety disorder, unspecified", "Z794: Long term (current) use of insulin", "G8929: Other chronic pain", "M549: Dorsalgia, unspecified", "M542: Cervicalgia", "K219: Gastro-esophageal reflux disease without esophagitis" ]

[ "I10", "F419", "Z794", "G8929", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: PSYCHIATRY\n \nAllergies: \nBactrim / Amoxicillin / Danocrine / Penicillins / Zoloft / \nIodine-Iodine Containing\n \nAttending: ___.\n \nChief Complaint:\n\"I have treatment resistant depression\"\n \nMajor Surgical or Invasive Procedure:\nn/a\n \nHistory of Present Illness:\nMs. ___ is a ___ year old woman with\nPMH of hypothyroidism, sleep apnea, PPH of post-traumatic stress\ndisorder, depression/anxiety, previous ECT tx, who presented to\nthe ___ w/worsening depressed mood and suicidal thoughts. \n\nThe patient reports that she has been severely depressed since\n___, at which time she made a suicide attempt by \ncarbon\nmonoxide poisoning. She is very tangential when providing\nhistory, but describes her longstanding relationship with her\npsychiatrist and psychologist as positive influences on her \nlife,\nand states that ECT was life-saving for her before in ___. She\nstates that she feels like she \"won the lottery\" by getting her\ninsurance company to pay for her admission and inpatient ECT. \nShe\nperseverates on the fact that she should be able to receive\noutpatient ECT but cannot due to the fact that she is \"single \nand\nlives alone.\" She also discusses her abusive ex-husband and how\nhe took her daughter away from her, which ___ into a\nconversation about a writer for the ___ who wrote a\nstory about her husband, which ___ into a story about how the\n___ team stole a story from ___, \nwhich\nthen went bankrupt and a key writer left for the ___ \nin\n___. She also discusses her former job at ___, ___, and several former ___ who suffered from\nmental illness at length. \n\nPer Dr. ___ consult note on ___ confirmed with patient\nand updated as relevant:\n\"She was a limited historian, at times providing a tangential \nand\nhard to follow narrative of recent events leading up to coming \nto\nthe ___.\n\nShe had a recent ___ presentation w/ depressive symptoms and was\nhospitalized at an OSH, which she feels was not helpful, in part\ndue to the facility apparently not having ECT available (no\nrecords to review at this time).\n\nShe describes a persistently depressed mood, along with\nneurovegetative symptoms (disrupted sleep, denies decreased need\nfor sleep). She denies homicidal ideation, denies auditory or\nvisual hallucinations, denies paranoid ideation. She states she\nhas been adherent to her medication regimen, but again has a\ndifficult time relating her responses/information in a clear,\ncoherent, linear manner.\n\nShe endorses suicidal thoughts, currently without specific \nintent\nor plan, but increasingly demoralized, hopeless, and desperate\nfor help/relief. \n\nSpoke w/ Dr. ___ to collaborate around patient's\ncare. \"\n\nOf note, the patient was medically cleared for ECT on ___\n(note in OMR on that date).\n\nPer Dr. ___ note on ___:\n\"Patient reports that she had a sleepless night due to a variety\nof environmental factors. Reports she feels \"like a wilted\nplant.\n\nPatient is unable to relay a linear history of her symptoms and\nwhat brought her to the emergency room, perseverating on \n___ as the start to her most recent worsening, but unable to\ndescribe what has happened between ___ until now. \n\nDiscusses the difficulty of stigma of mental illness and ECT,\nstating \"if I had breast cancer I'd be sailing smooth\". \n\nShe reports feelings of depressed mood, feelings of \npowerlessness\nspecifically regarding inability to restart ECT as an outpatient\ndue to insurance/logistical barriers. She reports 15 pound \nweight\nloss though is unable to relay over what time period this has\noccurred. \n\nWhen offered Prazosin for anxiety, patient reports that she has\n\"treatment resistant depression\" which is \"a genetically\ninherited syndrome\" and is \"done playing the medication game\". \n\nReports sadness over being \"dogless\", but that she feels she\ncannot get an emotional support service animal before she has \nhad\nsome ECT treatments. \"\n\nPsychiatric ROS Per Dr. ___ consult note on ___\nconfirmed with patient and updated as relevant:\npersistently depressed mood, along with\nneurovegetative symptoms (disrupted sleep, denies decreased need\nfor sleep). She denies homicidal ideation, denies auditory or\nvisual hallucinations, denies paranoid ideation. Endorses vague\nsymptoms of PTSD. \n\nMedical ROS - Per Dr. ___ consult note on ___ \nconfirmed\nwith patient and updated as relevant:\n\"+Fatigue, +mild HA, all other systems reviewed\nand are negative at this time\"\n\nCOLLATERAL from Dr. ___ Note from a previous visit \n___: \nReceived a phone call from Dr. ___ (___), her\nformer psychologist. He beings by informing me that he\nterminated his relationship with her over a year ago but still\nresponds to emails occasionally encouraging her to seek help\nelsewhere. Treated her for over ___ years. Ms. ___ came to his\noffice unannounced yesterday afternoon. States she horrific hx\nof PTSD in childhood and married a real sociopath who repeatedly\nused their daughter as a way of getting to her. Confirms one\nmajor depression when on disability in ___. She had ECT and\nafterwards became very high functioning, working at ___ as a\n___, then started to fall apart again ___ years ago. Ex husband\nreally broke her financially, had to sell her home to meet \ncourts\nfinancial requirements. Daughter went to ___ for college \nand\ntrying to find a way to help her-- daughter very hostile towards\nher. States she sounded terrible in emails. She was in ___\nfor many months, traveling back and forth. \nIn person yesterday, he was shocked to see the degree of\ncognitive incompetence, disorganization, unrealistic thinking--\nthinks phone/computer are hacked. Knows she is almost in\ncomplete isolation, burned through most of her friends. He has\nknown her for decades, have never been so scared for her as he\nwas yesterday. He was relieved to hear that she is here and\nsafe. \n \n___ Course:\nPatient was in good behavioral control throughout ___ stay. No\nphysical or chemical restraints required. \n\n \nPast Medical History:\n- Diagnoses: MDD, Seasonal affective disorder, post-partum\ndepression ___\n- Multiple medication trials\n- Hospitalizations: Most recent in ___. Patient has \ndifficulty recounting when her first hospitalization. Reports \nbeing at ___ in ___, ___, and likely at \n___ in ___.\n- Reports aborted suicide attempt in ___, describes sitting \nin her running car in the garage, prior to that an overdose at \nage ___.\n- Current treaters and treatment: psychiatrist, Dr. ___\n(___), and a psychologist, Dr. ___ (___). \n\n \nPast medical history:\n- 3 prior head injuries including being hit in the head with a \nbaseball bat while playing softball.\n \nSocial History:\n___\nFamily History:\nFather, depression, describes he was hospitalized, unknown \ndetails.\n \nPhysical Exam:\n# Admission Exam #\n\nVS: T: 98.2, BP: 110/60, HR:76 , R:18 , O2 sat: 100% on RA\nGeneral: Middle-aged female in NAD. Appears stated age.\nHEENT: Normocephalic, atraumatic. PERRL, EOMI. \nNeck: Supple.\nBack: No significant deformity.\nLungs: CTA ___. No crackles, wheezes, or rhonchi.\nCV: RRR, no murmurs/rubs/gallops. \nAbdomen: +BS, soft, nontender, nondistended. No palpable masses\nor organomegaly.\nExtremities: No clubbing, cyanosis, or edema.\nSkin: No rashes, abrasions, scars, or lesions. \n\nNeurological:\nCranial Nerves:\n-Pupils symmetry and responsiveness to light and accommodation:\nPERRLA\n-Visual fields: full to confrontation\n-EOM: full\n-Facial sensation to light touch in all 3 divisions: equal\n-Facial symmetry on eye closure and smile: symmetric\n-Hearing bilaterally to rubbing fingers: normal\n-Phonation: normal\n-Shoulder shrug: intact\n-Tongue: midline\nMotor: Normal bulk and tone bilaterally. No abnormal movements,\nno tremor. Strength: full power ___ throughout. Coordination:\nNormal on finger to nose test. Sensation: Intact to light touch\nthroughout. \nGait: Not assessed.\n\nCognition: \nWakefulness/alertness: AOx3\nAttention: intact to interview, able to perform DOTWB\nOrientation: oriented to person, time, place, situation\nExecutive function (go-no go, Luria, trails, FAS): not tested\nMemory: intact to recent and past history\nFund of knowledge: consistent with education\nCalculations: correctly states 7 quarters in $1.75\nAbstraction: apple/orange = \"fruit\", watch/ruler = \"measure\"\nVisuospatial: not assessed\nSpeech: increased rate, pressured, normal tone\nLanguage: native ___ speaker\n\nMental Status:\nAppearance: No apparent distress, appears stated age, well\ngroomed, appropriately dressed\nBehavior: Calm, cooperative, limited eye contact\nMood and Affect: \"Depressed\" / Dysphoric, constricted range\nThought Process: +loosening of associations, very tangential. \nThought Content: denies HI/AH/VH, no evidence of delusions or\nparanoia. Endorses SI but states she feels safe while in the\nhospital.\nJudgment and Insight: limited/limited. \n\n# Discharge #\nMSE: Alert, oriented, clear/coherent. Cooperative with \ninterview, cooperative, coherent, thankful. \"Better\" mood, rated \n___, with a euthymic affect that is congruent to conversation \nand normal in range (occasionally tearful when talking about \nstressors). No SI/HI/perceptual disturbances. Linear thought \nprocess. Good insight.\n \nPertinent Results:\n___ 11:55AM BLOOD WBC-7.6 RBC-3.85* Hgb-12.2 Hct-36.1 \nMCV-94 MCH-31.7 MCHC-33.8 RDW-13.6 RDWSD-46.0 Plt ___\n___ 06:49PM BLOOD WBC-15.7*# RBC-3.78* Hgb-11.8 Hct-35.4 \nMCV-94 MCH-31.2 MCHC-33.3 RDW-14.1 RDWSD-47.8* Plt ___\n___ 11:55AM BLOOD Neuts-71.4* Lymphs-15.7* Monos-10.2 \nEos-0.9* Baso-0.9 Im ___ AbsNeut-5.44 AbsLymp-1.20 \nAbsMono-0.78 AbsEos-0.07 AbsBaso-0.07\n___ 01:05PM BLOOD Neuts-75.8* Lymphs-16.7* Monos-5.6 \nEos-0.1* Baso-0.3 Im ___ AbsNeut-9.08* AbsLymp-2.00 \nAbsMono-0.67 AbsEos-0.01* AbsBaso-0.04\n___ 11:55AM BLOOD Plt ___\n___ 11:55AM BLOOD Glucose-88 UreaN-14 Creat-0.6 Na-138 \nK-3.9 Cl-102 HCO3-27 AnGap-13\n___ 06:33AM BLOOD Glucose-91 UreaN-22* Creat-0.7 Na-138 \nK-4.4 Cl-103 HCO3-28 AnGap-11\n___ 06:33AM BLOOD TSH-0.86\n___ 06:33AM BLOOD HCG-<5\n___ 11:55AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n\nCXR ___: IMPRESSION: No acute cardiopulmonary process. \n\n \nBrief Hospital Course:\n1. LEGAL & SAFETY: \nOn admission, the patient signed a conditional voluntary \nagreement (Section 10 & 11) and remained on that level \nthroughout their admission. She was also placed on 15 minute \nchecks status on admission and remained on that level of \nobservation throughout while being unit restricted.\n\n2. PSYCHIATRIC:\n# Major Depressive Disorder\nShe was admitted in the setting of depression and SI. She was \nevaluated by Dr. ___ ECT (which has worked very \nwell for her in the past) as well as medically cleared. A \ndecision was made to pursue ECT in the inpatient setting due to \nthe lack of sufficient social support to allow the patient to \nreceive ECT in the outpatient setting. In preparation for ECT, \nher Wellbutrin was discontinued. She was started on ECT. She \nwas unilateral for a total of 4 sessions and subsequently \ntransitioned to bilateral ECT due to poor initial response. She \nunderwent a total of 14 sessions with substantial improvement. \nDuring ECT, she did experience some confusion and memory loss, \nand at one point some shoulder/neck pain. By discharge, her mood \nwas a ___, she appeared brighter on exam, and she was \nfuture-oriented. She was able to make arrangements for \noutpatient ECT, so she was discharged with the plan to continue \nweekly ECT for at least 2 more sessions. Regarding her \nmedications: her home Seroquel was decreased to 25 mg QHS as it \nwas no longer needed in higher doses and was causing significant \nsedation. Wellbutrin SR was also added back at 150 mg daily. \n\n3. SUBSTANCE USE DISORDERS:\n# None\n\n4. MEDICAL\n# Bronchitis\n- During this admission she developed a minimally productive \ncough. X-rays were benign and she was afebrile. Initially, she \nwas managed supportively and symptomatically with cough syrup, \ncough drops, Tylenol and nasal sprays. However, after 2 weeks \nof failure to improve, she was started on duonebs and 5 day \ncourse of Azithromycin with significant improvement and \nresolution of her cough.\n\n5. PSYCHOSOCIAL\n# GROUPS/MILIEU: \nThe patient was encouraged to participate in the various groups \nand milieu therapy opportunities offered by the unit. The \npatient often attended these groups that focused on teaching \npatients various coping skills. While pleasant and interactive \nin group, she frequently perseverated and was hyper-verbal in \nregards to past social traumas (concern for sexual abuse of her \ndaughter, prior social injustice, \"sociopathic\" behavior of her \nex-husband, etc). Initially, her rumination on these topics \nlimited her benefiting and true involvement in group sessions, \nthough this improved during her admission.\n\n# COLLATERAL CONTACTS & FAMILY INVOLVEMENT:\nPsychiatrist: psychiatrist, Dr. ___, ___\nTherapist: Dr. ___\nFamily Involvement: minimal involvement though her brother ___ \nhelped make arrangements upon discharge.\n\nINFORMED CONSENT: The team discussed the indications for, \nintended benefits of, and possible side effects and risks of \nstarting antipsychotics medication, and risks and benefits of \npossible alternatives, including not taking the medication, with \nthis patient. We discussed the patient's right to decide \nwhether to take this medication as well as the importance of the \npatient's actively participating in the treatment and discussing \nany questions about medications with the treatment team, and I \nanswered the patient's questions. The patient appeared able to \nunderstand and consented to begin the medication.\n\nRISK ASSESSMENT\nOn presentation, the patient was evaluated and felt to be at an \nincreased risk of harm to herself based upon numerous factors. \nStatic risk factors include history of suicide attempts, prior \nhistory of trauma, hopelessness, divorcee, and chronic mental \nillness. Acute/potentially modifiable factors at the time \nincluded acute depression, active SI, isolation (lives alone), \nand acute mood episode. She had also been grieving the loss of \nher father and 2 beloved dogs over the 2 preceding years. Upon \ndischarge, SI, hopelessness, and acute depression had resolved. \nShe also worked on improving coping skills through discussion \nwith her treatment team and participation in coping group \ntherapy sessions. Social and situational changes that may \nbenefit her were also discussed. Finally, the patient is being \ndischarged with protective factors, including help-seeking \nbehaviors and the presence of current outpatient \nproviders/treatment with whom she states she has a positive \ntherapeutic relationship. Based on this assessment, the patient \nis not at an acutely elevated risk of self-harm at the time of \ndischarge. \n\nPROGNOSIS\nGuarded given that her depressions are recurrent and severe, \nultimately requiring ECT for treatment. Furthermore, her \nisolative social situation continues. However, she has a history \nof returning to high functionality following depression.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. BuPROPion (Sustained Release) 150 mg PO BID \n2. BuPROPion (Sustained Release) 100 mg PO QAM \n3. OLANZapine 20 mg PO DAILY \n4. QUEtiapine extended-release 300 mg PO QHS \n5. QUEtiapine Fumarate 50 mg PO DAILY \n6. proGESTerone micronized 100 mg oral DAILY \n7. Femring (estradiol acetate) 0.05 mg/24 hr vaginal Q3Mos \n\n \nDischarge Medications:\n1. Famotidine 40 mg PO DAILY \nTake on the morning of ECT with sips of water, or as needed, for \nheartburn. \nRX *famotidine 40 mg 1 tablet(s) by mouth Daily as needed Disp \n#*30 Tablet Refills:*0 \n2. BuPROPion (Sustained Release) 150 mg PO QAM \nRX *bupropion HCl 100 mg 1 tablet(s) by mouth Every morning Disp \n#*30 Tablet Refills:*0 \n3. QUEtiapine Fumarate 25 mg PO QHS:PRN insomnia \nTake as needed for sleep \nRX *quetiapine 25 mg 1 tablet(s) by mouth Every night as needed \nDisp #*30 Tablet Refills:*0 \n4. Femring (estradiol acetate) 0.05 mg/24 hr vaginal Q3Mos \nRX *estradiol acetate [Femring] 0.05 mg/24 hour 1 Every 3 months \nDisp #*1 Ring Refills:*0 \n5. proGESTerone micronized 100 mg oral DAILY \nRX *progesterone micronized 100 mg 1 capsule(s) by mouth Daily \nDisp #*30 Capsule Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nMajor Depressive Disorder\n\n \nDischarge Condition:\nMental Status: Mood improved, affect euthymic and stable, \nthought process linear, denies SI, no perceptual disturbances.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nYou were hospitalized at ___ for refractory depression. While \nyou were admitted you underwent ECT (electroconvulsive therapy). \n Your mood subsequently improved and you were felt to be safe \nfor discharge home.\n\nYou are scheduled for outpatient ECT with Dr. ___. For \nECT, please do the following:\n- Do not eat or drink anything after midnight on days of ECT. \n- You may take your medications before ECT with sips of water.\n- Do not drive or make any important decisions in the 24 hours \nafter ECT, as confusion is a side-effect of ECT.\n- Please have someone around you who can watch you for at least \n___ hours following ECT.\n\nIt was a pleasure to have worked with you, and we wish you the \nbest of health.\n\n-Please follow up with all outpatient appointments as listed - \ntake this discharge paperwork to your appointments.\n-Unless a limited duration is specified in the prescription, \nplease continue all medications as directed until your \nprescriber tells you to stop or change.\n-Please avoid abusing alcohol and any drugs--whether \nprescription drugs or illegal drugs--as this can further worsen \nyour medical and psychiatric illnesses.\n-Please contact your outpatient psychiatrist or other providers \nif you have any concerns.\n-Please call ___ or go to your nearest emergency room if you \nfeel unsafe in any way and are unable to immediately reach your \nhealth care providers.\nIt was a pleasure to have worked with you, and we wish you the \nbest of health.\n \nFollowup Instructions:\n___\n" ]

[ "F329", "E039", "F39", "G4730", "F4310", "J40" ]

[ "F329: Major depressive disorder, single episode, unspecified", "E039: Hypothyroidism, unspecified", "F39: Unspecified mood [affective] disorder", "G4730: Sleep apnea, unspecified", "F4310: Post-traumatic stress disorder, unspecified", "J40: Bronchitis, not specified as acute or chronic" ]

[ "F329", "E039" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nadhesive tape / Bactrim / codeine / doxycycline / gabapentin / \nhydrochlorothiazide / lisinopril / mybetriq / Percocet / \nquinacrine / tramadol\n \nAttending: ___.\n \nChief Complaint:\nabdominal pain, diarrhea\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nHPI(4): Ms. ___ is a ___ female with history of a\ncomplex medical history including gastric MALT (normal EGD\n___ of this year) in remission, thyroid cancer status post\nresection, surgeon syndrome, aortic insufficiency,\nretroperitoneal AV malformation, serrated adenoma of the colon,\nCKD stage III, hypertension; presenting with epigastric \nabdominal\npain and diarrhea. \n\nPain started yesterday, associated with anorexia, nausea, but no\nvomiting. She has had nonbloody diarrhea as well. Pain does not\nradiate to the back. She has no chest pain, no pain into the\narm/neck/jaw/shoulder, no shortness of breath, no cough, no\npalpitations. Patient has no headaches. Patient has had\nsubjective fevers at home. Patient has no dysuria, no vaginal\ndischarge, no arthralgias, no rash. No recent travel, no sick\ncontacts, no change in diet.\n\nIn the ED: \nVS: Tmax 102, otherwise VSS\nPE: Moderate epigastric abdominal pain without distention, no\nrebound/guarding, no peritonitic signs\nLabs: WBC 10.4, Cr 1.5, C diff negative, ___ improved with IVF\nwhile in ED\nImaging: CT A/P showed colitis\nImpression: admitting for colitis and ___, unable to tolerate PO\nas outpatient\nInterventions: cipro/flagyl\nCourse: patient feeling improved overall. Reports ongoing\nepigastric pain and mild nausea. Unfortunately she has not\nreceived a tray of food yet for po challenge, and has not had a\ntrial of po medications to ensure that she tolerates them. While\nI anticipate quick turnaround, she will need to be admitted for\nmonitoring and to ensure she tolerates po.\n\nOn arrival to the floor patient noted interval improvement in\nsymptoms though still with abdominal discomfort. She is\nrequesting broth to try stating she tolerated jello in the ED. \n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n \nPast Medical History:\nMALT lymphoma in remission\nHypothyroidism\nHypertension\nHyperlipidemia\nGERD\nAsthma/COPD\n \nSocial History:\n___\nFamily History:\nReviewed and found to be not relevant to this illness/reason for \nhospitalization.\n \nPhysical Exam:\nAdmission Physical Exam:\n========================\nVITALS: reviewed in POE \nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema. Oropharynx without\nvisible 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\nsymmetric\nSKIN: No obvious rashes or ulcerations noted on cursory skin \nexam\nNEURO: Alert, oriented, face symmetric, speech fluent, moves all\nlimbs\nPSYCH: pleasant, appropriate affect\n\nDischarge Physical Exam:\n========================\n \nPertinent Results:\nAdmission Labs:\n===============\n___ 07:50PM BLOOD WBC-10.4* RBC-4.34 Hgb-12.0 Hct-36.5 \nMCV-84 MCH-27.6 MCHC-32.9 RDW-16.0* RDWSD-49.2* Plt ___\n___ 07:50PM BLOOD Glucose-106* UreaN-17 Creat-1.5* Na-138 \nK-3.7 Cl-99 HCO3-23 AnGap-16\n___ 07:50PM BLOOD ALT-13 AST-25 AlkPhos-60 TotBili-0.6\n___ 11:58AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.7\n\n___ 2:10 am BLOOD CULTURE\n\n Blood Culture, Routine (Preliminary): \n GRAM NEGATIVE ROD(S). \n SENT TO ___ FOR IDENTIFICATION AND SENSITIVITY \n(___). \n\n Aerobic Bottle Gram Stain (Final ___: \n GRAM NEGATIVE ROD(S). \n Reported to and read back by ___ ___ \nAT 0704. \n\nImaging:\n========\nCT ABD & PELVIS WITH CO\n1. Ascending colon wall thickening with surrounding inflammatory \nchanges is consistent with colitis, the differential for which \nincludes infectious, inflammatory, or less likely ischemic. No \nperforation or imaging evidence for bowel wall ischemia.\n2. Slight interval decrease in overall size of a complex \nhypodense\nretroperitoneal lesion with calcifications and scattered soft \ntissue nodules, which may be a lymphovascular malformation.\n\nEKG ___: QTc 429\n\nDischarge Labs:\n===============\n___ 05:36AM BLOOD WBC-4.5 RBC-3.75* Hgb-10.3* Hct-30.9* \nMCV-82 MCH-27.5 MCHC-33.3 RDW-16.0* RDWSD-48.1* Plt ___\n___ 05:36AM BLOOD Glucose-88 UreaN-11 Creat-1.0 Na-137 \nK-4.3 Cl-103 HCO3-23 AnGap-11\n___ 05:36AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.3\n \nBrief Hospital Course:\nThis is a ___ year old female with past medical history of \ngastric MALT in remission, thyroid cancer status post resection, \nSjogren's syndrome, retroperitoneal AV malformation, serrated \nadenoma of the colon, CKD stage III, hypertension, cataracts, \nadmitted ___ with 1 day of abdominal pain, nausea and \ndiarrhea, imaging concerning for colitis, found to have gram \nnegative rod bacteremia.\n\n# Colitis of unclear etiology \n# Generalized abdominal pain \nPatient presented with several days of worsening diarrhea and \nabdominal pain. Admission CT showed ascending colon wall \nthickening with surrounding inflammatory changes, felt to be \nconsistent with colitis. Given concern for infection, patient \nwas started on empiric antibiotics, cipro and flagyl. Cdiff PCR \nwas negative.\nDiarrhea quickly resolved before stool cultures could be \nobtained. She was later able to produce a stool culture (after \none week of antibiotics), the results of which were still \npending at time of discharge. At time of discharge she was \ntolerating a regular diet. Of note, she had a colonoscopy on \n___ which showed polyps but otherwise was unrevealing. \nHowever, she will require close GI follow up and may need a \nrepeat colonoscopy to rule out malignancy once acute infection \nhas resolved. This was communicated to patient and her son prior \nto discharge. Per ___ office she will require a new GI referral \nsent prior to scheduling an appointment. She was discharged on \ncipro/flagyl for a planned 14 day course (last day ___.\n\n# GNR Sepsis secondary to Acute blood stream infection\nBlood cultures from hospital day 2 returned positive for gram \nnegative rods. Microbiology lab unable to identify organism and \nso cultures were sent to ___ Clinic for further identification. \nFinal identification was pending at time of discharge. She was \nseen by the infectious disease team, who felt that her \nbacteremia was either transient or was responding to antibiotic \ntreatment (cipro/flagyl as above). Organism was eventually \nidentified as paracoccus sanguinis, pansensitive. She was \ndischarged on ciprofloxacin for a two week course as above.\n\n# Hypothyroidism: continued home Levothyroxine \n\n# GERD: continued PPI \n\n# Hyperlipidemia: continued statin \n\n# Hypertension\n# Chronic Diastolic CHF \nContinued amLODIPine, Metoprolol. In setting of initial diarrhea \nand poor PO intake, torsemide was held but was restarted at \ndischarge\n\n# Cataracts: continued Lotemax and home autologous serum drops \n\n# COPD: continued Symbicort, prn albuterol\n\n> 30 minutes spent on discharge coordination and planning \n\nTransitional issues\n- discharged on cipro/flagyl with planned two week course (last \nday ___\n- needs GI follow up to ensure that colitis is resolving. ___ \nalso need repeat colonoscopy to exclude malignancy\n- CT Incidentally showed \"Slight interval decrease in overall \nsize of a complex\nhypodense retroperitoneal lesion with calcifications and \nscattered soft tissue nodules, which may be a lymphovascular \nmalformation\" \n- CXR incidentally showed \"Markedly tortuous aorta with \ndilatation of the ascending thoracic aorta.\" \"Bilateral \npulmonary arterial dilatation can be seen with pulmonary \narterial hypertension.\" \"Small to moderate hiatal hernia\" can \nconsider additional outpatient workup \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation 2 puffs BID \n2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ4H:PRN \n3. Lotemax (loteprednol etabonate) 0.5 % ophthalmic (eye) QHS \n4. Torsemide 5 mg PO DAILY \n5. Pantoprazole 40 mg PO Q12H \n6. Restasis 0.05 % ophthalmic (eye) BID \n7. Levothyroxine Sodium 112 mcg PO DAILY \n8. amLODIPine 10 mg PO DAILY \n9. Pravastatin 80 mg PO QPM \n10. Metoprolol Succinate XL 100 mg PO DAILY \n\n \nDischarge Medications:\n1. Ciprofloxacin HCl 500 mg PO Q12H \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day \nDisp #*15 Tablet Refills:*0 \n2. MetroNIDAZOLE 500 mg PO Q8H \nRX *metronidazole 500 mg 1 tablet(s) by mouth three times a day \nDisp #*22 Tablet Refills:*0 \n3. Ondansetron 4 mg PO Q8H:PRN severe nausea \nRX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours \nDisp #*15 Tablet Refills:*0 \n4. amLODIPine 10 mg PO DAILY \n5. Levothyroxine Sodium 112 mcg PO DAILY \n6. Lotemax (loteprednol etabonate) 0.5 % ophthalmic (eye) QHS \n7. Metoprolol Succinate XL 100 mg PO DAILY \n8. Pantoprazole 40 mg PO Q12H \n9. Pravastatin 80 mg PO QPM \n10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ4H:PRN \n11. Restasis 0.05 % ophthalmic (eye) BID \n12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation 2 puffs BID \n13. Torsemide 5 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nColitis\nBacteremia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\n\n \nDischarge Instructions:\nMs. ___: \n\nIt was a pleasure caring for you at ___. You were admitted \nwith diarrhea and abdominal pain and found to have colitis on CT \nscan. You were found to have an infection in your blood stream \nwhich was potentially related to the colitis. You were treated \nwith antibiotics and your symptoms improved. We are sending you \nhome on antibiotics for a total two week course. Your last day \nof antibiotics will be on ___.\n\nIt will be very important to see your GI doctor after leaving \nthe hospital. Your GI doctor can make sure that your symptoms \nare resolving. You may also need another colonoscopy. You should \ntalk to Dr. ___ scheduling this appointment since you \nwill need a referral.\n\nIt was a pleasure taking care of you, and we are happy that \nyou're feeling better!\n \nFollowup Instructions:\n___\n" ]

[ "A09", "R7881", "I130", "I5032", "N179", "M3500", "N183", "J449", "E785", "Q2739", "B9689", "E890", "I351", "E876", "K219", "H269", "Z8579", "Z85850", "Z86010" ]

[ "A09: Infectious gastroenteritis and colitis, unspecified", "R7881: Bacteremia", "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", "N179: Acute kidney failure, unspecified", "M3500: Sicca syndrome, unspecified", "N183: Chronic kidney disease, stage 3 (moderate)", "J449: Chronic obstructive pulmonary disease, unspecified", "E785: Hyperlipidemia, unspecified", "Q2739: Arteriovenous malformation, other site", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere", "E890: Postprocedural hypothyroidism", "I351: Nonrheumatic aortic (valve) insufficiency", "E876: Hypokalemia", "K219: Gastro-esophageal reflux disease without esophagitis", "H269: Unspecified cataract", "Z8579: Personal history of other malignant neoplasms of lymphoid, hematopoietic and related tissues", "Z85850: Personal history of malignant neoplasm of thyroid", "Z86010: Personal history of colonic polyps" ]

[ "I130", "I5032", "N179", "J449", "E785", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nmorphine\n \nAttending: ___.\n \nChief Complaint:\nSubdural hematoma \n \nMajor Surgical or Invasive Procedure:\n___ Dobhoff tube placement\n\n \nHistory of Present Illness:\n___ Sr is a ___ male with a PMHx of AF on \ncoumadin\nwho was in an MVC and was found to have L SDH with SAH, was\nadmitted to the neurosurgery service, and now has new-onset\naphasia.\n\n \nPast Medical History:\n- HTN\n- A-fib on Coumadin\n- Hypothyroidism \n \nSocial History:\n___\nFamily History:\nUnable to obtain\n \nPhysical Exam:\nOn Admission:\n=============\nPhysical Exam:\n98.9F 96/62 75 19 97RA\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: Lungs CTA bilaterally without R/R/W\nCardiac: irregularly irreg\nAbdomen: soft, NT/ND, normoactive bowel sounds, no masses or \norganomegaly noted.\nExtremities: No C/C/E bilaterally, 2+ radial, DP pulses \nbilaterally.\nSkin: no rashes or lesions noted.\n\nNeurologic:\n**Exam limited because he is very hard of hearing at baseline\n-Mental Status: Oriented to name and hospital but not BI or date \n(___). Disoriented to situation and unable to provide a \nhistory. Speech fluent with multiple neologigisms, symantic \nparaphasic errors, and syntactic errors (e.g., \"Rhesus Christ\" \ninstead of \"Jesus Christ\" when patient was surprised). Does not \nseem frustrated or aware of deficits. Able to follow \nappendicular but not cross-body commands. Names high and low \nfrequency words (watch, watch band, watch face). Repeats \"mama\" \nonly but not more complicated words or phrases. Able to read but \nwith paraphasic errors. Unable to describe stroke picture. \nUnable to participate in registration or recall testing. Unable \nto participate in attention testing.\n\n-Cranial Nerves:\nII, III, IV, VI: Pupils L<R (L 2.5-->2, R 3-->2). Moving eyes \nin all directions. ?Decr BTT on R. No hippus. Eyes orthotropic \nin primary gaze.\nV: Facial sensation intact to light touch (Says \"yes\" when asked \nif facial sensation symmetric to LT).\nVII: L NLFF.\nVIII: Grossly very hard of hearing.\nIX, X: Palate elevates symmetrically.\nXI: Did not cooperate with testing.\nXII: Tongue protrudes in midline.\n\n-Motor: Moving all extremities symmetrically spontaneously and \nto light stim. Cooperated with manual motor testing in UEs \n(except not with drift testing), and strength was ___. Did not \ncooperate with MMT in LEs. No adventitious movements, such as \ntremor, noted. No rhythmic shaking. \n\n-Sensory: Withdraws to light stim and noxious in all \nextremities. Says \"Yes\" when asked if sensation symmetric to LT. \nDoes not participate in extinction testing.\n\n-DTRs: ___ 1 throughout. Plantar response was flexor \nbilaterally.\n\nOn Discharge: \n=============\nVitals: 97.7 Axillary 119 / 80 L Lying 67 18 96 RA \n___: Elderly male, laying in bed, NAD, Dobhoff in place \nHEENT: Sclera anicteric\nHeart: Regularly irregular, no m/r/g \nLungs: Clear to auscultation bilaterally. \nAbdomen: Soft, nontender, nondistended.\nExt: Right ankle swollen around joint. Erythematous right medial \nmalleolus, improving. Erythematous medial aspect of left big \ntoe, improving. \nNeuro: AAOx2-3, moving all 4 extremities with volition, able to \nsqueeze hands, wiggle toes. Slight flattening of b/l nasolabial \nfolds. Some gradually improving expressive aphasia.\n \nPertinent Results:\nLabs on admission:\n==================\n___ 03:33PM BLOOD WBC-9.7 RBC-4.47* Hgb-14.4 Hct-42.1 \nMCV-94 MCH-32.2* MCHC-34.2 RDW-14.7 RDWSD-50.7* Plt ___\n___ 03:33PM BLOOD ___ PTT-22.9* ___\n___ 03:33PM BLOOD ___ 02:45AM BLOOD Glucose-103* UreaN-22* Creat-1.2 Na-143 \nK-3.8 Cl-108 HCO3-22 AnGap-17\n___ 03:33PM BLOOD Lipase-24\n___ 02:45AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.8\n___ 03:33PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 03:42PM BLOOD ___ pO2-48* pCO2-41 pH-7.37 \ncalTCO2-25 Base XS--1 Comment-GREEN TOP\n___ 03:42PM BLOOD Glucose-122* Lactate-1.5 Na-144 K-3.9 \nCl-108\n___ 03:42PM BLOOD Hgb-14.8 calcHCT-44 O2 Sat-81 COHgb-2 \nMetHgb-0\n___ 03:42PM BLOOD freeCa-1.08*\n\nImaging:\n=========\n___ NCHCT \n \nNo significant interval change in subdural and subarachnoid \nhemorrhages, along the left cerebral convexity, superior \ntentorium and left falx. \n\nCT HEAD W/O CONTRAST Study Date of ___ 8:14 ___ \nIMPRESSION: \n1. Left frontal convexity subdural hematoma has decreased, now \nwith hypodense fluid. Left parafalcine subdural hematoma is \ndecreasing in size. Small subdural hematoma along the left \ntentorium is not significantly changed. \n2. Near complete resolution of the left subarachnoid hemorrhage. \n\n3. Slightly increased small amount of hemorrhage layering in the \noccipital \nhorn of the right lateral ventricle, probably due to \nredistribution, with \nstable size of the lateral ventricles. \n\nMR HEAD W/O CONTRAST Study Date of ___ 5:38 ___ \nIMPRESSION: \n1. Subdural hematomas involving bilateral cerebral convexities, \nposterior falx and left tentorial leaflet. The left cerebral \nconvexity subdural hematomas are relatively unchanged compared \nto the prior study. The right cerebral convexity subdural \nhematoma appears slightly more prominent compared to the prior \nhead CTs. \n2. Extensive subarachnoid hemorrhage, relatively unchanged \nthough comparison is difficult given the differences in \ntechnique \n3. Intraparenchymal contusion involving the left frontal lobe. \n4. No acute infarct is seen, small foci of slow diffusion \nvisualized in the occipital lobes suggesting subacute ischemic \nchanges. \n \nCT HEAD W/O CONTRAST Study Date of ___ 5:46 AM \nIMPRESSION: \n1. Allowing for differences in slice acquisition and \nmeasurement, no \nsignificant change in the known left subdural hematoma and small \nsubarachnoid hemorrhage since ___. Small amount of \nintraventricular hemorrhage in the occipital horn of right \nlateral ventricle is also unchanged. \n2. No new intracranial hemorrhage identified. \n\nCT head w/o contrast ___\nOverall stable appearance of the head with no significant \nchanges since prior study performed ___. Evolution of \nleft superior parafalcine hematoma, subdural hemorrhage along \nthe left tentorium, subdural fluid collection along the left \nfrontal and parietal convexity, and intraventricular blood \nwithin the occipital horn of the right lateral ventricle. No \nnew hemorrhage. Stable ventriculomegaly. Slight rightward shift \nof normally midline structures appears unchanged.\n\nLower extremity venous doppler ___\nNo evidence of deep venous thrombosis in the right or left lower \nextremity veins.\n\nRight ankle x-ray ___\n1. Soft tissue swelling about the right ankle. However, no \nfracture dislocation is detected.\n2. Possible posterior tibiotalar joint effusion.\n3. Minimal spurring, without gross degenerative change.\n4. Chondrocalcinosis and vascular calcifications.\n\nCT chest ___\n1. No evidence of active intrathoracic infection or malignancy.\n2. Moderate atherosclerotic calcifications involve the aortic \narch and coronary arteries. No aneurysmal dilation or evidence \nof acute aortic injury. Note is additionally made of mild aortic \nvalvular calcifications.\n\nKUB ___\nMarked colonic distension with relative paucity of gas in the \ndistal pelvis, likely colonic ileus, less likely distal \nobstruction.\n\nRUQ US ___\nSludge within the gallbladder lumen without evidence to suggest \nacute\ncholecystitis.\n\nCT head w/o contrast ___\n1. Significant improvement of the left superior parafalcine \nsubdural hematoma with small amount of residual hyperdensity \nremaining.\n2. Interval resolution of a left tentorial subdural hematoma.\n3. Slight enlargement of the left convexity subdural fluid \ncollection resulting in 6 mm rightward shift of midline \nstructures.\n4. Small amount of intraventricular hemorrhage, improved since \nprior.\n5. No new hemorrhage identified.\n\nMRI head w/and w/o contrast ___\n1. Small presumed subacute infarct along the cortex of the left \nfrontal lobe with enhancement postcontrast is new from ___.\n2. Stable mixed subacute and chronic subdural hematoma along the \nleft frontal convexity, falx and tentorium.\n3. Stable mass effect with 6 mm of rightward shift of normally \nmidline\nstructures.\n4. Decreased subarachnoid hemorrhage.\n\n___ NCHCT IMPRESSION: \n \n1. Continued expected evolution of multicompartment intracranial \nhemorrhage. \nNo new or enlarging hemorrhage identified. \n2. Age related involutional changes and nonspecific white matter \nhypodensities \nlikely representing moderate chronic small vessel ischemic \ndisease. \n\nNotable labs:\n=============\n___ 06:17AM BLOOD ALT-276* AST-150* LD(LDH)-337* \nAlkPhos-161* TotBili-1.5\n___ 04:40AM BLOOD calTIBC-185* Ferritn-607* TRF-142*\n___ 05:44AM BLOOD Osmolal-273*\n___ 05:49AM BLOOD TSH-3.8\n___ 06:30AM BLOOD T4-5.5\n___ 07:50AM BLOOD Cortsol-18.0\n___ 06:30AM BLOOD HBsAg-Negative HBsAb-Negative \nHBcAb-NEGATIVE\n___ 07:50AM BLOOD Smooth-NEGATIVE\n___ 07:50AM BLOOD ___ * Titer-1:40\n___ 07:50AM BLOOD antiTPO-LESS THAN \n___ 06:30AM BLOOD HCV Ab-Negative\n___ 04:19AM BLOOD Lactate-1.0\n___ 10:41AM URINE Blood-NEG Nitrite-NEG Protein-30 \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG\n___ 10:41AM URINE RBC-4* WBC-2 Bacteri-NONE Yeast-NONE \nEpi-0\n___ 04:36PM URINE Hours-RANDOM Creat-145 Na-49\n___ 04:36PM URINE Osmolal-708\n\nMicro:\n======\n___ urine culture: no growth\n___ urine culture: no growth\n___ blood culture: no growth\n___ blood culture: no growth\n___ blood culture: no growth\n\nLabs on discharge:\n==================\n___ 03:58AM BLOOD WBC-10.4* RBC-4.29* Hgb-13.7 Hct-41.8 \nMCV-97 MCH-31.9 MCHC-32.8 RDW-15.3 RDWSD-55.2* Plt ___\n___ 10:33AM BLOOD PTT-71.3*\n___ 03:58AM BLOOD Plt ___\n___ 03:58AM BLOOD Glucose-111* UreaN-42* Creat-1.1 Na-143 \nK-4.3 Cl-103 HCO3-28 AnGap-16\n___ 06:49AM BLOOD ALT-33 AST-17\n___ 07:31AM BLOOD ALT-55* AST-23 AlkPhos-115 TotBili-0.7\n___ 03:58AM BLOOD Calcium-10.1 Phos-3.6 Mg-2.1\n \nBrief Hospital Course:\nMr. ___ is an ___ year old man with a past medical history \nof Afib on Coumadin, presenting from ___ s/p MVA \nfound to have a left ___ initially admitted to Neurosurgery \nservice with no surgical internveion, transferred to Medicine \nfor bradycardia, hypoxemia, lethargy, and fever. \n\n#Toxic-metabolic encephalopathy: Infectious work-up negative \n(see below). Patient with fluctuating mental status over many \ndays. Likely multifactorial with potential etiologies including \nsequelae of SDH and hospital delirium. No evidence of infection. \nStatus epilepticus not likely with EEG showing slow triphasic \nwaves suggestive of encephalopathy, but no sharp waves to \nindicate seizure activity. Vasospasm less likely given size and \nlocation of ___. Fluctuating mental status and changing neuro \nexam most likely secondary to shifting of blood products and \naccompanying cortical irritation that can persist for months. \nRepeat noncontrast head CT showed no new bleed and prior bleeds \nall improving, though there is a increased fluid pocket causing \na midline shift that does not explain his mental status and will \nnot be intervened upon by neurosurgery. MRI showed subacute \ninfarct, but the size and location do not fully explain his \nmental status. He was treated with delirium precautions, \naspiration precautions. Non-contrast CT head scan on ___ showed \nstable subdural hematoma, and neurosurgery recommended continued \nmonitoring / rehabilitation and were happy with progress. He was \ninitially started on quetiapine but had some increased \nsomnolence with this so it was weaned. The patient's mental \nstatus gradually improved to the point of discharge where he was \nable to recite his name, that he was in a hospital. He had \ndifficulty expressing where he was but made tremendous leaps. He \nwas able to feed himself with supervision from nursing. He will \nfollow-up with neurology and neurosurgery as outpatient in appx \n4 weeks. (See related appointments)\n\n#Fever: Initially empirically treated with vancomycin and \ncefepime for concerning new opacity on chest x-ray. Received 48 \nhours of vancomycin, and chest CT showed no infectious process, \nUA and urine cultures were also negative, and he had no \nlocalizing symptoms, so antibiotics were discontinued. Fevers \nwere most likely secondary to aspiration pneumonitis, given AMS, \nat risk for aspiration.\n\n#Bradycardia: When he was transferred to Medicine, he was \nintermittently bradycardic on home dose of metoprolol for rate \ncontrol of Afib. Etiology in the setting of ___ included ___ \nreflex to increased ICP, so his home metoprolol dose was \ndecreased, and he had no further episodes of bradycardia. He \nremained in atrial fibrillation with intraventricular conduction \ndelays on repeated ECGs with heart rate that fluctuated within \nnormal limits. \n\n#Hypoxemia: Had several episodes of hypoxemia. Most likely \nsecondary to aspiration pneumonitis and atelectasis as well as \nfluid overload from receiving maintenance fluids. Resolved with \nthree days of diuresis.\n\n#New subacute L frontal infarct: Found on brain MRI ___. \nNeurology recommended resuming Warfarin, and pt was cleared to \nrestart anticoagulation by Neurosurgery. Warfarin restarted \n___, briefly held from ___ given consideration of PEG \nbut restarted without bridge on discharge. GOAL INR ___.\n\n#Elevated transaminases: Elevated ALT and AST, and Alkphos that \nis downtrending. RUQ showed sludge, but no cholelithiasis and no \ndilated ducts, so cholecystitis less likely. Liver is of normal \nappearance making NASH, cirrhosis, or congestive hepatopathy \nunlikely. Thyroid disease could also cause elevated \ntransaminases, but T4 and TSH normal. Does not have chronic \nviral hepatitis with negative hepatitis B and C serologies. \nAdrenal insufficiency not likely with normal cortisol. \nAutoimmune hepatitis not likely with improving liver enzymes and \nisolated positive ___. Most likely secondary to medications. \nAntibiotics were discontinued and atorvastatin held. He was then \nstarted on pravastatin and LFTs were stable. \n\n#Anemia: Stable at 12.1. Iron studies suggestive of anemia of \nchronic inflammation.\n\n#Ankle/great toe/right MCP/right ___ PIP pain and swelling: \nPatient complained of pain in these areas during \nhospitalization. Most likely gout flare with a history of gout. \nReceived colchicine treatment dose followed by resuming his \nusual prophylactic colchicine therapy. Glucocorticoids were \navoided because of his mental status. \n\n# Nutrition: Speech and swallow consult recommended a ground \nsolid diet with nectar thick liquids, meds crushed in \napplesauce, oral care TID with chlorhexidine and swabs after \nmeals. There was concern for his PO intake, since he had a \nprolonged period where his mental status waxed and waned with \nperiods of somnolence that prevented him from eating because of \nconcern for aspiration. A Dobhoff was placed and he was \ninitiated on tube feeds. Prior to discharge, however, his mental \nstatus was much improved and swallowing service recommended:\nRECOMMENDATIONS:\n1. Ground solids with thin liquids\n2. Oral care TID\n3. Meds crushed in applesauce\n4. Staff to supervise meals to monitor rate of intake and \nensure\nmental status remains adequate for this diet upgrade (i.e. no\noral holding, no falling asleep mid-meal, no reduced\nmastication).\n5. Service to follow; should mental status decline, diet should\nbe downgraded back to puree/nectar or NPO dependent on LOC. \n \nIf he is able to meet his caloric needs with oral intake, his \ndobhoff tube can be removed.\n\n# AFib with CHADS2 score of 3: Prior to admission, rate-control \nwith metoprolol and anticoagulation with warfarin. Metoprolol \ndose was decreased as described above, and warfarin was \ninitially held and restarted as discussed above. \n\n# CKD: Baseline 1.\n\nChronic issues of hypothyroidism, hyperlipidemia, and \nhypertension were stable and continued on home medications, \nthough atorvastatin was changed to pravastatin.\n\nTransitional issues:\n====================\n[ ] neurology follow-up \n[ ] neurosurgery follow-up\n[ ] readdress nutrition and possible remove Dobhoff if improved \nPO intake. \n\nFormal nutrition recommendations on day of discharge:\nInterventions / Recommendations:\n- Kcal count x3 days\n- Send 2 Ensure Plus (350kcal, 13g protein/serving) each meal \n- Provide encouragement at mealtime \n- Use Ensure between meals \n- recommend Jevity 1.5 @ 60ml/hr to provide 2160kcal and 92g \nprotein/day \n[] Patient re-started on warfarin during inpatient admission \nwithout bridge for atrial fibrillation with approval from \nNeurosurgery. Held over weekend as nutrition plan evolved \n(considered PEG but improved), OK to restart warfarin per \nneurosurgery at discharge without bridge.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Levothyroxine Sodium 25 mcg PO DAILY \n2. Warfarin 5 mg PO 6X/WEEK (___) \n3. Warfarin 2.5 mg PO 1X/WEEK (___) \n4. Metoprolol Tartrate 100 mg PO BID \n5. Losartan Potassium 100 mg PO DAILY \n6. Colchicine 0.6 mg PO DAILY \n7. Atorvastatin 10 mg PO QPM \n8. Furosemide 20 mg PO QAM \n\n \nDischarge Medications:\n1. Colchicine 0.6 mg PO DAILY \n2. Levothyroxine Sodium 25 mcg PO DAILY \n3. Losartan Potassium 100 mg PO DAILY \n4. Metoprolol Tartrate 100 mg PO BID \n5. Bisacodyl 10 mg PR QHS:PRN constipation \n6. Docusate Sodium 100 mg PO BID \n7. LevETIRAcetam Oral Solution 1000 mg PO BID \n8. Miconazole Powder 2% 1 Appl TP TID:PRN skin rash \n9. Polyethylene Glycol 17 g PO DAILY \n10. Pravastatin 20 mg PO QPM \n11. Senna 17.2 mg PO BID constipation \n12. Furosemide 20 mg PO QAM \n13. Warfarin 5 mg PO 6X/WEEK (___) \n14. Warfarin 2.5 mg PO 1X/WEEK (___) \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary diagnosis:\n==================\nSubdural hematoma \nSubarachnoid hemorrhage\n\nSecondary diagnosis:\n====================\nAfib with CHADS2 score of 3 on Coumadin (held in the setting of \nSDH and SAH, then re-started without bridge per neruosurgery)\n4 cm aortic aneurysm\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure taking care of you here at ___.\n\nWhy was I here? \n- You were in a car accident and found to have a bleed in your \nbrain. \n- You had a fever, had difficulty breathing, feeling more tired \nand confused, and your heart was beating slowly.\n\nWhat was done while I was here?\n- The neurosurgery team saw you, and you did not need surgery \nfor the bleed in your brain.\n- You started taking Keppra, a medicine to help prevent a \nseizure after a bleed in your brain.\n- You had multiple pictures of your brain that showed that the \nbleed in your head did not get worse, and there were no new \nbleeds.\n- You had an EEG that showed that you were not having seizures.\n- You had pictures of your lungs that showed no infection.\n- You were seen by the speech and swallow team, who recommended \nfluids that are at least honey thick.\n- You had a gout flare and got medicines for it.\n- You received antibiotics, which were stopped when there was no \nsign of infection.\n- You were restarted on your blood thinner when CT images showed \nthat there was a very small area of stroke, and at that time, \nthe risk of a stroke became greater than a new bleed in your \nbrain. \n- You had a feeding tube to help you get enough calories.\n\nWhat should I do when I get home? \n- Continue taking your medicines as prescribed.\n- Follow-up with neurology.\n\nSincerely,\nYour ___ team\n\n****** \nActivity\n•We recommend that you avoid heavy lifting, running, climbing, \nor other strenuous exercise until your follow-up appointment.\n•You make take leisurely walks and slowly increase your activity \nat your own pace once you are symptom free at rest. ___ try to \ndo too much all at once.\n•No driving while taking any narcotic or sedating medication. \n•If you experienced a seizure while admitted, you are NOT \nallowed to drive by law. \n•No contact sports until cleared by your neurosurgeon. You \nshould avoid contact sports for 6 months. \n\nMedications\n•***Please do NOT take any blood thinning medication (Aspirin, \nIbuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. \n•***You have been discharged on Keppra (Levetiracetam). This \nmedication helps to prevent seizures. Please continue this \nmedication as indicated on your discharge instruction. It is \nimportant that you take this medication consistently and on \ntime. \n•***You have been prescribed Dilantin (Phenytoin) for \nanti-seizure medicine, take it as prescribed and follow up with \nlaboratory blood drawing in one week. This can be drawn at your \nPCP’s office, but please have the results faxed to ___.\n•You may use Acetaminophen (Tylenol) for minor discomfort if you \nare not otherwise restricted from taking this medication.\n\nWhat You ___ Experience:\n•You may have difficulty paying attention, concentrating, and \nremembering new information.\n•Emotional and/or behavioral difficulties are common. \n•Feeling more tired, restlessness, irritability, and mood swings \nare also common.\n•Constipation is common. Be sure to drink plenty of fluids and \neat a high-fiber diet. If you are taking narcotics (prescription \npain medications), try an over-the-counter stool softener.\n\nHeadaches:\n•Headache is one of the most common symptom after a brain bleed. \n\n•Most headaches are not dangerous but you should call your \ndoctor if the headache gets worse, develop arm or leg weakness, \nincreased sleepiness, and/or have nausea or vomiting with a \nheadache. \n•Mild pain medications may be helpful with these headaches but \navoid taking pain medications on a daily basis unless prescribed \nby your doctor. \n•There are other things that can be done to help with your \nheadaches: avoid caffeine, get enough sleep, daily exercise, \nrelaxation/ meditation, massage, acupuncture, heat or ice packs. \n\n \nWhen to Call Your Doctor at ___ for:\n•Severe pain, swelling, redness or drainage from the incision \nsite. \n•Fever greater than 101.5 degrees Fahrenheit\n•Nausea and/or vomiting\n•Extreme sleepiness and not being able to stay awake\n•Severe headaches not relieved by pain relievers\n•Seizures\n•Any new problems with your vision or ability to speak\n•Weakness or changes in sensation in your face, arms, or leg\n\nCall ___ and go to the nearest Emergency Room if you experience \nany of the following:\n\n \nFollowup Instructions:\n___\n" ]

[ "S065X9A", "G92", "S066X9A", "J690", "I639", "N179", "E222", "I4891", "J9811", "R4701", "S06369A", "R001", "R0902", "M109", "E039", "E8770", "V4352XA", "I129", "R748", "D649", "N189", "I712", "Z7901", "Y92410", "Z8546" ]

[ "S065X9A: Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter", "G92: Toxic encephalopathy", "S066X9A: Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, initial encounter", "J690: Pneumonitis due to inhalation of food and vomit", "I639: Cerebral infarction, unspecified", "N179: Acute kidney failure, unspecified", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "I4891: Unspecified atrial fibrillation", "J9811: Atelectasis", "R4701: Aphasia", "S06369A: Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of unspecified duration, initial encounter", "R001: Bradycardia, unspecified", "R0902: Hypoxemia", "M109: Gout, unspecified", "E039: Hypothyroidism, unspecified", "E8770: Fluid overload, unspecified", "V4352XA: Car driver injured in collision with other type car in traffic accident, initial encounter", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "R748: Abnormal levels of other serum enzymes", "D649: Anemia, unspecified", "N189: Chronic kidney disease, unspecified", "I712: Thoracic aortic aneurysm, without rupture", "Z7901: Long term (current) use of anticoagulants", "Y92410: Unspecified street and highway as the place of occurrence of the external cause", "Z8546: Personal history of malignant neoplasm of prostate" ]

[ "N179", "I4891", "M109", "E039", "I129", "D649", "N189", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROSURGERY\n \nAllergies: \nNo Allergies/ADRs on File\n \nAttending: ___\n \nChief Complaint:\nJump from moving vehicle\n \nMajor Surgical or Invasive Procedure:\nNone \n \nHistory of Present Illness:\n___ Critical is a ___ y/o male who presents to ___ on ___ with a moderate TBI from ___.\nPer OSH hospital report the patient was in the car with his\ngirlfriend, they got into a dispute and he jumped out of a \nmoving\ncar traveling about ___ m/hr. He was brought to an OSH with a GCS\nof 14 but agitated and combative, he was intubated for agitation\nand CT scan. CT scan showed a left SDH, tSAH, and a basilar \nskull\nfracture with minimal mass effect. He was then transferred to\n___ for further evaluation. Intubated, unable to obtain ROS \nupon arrival.\n \nPast Medical History:\nBipolar; ETOH and Opioid abuse\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\n===============\nON ADMISSION\n===============\n\nGCS upon Neurosurgery Evaluation: 7T\n\nAirway: [x]Intubated [ ]Not intubated\n\nEye Opening: \n [x]1 Does not open eyes\n [ ]2 Opens eyes to painful stimuli\n [ ]3 Opens eyes to voice\n [ ]4 Opens eyes spontaneously\n\nVerbal:\n [x]1 Makes no sounds\n [ ]2 Incomprehensible sounds\n [ ]3 Inappropriate words\n [ ]4 Confused, disoriented\n [ ]5 Oriented\n\nMotor:\n [ ]1 No movement\n [ ]2 Extension to painful stimuli (decerebrate response)\n [ ]3 Abnormal flexion to painful stimuli (decorticate response)\n [ ___ Flexion/ withdrawal to painful stimuli \n [x]5 Localizes to painful stimuli\n [ ]6 Obeys commands\n\nExam:\n\nGen: WD/WN, comfortable, NAD.\nNeuro:\n\nMental Status: Awake, alert, cooperative with exam, normal\naffect.\n\nOrientation: Oriented to person, place, and date.\n\nLanguage: Intubated\n\nIf Intubated:\n [x]Cough [x]Gag [x]Over breathing the vent\n\nCranial Nerves:\nI: Not tested\nII: Pupils equally round and reactive to light, 3 to 2\nmm bilaterally. \n\nMotor: \nNormal bulk and tone bilaterally. No abnormal movements,\ntremors. Strength- MAE with good strength, but not to commnads. \n+\nLocalizing x4. \n\n===============\nON DISCHARGE\n===============\n\n___:\n[x]AVSS \n\nExam:\n\nOpens eyes: [x]spontaneous [ ]to voice [ ]to noxious\n\nOrientation: [x]Person [x]Place [x]Time\n\nFollows commands: [ ]Simple [x]Complex [ ]None\n\nPupils: 3-2 mm bilaterally\n\nEOM: [x]Full [ ]Restricted\n\nFace Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No\n\nPronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No\n\nComprehension intact [x]Yes [ ]No\n\nMotor:\nTrapDeltoidBicepTricepGrip\nRight5/5 -->\nLeft5/5 -->\n\nIPQuadHamATEHLGast\nRight5/5 -->\nLeft5/5 -->\n\n[ ]Clonus [ ___ [x]Sensation intact to light touch\n[x]Propioception intact\n \nPertinent Results:\nPlease see OMR for pertinent imaging & labs\n \nBrief Hospital Course:\nOn ___, EuCritical ___ AKA ___ was admitted to \nthe neurosurgery service with left subdural hematoma, traumatic \nsubarachnoid hemorrhage and basilar skull fracture. He was \nintubated on transfer from OSH and monitored in the ICU for \nclose neurologic monitoring. \n\n#L SDH, tSAH, basilar skull fx. \nOn the day of admission, CTA head and neck was performed which \nshowed stable hemorrhages and no evidence of vascular injury. \nENT was consulted for left ear bloody otorrhea and basilar skull \nfracture; no wick was placed, as the TM was visualized as intact \ndespite hemotympanum; the patient was placed on CSF precautions, \ndry eye precautions, and antibiotic otic drops per ENT beginning \n___. He was extubated on ___, required multiple people to hold \nhim down while extubating, however he was much more appropriate \nlater in the afternoon. Patient transferred to the Neuro Step \nDown Unit for continued care on ___. The patient remained \nstable in SDU and was transitioned to PO Keppra before \ntransferring to the floor on ___. CT IAC, orbits, and sella \ndemonstrated complex, combined transverse and longitudinal \nfracture through the temporal bone, distracting the tegmen with \npartial opacification of the inner ear, presumably with a \ncombination of CSF and blood products, as well as a minimally \ndisplaced fracture through the carotid canal with fracture line \nextending into the sella turcica and the clivus. \n\n#DISCHARGE PLANNING: ___ work involved for disposition. \nThe patient was cleared for discharge to home with outpatient \ncognitive rehab per OT. The patient has elected to arrange for \nthis at ___ near his home and was therefore \nprovided with contact information. The patient will additionally \nfollow up with Drs. ___ (Otology) and \naudiology, for which he was provided contact information. The \npatient was provided with detailed instructions concerning \nfollow-up, medications (including antibiotic ear drops and \ncontinued seizure prophylaxis), CSF precautions, dry eye \nprecautions, and danger signs. All questions of the patient and \nfamily were answered prior to discharge.\n\n \nMedications on Admission:\nVivitrol\n \nDischarge Medications:\n1. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN Pain - Mild \n\nDo not exceed 6 tablets per day \nRX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___ \ntablet(s) by mouth every 4 hours as needed Disp #*24 Tablet \nRefills:*0 \n2. ALPRAZolam 1 mg PO DAILY AS NEEDED anxiety Duration: 7 Days \nDo not take more than one tablet per day \nRX *alprazolam 1 mg 1 tablet(s) by mouth daily as needed Disp \n#*7 Tablet Refills:*0 \n3. Ciprofloxacin 0.3% Ophth Soln 3 DROP BOTH EARS TID Duration: \n10 Days \nRX *ciprofloxacin HCl 0.2 % 3 drops by ear Three times per day \nin each ear Disp #*1 Package Refills:*0 \n4. Docusate Sodium 100 mg PO BID \n5. LevETIRAcetam 500 mg PO BID \nRX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth Twice per \nday Disp #*60 Tablet Refills:*3 \n6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every 4 hours \nas needed Disp #*20 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n___\ntSAH\nBasilar skull fx\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\n\nActivity Status: Ambulatory - Independent.\n\n \nFollowup Instructions:\n___\n" ]

[ "S065X0A", "S066X0A", "F17210", "R402353", "S02102A", "V481XXA", "Y929", "R402113", "R402213" ]

[ "S065X0A: Traumatic subdural hemorrhage without loss of consciousness, initial encounter", "S066X0A: Traumatic subarachnoid hemorrhage without loss of consciousness, initial encounter", "F17210: Nicotine dependence, cigarettes, uncomplicated", "R402353: Coma scale, best motor response, localizes pain, at hospital admission", "S02102A: Fracture of base of skull, left side, initial encounter for closed fracture", "V481XXA: Car passenger injured in noncollision transport accident in nontraffic accident, initial encounter", "Y929: Unspecified place or not applicable", "R402113: Coma scale, eyes open, never, at hospital admission", "R402213: Coma scale, best verbal response, none, at hospital admission" ]

[ "F17210", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / Zosyn / vancomycin\n \nAttending: ___.\n \nChief Complaint:\nAbdominal Pain\n \nMajor Surgical or Invasive Procedure:\n___ - Bedside decompressive exploratory laparotomy\n___ - Abdominal washout and dressing change\n___ - Abdominal washout and ___ patch placement\n___ - ___ patch tightening\n___ - ___ patch tightening\n___ - Bedside washout and ___ patch\n___ - Abdominal washout, ___ patch explantation and \nfascial closure\n___ - Open tracheostomy\nMultiple subsequent wound vac changes\n\n \nHistory of Present Illness:\n___ w history of heavy ETOH abuse presented to ___ \nyesterday ___ with abdominal pain one day after a heavy binge \ndrinking and episode of trauma to upper abdomen, found to have \nlipase 13,500, elevated LFT, and RUQ US w concern for possible \nCBD stone. CT scan was not performed at OSH or at ___ thus \nfar. He was transferred to ___ for ERCP.\nHowever there was severe duodenal edema which distorted the \nmajor papilla, so the procedure was aborted without cannulation. \nDuring the procedure the patient developed progressively \nworsening hypoxia requiring emergent intubation, and was \nsubsequently transferred to the FICU. Upon arrival there he was \nhypertensive to the 170s and tachycardic to the 130s, with low \nUOP ranging from ___. He has received approximately 13L \nfluid over the past 24hours. Over the past ___ hours, his UOP \ndropped to <10cc/hr and has become increasingly difficult to \nventilate, with plateau pressures in the high ___ and peak \npressures in the upper ___. He received a bolus of rocuronium 2 \nhours ago, but no paralytics since, and is moving all \nextremities spontaneously.\n \nPast Medical History:\nPMH:\n-Chronic inflammatory Demyelinating Polyneuropathy: Dense \nsensorimotor loss in bilateral lower extremities to midshin. \nDiagnosed in ___. \n-Anxiety\n\nPSH:\n-None\n\n \nSocial History:\n___\nFamily History:\nNo known family history of hepatobiliary disorder. Hypertension, \ngrandmother with diabetes. One cousin with ___. \nBell's palsy in cousin, and another cousin with cystinosis (an \nautosomal recessive lysosomal storage disease). Both on mother's \nside. Mother with granuloma ___,\n \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM \nGENERAL: Anxious, mild distress from pain. diaphoretic\nHEENT: miotic pupils. MMM. PERRL.\nNECK: supple. \nLUNGS: CTAB. Good airmovement \nCV: Tachycardic. RRR, normal S1, S2. No m/r/g\nABD: Distended/Obese, soft, mild tenderness. No rebound and \nguarding. \nEXT: WWP, no edema \nSKIN: No defects or bruising.\nNEURO: Anxious, oriented x3. Normal bulk and tone. Though thin \nLEs. No tremor. Normal strength in upper extremities. ___ \ndorsiflexion bilaterally. Toes downgoing. Dense sensor loss \nbelow mid shin. ;\nACCESS: PIV x2\n\nDISCHARGE PHYSICAL EXAM:\nVitals: Afebrile, VSS\nGEN: A&O, NAD \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, no rebound or guarding, \nnormoactive bowel sounds, no palpable masses. Midline wound vac \nin place. \nDRE: normal tone, no gross or occult blood \nExt: No ___ edema, ___ warm and well perfused \n \nPertinent Results:\n IMAGING:\n\n+ RUQUS (___): \n 1. Mildly distended gallbladder without evidence of \ncholelithiasis, \n intrahepatic, or extrahepatic biliary ductal dilatation. \n 2. Echogenic liver consistent with steatosis. Other forms of \nliver disease including steatohepatitis, hepatic fibrosis, or \ncirrhosis cannot be excluded on the basis of this examination. \n 3. Mild splenomegaly. \n + CXR (___): Low lung volumes. No evidence for acute \ncardiopulmonary process. \n - EKG (___): Mild LVH \n - MRCP (___): Evolving acute pancreatitis with a focus of \nnecrosis at the level of the pancreatic neck. The main \npancreatic duct appears intact.Moderate peripancreatic fluid is \nminimally changed in amount and appears slightly more organized \nsince the ___ examination. \n + RUQUS (___): \n 1. Echogenic liver consistent with steatosis. Other forms of \nliver disease including steatohepatitis, hepatic fibrosis, or \ncirrhosis cannot be excluded on the basis of this examination. \n 2. Moderate splenomegaly. \n 3. Decompressed gallbladder without evidence for cholecystitis. \n \n - UEUS (___): \n 1. Tiny non-occlusive thrombus within the right internal \njugular vein. \n 2. Assessment of the left upper extremity limited by catheter \ndressings. The IJ and vessels in the left upper extremity from \nthe mid upper arm to the antecubital fossa could not be imaged. \nNo evidence of deep venous thrombosis in the left subclavian, \naxillary, or imaged proximal and distal portions of the left \ncephalic, brachial, basilic veins. \n 3. Left PICC within a brachial and subclavian vein. \n - TTE (___): Poor image quality in evaluation of wall motion \nand valvular function. The left atrium and right atrium are \nnormal in cavity size. Left ventricular wall thickness, cavity \nsize, and global systolic function are normal (LVEF>70%). \n - CT abd/pelvis (___): \n PANCREAS: The pancreas remains edematous. Originating from the \nhead of the pancreas, there is a acute necrotic collection with \na suggestion of increased organization with a thin rim \nanteriorly, measuring 5.1 x 3.1 cm (02:36). There is a second \ncollection in the body of the pancreas with the suggestion of \norganization, measuring 3.8 x 2.1 cm. The tail of the pancreas \nmay also have a component of acute necrotic collection, which \nmay be organizing, though difficult to assess without \nadministration of contrast. There is no pancreatic ductal \ndilatation. Anterior to the pancreatic head acute necrotic \ncollection, there is another collection that is beginning to \norganize, measuring 10.1 x 5.9 cm (02:30). A right lower \nquadrant acute necrotic collection measures 1.9 x 3.8 cm (2:60). \nThere is residual layering retroperitoneal fluid, tracking along \nthe anterior and posterior bilateral perirenal fascia, decreased \ncompared to ___. \n\n MICROBIOLOGY:\n\n- BCx (___): STAPHYLOCOCCUS, COAGULASE NEGATIVE \n - UCx (___): No growth. \n - BCx (___): No growth. \n - UCx (___): No growth. \n - BCx (___): No growth. \n - Sputum cx (___): No growth. \n - Stool cx (___): C. diff. \n - Blood fungal/AFB cx (___): NGTD, pending. \n - Ascites fluid cx (___): NGTD, pending. \n - BCx (___): NGTD, pending. \n - PICC catheter tip cx (___): NGTD, pending. \n- c dif ___ negative\n\n LAB VALUES:\n\n***\nADMISSION LABS:\n___ 05:30AM URINE MUCOUS-MANY\n___ 05:30AM URINE GRANULAR-5* HYALINE-13*\n___ 05:30AM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE \nEPI-<1\n___ 05:30AM URINE BLOOD-SM NITRITE-NEG PROTEIN-300 \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-2* PH-6.0 \nLEUK-NEG\n___ 05:30AM URINE COLOR-RED APPEAR-Cloudy SP ___\n___ 05:30AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS* \ncocaine-NEG amphetmn-NEG mthdone-NEG\n___ 05:30AM URINE UHOLD-HOLD\n___ 05:30AM URINE HOURS-RANDOM\n___ 05:50AM PLT COUNT-249\n___ 05:50AM NEUTS-86.7* LYMPHS-5.9* MONOS-6.2 EOS-0.1* \nBASOS-0.2 IM ___ AbsNeut-14.50* AbsLymp-0.98* AbsMono-1.04* \nAbsEos-0.01* AbsBaso-0.04\n___ 05:50AM WBC-16.7* RBC-5.05 HGB-17.0 HCT-48.1 MCV-95 \nMCH-33.7* MCHC-35.3 RDW-13.3 RDWSD-46.5*\n___ 05:50AM TRIGLYCER-192*\n___ 05:50AM ALBUMIN-4.1 CALCIUM-8.6 PHOSPHATE-5.7* \nMAGNESIUM-1.7\n___ 05:50AM ALBUMIN-4.1 CALCIUM-8.6 PHOSPHATE-5.7* \nMAGNESIUM-1.7\n___ 05:50AM ALT(SGPT)-130* AST(SGOT)-116* ALK PHOS-64 TOT \nBILI-1.9* DIR BILI-0.6* INDIR BIL-1.3\n___ 05:50AM estGFR-Using this\n___ 05:50AM GLUCOSE-192* UREA N-10 CREAT-0.8 SODIUM-143 \nPOTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-22 ANION GAP-25*\n___ 06:07AM LACTATE-5.2*\n___ 07:32AM GLUCOSE-204* LACTATE-5.6* K+-4.4\n___ 12:00PM ___ PTT-25.3 ___\n___ 12:00PM PLT COUNT-206\n___ 12:00PM NEUTS-86.8* LYMPHS-6.2* MONOS-5.9 EOS-0.0* \nBASOS-0.4 IM ___ AbsNeut-13.69* AbsLymp-0.97* AbsMono-0.93* \nAbsEos-0.00* AbsBaso-0.07\n___ 12:00PM WBC-15.8* RBC-5.17 HGB-17.2 HCT-48.8 MCV-94 \nMCH-33.3* MCHC-35.2 RDW-13.5 RDWSD-46.5*\n___ 12:00PM ALBUMIN-3.7 CALCIUM-7.9* PHOSPHATE-4.3 \nMAGNESIUM-1.4*\n___ 12:00PM ALT(SGPT)-106* AST(SGOT)-91* LD(LDH)-428* ALK \nPHOS-58 TOT BILI-2.2*\n___ 12:00PM GLUCOSE-168* UREA N-11 CREAT-0.7 SODIUM-138 \nPOTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-15* ANION GAP-25*\n___ 12:11PM LACTATE-4.9*\n___ 12:11PM ___ PO2-80* PCO2-39 PH-7.36 TOTAL CO2-23 \nBASE XS--2\n___ 04:00PM LACTATE-3.9*\n___ 04:00PM ___ PO2-70* PCO2-39 PH-7.39 TOTAL CO2-24 \nBASE XS-0\n___ 09:56PM URINE MUCOUS-FEW\n___ 09:56PM URINE AMORPH-MOD\n___ 10:50PM TYPE-ART TEMP-38.7 RATES-28/ TIDAL VOL-400 \nPEEP-12 O2-100 PO2-67* PCO2-65* PH-7.20* TOTAL CO2-27 BASE XS--3 \nAADO2-584 REQ O2-96 AS/CTRL-ASSIST/CON INTUBATED-INTUBATED\n___ 10:50PM LACTATE-3.9* K+-4.8\n___ 10:50PM O2 SAT-85\n___ 10:50PM freeCa-1.05*\n___ 10:00PM ___ PO2-73* PCO2-70* PH-7.17* TOTAL \nCO2-27 BASE XS--4\n___ 09:57PM GLUCOSE-223* UREA N-12 CREAT-1.0 SODIUM-137 \nPOTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-22 ANION GAP-19\n___ 09:57PM CALCIUM-7.5* PHOSPHATE-4.8* MAGNESIUM-1.9\n___ 09:57PM WBC-17.2* RBC-5.16 HGB-17.2 HCT-50.9 MCV-99* \nMCH-33.3* MCHC-33.8 RDW-13.7 RDWSD-50.5*\n___ 09:57PM PLT COUNT-211\n___ 09:56PM URINE HOURS-RANDOM\n___ 09:56PM URINE UHOLD-HOLD\n\n___ 08:59AM BLOOD WBC-14.0*# RBC-3.32* Hgb-10.1* Hct-31.5* \nMCV-95 MCH-30.4 MCHC-32.1 RDW-14.4 RDWSD-49.7* Plt ___\n___ 04:26AM BLOOD WBC-21.9* RBC-3.10* Hgb-9.2* Hct-28.7* \nMCV-93 MCH-29.7 MCHC-32.1 RDW-14.4 RDWSD-48.7* Plt ___\n___ 06:30AM BLOOD WBC-26.4* RBC-2.97* Hgb-8.8* Hct-27.4* \nMCV-92 MCH-29.6 MCHC-32.1 RDW-14.4 RDWSD-48.8* Plt ___\n___ 05:41AM BLOOD WBC-30.6* RBC-2.80* Hgb-8.3* Hct-24.8* \nMCV-89 MCH-29.6 MCHC-33.5 RDW-14.1 RDWSD-45.4 Plt ___\n___ 06:50AM BLOOD WBC-20.0* RBC-3.22* Hgb-9.5* Hct-28.7* \nMCV-89 MCH-29.5 MCHC-33.1 RDW-13.6 RDWSD-44.7 Plt ___\n___ 10:40AM BLOOD WBC-18.0* RBC-3.06* Hgb-9.0* Hct-27.4* \nMCV-90 MCH-29.4 MCHC-32.8 RDW-13.5 RDWSD-44.0 Plt ___\n___ 05:25AM BLOOD WBC-14.9* RBC-2.99* Hgb-8.8* Hct-26.6* \nMCV-89 MCH-29.4 MCHC-33.1 RDW-13.3 RDWSD-43.5 Plt ___\n\n___ 06:30AM BLOOD Glucose-86 UreaN-21* Creat-3.5*# Na-133 \nK-3.7 Cl-91* HCO3-27 AnGap-19\n___ 07:00AM BLOOD Glucose-105* UreaN-37* Creat-3.7*# Na-134 \nK-3.5 Cl-92* HCO3-26 AnGap-20\n___ 09:20AM BLOOD Glucose-105* UreaN-21* Creat-2.8* Na-135 \nK-3.8 Cl-92* HCO3-25 AnGap-22*\n___ 06:50AM BLOOD Glucose-107* UreaN-28* Creat-2.6* Na-129* \nK-3.9 Cl-91* HCO3-23 AnGap-19\n___ 10:40AM BLOOD Glucose-118* UreaN-29* Creat-2.1* Na-133 \nK-3.8 Cl-94* HCO3-24 AnGap-19\n___ 05:25AM BLOOD Glucose-90 UreaN-29* Creat-1.7* Na-137 \nK-4.0 Cl-99 HCO3-23 AnGap-19\n \nBrief Hospital Course:\nMEDICAL HOSPITAL COURSE:\n\n___ yo M with no PMH who presents with abdominal pain, found to \nhave lipase of 13K consistent with pancreatitis, GPC bacteremia \nnow s/p ex-lap to improve oxygenation to be transferred to SICU \n___.\n\n# Acute Pancreatitis: Presented with lipase ___ to OSH c/w \npancreatitis. While patient has history of EToH intake, the \nepisode of pancreatitis was most likely secondary to a traumatic \nepisode to the upper abdomen. Reportedly had CBD stone on \ninformal ultrasound at ___ no biliary dilation or stone \nidentified here. ERCP attempted ___ but unable to visualize or \ncannulate papillae given significant gut edema. Triglycerides \nwas normal. Fulminant course was not c/w autoimmune \npancreatitis. Pancreatitis was complicated by firm and \ndistended abdomen raising concner for compartment syndrome. \nGiven difficulty ventilating (see below), he underwent bedside \nex lap ___. He was transferred to the surgical ICU for further \ncare.\n\n# Distributive Shock:\n# GPC bacteremia:\nShock likely primarily distribute ___ pancreatitis and \nbacteremia. Blood cultures resulted as ... Required pressors in \nsetting of intubation and positive pressure. He was aggressively \nbolused with IVF. Started on vanc/ meropenem (___) \n\n#Hypoxemic and hypercarbic respiratory failure: He became \nincreasingly tachypneic throughout the day. At ERCP on HD1 he \nbecame hypoxemic with significant difficulty oxygenating and \nventilating requiring paralysis and very high peak pressures. \nThis was likely secondary to high abdominal compartment \npressures leading to restrictive physiology, low lung volumes, \nworsening v/q mismatch, also possibly ARDS i/s/o pancreatitis. \nWith paralysis his oxygenation only improved slightly, \nultimately hastening surgical consult and ultimately leading to \na bedside ex-lap to relieve high compartment pressures. \n# renal failure- Oligouric/anuric, most likely ATN. Patient \nunderwent multiple treatments of hemodialysis. Prior to \ndischarge, his kidney function improved and he started urinating \non his own. His last HD was ___, and his HD access \nline was removed prior to discharge to rehab per the nephrology \nteam. \n\nCHRONIC ISSUES: \n\n# History of alcohol abuse: denied issues w/etoh initially but \nthen reported ___ night binge drinking. Started on versed drip \ngiven risk of withdrawal. \n\n# Chronic inflammatory Demyelinating Polyneuropathy: Very \nmarked. Has had nerve conduction studies but no formal \ndiagnosis. Has family history of neuropathies (___ \nand ___'s). \n\n# Communication: Family member name: ___\n ___ member relationship: Father\n ___ contact number: ___\n# Code: Full \n\nSURGICAL ICU COURSE:\n\nFollowing emergent beside exploratory-laparotomy, the patient \nwas transferred to the surgical ICU. His pressors were weaned. \nHis ventilatory status improved dramatically and his paralysis \nwas stopped. His creatinine continued to rise and renal was \nconsulted. The patient was started on CVVH. Overnight on POD1, \nthe patient was brought back to the OR for wash-out and Abthera \nVAC placement.\n\n___ - taken to MRCP where he was found to have large amount of \nedema of duodenum with major and minor papillae visualized but \nunable to access, suspect severe pancreatitis. There was \nhypoxemic, unable to oxygenate well, requiring paralysis. \n ___ - Difficulty ventilating PEEP to 20; PIPs in ___ \n Surgery evaluated and suspected abdominal compartment syndrome, \nperformed bedside xlap. Respiratory status better. Transferred \nto SICU. Cr rising, UOP declined despite 4L additional IVF \nboluses. Renal team found muddy brown casts and elongated casts \nin urine suggestive of acute on chronic renal failure. R IJ \ndialysis line placed, CVVH started. Continuing vanc/zosyn for \nnecrotizing pancreatitis. \n ___: high CVVH pressures o/n improved w/ catheter adjustment, \nlipemic blood samples in AM, attempted to wean propofol with \nprecedex, agitation problems, dilaudid/ketamine started, peep \nweaned \n ___: to OR, ___ placed, ABThera placed, higher PIPs in AM, \nLUE PICC placed \n ___: Ketamine d/c'd due to hallucinations. Eye drops started, \nTFs being advanced. New rash on b/l legs. D/c'd dilaudid gtt due \nto respiratory depression, transitioned to bolus dosing. Started \ndexmedatomidine. \n ___: OR for ___ patch with ACS, on spont vent during the \nday on prop only, tachypneic in ___, added low dose fent and \nincreased prop, pan cx, foley out, started vanc/zosyn for \nuptrending WBC and low grade fever, restart TF post-op, ABG with \ndecreased pH, placed back on rate \n ___: decreased TF to 75 mL/h from 105 mL/h given VCO2 in 440s \nand concern for overfeeding; CTA pancreas and chest showed \nnecrotizing pancreatitis, non-occlusive SMV thrombus, no PE, and \nbibasilar atelectasis; started heparin gtt for SMV thrombus; \nstopped CRRT with plan to start iHD tomorrow; started on \nPrecedex to limit propofol gtt; febrile to 103 despite Tylenol \no/n. \n ___: Min pressure support ___, 40% Fio2. OR today for \ntightening of Whitmann patch. Day 4 of phenobarb taper. \nPropofol@60, [email protected], fent@200, intermittent propofol \nboluses. Spiking fevers to 103 o/n, continued on vanc/zosyn for \nPNA vs infected pancreatitis. Hep gtt@ 1850. +14L for stay. \n ___: S/p ___ patch after 1 cm of reduction. Spiking fever \nof 103 early AM. WBC count 30 --> 50. Net even fluid balance. \nDCD vanc/zosyn, started meropenem/flagyl. Diflucan loading dose \ngiven, then DCD. BCx (including fungal Cx) & sputum Cx sent. TF \ndecreased 55->30; then stopped at 4PM. Soap suds enema given for \nno BM x4 days. Cdiff+. Miconazole powder switched to topical \ncream for groin. Dermatology c/s placed for all over body & \ngroin rashes: suggest these represent drug rash. CVVH restarted. \n \n ___: stopped fentanyl gtt and transitioned to dilaudid gtt, \nstarted vancomycin PO + PR. CT A/P negative for gas in the \npancreatic bed \n ___: to OR for ___ patch tightening by 1.5 inches, stopped \nmeropenem and now on PO vancomycin \n ___ Afebrile overnight, New acquired history of traumatic \ninjury from wooden board hitting him in the abdomen 5 days prior \nto hospitalization. Presentation suspicious for pancreatic \ntransection, MRCP and ERCP on hold, held and restarted hep gtt + \nCRRT, - 2 L off, ptt 62.8 -> 61.8, restarted on CMV after \nworsening academia, hypercarbia \n ___: Lactate 1.4 Hep gtt@3050. MRCP done. L IJ trialysis line \nplaced. CVVH restarted however DCD after 30 min due to machine \nclogging. In afternoon, HR 140s, SBP 75, MAP ___ Neo \nrestarted, IV ___ restarted. ___ negative for DVT. \nRUQ U/S negative for gallstones/CBD dil/distension. Hep gtt held \nfor 3 hrs during removal of R IJ CVL and before ACS (Dr. ___ \ncompleted bedside washout with minimal serosang fluid removed, \n___ patch closed 1.5cm with peak airway pressure 33. Hep \ngtt restarted @3050. \n ___: B/L UE ___ negative for major DVT. TTE EF 70%, normal \nglobal function. MRCP: patent pancreatic duct, necrosis at \ndistal tip of pancreas progressed from previous MRI. WBC 45.6. \nLactate 1.6. ETT replaced through bougie and video laryngoscope \ndue to pt. biting on pilot balloon. \n ___: WBC 46.6. Restarted tube feeds after MRCP showed patent \nduct. HD switched to CRRT for optimal diuresis, d/c'ed at 10pm \ndue to clotting of cartridge. L PICC removed after placement of \nR IJ triple lumen CVL. PTT supratherapeutic, heparin gtt \nheld/decreased. IV vanc dose held due to trough of 27. \n ___: Febrile to 102, repeat BCx sent, given IV Tylenol, started \ntube feeds, held for OR. To OR with ACS, fascia closed, vac in \nplace. Tachy to 150s immediately post-op, given HD, received 2.5 \nmg of metop and required neo during HD. Net 3 L off, weaned \npressors post HD. Switched from CMV to pressure support. Started \nlorazepam gtt for sedation with PRN dilaudid. \n ___: Started daily EKGs, QTc 490. WBC 20. Temp 101.3 @0700, \ncontinued w/ low grade temps, HR 140s, cultures resent. HD -3L. \nConsented for tracheostomy ___, TF held@ MN. Given Albumin 25% \n50cc. \n ___: Hep gtt held on call to OR. HD 3 L off. \n Taken to Or for open trach. No complications. Agitated on \narrival required 6mg of dilaudid. \n ___: Heparin drip restarted at 2100 ptt at 9AM,T max 102.5, \nfebrile twice over night. Tolerated trach collar well all day \nwith good ABGs, put back on CPAP ___ at night due to mild \nincreased respiratory effort. Pain and agitation well \ncontrolled. EKG after starting methadone showed QTc 436, down \nfrom 446. CRRT all day without issue, clotted and held at night. \nSevere agitation o/n with SBP 180s, given extra bolus of Ativan \nand drip increased to 3. \n ___: continue CRRT, restart Haldol PRN, QTC 396 on ECG, \ncontinue TF, continue hep gtt, wean Ativan to 2, transfuse 1 U \nPRBC for HCT 21, trach mask trial, acutely agitated in ___ \nrequiring stat haldol dilaudid and lorazepam, SC x 1, CRRT \nfilter clogged, kept off overnight into ___ per renal attending \n \n ___: Straight-cathed for ~100cc, UA/UCx sent. Trial on trach \nmask: tolerated for 4 hours then was placed on pressure support. \nBecame intermittently agitated in the evening and required \nSeroquel 50 x1, 8mg dilaudid and 1mg Ativan boluses in addition \nto increased rates of dilaudid gtt @4 and Ativan gtt @4. HD -3L. \nReceived 500cc 5% albumin for tachycardia to 150 with \nappropriate response. Given Benadryl 50mg for rash, some \nimprovement in pruritis. \n ___: Sedation improved on increased doses of diazepam, \nSeroquel. Started clonidine patch. Methadone increased (now 15 \nQ4H) with IV dilaudid prn. d/c'd Ativan. HD with 3.3 L off, \ntolerated well. Straight cath for urine 400ml. Tolerating trach \nmask >24 hours. DCed A line. Given 1 unit pRBC for Hct 20.3. QTc \n410, Seroquel QHS increased to 200. \n ___: Vac change ___. ___ evaluated/consented for tunneled HD \nline planned for ___. Tachy 150-160s sitting in chair, resolved \nin evening after being in bed. Slept >6 hours o/n, stable on \ncurrent regimen. \n ___ had tunneled HD line placed on the left, Speech and \nswallow evaluation for passy muir valve, failed ___ agitation \nand high tracheal pressures. HD removed 700cc today. Continued \non TFs. WBC down to 3. Continued tachycardia, improved with \ndilaudid. Father of pt expressing concerns over ice chips \n(allowed vs. not allowed) and WBC. \n ___: Blood and urine cx sent, due to leukopenia, c/f possible \noccult infection. Cannot downsize trach for 3 weeks per primary \nteam. 12pm valium dose held due to hypoventilation and elevated \npCO2 on venous gas, improved later in the day. Somnolent after \nOOB to chair and ___, so pm valium also held after discussion w/ \npharmacy. Daytime Seroquel discontinued due to concern for \nsleepiness and possible leukopenia, keeping nighttime dose. \n ___: ANC 124, placed on neutropenic precautions. Question of \nerythema around R IJ site (appears to be skin irritation); no \nfevers, WBC 3.1, felt by Dr. ___ to be the result of rxn to \nPO/PR vanco. Following discussion with ID service: IV flagyl \nDCD, PO/PR vanco DCD; placed on PO Flagyl 500 q8. HD negative \n2.5L. \n ___: d/c'd Aluminum hydroxide. Renal plans HD ___. d/c'd \nSeroquel. PIVs placed, d/c'd R IJ CVL. Flexiseal removed. \nBlanching erythema and slight induration noted around tunneled \nline. Paged ___ for evaluation. \n ___: failed PMV trial, continued hep gtt, pending CT ___ with \nHD to follow \n ___: failed PMV trial again, CT abd/pelvis with multiple \ncollections that are organizing; HD in the afternoon; vanc level \n<2.5; urine ordered to be sent tomorrow after straight cath for \nAIN work-up. \n ___: Methadone decreased to 10 q6h. Bowel regimen added due to \nsevere pain with BMs o/n. Slept all night without issue. Urine \nsmear negative for eosinophils.0\n___: Removed trach after dislodged overnight, WBC up to ___, \npassed speech/swallow, given diet,, UA/UCx, WBC up to 21 AM \n___, restarted PO metronidazole \n\nThe patient was then transferred to the floor and remained \nstable for the remainder of his hospital course, without \nabdominal pain. His white blood cell count downtrended prior to \ndischarge, and he remained afebrile. He started to tolerate a po \ndiet and his dobhof tube feeds were discontinued after adequate \npo intake. He completed a 10-day course of po flagyl for cdif \nand repeat c dif testing was negative. He continued to undergo \nwound vac changes for his midline wound and will go to rehab \nwith a wound vac in place. Prior to discharge, the patient \nstarted urinating and had improved renal function. Per \nnephrology, he no longer needed HD and his HD access was removed \nprior to discharge. \n \nMedications on Admission:\nnone\n \nDischarge Medications:\n1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild \n2. Artificial Tears ___ DROP BOTH EYES TID:PRN dry eyes \n3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation \n4. Clonidine Patch 0.2 mg/24 hr 1 PTCH TD QSUN \n5. Diazepam 5 mg PO BID \n6. DiphenhydrAMINE 25 mg PO QHS:PRN itching \n7. Docusate Sodium 100 mg PO BID:PRN constipation \n8. Famotidine 20 mg PO DAILY \n9. Lanthanum 500 mg PO TID W/MEALS \n10. Methadone 20 mg PO DAILY \nRX *methadone 10 mg 2 by mouth daily Disp #*60 Tablet Refills:*0 \n\n11. MetroNIDAZOLE 500 mg IV Q8H \nfinal day ___ \n12. Milk of Magnesia 30 mL PO Q6H:PRN constipation \n13. Ondansetron ___ mg PO Q8H:PRN nausea \n14. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ___ tablet(s) by mouth every 4 to 6 hours \nDisp #*40 Tablet Refills:*0 \n15. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n16. Sarna Lotion 1 Appl TP QID:PRN itch \n17. Senna 8.6 mg NG BID:PRN constipation \n18. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush \n \n19. ___ MD to order daily dose PO DAILY16 \n20. Warfarin 1 mg PO ONCE Duration: 1 Dose \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nNecrotizing pancreatitis secondary to trauma\nAcute kidney injury secondary to abdominal compartment syndrome\nClostridium difficile colitis\nNeutropenia\nMalnutrition \n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nYou were admitted to the acute care surgery service for \nmanagement of necrotizing pancreatitis secondary to trauma. This \nwas complicated by abdominal compartment syndrome, requiring \nbedside decompressive exploratory laparotomy on ___, \nhemodialysis for kidney failure, tube feeding for malnutrition, \nand tracheostomy. You are being discharged to rehab in stable \ncondition off tube feeds with your tracheostomy removed. Please \nfollow the below directions:\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.\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n \nFollowup Instructions:\n___\n" ]

[ "K859", "N170", "K550", "R579", "E46", "A047", "D709", "J9602", "J9601", "R7881", "M79A3", "G6181", "D62", "R442", "E872", "F10239", "S3991XA", "X58XXXA", "E669", "N189", "T41295A", "W228XXA", "Y929", "R451", "F419", "I10", "M21379", "E8351", "E8770", "Z6830", "B957", "Z781", "B356", "L271", "T360X5A", "E8339", "E8352", "D539" ]

[ "K859: Acute pancreatitis, unspecified", "N170: Acute kidney failure with tubular necrosis", "K550: Acute vascular disorders of intestine", "R579: Shock, unspecified", "E46: Unspecified protein-calorie malnutrition", "A047: Enterocolitis due to Clostridium difficile", "D709: Neutropenia, unspecified", "J9602: Acute respiratory failure with hypercapnia", "J9601: Acute respiratory failure with hypoxia", "R7881: Bacteremia", "M79A3: Nontraumatic compartment syndrome of abdomen", "G6181: Chronic inflammatory demyelinating polyneuritis", "D62: Acute posthemorrhagic anemia", "R442: Other hallucinations", "E872: Acidosis", "F10239: Alcohol dependence with withdrawal, unspecified", "S3991XA: Unspecified injury of abdomen, initial encounter", "X58XXXA: Exposure to other specified factors, initial encounter", "E669: Obesity, unspecified", "N189: Chronic kidney disease, unspecified", "T41295A: Adverse effect of other general anesthetics, initial encounter", "W228XXA: Striking against or struck by other objects, initial encounter", "Y929: Unspecified place or not applicable", "R451: Restlessness and agitation", "F419: Anxiety disorder, unspecified", "I10: Essential (primary) hypertension", "M21379: Foot drop, unspecified foot", "E8351: Hypocalcemia", "E8770: Fluid overload, unspecified", "Z6830: Body mass index [BMI]30.0-30.9, adult", "B957: Other staphylococcus as the cause of diseases classified elsewhere", "Z781: Physical restraint status", "B356: Tinea cruris", "L271: Localized skin eruption due to drugs and medicaments taken internally", "T360X5A: Adverse effect of penicillins, initial encounter", "E8339: Other disorders of phosphorus metabolism", "E8352: Hypercalcemia", "D539: Nutritional anemia, unspecified" ]

[ "J9601", "D62", "E872", "E669", "N189", "Y929", "F419", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nhydrochlorothiazide\n \nAttending: ___\n \nChief Complaint:\nBright red blood per rectum\n \nMajor Surgical or Invasive Procedure:\nColonoscopy w/ clip placement (___)\n\n \nHistory of Present Illness:\n___ gentleman w hx afib (CHADSVASC 5) on apixaban (dose-reduced \ns/p melena on last admission), HFpEF, discharged ___ ___ anemia and GI bleed, during which he had ___ w/ \npolypectomy, who presented with BRBPR. Per pt, started noticing \nmaroon stools again two days prior to presentation. Progressed \nto several bloody BMs for the two days prior to admission. \nReported this to his daughter, who brought him to ED. \n\nOn ROS, he denies any vomiting or hematemasis. Denies abd pain. \nDenies fever, cough, chest pain, DOE, SOB, orthopnea, dysuria. \nDoes feel lightheaded on standing though states this precedes \nthe blood in his stool. \n\nOf note, was admitted ___ after mechanical fall with a \nhead strike at the grocery store in the parking lot. He had a \nnondisplaced occipital fracture and was observed without need \nfor surgical intervention. In addition, he reported maroon \ncolored stool for several weeks and was found to be anemic. He \nwas evaluated by GI and underwent endoscopy (normal) and \ncolonoscopy, at which time an adenoma was removed. After these \nprocedures, the patient was hypotensive with SBP in the ___. An \nEKG was obtained which showed new ST depression and labs \nrevealed elevated troponin. He also experienced intermittent, \nasymptomatic bradycardic as low as the ___. Cardiology was \nconsulted and felt he was stable from a cardiac standpoint. His \nhome Carvedilol was held and his troponins were trended and \nremained stable. He was transfused 2 units of pRBCs. An echo \nwas also done demonstrating mild symmetric LVH with normal \ncavity size and systolic function. There was a mildly dilated RV \nmild aortic stenosis, mild mitral regurgitation, moderate \ntricuspid regurgitation, and severe pulmonary hypertension. His \ndose of apixaban was decreased from 5mg to 2.5mg after this \nadmission. \n\nIn the ED, initial vitals: T 97.5 HR 74 BP 112/50 RR 18 99% RA \n\n - Exam notable for: well appearing, slightly pale. abd + LLQ \ntenderness to palpation. rectal: grossly bloody, no active \nbleeding. scattered bruises from recent fall that resulted in \nmost recent admission\n\n - Labs notable for: \n - UA unremarkable, UCx pending\n - 140/94/59\n ----------< 110\n 3.4/29/1.8\n - INR 2.5 \n - 8.0/6.9\\188 \n\n - Imaging notable for: \nCTABP W CON \n1. Colonic diverticulosis without evidence of acute \ndiverticulitis. No bowel obstruction or bowel wall thickening.\n2. Cholelithiasis without acute cholecystitis.\n3. Enlarged prostate gland.\n4. Extensive arterial calcifications.\n\n - Consultants: GI ___ hx afib on eliquis, chf discharged ___ \n___ anemia and GI bleed, had ___ w/ polypectomy on \n___ for the polyp that was the source of bleeding. Now presents \ntoday with BRBPR, presumed post-polypectomy bleed. Rec'd: hold \napixaban if safe to do so, pRBC transfusion, trend hgb, prep \nwith moviprep rapid protocol for colonoscopy tomorrow. Ok for \nclears while prepping, NPO when prep completed. mIVF. Will see \nin AM.\n\n - Pt given: 1L NS \n - Vitals prior to transfer: T 98.0 HR 67 BP 130/52 RR 16 98% RA \n\n\nUpon arrival to the floor, the patient confirms the above HPI.\nDiscussed that he is usually primary caretaker for his wife,\n___, who has dementia. His daughter, ___, mentioned he\nprobably should have gone to rehab after last discharge but he\nwas resistant as he wanted to get home to his wife. Would like \nto\ndiscuss this w team during this admission. \n \nPast Medical History:\n-Atrial fibrillation on apixaban\n-CAD (angina, inferolateral nuclear perfusion defect on \nETT-MIBIs ___ and ___\n-Hyperlipidemia\n-Persistently elevated CK\n-Polymyalgia rheumatic - per chart, patient states he has \nrheumatoid arthritis, not PMR\n-___ esophagus\n-Lumbar spinal stenosis\n-Gout\n-Hearing loss\n-Diverticulosis\n-BPH\n\nPast Surgical History\n-Laminectomy L2-L5, facetectomy and foraminotomy with \narthrodesis -Screw instrumentation and allograft ___\n-I+D of wound from spine surgery ___\n-Right inguinal hernia repair ___\n-Appendectomy ___\n-Right inguinal hernia repair ___\n-Bilateral laparoscopic spigelian hernia repairs\n-Bilateral cataract surgery\n-Bilateral carpal tunnel surgery\n \nSocial History:\n___\nFamily History:\nFather with \"arteriosclerosis,\" both parents died ___ years.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n=======================\nVITALS: T 98.0PO BP 151/56 HR 60 RR18 97 Ra \nGENERAL: elderly gentleman, very talkative, NAD\nHEENT: sclera anicteric, MMM, OP clear\nCARDIAC: rrr, +SEM at RUSB, no rubs or gallops\nLUNGS: CTABL, nl WOB on RA\nABDOMEN: soft, tender to deep palp in RLQ, non-distended, bowel \nsounds present, no organomegaly, no rebound or guarding\nGU: No foley\nEXTREMITIES: warm, well perfused, no cyanosis or edema\nSKIN: warm, dry, very large (8cm x 14cm) bruise on L buttock \nextending down L thigh from prior fall, healing per pt\nNEURO: AOx3, CNII-XII intact, ___ strength upper/lower \nextremities, grossly normal sensation \n\nDISCHARGE PHYSICAL EXAM:\n=======================\nVITALS: Temp: 97.8 PO BP: 122/60 HR: 56 RR: 18 O2 sat: 97% O2 RA\nGENERAL: Elderly gentleman, pleasant, NAD\nHEENT: sclera anicteric, MMM, OP clear\nCARDIAC: Irregularly irregular with normal S1/S2. +SEM at RUSB,\nLUSB and LLSB, loudest at LLSB. No rubs or gallops. \nLUNGS: CTAB. nl WOB on RA\nABDOMEN: soft, non-tender, non-distended, bowel sounds present, \nno rebound or guarding. \nEXTREMITIES: warm, well perfused, no ___ edema or erythema \nSKIN: warm, dry, large bruise on L buttock extending down L \nthigh from prior fall, healing. \nNEURO: AOx3, Moves all extremities. \n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 02:14PM BLOOD WBC-8.0 RBC-2.49* Hgb-6.9* Hct-21.7* \nMCV-87 MCH-27.7 MCHC-31.8* RDW-17.7* RDWSD-55.2* Plt ___\n___ 02:14PM BLOOD Neuts-63.5 Lymphs-17.8* Monos-9.8 \nEos-7.2* Baso-0.9 Im ___ AbsNeut-5.06 AbsLymp-1.42 \nAbsMono-0.78 AbsEos-0.57* AbsBaso-0.07\n___ 02:14PM BLOOD Glucose-110* UreaN-59* Creat-1.8* Na-140 \nK-3.4* Cl-94* HCO3-29 AnGap-17\n\nPERTINENT LABS/MICRO:\n===================\n___ 02:14PM BLOOD Hgb-6.9* Hct-21.7* \n___ 06:20AM BLOOD Hgb-8.8* Hct-27.5* \n___ 01:13PM BLOOD Hgb-7.8* Hct-24.9* \n___ 11:16PM BLOOD Hgb-8.5* Hct-26.2* \n___ 01:00PM BLOOD Hgb-8.8* Hct-27.0* \n___ 04:40AM BLOOD Hgb-7.7* Hct-25.1*\n___ 09:00AM BLOOD Hgb-8.2* Hct-26.1* \n\nDISCHARGE LABS:\n==============\n___ 09:00AM BLOOD WBC-6.8 RBC-2.93* Hgb-8.2* Hct-26.1* \nMCV-89 MCH-28.0 MCHC-31.4* RDW-17.2* RDWSD-54.5* Plt ___\n___ 04:40AM BLOOD Glucose-131* UreaN-25* Creat-1.5* Na-138 \nK-4.0 Cl-100 HCO3-25 AnGap-13\n___ 04:40AM BLOOD Calcium-8.8 Phos-4.3 Mg-2.2\n\nPERTINENT IMAGING/PROCEDURES:\n===========================\n___ CT Abd/pelvis w/ Contrast:\n1. Colonic diverticulosis without evidence of acute \ndiverticulitis. No bowel obstruction or bowel wall thickening.\n2. Cholelithiasis without acute cholecystitis.\n3. Enlarged prostate gland.\n4. Extensive arterial calcifications.\n\n___ Colonoscopy:\n- Inverted diverticulum in the rectum \n- The site of the prior polypectomy was noted in the proximal \nascending colon. There was an overlying clot, indication recent \nbleeding. This was removed, with spontaneous bleeding \nencountered. A dark spot which was possibly a visible vessel \nversus eschar was noted but did not appear to be the source of \nbleeding. Epinephrine injection was successfully applied for \nhemostasis. Three endoclips were successfully applied to the \nproximal ascending colon polypectomy site for the purpose of \nhemostasis\n \nBrief Hospital Course:\nMr. ___ is a ___ year old man with afib on apixaban \n(dose-reduced s/p melena on last admission), HFpEF, and recent \nevaluation for fall, anemia and GI bleed for which colonoscopy \nshowed a polyp s/p polypectomy, who presented to ED with several \ndays of BRBPR. Repeat colonoscopy showed bleeding from the \npolypectomy site, treated with clip placement. Following the \nprocedure, the patient was monitored and remained \nhemodynamically stable with stable blood counts. \n\nACUTE ISSUES:\n=============\n# S/p polypectomy\n# BRBPR\n# Acute blood loss anemia \nThe patient was recently hospitalized for a mechanical fall, at \nwhich time he was noted to have anemia with concern for GI bleed \nin the setting of anticoagulation (apixaban). EGD was negative \nand colonoscopy showed a 4 cm polyp with stigmata of recent \nbleeding, treated with polypectomy. The patient re-presented \nthis hospitalization with several episodes of hematocheiza. Hgb \non admission was 6.9, down from 7.5-8.5 during last \nhospitalization. He was transfused a total of 2u pRBC during the \nhospitalization with a transfusion goal of >8 given prior signs \nof cardiac ischemia with lower threshold. A repeat colonoscopy \non ___ showed bleeding from the polypectomy site, which was \ntreated successfully with clipping. His Hgb remained stable for \n24 hours after the procedure and he remained asymptomatic. His \napixaban was held on admission and discharge with plan to \nrestart on ___ per GI recommendations. The patient should \nfollow up with his PCP for further management. Additionally, \niron studies consistent with iron deficiency anemia. Consider \niron supplementation as an outpatient. \n\n# ___ on CKD \nCr 1.9 on admission from a baseline of 1.1-1.3 (though difficult \nto determine given recent hospitalization). Felt to be \nhypovolemic due to bleeding and hypovolemia. He was given \nintravenous fluids and blood and his Cr improved to ~1.4-1.5 at \ndischarge. Of note, allopurinol was dose-reduced and colchicine \nwas held at discharge. He will need repeat BMP at his follow up \nappointment. \n\n# Afib on apixaban \nHx of atrial fibrillation, CHADSVASC of 5, on apixaban, which \nwas dose-reduced due to his recent lower GI bleed. This \nadmission, apixaban and carvedilol were held due to ongoing \nbleeding. Carvedilol was restarted prior to discharged and \ndecision was made to hold anticoagulation for ___ days following \nthe procedure. He should restart apixaban (low dose) on ___.\n\n# Hypertension \nHome carvedilol held initially due to bleeding and concern for \nHD instability. He remained hemodynamically stable and his home \ncarvedilol was restarted prior to discharge. \n\n# Lightheadedness\nPatient reported intermittent lightheadedness with standing, \nwhich has been occurring chronically for him as an outpatient. \nTamsulosin and diuresis were held initially. Orthostatic vital \nsigns were negative. Unclear etiology. Ultimately, he was \nrestarted on his home BPH and diuretic regimen. \n\nCHRONIC ISSUES:\n===============\n# HFpEF\nPresented on torsemide 100 mg and prn metolazone at home. Dry \nweight ~160 lbs. Diuretics initially held due to ongoing \nbleeding and then colonoscopy prep. He was restarted on \ntorsemide prior to discharge. Wt at discharge: 163.8 lb (prior \nto torsemide re-initiation). He should continue with current \nregimen. \n\n# CAD\nContinued home aspirin and statin. \n\n# Gout ppx\nDose-reduced home allopurinol and held colchicine due to ___. \nBoth medication changes remained at time of discharge. He will \nneed follow up for renal function monitoring and re-uptitration \nof these medications. \n\n# BPH\nHome finasteride and tamsulosin initially held. Restarted prior \nto discharge. \n\nTRANSITIONAL ISSUES:\n===================\n[] Discharge weight: 163.8 lb \n[] Apixaban held at discharge, should be restarted on ___ \n[] Repeat BMP and CBC at follow up appointment with PCP ___ - \nmonitor anemia and renal function specifically \n[] Likely needs transfusion goal of hemoglobin 8 given prior \ncardiac ischemia with lower levels \n[] Iron studies consistent with iron deficiency anemia, consider \niron transfusion as an outpatient\n[] Allopurinol dose reduced and colchicine held at discharge, \nconsider altering regimen based on renal function\n\nFull code, limited life sustaining measures (confirmed)\n___ (Daughter) \nPhone number: ___ \n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Colchicine 0.6 mg PO DAILY \n3. Finasteride 5 mg PO DAILY \n4. Omeprazole 20 mg PO DAILY \n5. Rosuvastatin Calcium 20 mg PO QPM \n6. Tamsulosin 0.8 mg PO DAILY \n7. Torsemide 100 mg PO DAILY \n8. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN itchy \nrash \n9. Aspirin 81 mg PO DAILY \n10. Carvedilol 3.125 mg PO BID \n11. Metolazone 2.5 mg PO DAILY:PRN weight >165lb \n12. Gabapentin 300 mg PO TID \n13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n14. Apixaban 2.5 mg PO BID \n15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n16. Potassium Chloride 20 mEq PO DAILY \n17. Acetaminophen 650 mg PO TID:PRN Pain - Mild \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO TID:PRN Pain - Mild \n2. Allopurinol ___ mg PO DAILY \nRX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0 \n3. Aspirin 81 mg PO DAILY \n4. Carvedilol 3.125 mg PO BID \n5. Finasteride 5 mg PO DAILY \n6. Gabapentin 300 mg PO TID \n7. Metolazone 2.5 mg PO DAILY:PRN weight >165lb \n8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \n9. Omeprazole 20 mg PO DAILY \n10. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First \nLine \n11. Potassium Chloride 20 mEq PO DAILY \n12. Rosuvastatin Calcium 20 mg PO QPM \n13. Tamsulosin 0.8 mg PO DAILY \n14. Torsemide 100 mg PO DAILY \n15. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID:PRN itchy \nrash \n16. HELD- Apixaban 2.5 mg PO BID This medication was held. Do \nnot restart Apixaban until ___\n17. HELD- Colchicine 0.6 mg PO DAILY This medication was held. \nDo not restart Colchicine until discuss with your primary care \nprovider\n\n \n___:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n#Primary:\nAcute lower GI bleed\nBleeding for polypectomy site\n\n#Secondary:\nAcute blood loss anemia\nAcute kidney injury\nChronic kidney disease\nAtrial fibrillation\nHypertension\nHeart failure w/ preserved EF\nCoronary artery disease\nLightheadedness\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 ___ \n___! \n\nWhy you were admitted to the hospital:\n- You were having bloody bowel movements.\n\nWhat happened while you were here:\n- A repeat colonoscopy (camera examining the large colon) showed \nbleeding from the site where the polyp had been removed. \n- The site was clipped (closed) and the bleeding stopped.\n- You were given a couple blood transfusions to support your \nblood counts during this time.\n\nWhat you should do once you return home:\n- You should follow up with your primary care provider (you have \nan appointment scheduled for ___.\n- Please do not start taking the apixaban until ___. We have \nadjusted some of the dosing in your medication to appropriately \nmatch your kidney function. Please note the changes below.\n- Weigh yourself every morning, call MD if weight goes up more \nthan 3 lbs\n\nSincerely, \nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "K91840", "I130", "I5032", "N179", "D62", "Y838", "Y92239", "I4891", "Z7901", "N189", "I2510", "K2270", "K219", "E785", "D509", "I959", "K5730", "M109", "E861", "M069", "I2720" ]

[ "K91840: Postprocedural hemorrhage of a digestive system organ or structure following a digestive system procedure", "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", "N179: Acute kidney failure, unspecified", "D62: Acute posthemorrhagic anemia", "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", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "I4891: Unspecified atrial fibrillation", "Z7901: Long term (current) use of anticoagulants", "N189: Chronic kidney disease, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "K2270: Barrett's esophagus without dysplasia", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "D509: Iron deficiency anemia, unspecified", "I959: Hypotension, unspecified", "K5730: Diverticulosis of large intestine without perforation or abscess without bleeding", "M109: Gout, unspecified", "E861: Hypovolemia", "M069: Rheumatoid arthritis, unspecified", "I2720: Pulmonary hypertension, unspecified" ]

[ "I130", "I5032", "N179", "D62", "I4891", "Z7901", "N189", "I2510", "K219", "E785", "D509", "M109" ]

[]

[ " \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:\nFall\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ year old female who was found down this morning. She is with \nher daughter. The patient does not remember the fall but knows \nthat she fell. She was found down this morning around 11AM by \nher daughter, last seen the previous night around 9PM. Reports \npain \"everywhere,\" not localizing to any one area. Went to ___ \n___ then transferred here after a pan-scan. No symptoms \nother than pain. \n\n \nPast Medical History:\nPMHx: COPD, neuropathy, NSTEMI, dCHF, anemia, gout, stage III\nkidney disease\n\nPSHx: tonsillectomy\n \nSocial History:\n___\nFamily History:\nNon-contributory \n \nPhysical Exam:\nAdmission Physical Exam:\nVS: 98.2, 97, 95/59, 15, 100% 3L NC \nGen: NAD, thin woman\nNeuro: GCS 15, CN intact\nHEENT: scalp lac that is stapled \nCV: RRR\nPulm: CTA b/l\nAbd: soft, nondistended, nontender\nPelvis: stable\nExt: b/l lower legs with chronic venous stasis changes, \notherwise\nno lesions, bruises, or abrasions to upper or lower extremities\nBack: no lesions, no tenderness to the spine, no stepoffs\n\nDischarge Physical Exam:\nVS: T: 97.8 PO BP: 109/65 HR: 105 RR: 20 O2: 91% 3L \nGEN: A+Ox3, NAD\nHEENT: Left scalp laceration with staples OTA, wound \napproximated, no s/s infection\nCV: Sinus tachycardia\nPULM: CTA b/l\nABD: soft, non-distended, non-tender to palpation\nEXT: trace edema b/l ___, no induration or erythema. b/l chronic \nvenous stasis changes\n\n \nPertinent Results:\nIMAGING:\n\nOSH imaging, reviewed with radiology here, reads from OSH below\n\nNCHCT: No acute abnormality\n\nCT C spine: No evidence of acute cervical spine fracture\n\nCT chest: Multiple left rib fractures (left lateral fourth rib,\nleft posterolateral eighth and ninth ribs). Severe chronic\nemphysematous changes.\n\nCT A/P: No evidence of solid organ or visceral injury. Multiple\npelvic fractures b/l. Fractures include bilateral pubic rami,\nleft acetabulum, and left sacrum. (On re-read here, also likely\nchronic L2 compression fracture.)\n\n___: CXR:\nNo focal consolidation.\n\n___: ECHO:\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 are normal. Due \nto suboptimal technical quality, a focal wall motion abnormality \ncannot be fully excluded. Left ventricular systolic function is \nhyperdynamic (EF = 80%). Tissue Doppler imaging suggests a \nnormal left ventricular filling pressure (PCWP<12mmHg). There is \nno left ventricular outflow obstruction at rest or with \nValsalva. There is no ventricular septal defect. with normal \nfree wall contractility. There is abnormal septal \nmotion/position consistent with right ventricular \npressure/volume overload. 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 appears \nstructurally normal with trivial mitral regurgitation. There is \nmoderate pulmonary artery systolic hypertension. There is no \npericardial effusion. There is an anterior space which most \nlikely represents a prominent fat pad. \n\n___: PELVIS W/JUDET VIEWS (3V):\nKnown bilateral inferior pubic rami and right superior pubic \nramus fractures again demonstrated. Known L2 fracture not well \nseen on current radiograph. No evidence of additional \nfractures. \n\n___: FOOT AP,LAT & OBL LEFT:\nHammertoe configuration of the digits. No acute fracture or \ndislocation.\n\n___: CTA Chest:\nNo evidence of pulmonary embolism or aortic abnormality. \n \nMultiple acute left-sided rib fractures. \n \nSevere emphysematous changes throughout the lungs. \n \nSmall bilateral pleural effusions, which have mildly increased \nsince the \nprevious study. \n\n___: CXR:\nLungs are hyperexpanded with stable bilateral pleural effusions \nand bibasilar atelectasis. Mild pulmonary vascular congestion \nis unchanged. There is biapical pleural thickening. No \npneumothorax is seen \n\nLABS:\n\n___ 06:51PM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 06:51PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-NEG\n___ 06:51PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE \nEPI-1\n___ 06:51PM URINE HYALINE-8*\n___ 06:51PM URINE MUCOUS-RARE*\n___ 05:29PM K+-3.9\n___ 05:25PM GLUCOSE-118* UREA N-17 CREAT-1.0 SODIUM-137 \nPOTASSIUM-5.8* CHLORIDE-95* TOTAL CO2-29 ANION GAP-13\n___ 05:25PM CK(CPK)-900*\n___ 05:25PM CALCIUM-8.6 PHOSPHATE-4.2 MAGNESIUM-1.8\n___ 05:25PM WBC-14.3* RBC-4.85 HGB-10.7* HCT-34.7 MCV-72* \nMCH-22.1* MCHC-30.8* RDW-17.2* RDWSD-42.3\n___ 05:25PM NEUTS-84.6* LYMPHS-8.9* MONOS-5.1 EOS-0.6* \nBASOS-0.2 IM ___ AbsNeut-12.12* AbsLymp-1.27 AbsMono-0.73 \nAbsEos-0.08 AbsBaso-0.03\n___ 05:25PM PLT COUNT-233\n___ 05:25PM ___ PTT-26.1 ___\n\nMICROBIOLOGY:\n___ 6:51 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH.\n \nBrief Hospital Course:\nMrs ___ is a ___ y/o F w/ PMH COPD, NSTEMI, CHF, ___ \ntransferred from OSH after fall at home on ___. She was \nfound to have 3 left-sided rib fractures (Ribs 4,8,9), bilateral \npubic rami fractures, a left acetabular fracture, left sacral \nfracture and a scalp laceration. The patient was admitted to \nthe Trauma Surgery service where she received pain medication \nand pulmonary toileting. The Orthopedic Surgery service was \nconsulted for the patient's pubic rami, acetabular and sacral \nfractures and recommended non-operative management and she could \nbe WBAT BLE. \n\nThe patient was transferred to the ___ on ___ for hypoxia \non floor associated with tachycardia. A chest x-ray was done \nwhich showed: minimal new bilateral pleural effusions. Otherwise \nunchanged radiograph, signs of mild to moderate interstitial \npulmonary edema. Borderline size of the heart. No evidence of \npneumonia. No pneumothorax. An EKG was done which showed sinus \ntach with a few runs of atrial fibrillation. The patient \nreceived 20mg IV Lasix and was transferred to the ICU.\n\nOn Arrival to ___ she was tachycardic but 99% on 6L NRB. she \nrequired no sedation her pain was controlled with Morphine ___ \nIV Q4H PRN, Oxyocodone ___ PO Q4H PRN, Acetaminophen 650 mg \nPO: PRN and Lidocaine Patch QAM. A trial of IVF bolus showed no \nimprovement in tachycardia. TTE was performed for possible \nsyncopal episode showing EF 80% and fluid overload. The patient \nhad a CT PE for hypoxia/tachycardia without evidence of PE. \nHer O2 req was improved with IV Lasix but she remained \npersistently tachycardic. the patient was given IV metoprolol \nwhich resulted in improvement of her HR but decrease in her BP \nwhich necessitate fluid boluses. O2 was weaned and the patient \nremained stable on ___ NC. The Pulmonary service was consulted \nfor help with ongoing management of her COPD. Pulmonary \nrecommended her O2 goal should be between 88%-92% and \nrecommended that the patient follow-up in the outpatient \nPulmonary clinic for pulmonary function testing and further \nmanagement.\n\nThe patient's pain was well controlled and she resumed her \nregular diet without any issues. she was transferred back to \nthe floor to continue her recovery.\n\nThe patient worked with Physical Therapy and it was recommended \nthat she be discharged to rehab to continue her recovery. At the \ntime of discharge, the patient was doing well, afebrile with \nstable vital signs. The patient was tolerating a regular diet, \nambulating with the rolling walker with assist, voiding without \nassistance, and pain was well controlled. The patient was \ndischarged home without services. The patient received discharge \nteaching and follow-up instructions with understanding \nverbalized and agreement with the discharge plan.\n\n \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Furosemide 40 mg PO DAILY \n2. Gabapentin 300 mg PO BID \n3. Allopurinol ___ mg PO DAILY \n4. Tiotropium Bromide Dose is Unknown IH DAILY \n5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Aquaphor Ointment 1 Appl TP TID:PRN legs \n3. Docusate Sodium 100 mg PO BID \nplease hold for loose stool \n4. Heparin 5000 UNIT SC BID \n5. Ipratropium-Albuterol Neb 1 NEB NEB Q4H \n6. Lidocaine 5% Patch 1 PTCH TD QAM \n7. Metoprolol Tartrate 6.25 mg PO BID \nHold for SBP<100, HR<60 \n8. Nystatin Cream 1 Appl TP BID to groin as needed \n9. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nWean as tolerated. Patient may request partial fill. \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*30 Tablet Refills:*0 \n10. Sarna Lotion 1 Appl TP BID:PRN to psoriatic patches \n11. Senna 17.2 mg PO HS \nHold for loose stool \n12. Tiotropium Bromide 2 puffs IH DAILY \n13. Allopurinol ___ mg PO DAILY \n14. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n15. Furosemide 40 mg PO DAILY \n16. Gabapentin 300 mg PO BID \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\n-Scalp laceration\n-Left 4,8,9th rib fractures\n-Bilateral pubic rami fractures\n-Left acetabular fracture\n-Left sacral 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:\nDear Ms. ___,\n\nYou were admitted to ___ after \na fall. You were found to have a scalp laceration, left-sided \nrib fractures and pelvic fractures. You were admitted to the \nTrauma service for pain control and to monitor your breathing. \nThe Orthopedic Surgery service evaluated your pelvic fractures \nand these did not require surgery. You may bear weight as \ntolerated on both legs. \n\nDuring your hospitalization, you had difficulty breathing and \nyour heart rate was elevated. You were transferred to the \ntrauma intensive care unit to treat you and monitor you more \nclosely. After remaining stable, you were transferred back to \nthe surgical floor. The Pulmonary service was consulted for your \nknown diagnosis of chronic obstructive pulmonary disease (COPD) \nand they recommended you follow-up in the outpatient Pulmonary \nclinic for pulmonary function testing. \n\nYou worked with Physical Therapy and it is recommended that you \nbe discharged to rehab to continue your recovery. You are now \nready to be discharged from the hospital. Please note the \nfollowing discharge instructions:\n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n\nRib Fractures:\n\n* Your injury caused left-sided rib fractures which can cause \nsevere pain and subsequently cause you to take shallow breaths \nbecause of the pain.\n \n* You should take your pain medication as directed to stay ahead \nof the pain otherwise you won't be able to take deep breaths. If \nthe pain medication is too sedating take half the dose and \nnotify your physician.\n \n* Pneumonia is a complication of rib fractures. In order to \ndecrease your risk you must use your incentive spirometer 4 \ntimes every hour while awake. This will help expand the small \nairways in your lungs and assist in coughing up secretions that \npool in the lungs.\n \n* You will be more comfortable if you use a cough pillow to hold \nagainst your chest and guard your rib cage while coughing and \ndeep breathing.\n \n* Symptomatic relief with ice packs or heating pads for short \nperiods may ease the pain.\n \n* Narcotic pain medication can cause constipation therefore you \nshould take a stool softener twice daily and increase your fluid \nand fiber intake if possible.\n \n* Do NOT smoke\n \n* If your doctor allows, non-steroidal ___ drugs \nare very effective in controlling pain ( ie, Ibuprofen, Motrin, \nAdvil, Aleve, Naprosyn) but they have their own set of side \neffects so make sure your doctor approves.\n \n* Return to the Emergency Room right away for any acute \nshortness of breath, increased pain or crackling sensation \naround your ribs (crepitus).\n\nGeneral Discharge Instructions:\n\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.\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n \n \nFollowup Instructions:\n___\n" ]

[ "S3210XA", "S32402A", "S2242XA", "J9691", "G629", "I5032", "S32592A", "S32591A", "S0101XA", "W19XXXA", "Y92090", "I252", "N183", "I878", "T40605A", "Y92239", "D649", "Z9981", "J439" ]

[ "S3210XA: Unspecified fracture of sacrum, initial encounter for closed fracture", "S32402A: Unspecified fracture of left acetabulum, initial encounter for closed fracture", "S2242XA: Multiple fractures of ribs, left side, initial encounter for closed fracture", "J9691: Respiratory failure, unspecified with hypoxia", "G629: Polyneuropathy, unspecified", "I5032: Chronic diastolic (congestive) heart failure", "S32592A: Other specified fracture of left pubis, initial encounter for closed fracture", "S32591A: Other specified fracture of right pubis, initial encounter for closed fracture", "S0101XA: Laceration without foreign body of scalp, initial encounter", "W19XXXA: Unspecified fall, initial encounter", "Y92090: Kitchen in other non-institutional residence as the place of occurrence of the external cause", "I252: Old myocardial infarction", "N183: Chronic kidney disease, stage 3 (moderate)", "I878: Other specified disorders of veins", "T40605A: Adverse effect of unspecified narcotics, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "D649: Anemia, unspecified", "Z9981: Dependence on supplemental oxygen", "J439: Emphysema, unspecified" ]

[ "I5032", "I252", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Hydralazine\n \nAttending: ___.\n \nChief Complaint:\nDyspnea, wt gain, bradycardia\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMr. ___ is a ___ year old pt of Dr. ___ with h/o\ncirrhosis from HCV (s/p DDLT ___, pneumonia, AF on Eliquis,\nHFpEF (LVEF 78%, ___, CKD, TIIDM, hepatocellular carcinoma,\nhepatoma, and CAD (nonobstructive cath ___ being transferred\nfrom ___ for persistent bradycardia in the ___.\n\nMr. ___ reports that for the past 3 weeks he has had \nworsening\ndyspnea on exertion. He was recently on vacation to ___ for two weeks and was eating out ___ a week. He thinks\nhe has gained at least 10 pounds over this time frame, up to\naround 244, but did not have a scale during his vacation. He\nreturned from his trip on ___ and felt he could barely walk\na few steps before becoming short of breath, when normally he\ncould walk around his house fairly comfortably. \n\nOn ___ he felt weak, dizzy and then vomited and had fecal\nincontinence. He developed chills and then fevers. He felt\nacutely short of breath even at rest and called ___ when he was\ntransferred to ___. Transferred to the ICU because\nof slow afib/flutter with - rate in ___, however did receive\nCarvedilol 25mg at 2am. Hr persistently 33 all day. Has had\nseveral episodes down to 28 ___P stable @ Bp 134/43 and \nhe\nis asymptomatic. NO pacing wire in place. He was initially\ntreated with BIPAP but has been on O2 2lnc.\n\nLabs from OSH:\nNa 133, K 3.5, Creat 2.97\nWbc 9, plt 165, Hb 9.5, hct 29.9\nTrop 0.05\nBnp 7295\nInitial Lactate yesterday ___ was ___, down to 1.32 @ 158 \nam\n___. \n\nVitals on transfer: Temp 98.3, hr 32, 131/49, map 70, 93% 2___ \nWt : 112 KG \n\nUpon meeting the patient on the floor, he reports feeling\nterrible due to intense rigoring and feeling freezing cold. \n \nPast Medical History:\nHepatitis C c/b ___ s/p liver transplant in ___\n___ \nnon-obstructive CAD\nT2DM \nHTN\nHLD\nCKD stage III\nL carotid artery stenosis (60%)\n \nSocial History:\n___\nFamily History:\nMother - died at age ___ of Alzheimer's disease\nFather - died at age ___ of CAD s/p CABG\nNo family history of liver disease\n \nPhysical Exam:\nAdmission Physical exam\n====================== \n24 HR Data (last updated ___ @ ___)\n Temp: 99.0 (Tm 99.0), BP: 139/63 (133-139/63-65), HR: 50\n(42-50), RR: 18 (___), O2 sat: 94% (90-94), O2 delivery: 5l \nGENERAL: Rigoring, uncomfortable appearing \nHEENT: Pupils equal and reactive, nasal cannula in place, moist\nmucous membranes\nNECK: JVP 14-16cm\nCARDIAC: S1/S2 slow, irregular, no obvious murmurs, brisk \ncarotid\nupstrokes\nLUNGS: Rales ___ up lung fields, scattered rhonchi, no use of\naccessory muscles \nABDOMEN: Soft, mildly distended, non-tender to plapation. \nVentral\nhernia. Large ___ scar on abdomen. \nEXTREMITIES: Warm, at ___ pitting edema to mid shins. \nPULSES: Distal pulses palpable and symmetric. \n\nDISCHARGE PHYSICAL EXAM:\n========================\n24 HR Data (last updated ___ @ 735)\n Temp: 98.0 (Tm 98.0), BP: 114/73 (80-138/38-73), HR: 62\n(57-70), RR: 20 (___), O2 sat: 96% (96-100), O2 delivery: RA,\nWt: 232.14 lb/105.3 kg \nFluid Balance (last updated ___ @ 816) \n  Last 8 hours Total cumulative -820ml\n    IN: Total 780ml, PO Amt 780ml\n    OUT: Total 1600ml, Urine Amt 650ml, True urine 950ml\n  Last 24 hours Total cumulative -1190ml\n    IN: Total 2210ml, PO Amt 2210ml\n    OUT: Total 3400ml, Urine Amt 650ml, True urine 2750ml \n\nGENERAL: NAD \nHEENT: Pupils equal and reactive, moist mucous membranes\nNECK: No JVD\nCARDIAC: S1/S2 slow, irregular, no obvious murmurs, brisk \ncarotid\nupstrokes\nLUNGS: Faint crackles in left base\nABDOMEN: Soft, mildly distended, non-tender to plapation. \nVentral\nhernia. Large ___ scar on abdomen. \nEXTREMITIES: Warm, trace edema. Charcot food deformity \nPULSES: Distal pulses palpable and symmetric. \n \nPertinent Results:\nAdmission labs\n===============\n\n___ 07:20PM ___ PTT-40.2* ___\n___ 07:20PM PLT COUNT-182\n___ 07:20PM NEUTS-78.7* LYMPHS-9.7* MONOS-8.0 EOS-2.4 \nBASOS-0.3 IM ___ AbsNeut-8.16* AbsLymp-1.00* AbsMono-0.83* \nAbsEos-0.25 AbsBaso-0.03\n___ 07:20PM WBC-10.4* RBC-3.95* HGB-10.1* HCT-31.9* \nMCV-81* MCH-25.6* MCHC-31.7* RDW-17.4* RDWSD-50.1*\n___ 07:20PM ALBUMIN-3.8 CALCIUM-9.4 PHOSPHATE-5.0* \nMAGNESIUM-2.3\n___ 07:20PM ALT(SGPT)-13 AST(SGOT)-20 LD(LDH)-291* ALK \nPHOS-111 TOT BILI-1.2\n___ 08:01PM LACTATE-1.6\n___ 08:15PM URINE MUCOUS-RARE*\n___ 08:15PM URINE HYALINE-57*\n___ 08:15PM URINE RBC->182* WBC-14* BACTERIA-FEW* \nYEAST-NONE EPI-<1\n___ 08:15PM URINE COLOR-Yellow APPEAR-Hazy* SP ___\n___ 08:15PM URINE COLOR-Yellow APPEAR-Hazy* SP ___\n___ 08:15PM URINE COLOR-Yellow APPEAR-Hazy* SP ___\n\nDischarge labs\n==============\n___ 08:14AM BLOOD WBC-10.3* RBC-3.49* Hgb-8.8* Hct-28.3* \nMCV-81* MCH-25.2* MCHC-31.1* RDW-17.7* RDWSD-51.7* Plt ___\n___ 08:14AM BLOOD Plt ___\n___ 08:14AM BLOOD Glucose-210* UreaN-101* Creat-3.0* \nNa-133* K-4.1 Cl-91* HCO3-23 AnGap-19*\n___ 08:14AM BLOOD Calcium-9.5 Phos-5.5* Mg-2.8*\n\nImaging\n=======\nTTE ___\nIMPRESSION: Bicuspid aortic valve with fusion of the right and \nleft commissures ___ 1A) with\nmild aortic stenosis and trace aortic regurgitation. Moderate \nsymmetric left ventricular\nhypertrophy with normal cavity size and regional/global systolic \nfunction. Mild right ventricular\ncavity dilation with normal systolic function. Mild ___ \nregurgitation. Mild tricuspid regurgitation.\nMild pulmonary artery systolic hypertension.\nCompared with the prior TTE ___, the findings \n\n \nBrief Hospital Course:\nPatient is a ___ year old male with PMHx hepatocellular carcinoma \ns/p liver transplant ___ on Cyclosporine, pneumonia, AF on \nEliquis, HFpEF (LVEF 78%, ___, CKD, TIIDM, hepatoma, and \nCAD (nonobstructive cath ___ being transferred from ___ \nfor persistent bradycardia in the ___ and HFpEF exacerbation. \nHis carvedilol was stopped with improvement in heart rates to \nthe ___. He was aggressively diuresed with a Lasix gtt, and his \nvolume status/symptoms of SOB of improved. His course was \ncomplicated by a traumatic foley placement with hematura. He \ncontinued to pass large clots/blood so a foley was inserted and \nbladder irrigation initiated. The urine cleared up to a light \npink and he was able to be discharged home. Foley catheter was \nremoved and patient was voiding prior to discharge.\n\n====================\nTRANSITIONAL ISSUES: \n====================\n\nDISCHARGE WEIGHT: 105.3kg/232.14lb (dry weight likely ~234)\nDISCHARGE BUN/Cr: 101/3.0\nDISCHARGE DIURETIC: plan to restart Torsemide 120mg daily on \n___\n\nMEDICATION CHANGES: \n- STOPPED: Carvedilol 50mg BID\n- CHANGED: Apixaban 5mg to 2.5mg BID\n- HELD: Spironolactone, potassium chloride supplementation\n\nFor Cardiology:\n[] HF exacerbation in the setting of medication non compliance \nwith possible contribution from bradycardia. \n[] Bradycardic to 30. Stopped carvedilol with subsequent HRs \n50-60s. Small dose was tried but patient started to have skipped \nbeats, as such was permanently discontinued\n[] Spironolactone held given ___, consider restarting (baseline \ncreat ~2.5)\n[] Torsemide to be restarted on ___ repeat lytes on \n___\n\nFor Urology:\n[] Patient with traumatic foley placed at ___ for unclear \nreasons. Possibly to measure urine output in patient with \naltered mental status. Voiding trial here with continued \nbleeding and passage of large blood clots, necessitating a 3-way \nfoley with CBI. Foley discontinued on discharge. Still with \nblood on urine on discharge, but not retaining and only \noccasional small clot. Please follow-up symptoms\n[] Bladder ultrasound showed frondlike nodular soft tissue on \nthe posterior wall of the urinary bladder is concerning for \nurothelial neoplasm. Cystoscopy and urology consult is \nrecommended. Follow-up within 4 weeks of discharge.\n\nFor PCP:\n[] Presented with ___ - follow-up creatinine (baseline is ~2.5)\n[] Follow-up urinary bleeding/clots after traumatic cath\n[] Stopped carvedilol - follow-up blood pressures, heart rate, \npalpitations, lightheadedness.\n[] Admitted for heart failure exacerbation - follow-up weight, \nblood pressures and symptoms of SOB. Euvolemic at discharge.\n\n=============== \nACTIVE ISSUES: \n===============\n# HFpEF exacerbation\n# Volume overload\nEcho ___ showed EF >70%. Patient presented with weight gain \nof at least 10 pounds with a reported home weight around 244 and \na recent discharge weight of 234. He endorses dietary \nindiscretion after being on vacation for 2 weeks and eating out \n___ a week. Found to be clinically volume overloaded with \nelevated JVP, hypoxia, pulmonary edema, and lower extremity \nedema. Initally bolused 200 mg IV lasix with metolazone, \nhowever, due to lack of adequate UOP, was transitioned to Lasix \ndrip at 20mg/hr with good response. Patient's SOB and volume \nstatus improved and he was transitioned to his home torsemide \ndose, to be restarted on ___. For afterload reduction, we \nstopped carvedilol due to bradycardia and continued his home \nclonidine and prazosin. Spirolactone was added during \nhospitalization, but was held given ___ on discharge. The \npatient is not on an ___ because of creatinine. Decision to \nrestart spironolactone is deferred to outpatient cardiologist.\n\n# Bradycardia\n# Atrial Fibrillation\nCHADS-VASC of ___. \nPresented in slow AF. He was as low as high 20's at the outside \nhospital and mentating well. He was noted to be sensitive to \nbeta blockade during last hospitalization. Home carvedilol 50mg \nBID was held inpatient and his HRs improved to 40's to 60's. \nAblation of AF had been discussed with his electrophysiologist, \n___, but deferred as it was not entirely clear this \nwas contributing to his HF exacerbations. Could be discussed \nagain as outpatient. Tried very low dose carvedilol and patient \nbegan to have skipped beats so discontinued prior to discharge. \nWe decreased his home apixaban 5mg BID dose to 2.5mg BID given \nhis kidney function.\n\n# Community Acquired Pneumonia \nPatient presented with a vomiting, subjective fevers and chills, \nhypoxia and opacity on CXR. All concerning for CAP. OSH started \nhim on rocephin and Zithromax for possible PNA. He was rigoring \non presentation here concerning for severe infection, so abx \nwere broadened to Meropenem and Vancomycin, due to his \npresentation and immunosuppression. He improved quickly and was \ntransitioned back to levofloxicin to complete a 5 day course. \nLast day for antibiotics was ___.\n\n# ___ on CKD\nRecent Cr baseline has been around 1.9 to 2.5. Presented with \ncreatinine of 3.3. Likely cardiorenal given improvement with \ndiuresis, however in the days preceding discharge may also have \nbeen component of pre-renal injury in the setting of \nover-diuresis, given subsequent improvement with holding of \ndiuresis. Discharge Cr 3.0. Will need repeat set of electrolytes \non ___.\n\n#Hematuria\nPatient with traumatic foley at OSH. Voiding trial here with \ncontinued bleeding and passage of clots. Hemoglobin stable. \nUltrasound was obtained which showed large clot burden and \npossible frondlike nodular soft tissue concerning for urothelial \nneoplasm. Bladder was irrigated and large foley placed with \nremoval of several clots. Repeat ultrasound with stable mass. \nCBI for 24 hours with clearing of urine. Foley removed and \npatient discharged after passing voiding trial with red but not \nfrankly bloody urine, and only occasional small clots.\n\n=============== \nCHRONIC ISSUES: \n===============\n\n# Gout (left ankle)\nFollows with Dr. ___ [rheum] as an outpatient. Gave dosed \nreduce allopurinol given worsening renal function, but \ntransitioned back to home dose of 300mg daily on discharge.\n\n# HTN\nContinued clonidine and prazosin. Restarted amlodipine as BP \nimproved to systolics in 150's with discontinuation of \ncarvedilol as detailed above.\n\n# Type II DM\nReported taking about 60-80u lantus in AM and about 30u in ___. \nSometimes he does not using any standing Humalog or sliding \nscale. Dose reduced lantus due to likely diet modification and \nsome hypoglycemia during last admission. He was given Lantus 50 \nUnits AM, 30units ___ and slidding scale. Discharged on admission \ninsulin regimen, with strict instructions to call PCP if concern \nfor hypoglycemia.\n\n# HCC s/p liver transplant: LFTs unremarkable.\nContinued home cyclosporine (goal 50-75). Transplant hepatology \nwas consulted. Daily cyclosporine level was monitored.\n\n# OSH \nContinued BiPAP at night\n\n=========================================\n# CODE STATUS: Full\n# CONTACT: ___, wife, ___\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfurther investigation.\n1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever \n2. Albuterol Inhaler ___ PUFF IH TID:PRN coughing/wheezing \n3. Allopurinol ___ mg PO DAILY \n4. amLODIPine 10 mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. Atorvastatin 10 mg PO QPM \n7. Calcitriol 0.25 mcg PO EVERY OTHER DAY \n8. CARVedilol 50 mg PO BID \n9. CloNIDine 0.4 mg PO BID \n10. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H \n11. Multivitamins 1 TAB PO DAILY \n12. Prazosin 10 mg PO QHS \n13. Potassium Chloride 20 mEq PO BID \n14. Apixaban 5 mg PO BID \n15. Torsemide 120 mg PO DAILY \n16. Colchicine 0.6 mg PO EVERY OTHER DAY \n17. Glargine 80 Units Breakfast\nGlargine 50 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n\n \nDischarge Medications:\n1. Apixaban 2.5 mg PO BID \nRX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0 \n2. Glargine 80 Units Breakfast\nGlargine 50 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever \n4. Albuterol Inhaler ___ PUFF IH TID:PRN coughing/wheezing \n5. Allopurinol ___ mg PO DAILY \n6. amLODIPine 10 mg PO DAILY \n7. Aspirin 81 mg PO DAILY \n8. Atorvastatin 10 mg PO QPM \n9. Calcitriol 0.25 mcg PO EVERY OTHER DAY \n10. CloNIDine 0.4 mg PO BID \n11. Colchicine 0.6 mg PO EVERY OTHER DAY \n12. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H \n13. Multivitamins 1 TAB PO DAILY \n14. Prazosin 10 mg PO QHS \n15. Torsemide 120 mg PO DAILY \n16. HELD- Potassium Chloride 20 mEq PO BID This medication was \nheld. Do not restart Potassium Chloride until infromed by \ncardiology/your PCP\n\n \n___:\nHome With Service\n \nFacility:\n___.\n \nDischarge Diagnosis:\n==================\nPrimary diagnosis:\n==================\n\nHFpEF excerterbation\n\n====================\nSecondary diagnoses:\n====================\n\nPneumonia\nAtrial fibrillation with slow ventricular response\nHematuria \n___ on CKD\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? \nYou were feeling short of breath because you had fluid in your \nlungs. This was caused by a condition called heart failure, \nwhere your heart does not pump hard enough and fluid backs up \ninto your lungs. You also had a slow heart rate and fevers and \nchills concerning for an infection in your lungs (pneumonia). \n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL? \nYou were given medications to help get the fluid out. We treated \nyour lung infection with antibiotics. As we took off fluid your \nbreathing got better. Your hospitalization was also complicated \nby bleeding in your urine which improved with flushing with \nwater.\n\nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? \n- Take all of your medications as prescribed (listed below) \n- Please take Torsemide 120mg daily starting on ___\n- Follow up with your doctors as listed below \n- Weigh yourself every morning. Your weight on discharge is \n232lbs. Call your doctor if your weight goes up more than 3 \npounds \n- Call you doctor if you notice any of the \"danger signs\" listed \nbelow; in particular if you notice decreased urination, \nworsening severity of blood or clots in urine or worsening pain \nwhen urinating, please call urology at ___. \n \nIt was a pleasure taking care of you!\n \nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "I130", "I5033", "J189", "N179", "Z944", "N029", "N183", "E1122", "Z794", "I4891", "Z7902", "E785", "I6522", "I2510", "Z8505", "Z87891", "M109", "J449", "E1121", "N3289", "N4889" ]

[ "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", "J189: Pneumonia, unspecified organism", "N179: Acute kidney failure, unspecified", "Z944: Liver transplant status", "N029: Recurrent and persistent hematuria with unspecified morphologic changes", "N183: Chronic kidney disease, stage 3 (moderate)", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "Z794: Long term (current) use of insulin", "I4891: Unspecified atrial fibrillation", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "E785: Hyperlipidemia, unspecified", "I6522: Occlusion and stenosis of left carotid artery", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z8505: Personal history of malignant neoplasm of liver", "Z87891: Personal history of nicotine dependence", "M109: Gout, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "N3289: Other specified disorders of bladder", "N4889: Other specified disorders of penis" ]

[ "I130", "N179", "E1122", "Z794", "I4891", "Z7902", "E785", "I2510", "Z87891", "M109", "J449" ]

[]

[ " \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:\nBronchoscopy ___\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with a past medical history of\nR parieto-occipital IPH in ___ in the setting of PRES due to\nhypertension, CKD ___ membranous nephropathy w/ prior nephrotic\nrange proteinuria, and previous seizure disorder now off AEDs \nwho\npresents with confusion.\n\nPt was in normal state of health until 10 AM on ___. She noted\nfeeling off to her husband but did not explicitly complain of \nHA,\nshortness of breath or cough. She then said she was going to\ntake a shower and then proceeded to go upstairs. After a\nprolonged period her husband called out to see if she was done \nto\nwhich she replied \"yes\". He went to go see her and found her at\nthe top of the stairs, with a \"blank stare\" and her head turned\nto the L and her L arm outstretched. She was able to talk to him\nbut she was delayed in answering. After a few minutes she was\nable to turn hear head normally. He went to go get her blood\npressure cuff and noted that when he handed it to her she was\nconnecting it backwards and was staring off. Her husband called\nthe patient's sister who spoke to the patient on the phone and\nnoted her to be silent then would say \"im fine, im ok\" \"I need \nto\ncheck my blood pressure\" and then would stop speaking for a\nprolonged period. Due to this her sister and husband decided to\ncall EMS. \n\nEMS initially brought pt to ___ where she was noted to\nhave seizure-like activity, including rightward eye deviation,\nbilateral lower extremity convulsions, left arm extension. She\nreceived multiple doses of Ativan without resolution of the\nseizure. Ultimately she was intubated for airway protection. She\nwas transferred to ___ ED for further evaluation.\n\nIn the ED, \n- Initial Vitals: Temp 95.5 HR 96 BP 201/64 SaO2 100% on Vent\n- Exam: pupils reactive, patient not responsive to painful\nstimuli in any extremity. She was continued on propofol for\nsedation\n- Labs notable for Cr 2.1, K 4.7, Flu negative, WBC 13.8 \n- Imaging: \n1. CXR: Complete opacification of the left hemithorax without\ndeviation of the mediastinal structures.\n2. CT chest w/o contrast: Near complete collapse of the left\nlung. No central airway obstructing\nlesion is seen. This lung collapse may be related to distal\nairway mucoid\nimpaction.\n3. NCHCT w/ no acute intracranial process, stable\nencephalomalacia\n- Consults: Neurology: \n- Rec loading with Keppra, Agree with MICU admission given\nshortage of Neuro ICU beds and ongoing infection, renal issues;\nCVEEG to look for seizure activity , call neurology resident on\ncall once connected for preliminary read to decide if she needs\nadditional AEDs quickly;Continue keppra, renally dosed according\nto patient's GFR; consider further imaging for opacification of \nL\nhemithorax; Lower blood pressure slowly, avoid hypotension as\nthis puts patient at risk for watershed infarcts; Ativan 2mg if\nclinical seizure activity >3 minutes and call neurology; Will\nneed an MRI brain with and without contrast during admission \n- Interventions: IV Keppra, Propofol, midazolam, Cefepime,\nvancomycin, LR x 2 L. Right femoral central line was placed and\npt was started on cvEEG. \n\nOn arrival to the ICU, pt is intubated and sedated. History\ncorroborated with pt's husband. On arrival to the MICU noted to\nflex UEs towards core in rhythmic fashion. Broke with 2 mg IV\nMidazalam. \n\nROS: Unable to obtain in setting of mental state\n \nPast Medical History:\n- R parietal hemorrhage and PRES\n- CKD. ___ membranous nephropathy. Follows with Dr. ___ at\n___ \n- HTN\n- HLD\n- colonoscopy with tubular adenoma in ___\n- Mild MR\n- Aortic stenosis, moderate - TTE ___\n?bicuspid, normal aortic ___\n \nSocial History:\n___\nFamily History:\nFather had thoracic aortic aneurysm ___, afib\nMother passed away at age ___, unsure from what\nMaternal grandmother had MI\n \nPhysical Exam:\nADMIT PHYSICAL EXAM:\n=====================\nVS: Temp 98.5 HR 69 BP 125/56 SaO2 100% \nGEN: Obese woman intubated and sedated. On arrival to the MICU\nnoted to flex UEs towards core in rhythmic fashion. Broke with 2\nmg IV Midazalomam \nEYES: Pupils 1-2 mm, reactive\nHENNT: ETT/OG in place\nCV: NRRR, N S1 and S2, soft IV/VI blowing murmur heard best at\nthe apex\nRESP: Decreased breath sounds left lung diffusely\nGI: Soft, NtD, ND\nNEURO: Does not arouse to noxious stimulation. Does\nnot follow commands axial or appendicular. Does not regard or\ntrack examiner. Withdraws all extremities to noxious stimuli,\nalso moving\nspontaneously \n\nDISCHARGE PHYSICAL EXAM:\n========================\n24 HR Data (last updated ___ @ 805)\n Temp: 98.0 (Tm 98.5), BP: 157/90 (118-157/70-91), HR: 88\n(88-94), RR: 20 (___), O2 sat: 98% (95-100), O2 delivery: RA \n\nGEN: awake, alert, appears well and comfortable\nCV: RRR, normal s1/s2, systolic ejection murmur\nLUNGS: clear to auscultation bilaterally\nABD: soft, nontender, nondistended\nEXT: warm, well perfused, no swelling\nNEURO: A&Ox3\n\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 06:00PM BLOOD WBC-13.8* RBC-3.75* Hgb-11.1* Hct-36.3 \nMCV-97 MCH-29.6 MCHC-30.6* RDW-12.5 RDWSD-44.5 Plt ___\n___:11PM BLOOD Glucose-113* UreaN-49* Creat-2.1* Na-139 \nK-4.7 Cl-102 HCO3-18* AnGap-19*\n___ 04:11PM BLOOD ALT-27 AST-39 AlkPhos-68 TotBili-0.5\n___ 04:11PM BLOOD Lipase-21\n___ 04:44PM BLOOD Lipase-19\n___ 04:44PM BLOOD Albumin-4.3 Calcium-8.5 Phos-4.1 Mg-1.9\n___ 04:11PM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG\n___ 04:28PM BLOOD Type-ART pO2-92 pCO2-48* pH-7.29* \ncalTCO2-24 Base XS--3 Intubat-INTUBATED\n___ 04:51PM BLOOD Lactate-1.5\n\nPERTINENT INTERVAL LABS\n======================\n___ 05:45PM BLOOD Hapto-208*\n___ 03:49PM BLOOD Lactate-0.9\n\nMICROBIOLOGY\n=============\n___ 3:53 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary): \n BACILLUS SPECIES; NOT ANTHRACIS. \n Isolated from only one set in the previous five days. \n Aerobic Bottle Gram Stain (Final ___: \n Reported to and read back by ___. ___ ON ___ AT \n0010. \n GRAM POSITIVE ROD(S). \n\n___ 3:53 pm BLOOD CULTURE\n Blood Culture, Routine (Preliminary): \n STAPHYLOCOCCUS, COAGULASE NEGATIVE. \n Isolated from only one set in the previous five days. \n SENSITIVITIES PERFORMED ON REQUEST.. \n STAPHYLOCOCCUS, COAGULASE NEGATIVE. ___ MORPHOLOGY. \n Isolated from only one set in the previous five days. \n SENSITIVITIES PERFORMED ON REQUEST.. \n Aerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS. \n Reported to and read back by ___ (___) @12:43 \n(___). \n Anaerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE COCCI IN CLUSTERS. \n\nBlood Cultures - NGTD\n\nRADIOLOGY\n============\nCT Head w/o Contrast ___. No acute intracranial process. MRI would be more sensitive \nin the\ndetection of acute infarct.\n2. Stable encephalomalacia in the right parieto-occipital region\n\nMRI Head w/o Contrast ___. No acute infarct or intracranial hemorrhage.\n2. Old hemorrhagic infarcts involving the right occipital and \nparietal lobes.\n3. Mild-to-moderate sphenoid sinus disease.\n\nDISCHARGE LABS\n==============\n___ 05:20AM BLOOD Glucose-102* UreaN-28* Creat-1.8* Na-143 \nK-4.4 Cl-111* HCO3-23 AnGap-9*\n___ 05:20AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.___RIEF HOSPITAL SUMMARY\n======================\nMs. ___ is a ___ woman with a history of right \nparieto-occipital IPH in ___ in the setting of PRES due to \nhypertension, complicated by seizure disorder weaned off Keppra \nin ___ due to normal outpatient EEG, chronic kidney disease \nsecondary to membranous nephropathy, and hypertension who \npresented with encephalopathy concerning for seizure. She was \nintubated at ___ for airway protection and transferred \nto ___, admitted to the MICU from ___. Course complicated by \nleft lower lung collapse secondary to mucus plugging s/p \nbronchoscopy and hypotension requiring pressors. Neurology \nevaluated her, EEG showed no ongoing seizures or epileptiform \nactivity, and she was discharged on Keppra.\n\nTRANSITIONAL ISSUES\n===================\n[ ] Anemia with no evidence of prior workup. Patient would \nbenefit from iron studies and repeat CBC outpatient for further \nworkup.\n[ ] Patient prefers switching to once daily Keppra dosing \nbecause of somnolence.\n[ ] Patient told she should not drive a vehicle for at least 6 \nmonths, this should be further followed up by PCP\n\nMEDICATION CHANGES\n==================\n- started Keppra 500mg BID\n\nACTIVE ISSUES\n=============\n# ACUTE ENCEPHALOPATHY # SEIZURE DISORDER\nWitnessed seizure on arrival to MICU. Neurology consulted and \ndetermined seizures likely secondary to previous PRES. \nMeningitis considered and patient initially treated with \nceftriaxone, ampicillin, and acyclovir but given patient's rapid \nimprovement in mental status and low concern for infection these \nwere stopped and LP deferred. EEG showed no evidence of \nepileptiform activity. CTH on arrival showed no bleed. MRI \nshowed old area of hemorrhage but no acute changes. Neurology \nrecommended patient remain on Keppra for at least 3 months.\n\n# HYPOTENSION and previous history of # HYPERTENSION\nSBP initially 200s in ED, dropped to ___ in setting of sedation \nwith propofol requiring levophed briefly. She was weaned off \npressors after extubation. Initially concern for infection given \nblood cultures positive for coagulase negative staph (2 \nmorphologies) and bacillus, but per ID these are likely \ncontaminant. No further hypotensive episodes after called out \nfrom ICU. Restarted home torsemide and Lisinopril. \n\n# LEFT LUNG COLLAPSE s/p BRONCHOSCOPY\n# HYPOXEMIC RESPIRATORY FAILURE REQUIRING INTUBATION\nCXR showed whiteout of left hemithorax on presentation, resolved \nwith positive pressure and bronchoscopy. Low concern for \npulmonary infection, comfortable on room air after called out to \nfloor. \n\n# POSITIVE BLOOD CULTURES\nPositive blood cultures for coag negative staph (two \nmorphologies) and bacillus. Patient initially started on \nvancomycin but this was discontinued after discussion with \ninfectious disease, who felt that given her clinical course and \nthe potpourri of bacteria these cultures were likely \ncontaminant. She remained afebrile and hemodynamically stable \nwithout antibiotics.\n\nCHRONIC ISSUES\n==============\n# CHRONIC KIDNEY DISEASE\nAt baseline throughout admission.\n\n# ANEMIA\nStable throughout hospitalization.\n\n# MODERATE AORTIC STENOSIS, MILD MITRAL REGURGITATION\nMurmur noted on admission, not new per patient as she routinely \nundergoes TTE surveillance. Deferred repeat TTE given low \nconcern for bacteremia.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Cyanocobalamin 1000 mcg PO DAILY \n2. Calcitriol 0.5 mcg PO 3X/WEEK (___) \n3. Atorvastatin 80 mg PO QPM \n4. Lisinopril 5 mg PO DAILY \n5. Torsemide 40 mg PO DAILY \n6. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. LevETIRAcetam 500 mg PO BID \nRX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice \ndaily Disp #*47 Tablet Refills:*0 \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Calcitriol 0.5 mcg PO 3X/WEEK (___) \n5. Cyanocobalamin 1000 mcg PO DAILY \n6. Lisinopril 5 mg PO DAILY \n7. Torsemide 40 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES\n=================\nACUTE ENCEPHALOPATHY\nSEIZURE DISORDER\nBACETEREMIA\n\nSECONDARY DIAGNOSES\n===================\nANEMIA\nHYPOTENSION \nHYPERTENSION\nLEFT LUNG COLLAPSE\nCHRONIC KIDNEY DISEASE\nCORONARY ARTERY DISEASE\nHYPERTENSION\nAORTIC STENOSIS\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 our pleasure to care for you at ___. You were \ntransferred to our hospital because of seizure-like activity. \n\nWHAT HAPPENED IN THE HOSPITAL?\n- You were admitted to our ICU where you required medications to \nkeep your blood pressure up. We were able to take the breathing \ntube out of your mouth and control your seizures with \nmedications.\n- A portion of your lung was collapsed. You had a procedure \ncalled a bronchoscopy to remove a mucus plug from your lung. \n- Our neurology team evaluated you and did an EEG, which showed \nno evidence of ongoing seizures or epilepsy while taking the \nkeppra. You will need to keep taking keppra when you leave the \nhospital.\n- Our physical therapists worked with you.\n\nWHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?\n- Please take all of your prescribed medications\n- Please go to your doctors' appointments\n\nWe wish you the best!\n\nSincerely,\nYour care team at ___ \n \nFollowup Instructions:\n___\n" ]

[ "I69898", "J9601", "N184", "J9819", "E872", "T17890A", "N022", "G40909", "X58XXXA", "Y929", "D649", "D696", "I959", "I2510", "I080", "E669", "Z6834", "E785", "I10" ]

[ "I69898: Other sequelae of other cerebrovascular disease", "J9601: Acute respiratory failure with hypoxia", "N184: Chronic kidney disease, stage 4 (severe)", "J9819: Other pulmonary collapse", "E872: Acidosis", "T17890A: Other foreign object in other parts of respiratory tract causing asphyxiation, initial encounter", "N022: Recurrent and persistent hematuria with diffuse membranous glomerulonephritis", "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "X58XXXA: Exposure to other specified factors, initial encounter", "Y929: Unspecified place or not applicable", "D649: Anemia, unspecified", "D696: Thrombocytopenia, unspecified", "I959: Hypotension, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I080: Rheumatic disorders of both mitral and aortic valves", "E669: Obesity, unspecified", "Z6834: Body mass index [BMI] 34.0-34.9, adult", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension" ]

[ "J9601", "E872", "Y929", "D649", "D696", "I2510", "E669", "E785", "I10" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nLisinopril / Aspirin / IV Dye, Iodine Containing\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\n___: prior PPM removal & upgrade to CRT-P ___ \nPACEMAKER ___ QUAD CRTP MRI SURESCAN ___)\n___: thoracentesis\n___: pleurex catheter placement\n\nattach\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 01:40PM BLOOD WBC-8.0 RBC-5.03 Hgb-11.7* Hct-40.2 \nMCV-80* MCH-23.3* MCHC-29.1* RDW-23.1* RDWSD-64.0* Plt ___\n___ 01:40PM BLOOD Neuts-77.3* Lymphs-11.8* Monos-7.7 \nEos-1.9 Baso-0.9 Im ___ AbsNeut-6.15* AbsLymp-0.94* \nAbsMono-0.61 AbsEos-0.15 AbsBaso-0.07\n___ 01:40PM BLOOD Glucose-112* UreaN-24* Creat-1.2 Na-141 \nK-4.5 Cl-99 HCO3-27 AnGap-15\n___ 01:40PM BLOOD ALT-7 AST-19 LD(LDH)-246 AlkPhos-74 \nTotBili-0.2\n___ 01:40PM BLOOD CK-MB-2 cTropnT-0.02* proBNP-430\n___ 01:40PM BLOOD Albumin-3.7 Calcium-9.5 Phos-3.7 Mg-1.5*\n\nPERTINENT LABS:\n===============\n___ 09:36PM BLOOD CK-MB-2 cTropnT-0.02*\n___ 01:40PM BLOOD %HbA1c-6.6* eAG-143*\n___ 01:11PM BLOOD Lactate-2.1*\n___ 05:34PM BLOOD Lactate-1.6\n___ 07:30PM BLOOD Lactate-2.4*\n___ 11:58PM BLOOD Lactate-1.4\n___ 10:57AM BLOOD Lactate-2.4*\n___ 01:11PM BLOOD ___ pO2-189* pCO2-40 pH-7.62* \ncalTCO2-43* Base XS-18 Comment-GREEN TOP\n___ 05:34PM BLOOD pO2-113* pCO2-72* pH-7.39 calTCO2-45* \nBase XS-15 Comment-GREEN TOP\n___ 07:30PM BLOOD pO2-86 pCO2-70* pH-7.39 calTCO2-44* Base \nXS-13 Comment-GREEN TOP\n___ 11:58PM BLOOD ___ pO2-241* pCO2-68* pH-7.41 \ncalTCO2-45* Base XS-15\n___ 10:57AM BLOOD ___ pO2-75* pCO2-65* pH-7.43 \ncalTCO2-45* Base XS-15\n\nPLEURAL FLUID STUDIES:\n====================== \n___ 1:34 pm PLEURAL FLUID PLEURAL FLUID. \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, if \napplicable. \n\n FLUID CULTURE (Preliminary): NO GROWTH. \n\n ANAEROBIC CULTURE (Preliminary): NO GROWTH. \n___ 03:39PM URINE Color-Yellow Appear-Clear Sp ___\n___ 03:39PM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG\n\nPOSITIVE FOR MALIGNANT CELLS.\n- Metastatic lung adenocarcinoma.\n- Immunohistochemical stains show the following profile in tumor \ncells:\nPositive: TTF-1, Napsin-A\nNegative: NKX3.1\n\nIMAGING:\n========\nCXR, ___:\nStable moderate cardiomegaly with associated mildly worsened \npulmonary edema, now moderate to severe. \n \nCXR, ___:\n___ CRT upgrade. No pneumothorax. 1 lead projects over \nthe right \natrium, 1 over the right ventricle and a third 1 over the \ncoronary sinus. \nStable low lung volumes with moderate cardiomegaly. Mild \npulmonary edema and a moderate right pleural effusion. No \npneumothorax. \n\nCXR, ___:\nIMPRESSION: \nIncreased volume of the right pleural effusion. \nMild improvement of the pulmonary edema component.\n\nCXR, ___:\nCompared to chest radiographs since ___ most recently \n___. \n \nLarge left pneumothorax is new. Left pleural effusion is small. \n Transvenous \natrial biventricular pacer leads are in standard placements. \n \nLarge right pleural effusion and severe middle and lower lobe \natelectasis are \nunchanged. Pulmonary edema in the right upper lobe is \nexaggerated by the \ncompromise of ventilation in the remainder of both lungs. \n \nCardiomediastinal silhouette is probably still moderately \nenlarged. \n\nCXR, ___:\nLungs are low volume with stable moderate right pleural effusion \nstable small left pleural effusion. A left-sided pigtail \ncatheter has been placed in the interim. The left pneumothorax \nhas resolved. Left-sided pacemaker is unchanged. \nCardiomediastinal silhouette is stable. \n\nCXR, ___:\nResolution of left-sided pneumothorax. \n\nCXR, ___: \nNo significant change in right mid lung airspace opacity. No \npneumothorax.\n\nCT Head w/ Contrast ___: \n1. No evidence of acute intracranial abnormality. \n2. Please note MRI is more sensitive for the detection of \nintracranial masses. \n\nCT Chest w/o contrast ___: \n1. There is diffuse consolidation in the middle lobe extending \ninto the right upper lobe. Coinciding right hilar mass is \npossible although difficult to assess, particularly without \ncontrast administration. This suggests pneumonia. Septal \nthickening and ground-glass in the right upper lobe does not \ninclude definitive nodular elements of this may be an area of \nedema or additional infection, although the possibility of \nlymphangitic spread of cancer is not excluded. This area is \ndifficult to assess in part due to motion artifact. \n2. A separate 3 cm mass is seen in the right lower lobe \nconcerning for primary or metastatic malignancy. \n3. Enlarged mediastinal nodes are concerning for metastatic \nspread of \nmalignancy although reactive lymphadenopathy is a possibility. \nIt is \ndifficult to accurately stage any carcinoma in the presence of \nsuspected \ncoinciding widespread infectious process in the right lung. \n\n*PET CT READ PENDING ON DISCHARGE\n\nELECTROPHYSIOLOGY:\n==================\nCT A/P w/o contrast ___: \n1. No evidence of metastatic disease within the abdomen within \nthe limitations of non-contrast study. \n\nVideo Swallow ___: \nNormal oropharyngeal swallowing videofluoroscopy.\n\nCXR ___: \nModerate right pleural effusion. Interstitial and ground-glass \nprominence in the right lung may reflect pneumonia when compared \nto the CT chest dated ___. \n\nPPM Interrogation ___: \nPacemaker Interrogation\nDate of Implant: ___\n\nIndication: heart failure\nDevice brand/name: MDT ___ CRT-P ___\n\nInterrogation\nBattery voltage/time to ERI: 839\nPresenting rhythm: AS VP\nUnderlying rhythm: SR with AV block and occasional V escape\nMode,base and upper track rate: DDD 60-130\n\nLead Testing\nP waves: 2.4 mv A thresh: 0.5 V@ 0.4ms A imp: 342 ohms\nRV: R waves: n/a mv thresh: 0.75 V@ 0.4ms RV imp: 361 ohms\nLV: R waves: n/a mv thresh: 1 V@ 0.4ms imp: 475 ohms\n\nDiagnostics:\nAP: <0.1%\nVP: 100% BiV pacing\nEvents: none\n\nDISCHARGE LABS:\n===============\n___ 07:05AM BLOOD WBC-7.4 RBC-3.92* Hgb-9.6* Hct-33.1* \nMCV-84 MCH-24.5* MCHC-29.0* RDW-19.3* RDWSD-51.7* Plt ___\n___ 07:05AM BLOOD Glucose-192* UreaN-51* Creat-1.3* Na-142 \nK-4.2 Cl-90* HCO3-40* AnGap-12\n___ 07:05AM BLOOD Calcium-9.1 Phos-4.9* Mg-2.3\n \nBrief Hospital Course:\nTRANSITIONAL ISSUES:\n====================\n\nHEME-ONC: \n[]please follow-up in thoracic ___ clinic re: further \ntissue biopsy for workup of lung adenocarcinoma\n[] f/u results of PET-CT\n\nPCP: \n[]please get repeat Chem7 within 1 week to evaluate Cr & \nelectrolytes\n[]please assess volume status and if appear volume overloaded, \nplease increase torsemide to 80mg BID\n[]FSBG's elevated while inpatient. Discharged on home metformin.\n[]f/u respiratory status on home O2\n\n___: \nPleurX orders: _Right_____ (side)\n\n1. Please drain Pleurx catheter \n[ ] Daily \n[x ] M, W, F \n[ ] Other ______________\n2. Keep a daily log of drainage amount and color, have the\npatient bring it with them to their next pleural appointment. \n2. Do not drain more than 1000 ml per drainage.\n3. Stop draining for pain, chest tightness, or cough.\n4. Do not manipulate catheter in any way.\n5. You may shower with an occlusive dressing\n6. If the drainage is less than 50cc for three consecutive\ndrainages please call the office for further instructions.\nPlease call ___ if there are any questions.\n\nDISCHARGE WEIGHT: 200.84 lb\nDISCHARGE Cr: 1.3\n\n# Contacts/HCP/Surrogate and Communication: Contact son ___\n___, or daughter ___ ___ . \n# Code Status/ACP: presumed full \n\nBRIEF HOSPITAL COURSE:\n======================\nMr. ___ is an ___ gentleman with a history of HFmrEF (newly \nreduced EF to 40% - ___, Mobitz type two 2:1 AV block s/p \ndual chamber MDT Adapta pacemaker (___), stroke on Plavix \n(___), HTN, Type II diabetes, prostate cancer status post XRT, \nand Graves disease w/ ___ ophthalmopathy who presented as a \ntransfer from the ___ clinic with concerns for weight gain and \nvolume overload, found to have acute heart failure exacerbation. \nPatient was initially actively diuresed with lasix requiring a \ndrip. On ___, patient underwent CRT-P upgrade. His procedure \nwas complicated by developed of L PTX on ___, for which patient \nunderwent CT guided chest tube placement with resolution of PTX. \nUnfortunately, fluid from this thoracentesis revealed lung \nadenocarcinoma. He subsequently underwent staging scans per \noncology recommendations. Due to re-accumulation of malignant \npleural effusion, he ultimately had a pleurex catheter placed in \naddition to continued diuresis. \n\nCORONARIES: Unknown\nPUMP: EF 40% \nRHYTHM: Sinus rhythm, right ventricular pacing\n\n=============== \nACTIVE ISSUES: \n=============== \n# Acute exacerbation of heart failure with moderately reduced EF\n(EF 40%):\nPatient was recently admitted in ___ with new onset HFrEF \nfelt to be due to desynchrony with plan to upgrade to CRT as an \noutpatient. Following discharge, patient endorsed a month of \nworsening SOB, orthopnea, and weight gain for which he presented \nto ___ on ___ where he was found to be in HFmrEF exacerbation \nwith a new O2 requirement. His suspected dry weight from prior \ndischarge in ___ was ~203 lbs. On admission patient was \n~207 lbs. Patient was initially managed with IV lasix boluses \nbut with poor output and persistence of new O2 requirement \nrequiring up titration to a lasix gtt. On ___, patient \nunderwent CRT-D upgrade with EP. Following this procedure, \npatient persisted in a volume overloaded state requiring \nincreased lasix gtt up to 30 mg/hr with boluses of 200 mg IV \nlasix and augmentation with 5 mg metolazone. After brief episode \nof hypotension, he was subsequently cautiously diuresed with IV \nlasix boluses. He will be discharged on a diuretic regimen of \ntorsemide 60mg BID. His weight upon discharge is 200.84 lb. \n\n#L PTX\n#Bilateral Malignant Pleural Effusions\nOn ___, patient was incidentally noted with a large L PTX on \nCXR obtained to evaluate a productive cough. This was suspected \nto be a late complication from CRT upgrade procedure. IP was \ninitially consulted, but unable to place a bedside chest tube \ngiven CRT device placement blocking anterior approach. ___ was \nsubsequently consulted and performed a CT guided chest tube \nplacement which subsequently resolved his PTX. With the chest \ntube in place, ___ also performed a R sided thoracentesis on a \npleural effusion noted on CXR from ___, removing 1.5L of fluid. \nThis fluid showed lung adenocarcinoma. Due to reaccumulation of \nthese fluids and the belief that the effusions were contributing \nto his ongoing supplemental O2 requirements, ___ placed a pleurex \ncatheter prior to discharge. \n\n# Adenocarcinoma of Lung\n# Malignant Pleural Effusions\nFound to have adenocarcinoma in cytology of left pleural fluid, \nthus at least stage 4a. CT imaging revealed 3cm mass RLL and \nsignificant mediastinal LAD. No clear lesions in a/p though \nlimited by lack of contrast. No mass effect brain. Due to \nongoing ___ conversations with pt and family, deferred EBUS \nbiopsy of lung mass and are awaiting PET CT imaging to determine \nif there are other areas amenable to less invasive biopsy. \nHeme/Onc was consulted and provided assistance in workup and \nconversations with family. Palliative care was also consulted \nfor early introduction. \n\n# Acute hypoxemic resp failure:\nPatient admitted with SOB and orthopnea in the context of HFmrEF \nexacerbation as above. He had a persistent O2 requirement \nbetween ___ NC with an exam notably for expiratory wheezes and \ncrackles. Due to productive cough he was treated for presumed \nCAP vs. aspiration. Given concern for aspiration, pt was \nevaluated by SLP who recommended pureed diet with honey \nthickened liquids. Patient was also diuresed as above and placed \non standing duonebs and albuterol PRN given concern for \npotential undiagnosed COPD given former smoking history. It was \nalso felt that his newly discovered lung adenocarcinoma & \nmalignant pleural effusions were large contributors to his \nongoing oxygen requirements despite appearing otherwise \neuvolemic on exam. All of these factors in combination likely \nalso contributed to pt's CO2 retention. \n\n# Iron Deficiency anemia:.\nPatient with a known history of iron deficiency anemia. He was \ncontinued on ferrous sulfate 325 mg PO QOD. He was also on \npantoprazole 40 mg daily. His H/H remained stable throughout his \nhospitalization. \n\n___\nCr variable throughout hospitalization, largely felt to be ___ \naggressive diuresis. Cr upon discharge 1.3. \n\nCHRONIC ISSUES: \n================ \n# HLD:\nContinued home atorvastatin 10mg PO QPM.\n\n# DM:\nA1C 6.6% on this admission. His home metformin was held. FSBGs \nremained grossly elevated in 200-400s throughout admission \ndespite uptitration of basal/bolus insulin. Okay to resume home \nmetformin upon discharge. \n\n# BPH:\nOkay to resume Tamsulosin 0.4mg PO QHS upon discharge.\n\n#s/p Cataract Surgery\nPer opthalmology, stopped ketorolac drops and appropriately \nweaned his prednisolone drops. \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfurther investigation.\n1. Atorvastatin 10 mg PO QPM \n2. ketorolac 0.4 % ophthalmic (eye) QID \n3. Losartan Potassium 25 mg PO DAILY \n4. MetFORMIN (Glucophage) 850 mg PO BID \n5. Metoprolol Succinate XL 12.5 mg PO DAILY \n6. Pantoprazole 40 mg PO Q24H \n7. Polyethylene Glycol 17 g PO BID \n8. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE QID \n9. Senna 8.6 mg PO BID \n10. Tamsulosin 0.4 mg PO QHS \n11. Torsemide 20 mg PO DAILY \n12. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \n13. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line \n14. Ferrous Sulfate 325 mg PO DAILY \n\n \nDischarge Medications:\n1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB \nRX *albuterol sulfate 90 mcg ___ Puff IH Q6H: PRN Disp #*1 \nInhaler Refills:*0 \n2. Lidocaine 5% Patch 1 PTCH TD QPM for near pleurex site \nRX *lidocaine 5 % Apply to area with pain QPM Disp #*20 Patch \nRefills:*0 \n3. Acetaminophen 1000 mg PO Q8H \n4. Ferrous Sulfate 325 mg PO EVERY OTHER DAY \n5. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE TID \nDuration: 4 Days \n6. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE DAILY \nDuration: 4 Days \n7. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE BID \nDuration: 4 Days \n8. Torsemide 60 mg PO BID \nRX *torsemide 20 mg 3 tablet(s) by mouth twice a day Disp #*120 \nTablet Refills:*0 \n9. Atorvastatin 10 mg PO QPM \n10. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line \n11. MetFORMIN (Glucophage) 850 mg PO BID \n12. Metoprolol Succinate XL 12.5 mg PO DAILY \n13. Pantoprazole 40 mg PO Q24H \n14. Polyethylene Glycol 17 g PO BID \n15. Senna 8.6 mg PO BID \n16. Tamsulosin 0.4 mg PO QHS \n17.Oxygen Therapy\nICD 10: C34.9, R09.02, Supplementary Oxygen, Length of need: 6 \nmonths. Equipment: Concentrator, Portable, Nasal Canula, 2L \nflow. Indications: At Rest on RA, 88% or less. Ambulate on RA, \n88% or Less. Ambulate on O2, to show improvement. \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\n==================\nacute on chronic HFmrEF exacerbation\nleft PTX\nmalignant pleural effusion\nlung adenocarcinoma\n\nSECONDARY DIAGNOSES:\n====================\nHTN\nT2DM\npneumonia\nacute kidney injury\n\n \nDischarge Condition:\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\nLevel of Consciousness: Alert and interactive.\nMental Status: Clear and coherent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nIt was a pleasure taking care of you at the ___ \n___! \n\nWHY WAS I IN THE HOSPITAL? \n========================== \n- You were admitted because of shortness of breath and weight \ngain. \n\nWHAT HAPPENED IN THE HOSPITAL? \n============================== \n- Your weight gain and shortness of breath were felt to be \nrelated to a condition called heart failure, where your heart \ndoes not pump hard enough and fluid backs up into your lungs. \nYou were given a diuretic medication through the IV to help get \nthe fluid out. You improved considerably and were ready to leave \nthe hospital. \n- You received a pacemaker device called CRT-D which helped your \nheart beat more effectively. \n- You were found to have a collapsed lung after the above \npacemaker was placed. This was treated with a chest tube and has \nsince resolved. \n- You were given antibiotics to treat a possible pneumonia. \n- You were found to have fluid surrounding your lungs, this was \ndrained with a catheter. Testing on the fluid that was drained \nshowed that you have lung cancer. \n- You met with the cancer doctors (___) who helped \ncoordinate various pictures to be taken to help evaluate your \nlung cancer. \n- You also had a more permanent catheter placed on the right \nside of your chest to help drain the fluid from around your \nright lung and to prevent it from making you feel short of \nbreath. \n\nWHAT SHOULD I DO WHEN I GO HOME? \n================================ \n- Be sure to take all your medications and attend all of your \nappointments listed below. \n- Your weight at discharge is 200.84 lb. Please weigh yourself \ntoday at home and use this as your new baseline \n- Please weigh yourself every day in the morning. Call your \ndoctor if your weight goes up by more than 3 lbs. \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" ]

[ "I130", "I5023", "J9601", "J189", "I442", "C3431", "J910", "J95811", "I69354", "N179", "E1122", "N183", "Z950", "Z87891", "Z8546", "D696", "D509", "E0500", "Y838", "Y92238" ]

[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5023: Acute on chronic systolic (congestive) heart failure", "J9601: Acute respiratory failure with hypoxia", "J189: Pneumonia, unspecified organism", "I442: Atrioventricular block, complete", "C3431: Malignant neoplasm of lower lobe, right bronchus or lung", "J910: Malignant pleural effusion", "J95811: Postprocedural pneumothorax", "I69354: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side", "N179: Acute kidney failure, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N183: Chronic kidney disease, stage 3 (moderate)", "Z950: Presence of cardiac pacemaker", "Z87891: Personal history of nicotine dependence", "Z8546: Personal history of malignant neoplasm of prostate", "D696: Thrombocytopenia, unspecified", "D509: Iron deficiency anemia, unspecified", "E0500: Thyrotoxicosis with diffuse goiter without thyrotoxic crisis or storm", "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", "Y92238: Other place in hospital as the place of occurrence of the external cause" ]

[ "I130", "J9601", "N179", "E1122", "Z87891", "D696", "D509" ]

[]

[ " \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:\nSOB\n \nMajor Surgical or Invasive Procedure:\nCT guided lung biopsy\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old male with a past medical history\nof lung cancer, throat cancer, pancreatic mass, who presents \nwith\nshortness of breath.\n\nPatient reports that he has been feeling short of breath \"for\naround a month or two\" with worsening cough. It has \nprogressively\ngotten worse, is worsened with exertion, associated with cough,\nbut no fevers or chills. Reports no chest pain, but does have a\nheadache and abdominal pain when he coughs. Also reports\nassociated diarrhea. He went to urgent care on ___, where a\nchest x-ray showed a pneumonia. He received IM ceftriaxone and\nwas started on azithromycin and cefuroxime, which he states he\nhas been taking without improvement. He therefore presented to\nthe ED. \n\nOn review of records, patient was last hospitalized in ___ for\nvertebral osteomyelitis and endocarditis, and was discharged to\ncomplete a course of antibiotics. A CTA at the time showed\nemphysematous changes. He recently switched PCPs, and now is at\n___. Given concerns for COPD there, it was\nrecommended that he start on inhalers, but it appears that\npatient missed follow up appointments. \n\nRegarding lung cancer, patient reports that a nodule was removed\nin ___. Records indicate that this was adenocarcinoma, though\npathology is not available (was done at either ___ or ___ per\npatient.) A CTA in our records from ___ show a 5 x 6 mm nodule\nin the left lower lobe adjacent to the fissure, with radiology\nrecommending followup in ___ months. \n\nRegarding throat cancer, patient was last seen in follow up on\n___. A flexible indirect laryngoscopy was done which was\nunremarkable. \n\nRegarding pancreatic mass, patient last had an MRI (that I am\nable to find) in ___, which showed a \"11 mm septated cyst in \nthe\nhead of the pancreas as described previously. It is unchanged\ncompared with ___. It stability for ___ years would mitigate\nagainst malignant process.\"\n\nIn the ED:\n\nInitial vital signs were notable for: T 97.8, HR 105, BP 139/88,\nRR 22, 89% RA \n\nExam notable for: mild tachypnea with no increased WOB. poor\nairflow with diffuse expiratory wheezing\n\nLabs were notable for:\n\n- CBC: WBC 7.5 (68%n, 12.5%l, 7.6%m, 10.6%eos), hgb 15.5, plt \n196\n\n- Lytes \n\n140 / 101 / 21 AGap=14 \n------------- 120 \n4.5 \\ 25 \\ 1.2 \n\n- flu negative \n\nStudies performed include: CXR with no cardiopulmonary process. \n\nPatient was given:\n___ 12:22 IH Ipratropium-Albuterol Neb 1 NEB \n___ 12:25 IH Ipratropium-Albuterol Neb 1 NEB \n___ 12:25 IH Ipratropium-Albuterol Neb 1 NEB \n___ 12:33 IV MethylPREDNISolone Sodium Succ 40 mg \n___ 16:26 IV Azithromycin 500 mg IV \n___ 20:23 IVF LR @ 125 mL/hr \n___ 20:27 IH Albuterol 0.083% Neb Soln 1 NEB \n___ 20:27 IH Ipratropium Bromide Neb 1 NEB \n\nVitals on transfer: HR 103, BP 146/96, RR 20, 90% 2L NC \n\nUpon arrival to the floor, patient recounts history as above. He\nstates that overall he is feeling a bit better, which he thinks\nis from the supplemental oxygen. \n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n\n \nPast Medical History:\n- LUL adenocarcinoma - s/p LUL mass resection in ___ at ___ \n- HPV related squamous cell carcinoma of the base of tongue\nstatus post radiation completed in ___\n- Ileocecectomy at ___ in ___ (pt states appendectomy was \"part\nof\" this operation in which a \"mass the size of an orange\" was\nremoved via R paramedian incision)\n- PANCREATIC LESION - Followed by Dr. ___ at ___. Noted in ___. MRI showed 14 mm; a\nbiopsy was attempted but not done. In ___ had MRI scan \nthat\nshowed stable, 12 x 12 mm septate cystic mass in uncinate \nprocess\nof pancreas, unchanged from ___. In ___ had a PET and\nEGD/EUS in ___. No pancreatic or biliary duct dilatation.\nMost likely IPMN. \n- Prurigo nodularis\n- Tobacco use, active\n- endocarditis\n- T7-9 discitis and osteomyelitis \n- internal hemorrhoids\n- glaucoma \n- colon polyp \n\n \nSocial History:\n___\nFamily History:\nNo heart, liver, lung disease disease. Father with a muscular \ndegenerative problem. \n \nPhysical Exam:\nVITALS: T 97.8, HR 103, BP 136/73, RR 24, 94% 2L \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. Poor\ndentition.\nCV: Heart regular, no murmur, no S3, no S4. No JVD.\nRESP: Lungs with very poor air movement and virtually no lung\nsounds appreciate. No wheezes noted. \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: Diffuse thicked, dry skin with evidence of previous\nexcoriations \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 \nPertinent Results:\n___ 12:10PM BLOOD WBC-7.5 RBC-5.07 Hgb-15.5 Hct-48.5 MCV-96 \nMCH-30.6 MCHC-32.0 RDW-14.4 RDWSD-50.2* Plt ___\n___ 03:27PM BLOOD Glucose-120* UreaN-21* Creat-1.2 Na-140 \nK-4.5 Cl-101 HCO3-25 AnGap-14\n___ 09:13AM BLOOD ALT-25 AST-47* AlkPhos-109 TotBili-0.4\n___ 03:27PM BLOOD cTropnT-0.02* proBNP-93\n___ 03:27PM BLOOD Calcium-9.7 Phos-2.4* Mg-1.9\n\nCTA CHEST:\nIMPRESSION: \n1. No evidence of pulmonary embolism or aortic abnormality. \n2. New 2.1 cm right middle lobe spiculated nodule and 1.5 cm \nright lower lobe spiculated nodule, concerning for malignancy. \n3. 6 mm left perifissural nodule is stable since ___, likely \nintrapulmonary lymph node. \n4. Emphysema. \n5. Diffuse mild bronchial wall thickening and scattered areas of \nmucous plugging, likely due to chronic small airway disease. \n\n \nBrief Hospital Course:\nMr. ___ is a ___ year old man with a past medical history \nof lung cancer, throat cancer, pancreatic mass, COPD who \npresented with shortness of breath in the setting of recently \ndiagnosed pneumonia and likely COPD, as well as a history of \nlung cancer. Found to have new speculated lung nodules \nconcerning for malignancy.\n\n# Acute hypoxemic respiratory failure\n# Bacterial Pneumonia \n# COPD exacerbation \nSymptoms most consistent with an infectious trigger of his COPD. \n Initial concern was for bacterial PNA and he was placed \nantibiotics. No clear consolidation was found but antibiotics \nwere continued given COPD flare. He had evidence of \nbronchospasm as well based on exam and improved markedly after \n48 hr of antibiotics and steroids. He completed a 5 day course \nof antibiotics and will complete a 5 day course of Prednisone \n40mg daily on ___. He will cont albuterol as well. Tiotropium \nwas added to his chronic regimen. Consider pulm referral for \nongoing care.\n\n# Lung masses:\nSpiculated nodules found concerning for new malignancy. \nReviewed with patient and wife in detail. They were interested \nin pursuing dx. Reviewed case with ___ and oncology. Safest \nstep was for CT guided bx of RML lesion. He was felt to be at \ninherent risk for PTX given his COPD. Given treatment above he \nwas felt to be medically optimized for this procedure. CT \nguided lung bx was performed on ___ without complications\n- Close outpatient follow up to review results and appropriately \nrefer patient for additional work up/staging pending biopsy \nresults\n\n# Eosinophilia - Absolute eos 800 on admission. Resolved on\nrepeat. ? spurious\n- Resolved on follow up\n\n# Rash\n# Pruritis \nPatient reports having seen multiple dermatologists for chronic \npruritis. He was evaluated by derm here in ___, who felt that \nhis exam was consistent with prurigo nodularis, and recommended \ntopical steroids, as well as bleach baths at home for\ndecolonization. \n- clobetasol ointment BID to affected areas - avoid face, groin, \naxillae \n\n# Tobacco use\n- nicotine patch \n\n# BPH - Prescribed Flomax by PCP, but not taking. \n- monitor for symptoms \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob \n\n \nDischarge Medications:\n1. GuaiFENesin ___ mL PO Q6H:PRN cough \nRX *guaifenesin 100 mg/5 mL 5 ml by mouth four times a day \nRefills:*0 \n2. PredniSONE 40 mg PO DAILY \nlast dose on ___ \nRX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*1 \nTablet Refills:*0 \n3. Tiotropium Bromide 1 CAP IH DAILY \nRX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 \ncapsule INH once a day Disp #*30 Capsule Refills:*0 \n4. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob \nRX *albuterol sulfate 90 mcg ___ puffs INH every four (4) hours \nDisp #*1 Inhaler Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nCOPD with exacerbation\nBacterial bronchitis vs pneumonia\nSpiculated lung nodules/masses\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 with a flare of your COPD caused by a lung \ninfection. This improved with steroids and antibiotics.\n\nWe also found to small lung lesions on CT scan that were \nconcerning for cancer. You underwent a CT guided lung biopsy. \nIt is very important that you follow up with your PCP to review \nthe results of this, and to make sure your symptoms are \nimproving.\n \nFollowup Instructions:\n___\n" ]

[ "J440", "J9601", "J159", "J441", "Z85118", "Z85810", "F17210", "N400", "L281", "R918", "J209" ]

[ "J440: Chronic obstructive pulmonary disease with (acute) lower respiratory infection", "J9601: Acute respiratory failure with hypoxia", "J159: Unspecified bacterial pneumonia", "J441: Chronic obstructive pulmonary disease with (acute) exacerbation", "Z85118: Personal history of other malignant neoplasm of bronchus and lung", "Z85810: Personal history of malignant neoplasm of tongue", "F17210: Nicotine dependence, cigarettes, uncomplicated", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "L281: Prurigo nodularis", "R918: Other nonspecific abnormal finding of lung field", "J209: Acute bronchitis, unspecified" ]

[ "J9601", "F17210", "N400" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nCodeine / Percocet / Reglan\n \nAttending: ___.\n \nChief Complaint:\nLeft hip pain\n \nMajor Surgical or Invasive Procedure:\nLeft hip hemiarthroplasty\n\n \nHistory of Present Illness:\n___ female w/ Alzheimer's/mixed dementia, HTN, HLD, pacemaker, \nType II DM, scleroderma, colostomy (hx of partial SBO), anxiety, \nhistory of breast cancer at about age ___ (status post \nlumpectomy, radiation, chemo), unspecified asthma, history of \nunspecified kidney cancer status post nephrectomy about ___ years \nago who presents in transfer from ___ for the above \nfracture s/p mechanical fall. Per report she was in the dining \nroom of her nursing home yesterday when she stood and twisted \nsuffering a mechanical fall. This was witnessed. She was noted \nto hit her head. No loss of consciousness. Per report she did \nambulate a few steps after her fall. She has an abrasion at her \nhead. Unable to answer questions regarding numbness or \ntingling. The patient appears rather comfortable when lying in \nbed and not moving. She is not on blood thinners. Does take \naspirin daily last dose likely ___.\n\n \nPast Medical History:\nPMH/PSH: Alzheimer's/mixed dementia, HTN, HLD, pacemaker, Type \nII DM, scleroderma, colostomy (hx of partial SBO), anxiety, \nhistory of breast cancer at about age ___ (status post \nlumpectomy, radiation, chemo), unspecified asthma, history of \nunspecified kidney cancer status post nephrectomy about ___ years \n\n \nSocial History:\n___\nFamily History:\nBrother - unspecified blood cancer \nSister - ___ \nAunt - RA \n\n \nPhysical Exam:\nPhysical exam on discharge:\nOBJECTIVE:\n___ 2219 Temp: 97.6 AdultAxillary BP: 155/89 R Lying HR: 65\nRR: 16 O2 sat: 97% O2 delivery: Ra \nGEN: well appearing, NAD, AOx0\nCV: regular rate\nPULM: non-labored breathing on room air\n\n \nPertinent Results:\n___ 03:46AM BLOOD WBC-7.3 RBC-2.46* Hgb-7.7* Hct-24.0* \nMCV-98 MCH-31.3 MCHC-32.1 RDW-12.2 RDWSD-43.5 Plt ___\n___ 03:46AM BLOOD Glucose-199* UreaN-23* Creat-0.6 Na-141 \nK-4.2 Cl-105 HCO3-25 AnGap-11\n___ 03:46AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.1\n \nBrief Hospital Course:\nThe patient presented as a same day admission for surgery. The \npatient was taken to the operating room on ___ for left \nhip hemiarthroplasty, which the patient tolerated well. For full \ndetails of the procedure please see the separately dictated \noperative report. The patient was taken from the OR to the PACU \nin stable condition and after satisfactory recovery from \nanesthesia was transferred to the floor. The patient was \ninitially given IV fluids and IV pain medications, and \nprogressed to a regular diet and oral medications by POD#1. The \npatient was given ___ antibiotics and anticoagulation \nper routine. The patient's home medications were continued \nthroughout this hospitalization. The patient worked with ___ who \ndetermined that discharge to ___ rehabilitation 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. The patient is \nweightbearing as tolerated in the left lower extremity, and will \nbe discharged on subcutaneous heparin for DVT prophylaxis. The \npatient will follow up with Dr. ___ routine. 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 \nMedications on Admission:\n1. Celebrex ___ mg BID\n2. Celexa 30mg daily\n3. lisinopril 20 mg-hydrochlorothiazide 12.5 mg tablet daily\n4. lorazepam 0.25 mg daily\n5. Namenda XR 28 mg daily \n6. Namenda 10 mg BID\n7. Reglan 10 mg TID\n8. Protonix 40 mg daily\n9. trazodone 100 mg daily\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q4H \n2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation \n3. Docusate Sodium 100 mg PO BID \n4. Heparin 5000 UNIT SC TID \n5. LevETIRAcetam 1000 mg IV Q12H \n6. Senna 8.6 mg PO BID \n7. Celebrex ___ mg BID\n8. Celexa 30mg daily\n9. lisinopril 20 mg-hydrochlorothiazide 12.5 mg tablet daily\n10. lorazepam 0.25 mg daily\n11. Namenda XR 28 mg daily \n12. Namenda 10 mg BID\n13. Reglan 10 mg TID\n14. Protonix 40 mg daily\n15. trazodone 100 mg daily\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nDisplaced left femoral neck fracture\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:\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 in the left lower extremity\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 subcutaneous heparin 3 times 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\nPhysical Therapy:\nWeightbearing as tolerated left lower extremity\nPhysical therapy\nTreatments Frequency:\nFollow-up in clinic in 2 weeks for postop visit and wound check\nStaples will be removed at that time\n \nFollowup Instructions:\n___\n" ]

[ "S72002A", "W010XXA", "G309", "F0280", "E785", "Z950", "J45909", "E119", "M349", "F419", "Z853", "G9389", "Y92128", "I10", "Z85528", "Z923", "Z9221", "Z933", "Z87891" ]

[ "S72002A: Fracture of unspecified part of neck of left femur, initial encounter for closed fracture", "W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter", "G309: Alzheimer's disease, unspecified", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "E785: Hyperlipidemia, unspecified", "Z950: Presence of cardiac pacemaker", "J45909: Unspecified asthma, uncomplicated", "E119: Type 2 diabetes mellitus without complications", "M349: Systemic sclerosis, unspecified", "F419: Anxiety disorder, unspecified", "Z853: Personal history of malignant neoplasm of breast", "G9389: Other specified disorders of brain", "Y92128: Other place in nursing home as the place of occurrence of the external cause", "I10: Essential (primary) hypertension", "Z85528: Personal history of other malignant neoplasm of kidney", "Z923: Personal history of irradiation", "Z9221: Personal history of antineoplastic chemotherapy", "Z933: Colostomy status", "Z87891: Personal history of nicotine dependence" ]

[ "E785", "J45909", "E119", "F419", "I10", "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:\nDyspnea\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old lady with history of multiple myeloma \nc/b pancytopenia requiring transfusions and CKD who presented \nwith acute onset dyspnea, now admitted to the MICU due to \nconcern for hypoxic respiratory failure.\n\nPatient reports waking up acutely at 2AM with sudden onset of \nshortness of breath, which is worse when she is lying down or \nstanding up (but improved with she is sitting up and leaning \nforward). She has never had symptoms like this before. She \ndenies any palpitations, abdominal pain, nausea, vomiting, \ndysuria, bowel changes, recent fever, lower extremity swelling, \nrecent travel, prior history of blood clot. She endorses chest \npain when she is taking in a deep breath.\n\nIn ED initial VS: T 98.6 BP 152/86 RR 19 HR 97 94% 2L NC\nExam: Bibasilar crackles, no evidence of lower extremity edema \nPatient was given:\n- 2u pRBC\n- IV furosemide 40 mg x 1 \n- Nitro gtt\nShe had increasing oxygen requirement and was placed on BiPAP \n___.\n\nLabs:\n(1) CBC: WBC 3.6 Hgb 5.9 Plt 49; recent baseline Hgb ~8\n(2) Chem 7: Na 139 K 3.9 Cl 110 HCO3 18, BUN 45 Cr 3.3\n(3) Coags: PTT 21.6, INR 1.0\n(4) BNP 34811 from 12536 ___\n(5) U/A: WBC 2, neg leuks, neg nitrites\n \nImaging notable for: \n- CXR: Worsening bibasilar opacities, potentially due to \nincreased atelectasis, aspiration or infection not excluded. \nMild pulmonary vascular engorgement similar to the previous \nstudy. Moderate right pleural effusion slightly decreased in \nsize with small left pleural effusion, unchanged.\n- ___ dopplers negative for DVT\nThere was consideration of possible PE but no CTA was performed \ngiven renal function\n\nConsults: Heme/onc- outpatient oncologist does not advise \nanticoagulation given thrombocytopenia and renal disease. If DVT \nwere to be demonstrated, would consider IVC filter. Low \nthreshold to cover with antibiotics given immunocompromise.\n\nEKG per my read: Sinus rhythm at rate ___, no significant ST-T \nwave changes\n\nOn arrival to the MICU, she confirmed history as above. Her only \nother complaint was that of a headache \n\nOf note, she has had multiple recent admissions to ___. \nIn ___ she was admitted for severe diarrhea with dehydration \nand fever, found to have C. diff colitis c/b septic shock, \ntreated with PO vancomycin and IV metronidazole as well as \ncefepime as she was neutropenic on admission. Course complicated \nby ___ due to ATN and episode of obtundation. She was initially \ncovered broadly for meningoencephalitis and nonconvulsive SE; \nbut with negative LP and EEG demonstrating toxic metabolic \nencephalopathy, hence meningoencephalitis coverage was \ndiscontinued. In discussion with renal, it was thought that her \nAMS was due to cefepime toxicity and possible uremic \nencephalopathy, and she did receive 2 HD session with \nimprovement of mental status; ultimately discharged to rehab.\nIn ___ she re-presented with headache, hypertension, diarrhea \nand uptrending Cr. At that time thought to be noninfectious \ndiarrhea. Hypertension was attributed to ongoing ___ and treated \nwith labetalol; nephrology evaluated patient and thought that \nher rising Cr was still due to ATN (not yet experiencing renal \nrecovery). Headache was attributed to hypertension and improved \nwith treatment of hypertension. \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:\n- Multiple myeloma\n- Osteopenia\n- Cervical spondylosis with myelopathy\n- T8 compression fracture\n- Glaucoma\n- Dyslipidemia\n- Arthralgia of right hip\n- Hemangioma of vertebral body\n- C4-6 laminectomy and spinal fusion (___) \n\nONCOLOGIC HISTORY: Please refer to heme/onc note for details.\n \nSocial History:\n___\nFamily History:\nFather with diabetes\nMother with CVA\nNo family history of malignancy.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nVITALS: Reviewed in metavision\nGENERAL: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: Supple, JVP not elevated, no LAD \nLUNGS: Bibasilar fine crackles and decreased BS at bilateral \nbases\nCV: Borderline tachycardic, regular rhythm, normal S1 S2, no \nmurmurs, rubs, gallops \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: AOx4, ___ strength throughout, CN II-XII grossly intact\n\nDISCHARGE PHYSICAL EXAM\n=======================\nVS: 98.0 146/80 74 18 99% RA \nI/O 24hr: 760/575\nGENERAL: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: Supple, JVP not elevated, no LAD \nLUNGS: No accessory muscle use. Clear to auscultation b/l.\nCV: regular rhythm, normal S1 S2, no murmurs, rubs, gallops \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: Very few scattered petechiae over dorsal feet \nNEURO: AOx4, ___ strength throughout, CN II-XII grossly intact\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 09:35AM BLOOD WBC-3.6* RBC-1.96*# Hgb-5.9*# Hct-18.6*# \nMCV-95 MCH-30.1 MCHC-31.7* RDW-15.2 RDWSD-49.5* Plt Ct-49*\n___ 09:17PM BLOOD WBC-4.4 RBC-2.69*# Hgb-8.1*# Hct-24.1*# \nMCV-90 MCH-30.1 MCHC-33.6 RDW-15.3 RDWSD-47.3* Plt Ct-41*\n___ 09:35AM BLOOD Neuts-78.4* Lymphs-11.8* Monos-8.8 \nEos-0.5* Baso-0.0 Im ___ AbsNeut-2.85# AbsLymp-0.43* \nAbsMono-0.32 AbsEos-0.02* AbsBaso-0.00*\n___ 09:17PM BLOOD Neuts-80.3* Lymphs-9.6* Monos-9.2 \nEos-0.2* Baso-0.2 Im ___ AbsNeut-3.51 AbsLymp-0.42* \nAbsMono-0.40 AbsEos-0.01* AbsBaso-0.01\n___ 09:35AM BLOOD ___ PTT-21.6* ___\n___ 09:35AM BLOOD Plt Ct-49*\n___ 09:35AM BLOOD Glucose-96 UreaN-45* Creat-3.3* Na-139 \nK-3.9 Cl-110* HCO3-18* AnGap-15\n___ 09:17PM BLOOD CK(CPK)-29\n___ 09:35AM BLOOD ___\n___ 09:17PM BLOOD CK-MB-1 cTropnT-0.04*\n___ 09:17PM BLOOD Calcium-7.1* Phos-4.8* Mg-1.3*\n___ 09:32PM BLOOD ___ pO2-40* pCO2-39 pH-7.30* \ncalTCO2-20* Base XS--6\n\nIMAGING\n=======\nCXR (___):\n1. Worsening bibasilar opacities, potentially increased \natelectasis, but \naspiration or infection is not excluded. \n2. Mild pulmonary vascular engorgement, similar to the previous \nstudy. \n3. Moderate size right pleural effusion, slightly decreased in \nsize, with \nsmall left pleural effusion, likely unchanged. \n\n___ (___):\nNo evidence of deep venous thrombosis in the right or left lower \nextremity \nveins. \n\nTTE (___):\nThe left atrium is elongated. There is mild symmetric left \nventricular hypertrophy. The left ventricular cavity size is \nnormal. Overall left ventricular systolic function is normal \n(LVEF = 65%). Tissue Doppler imaging suggests an increased left \nventricular filling pressure (PCWP>18mmHg). The right \nventricular free wall is hypertrophied. Right ventricular \nchamber size is normal with normal free wall contractility. The \ndiameters of aorta at the sinus, ascending and arch levels are \nnormal. The aortic valve leaflets (3) are mildly thickened but \naortic stenosis is not present. No aortic regurgitation is seen. \nThe mitral valve leaflets are mildly thickened and retracted. An \neccentric, posteriorly directed jet of Moderate to severe (3+) \nmitral regurgitation is seen. Due to the eccentric nature of the \nregurgitant jet, its severity may be significantly \nunderestimated (Coanda effect). Moderate [2+] tricuspid \nregurgitation is seen. There is moderate pulmonary artery \nsystolic hypertension. There is a small pericardial effusion. \nThe effusion appears circumferential. There are no \nechocardiographic signs of tamponade. Echocardiographic signs of \ntamponade may be absent in the presence of elevated right sided \npressures. Compared with the prior study (images reviewed) of \n___, significant mitral and tricuspid regurgitation is now \npresent. \n \n\nMICRO\n======\nUrine Culture (___): negative\n\nDISCHARGE LABS\n==============\n___ 05:16AM BLOOD WBC-2.3* RBC-2.77* Hgb-8.2* Hct-24.7* \nMCV-89 MCH-29.6 MCHC-33.2 RDW-14.8 RDWSD-46.6* Plt Ct-49*\n___ 05:16AM BLOOD Glucose-83 UreaN-57* Creat-3.8* Na-134 \nK-4.1 Cl-101 HCO3-19* AnGap-18\n___ 05:16AM BLOOD Calcium-7.4* Phos-4.9* Mg-2.___ with a PMH of multiple myeloma c/b pancytopenia requiring \ntransfusions and CKD who presented with acute onset dyspnea, \nadmitted to the MICU due to concern for hypoxic respiratory \nfailure.\n\n# Acute hypoxic respiratory failure. Pt p/w pulmonary edema iso \npoorly controlled hypertension which is likely cause of her \ndyspnea. TTE ___ was notable for new MR/TR. Pt received \ndiuresis with IV Lasix which improved her respiratory status. \nShe has stable pleural effusions compared to imaging in ___. No fevers, leukocytosis, cough to suggest infection. \nHypoxia improved with Lasix, LENIs negative, making PE also \nunlikely. No e/o ischemic changes on EKG. She was discharged on \nLasix 40mg PO daily, with ___ in place to monitor BP and volume \nstatus.\n\n# Hypertensive urgency: Patient with history of labile blood \npressures, was discharged on 300 mg labetolol TID during last \nadmission. HTN was attributed to renal failure in past (ATN from \nadmission ___. Of note that she was on Carfilzomib in past \nwhich can also cause elevated blood pressures. Pt was initially \ntreated with a labetolol drip and then transitioned to labetolol \n300 mg TID. Her BP remained 110-120 systolic on the floor.\n\n# Acute on chronic anemia/thrombocytopenia. Anemia previously \nattributed to chemotherapy toxicity and multiple myeloma. Pt \nreceiving scheduled transfusions as outpatient. She did not \nrequire transfusion during admission.\n\n# Headache: HA possible ___ hypertensive urgency, however pt \nalso has known multiple lytic lesions present throughout the \ncalvarium seen on ___ CT. Neuro exam nonfocal. Pt continued to \nreceive Tylenol and oxycodone for pain relief. \n\n================= \nCHRONIC ISSUES \n================= \n# Chronic kidney disease: Due to MM and episode of ATN, Cr \nimproved during admission. \n \n# Multiple myeloma: On Cytoxan and dexamethasone as outpatient. \nPt was continued on acyclovir 400 mg PO BID. \n \n# Depression: Pt was continued on home sertraline 300 mg QD and \ntrazodone 200 mg QHS. \n\n# Glaucoma: Pt was continued on Timolol Maleate 0.5% 1 drop both \neyes daily\n\nTRANSITIONAL ISSUES:\n-Pt discharged on Lasix 40mg daily, with instructions to hold \nLasix if BP <100/60. ___ services were arranged\n-Should see a cardiologist after discharge for medication \nmanagement as well as follow-up of new MR, TR\n-Would strongly consider adding additional agent, such as \nIsosorbide to decrease both preload, if SBP persistently >150/90\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Acyclovir 400 mg PO Q12H \n3. LORazepam 0.5 mg PO Q4H:PRN nauea \n4. Multivitamins 1 TAB PO DAILY \n5. Sertraline 300 mg PO DAILY \n6. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY \n7. TraZODone 200 mg PO QHS:PRN insomnia \n8. Benzonatate 100 mg PO TID:PRN cough \n9. Labetalol 300 mg PO TID \n10. Sodium Bicarbonate 650 mg PO TID \n11. Clotrimazole Cream 1 Appl TP BID \n12. Ondansetron 8 mg PO Q8H:PRN nausea \n13. Vitamin D 800 UNIT PO DAILY \n\n \nDischarge Medications:\n1. Furosemide 40 mg PO DAILY \nRX *furosemide 20 mg 2 tablet(s) by mouth once a day Disp #*60 \nTablet Refills:*0 \n2. Nephrocaps 1 CAP PO DAILY \nRX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1 \ncapsule(s) by mouth once a day Disp #*30 Capsule Refills:*0 \n3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n4. Acyclovir 400 mg PO Q12H \n5. Benzonatate 100 mg PO TID:PRN cough \n6. Clotrimazole Cream 1 Appl TP BID \n7. Labetalol 300 mg PO TID \n8. LORazepam 0.5 mg PO Q4H:PRN nauea \n9. Ondansetron 8 mg PO Q8H:PRN nausea \n10. Sertraline 300 mg PO DAILY \n11. Sodium Bicarbonate 650 mg PO TID \n12. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY \n13. TraZODone 200 mg PO QHS:PRN insomnia \n14. Vitamin D 800 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY\n========\nAcute hypoxic respiratory failure\nHypertensive emergency\nNew onset tricuspid regurgitation\nNew onset mitral regurgitation\nMultiple myeloma\n\nSECONDARY\n=========\nChronic kidney disease\nAnemia\nThrombocytopenia\nDepression\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 care of you at ___ \n___.\n\nYou were in the hospital because you were having trouble \nbreathing. Your blood pressure was also very high.\n\nYou were initially in the ICU and had a breathing machine called \nBiPAP. You also received medicine to lower your blood pressure \nand remove extra fluid.\n\nWhen you leave the hospital:\n-Check your blood pressure at least once per day.\n-If your blood pressure is less than 100/60, do not take Lasix \nthat day.\n-If you are feeling lightheaded or dizzy, drink more fluids. \nCall your doctor if you don't feel well.\n-You should call your primary doctor to get a referral to a \ncardiologist.\n\nBest wishes,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "J9601", "I130", "I5033", "I161", "N189", "N179", "C9002", "J811", "I081", "C7951", "D6959", "D6481", "T451X5A", "F329", "R51", "H409" ]

[ "J9601: Acute respiratory failure with hypoxia", "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", "I161: Hypertensive emergency", "N189: Chronic kidney disease, unspecified", "N179: Acute kidney failure, unspecified", "C9002: Multiple myeloma in relapse", "J811: Chronic pulmonary edema", "I081: Rheumatic disorders of both mitral and tricuspid valves", "C7951: Secondary malignant neoplasm of bone", "D6959: Other secondary thrombocytopenia", "D6481: Anemia due to antineoplastic chemotherapy", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "F329: Major depressive disorder, single episode, unspecified", "R51: Headache", "H409: Unspecified glaucoma" ]

[ "J9601", "I130", "N189", "N179", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: ORTHOPAEDICS\n \nAllergies: \n___\n \nAttending: ___.\n \nChief Complaint:\nFlexor tenosynovitis of the left long finger\n \nMajor Surgical or Invasive Procedure:\nIrrigation and debridement of the flexor tendon sheath of the \nleft long finger ___ ___\n\n \n___ of Present Illness:\n___ male with PMH throat cancer s/p resection and rad tx,\nHTN, hypothyroidism who presents with four days of progressive\nleft long finger swelling and pain. Patient states that he was\nmoving a stove downstairs when he felt something puncture \nthrough\nhis finger. He is not sure what it was as he was unable to put\nthe stove down to check. After this, there was some bleeding \nfrom\nthe finger and he soon developed some redness and increasing\npain. He states that for the past 3 days, he has been able to\ndischarge some pus and blood from the puncture wound. Today, \nthe\npain has become significantly worse. He is unable to range the\nfinger. Denies pain ___ any of his other fingers. He does\nendorse subjective fevers and chills. His last p.o. intake was \nat\n630AM this morning.\n \nPast Medical History:\n-Throat/tongue cancer (___), s/p surgical excision, XRT, chemo\n-GERD\n-Polysubstance abuse\n-septic right shoulder ___ ___ \n-Hepatitis C\n* htn\n* hypothyroidism\n* HCV\n* throat CA T3N2 ___, resected + chemo + radiation\n* chest wall abscess + MSSA septic arthritis R shoulder ___ s/p\nabx\n \nSocial History:\n___\nFamily History:\n-Sister: ___ cancer\n-Mother: CAD, uterine cancer \n-Brother: CAD \n\n \nPhysical ___:\nNAD, A&Ox4\nnl resp effort\n Left upper extremity:\n- improved swelling diffusely throughout the L long finger\n- improved erythema along the length of the L long finger\n- Soft, non-tender arm and forearm\n- Full, painless ROM at shoulder, elbow, wrist, ROM of the L \nlong\nfinger less limited by pain and swelling\n- Fires EPL/FPL/DIO\n- SILT axillary/radial/median/ulnar nerve distributions\n- 2+ radial pulse, WWP L long finger distally with brisk cap\nrefill\n \nPertinent Results:\n___ 05:45AM BLOOD WBC-16.9* RBC-2.93* Hgb-9.5* Hct-30.3* \nMCV-103* MCH-32.4* MCHC-31.4* RDW-13.1 RDWSD-49.4* Plt ___\n___ 03:06PM BLOOD WBC-21.0* RBC-3.51* Hgb-11.5* Hct-36.0* \nMCV-103* MCH-32.8* MCHC-31.9* RDW-13.1 RDWSD-48.6* Plt ___\n___ 05:45AM BLOOD Neuts-84.3* Lymphs-5.4* Monos-8.7 \nEos-0.7* Baso-0.4 Im ___ AbsNeut-14.23* AbsLymp-0.91* \nAbsMono-1.46* AbsEos-0.12 AbsBaso-0.06\n___ 03:06PM BLOOD Neuts-84.9* Lymphs-5.4* Monos-7.9 \nEos-0.6* Baso-0.3 Im ___ AbsNeut-17.83* AbsLymp-1.13* \nAbsMono-1.66* AbsEos-0.12 AbsBaso-0.07\n___ 05:45AM BLOOD Plt ___\n___ 03:06PM BLOOD Plt ___\n___ 03:06PM BLOOD ___ PTT-29.5 ___\n___ 05:45AM BLOOD Glucose-100 UreaN-15 Creat-1.2 Na-137 \nK-3.9 Cl-99 HCO3-26 AnGap-12\n___ 03:06PM BLOOD Glucose-100 UreaN-20 Creat-0.9 Na-138 \nK-3.8 Cl-97 HCO3-27 AnGap-14\n___ 05:45AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.6\n___ 06:00AM BLOOD WBC-9.2 RBC-3.15* Hgb-10.4* Hct-32.0* \nMCV-102* MCH-33.0* MCHC-32.5 RDW-12.5 RDWSD-46.7* Plt ___\n___ 04:28AM BLOOD WBC-12.4* RBC-2.93* Hgb-9.5* Hct-30.2* \nMCV-103* MCH-32.4* MCHC-31.5* RDW-12.6 RDWSD-47.1* Plt ___\n___ 06:00AM BLOOD Neuts-73.0* Lymphs-10.3* Monos-12.2 \nEos-3.3 Baso-0.3 Im ___ AbsNeut-6.70* AbsLymp-0.95* \nAbsMono-1.12* AbsEos-0.30 AbsBaso-0.03\n___ 04:28AM BLOOD Neuts-76.5* Lymphs-9.9* Monos-10.6 \nEos-2.2 Baso-0.2 Im ___ AbsNeut-9.50* AbsLymp-1.23 \nAbsMono-1.32* AbsEos-0.27 AbsBaso-0.03\n___ 06:00AM BLOOD Plt ___\n___ 04:28AM BLOOD Plt ___\n___ 06:00AM BLOOD Glucose-102* UreaN-10 Creat-0.9 Na-142 \nK-4.2 Cl-101 HCO3-27 AnGap-14\n___ 04:28AM BLOOD Glucose-104* UreaN-12 Creat-1.1 Na-139 \nK-4.2 Cl-98 HCO3-29 AnGap-12\n___ 06:00AM BLOOD CRP-90.9*\n___ 04:28AM BLOOD CRP-130.7*\n___ 07:50AM BLOOD WBC-7.3 RBC-3.26* Hgb-10.7* Hct-32.6* \nMCV-100* MCH-32.8* MCHC-32.8 RDW-12.4 RDWSD-45.6 Plt ___\n___ 07:50AM BLOOD Plt ___\n___ 07:50AM BLOOD Glucose-93 UreaN-14 Na-140 K-4.6 Cl-101 \nHCO3-27 AnGap-12\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 flexor tenosynovitis of the left long finger and was \nadmitted to the orthopedic surgery service. The patient was \ntaken to the operating room on ___ for irrigation and \ndebridement of the left long finger flexor tendon sheath, which \nthe patient tolerated well. For full details of the procedure \nplease see the separately dictated operative report. The patient \nwas taken from the OR to the PACU ___ 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 started on broad spectrum \nIV antibiotics on admission, and subcutaneous anticoagulation \nper routine. The patient's home medications were continued \nthroughout this hospitalization. The ___ hospital course \nwas otherwise unremarkable. He will be discharged with plans to \nfollow up at ___ for daily CTX infusions.\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 \ncoffee cup weight ___ ___ the left ___, and will be \ndischarged on Ceftriaxone for continued antibiotic therapy. The \npatient will follow up with Dr. ___ routine. A \nthorough discussion was had with the patient regarding the \ndiagnosis and expected post-discharge course including reasons \nto call the office or return to the hospital, and all questions \nwere answered. The patient was also given written instructions \nconcerning precautionary instructions and the appropriate \nfollow-up care. The patient expressed readiness for discharge.\n\nINFECTIOUS DISEASE ASSESSMENT AND RECOMMENDATIONS:\n\n# penetrating injury to Lt ___ digit\n# grp A strep LT third digit infection with flexor tenosynovitis\n___\n# s/p surgical debridement ___ finger/tendon sheath ___\n# fever; ;leukocytosis\n# chronic HCV infection\n# h/o remote opioid use disorder \n\nAllergies: \ndarvon\n\nCurrent OPAT antibiotic regimen:\nIV ceftriaxone 2 grams IV q24h \n\nProjected duration of OPAT regimen\nStart date: ___\nStop date: ___\n\nNOTE: Will complete minimum 4 week course; may need to extend to\n6 weeks\n\nLAB MONITORING RECOMMENDATIONS: \nWeekly safety labs\n•CBC/diff\n•BUN/ creat\n•ALT, AST\n•CRP\n\nALL LAB RESULTS SHOULD BE SENT TO:\nATTN: ___ CLINIC - FAX: ___\n___ MD\n\nFOLLOW UP APPOINTMENTS: \n___: ___ MD \n___ ___ at 10:00 am\n\nTransition of care\n___ y/o male; h/o throat cancer ___ s/p resection/chemo/RT;\nHypothyroidism; prior opioid use disorder; sustained penetaring\ninjurty to LT ___ finger; admitted ___ with L ___ digit\nswelling and pain x4d after init puncture wound; leukocytosis of \n\nPt underwent surgical debridement ___ ; intra op findings with\ngross purulence; flexor tenosynovitis and lymphangitis. \nPrelim culture LT ___ tendon isolated grp A strep. Surveillance\nBC from ___ no growth.\nPt will complete minimum 4 week course of IV ceftriaxone for Lt\nfinger grp A strep tenosyvnovitis \n\nSafety labs \n___\nWBC 9 (12K) \nHCT 32\nPlt 320K\n\nBUN 10; creat 0.9\n\nInflammatory markers: \nCRP 90\n\nMicro:\n___ BC; no growth\n\n___ LT ___ finger tip\nTime Taken Not Noted ___ Date/Time: ___ 8:30 pm\n SWAB LEFT LONGFINGER TIP. \\\n GRAM STAIN (Final ___: \n 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. \n 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. \n ___ PAIRS AND CHAINS. \n\n WOUND CULTURE (Final ___: \n BETA STREPTOCOCCUS GROUP A. MODERATE GROWTH. \n IDENTIFICATION PERFORMED ON CULTURE # ___\n___. \n\n FUNGAL CULTURE (Preliminary): \n\n ANAEROBIC CULTURE (Preliminary): \n\n___ Lt long finger flexor \nTime Taken Not Noted ___ Date/Time: ___ 8:29 pm\n SWAB LEFT LONG FINGER FLEXOR. \n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. \n NO MICROORGANISMS SEEN. \n\n WOUND CULTURE (Final ___: \n BETA STREPTOCOCCUS GROUP A. SPARSE GROWTH. \n\n FUNGAL CULTURE (Preliminary): \n\n ANAEROBIC CULTURE (Preliminary): \n\n \nMedications on Admission:\nMedications - Prescription\nALBUTEROL SULFATE - albuterol sulfate HFA 90 mcg/actuation\naerosol inhaler. - (Prescribed by Other Provider)\nFOLIC ACID - folic acid 1 mg tablet. 1 tablet(s) by mouth - \n(Prescribed by Other Provider)\nOXYCODONE - oxycodone 5 mg tablet. 1 tablet(s) by mouth Q4-6hrs\nas needed for pain Do NOT drive while on this medication. Do \nNOT\ndrink alcohol while on this medication\nPANTOPRAZOLE - pantoprazole 40 mg tablet,delayed release. 1\ntablet(s) by mouth - (Prescribed by Other Provider)\n \nMedications - OTC\nTHIAMINE HCL (VITAMIN B1) - thiamine HCl (vitamin B1) 100 mg\ntablet. 1 tablet(s) by mouth - (Prescribed by Other Provider)\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \nRX *acetaminophen 650 mg 1 tablet(s) by mouth 5 times daily Disp \n#*50 Tablet Refills:*0 \n2. CefTRIAXone 2 gm IV Q24H \nRX *ceftriaxone ___ dextrose,iso-os 2 gram/50 mL 2 grams IV Q24hr \nDisp #*36 Intravenous Bag Refills:*0 \n3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp \n#*40 Tablet Refills:*0 \n4. Gabapentin 600 mg PO TID \n5. Levothyroxine Sodium 50 mcg PO DAILY \n6. Lisinopril 40 mg PO DAILY \n7. Omeprazole 20 mg PO DAILY \n8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe \nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*26 Tablet Refills:*0 \n9. Senna 8.6 mg PO BID:PRN constipation \nRX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp \n#*40 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nFlexor tenosynovitis left long finger\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nINSTRUCTIONS AFTER ___ EXTREMITY SURGERY:\n\n- You were ___ the hospital for ___ surgery. It is normal to \nfeel 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- do not lift or carry anything heavier than a cup of coffee \nwith your left ___\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-- Please take your antibiotics (CEFTRIAXONE) as prescribed, \nrefer to Infectious Disease recommendations below\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\nSOAKS\n- soak your left ___ and long finger ___ dilute betadine ( 2 \ntablespoons of betadine per liter of saline or water) three \ntimes daily. Soak your finger for 15minutes at a time three \ntimes daily until your follow up appointment.\n- make sure to dry your finger and ___ off well ___ between \nsoaks\n- you may replace the dressings to your finger ___ between soaks\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 ___ 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 ___ DAYS OF REHAB\n\nINFECTIOUS DISEASE ASSESSMENT AND RECOMMENDATIONS:\n\n# penetrating injury to Lt ___ digit\n# grp A strep LT third digit infection with flexor tenosynovitis\n___\n# s/p surgical debridement ___ finger/tendon sheath ___\n# fever; ;leukocytosis\n# chronic HCV infection\n# h/o remote opioid use disorder \n\nAllergies: \ndarvon\n\nCurrent OPAT antibiotic regimen:\nIV ceftriaxone 2 grams IV q24h \n\nProjected duration of OPAT regimen\nStart date: ___\nStop date: ___\n\nNOTE: Will complete minimum 4 week course; may need to extend to\n6 weeks\n\nLAB MONITORING RECOMMENDATIONS: \nWeekly safety labs\n•CBC/diff\n•BUN/ creat\n•ALT, AST\n•CRP\n\nALL LAB RESULTS SHOULD BE SENT TO:\nATTN: ___ CLINIC - FAX: ___\n___ MD\n\nFOLLOW UP APPOINTMENTS: \n___: ___ MD \n___ ___ at 10:00 am\n\nTransition of care\n___ y/o male; h/o throat cancer ___ s/p resection/chemo/RT;\nHypothyroidism; prior opioid use disorder; sustained penetaring\ninjurty to LT ___ finger; admitted ___ with L ___ digit\nswelling and pain x4d after init puncture wound; leukocytosis of \n\nPt underwent surgical debridement ___ ; intra op findings with\ngross purulence; flexor tenosynovitis and lymphangitis. \nPrelim culture LT ___ tendon isolated grp A strep. Surveillance\nBC from ___ no growth.\nPt will complete minimum 4 week course of IV ceftriaxone for Lt\nfinger grp A strep tenosyvnovitis \n\nSafety labs \n___\nWBC 9 (12K) \nHCT 32\nPlt 320K\n\nBUN 10; creat 0.9\n\nInflammatory markers: \nCRP 90\n\nMicro:\n___ BC; no growth\n\n___ LT ___ finger tip\nTime Taken Not Noted ___ Date/Time: ___ 8:30 pm\n SWAB LEFT LONGFINGER TIP. \\\n GRAM STAIN (Final ___: \n 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. \n 2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. \n ___ PAIRS AND CHAINS. \n\n WOUND CULTURE (Final ___: \n BETA STREPTOCOCCUS GROUP A. MODERATE GROWTH. \n IDENTIFICATION PERFORMED ON CULTURE # ___\n___. \n\n FUNGAL CULTURE (Preliminary): \n\n ANAEROBIC CULTURE (Preliminary): \n\n___ Lt long finger flexor \nTime Taken Not Noted ___ Date/Time: ___ 8:29 pm\n SWAB LEFT LONG FINGER FLEXOR. \n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. \n NO MICROORGANISMS SEEN. \n\n WOUND CULTURE (Final ___: \n BETA STREPTOCOCCUS GROUP A. SPARSE GROWTH. \n\n FUNGAL CULTURE (Preliminary): \n\n ANAEROBIC CULTURE (Preliminary): \n\nPhysical Therapy:\ncoffee cup weight bearing to the left ___\nTreatments Frequency:\nTID soaks ___ dilute betadine with dry dressing changes between \nsoaks\n \nFollowup Instructions:\n___\n" ]

[ "M65142", "I891", "I10", "B950", "K219", "B1920", "F1190", "E039", "F17210", "Z85819" ]

[ "M65142: Other infective (teno)synovitis, left hand", "I891: Lymphangitis", "I10: Essential (primary) hypertension", "B950: Streptococcus, group A, as the cause of diseases classified elsewhere", "K219: Gastro-esophageal reflux disease without esophagitis", "B1920: Unspecified viral hepatitis C without hepatic coma", "F1190: Opioid use, unspecified, uncomplicated", "E039: Hypothyroidism, unspecified", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z85819: Personal history of malignant neoplasm of unspecified site of lip, oral cavity, and pharynx" ]

[ "I10", "K219", "E039", "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROSURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___\n \nChief Complaint:\nBilateral lower extremity numbness and weakness \n \nMajor Surgical or Invasive Procedure:\n___: C6-C7 laminectomy\n\n \nHistory of Present Illness:\n___ yo M with gradual inability to walk due to lower limb \nweakness\nand imbalance. The problem started ___ m ago and he could walk\nusing a cane first, but gradually decreased and had more falls.\nCurrently he is totally wheelchair bound. He denies paresthesias\nin hand or legs.\n \nPast Medical History:\nhypertension\nDiabetes \n2 times laminectomy (lower thoracic) in ___ and ___ in ___\n\n \nSocial History:\n___\nFamily History:\nnon-contributory\n \nPhysical Exam:\nUPON DISCHARGE: \nGeneral: No acute distress\nPulmonary: Breathing comfortably on room air. \nNeuro: \n Patient is oriented to person, place and date. \n Opening eyes spontaneously and interacting with exam. \n Following complex commands.\n Speech fluent and comprehension intact. \n\nMotor:\nTrapDeltoidBicepTricepGrip\nRight555 5 5 \nLeft555 5 5 \n\nIPQuadHamATEHLGast\nRight322 0 0 3\nLeft3 2 2 0 0 3\n\nWound: [x] Clean, dry, intact \n\n \nPertinent Results:\nPlease refer to ___ for relevant imaging and lab results \n \nBrief Hospital Course:\nMr. ___ was electively admitted for C6-7 laminectomy. \n\n# cervical spondylosis \nOn ___ he was taken to the OR and underwent C6-7 laminectomy \nwith Dr. ___. Procedure was uncomplicated, please see \noperative report for full details. No postop imaging was \nindicated. He was given soft collar for comfort. He regained \nsome strength/sensation postop. He was evaluated by ___, who \nrecommended acute rehab at discharge. On POD#2 his pain remained \nwell controlled, he was tolerating PO diet, and voiding with \ncondom catheter. He was cleared to discharge to rehab in stable \ncondition. \n \nMedications on Admission:\ncarvedilol 25 mg daily\nfurosemide 40 mg daily\nlisinopril 20 mg daily\nmetformin 500 mg daily\ncholecalciferol (vitamin D3) 2,000 unit cap daily\n \n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN for fever or pain \n2. Diazepam 5 mg PO Q8H:PRN muscle spasm \n3. Docusate Sodium 100 mg PO BID \n4. Heparin 5000 UNIT SC BID \n5. Insulin SC \n Sliding Scale\nFingerstick QACHS\nInsulin SC Sliding Scale using REG Insulin \n6. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN pain \n7. Senna 17.2 mg PO QHS \n8. Carvedilol 25 mg PO BID \n9. Furosemide 40 mg PO DAILY \n10. Lisinopril 20 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nCervical Spondylosis\nSevere stenosis due to ligamentous calcification \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:\nSurgery\n• Your dressing was removed the second day after surgery. \n• Your incision is closed with staples. You will need staple \nremoval. Please keep your incision dry until staple removal.\n• Do not apply any lotions or creams to the site. \n• Please avoid swimming for two weeks after suture/staple \nremoval.\n• Call your surgeon if there are any signs of infection like \nredness, fever, or drainage. \n\nActivity\n• We recommend that you avoid heavy lifting, running, climbing, \nor other strenuous exercise until your follow-up appointment.\n• You make take leisurely walks and slowly increase your \nactivity at your own pace. ___ try to do too much all at once.\n• No driving while taking any narcotic or sedating medication. \n• No contact sports until cleared by your neurosurgeon. \n\nMedications\n• Please do NOT take any blood thinning medication (Aspirin, \nIbuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. \n• You may use Acetaminophen (Tylenol) for minor discomfort if \nyou are not otherwise restricted from taking this medication.\n• It is important to increase fluid intake while taking pain \nmedications. We also recommend a stool softener like Colace. \nPain medications can cause constipation. \n\nWhen to Call Your Doctor at ___ for:\n• Severe pain, swelling, redness or drainage from the incision \nsite. \n• Fever greater than 101.5 degrees Fahrenheit\n• New weakness or changes in sensation in your arms or legs.\n\n \nFollowup Instructions:\n___\n" ]

[ "M4712", "M4802", "M4602", "G8310", "Z23", "I10", "E119", "Z794", "Z993", "K5900", "R509", "D72829", "Z7902" ]

[ "M4712: Other spondylosis with myelopathy, cervical region", "M4802: Spinal stenosis, cervical region", "M4602: Spinal enthesopathy, cervical region", "G8310: Monoplegia of lower limb affecting unspecified side", "Z23: Encounter for immunization", "I10: Essential (primary) hypertension", "E119: Type 2 diabetes mellitus without complications", "Z794: Long term (current) use of insulin", "Z993: Dependence on wheelchair", "K5900: Constipation, unspecified", "R509: Fever, unspecified", "D72829: Elevated white blood cell count, unspecified", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]

[ "I10", "E119", "Z794", "K5900", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: CARDIOTHORACIC\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / Spinach / Penicillins\n \nAttending: ___\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\n___ - Coronary artery bypass grafts x 2: left internal \nmammary artery to left anterior descending artery; saphenous \nvein graft to ramus intermedius \n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old man with a history of coronary \nartery disease, hyperlipidemia and hypertension. He was admitted \nto ___ from ___ for chest, abdominal, and left \nflank pain. A CT scan revealed a kidney stone. She was treated \nwith dilaudid and ketorolac. In this setting she developed \nsudden onset of crushing substernal chest pain, similar to the \npain she had prior to her getting a stent. She had dynamic \nchanges in her EKG. Troponins were negative. She was given \nnitroglycerin with resolution of her pain. She was\ndischarged home with treatment for a UTI/pyelonephritis and was \nreferred for an outpatient cardiac catheterization. Cardiac \ncatheterization was performed and she developed chest pain \nduring the procedure. The study demonstrated left main disease. \nAn IABP was placed and cardiac surgery was consulted for \nemergent CABG. After Dr. ___ has reviewed it was determined to \ntake her emergently to OR for CABG. \n\n \nPast Medical History:\nBreast Cancer \nChronic Cough\nCoronary Artery Disease s/p stent \nHyperlipidemia\nHypertension\nOsteoarthritis \nPostnasal Drip\nST Elevation Myocardial Infarction, ___\n \n\n \nSocial History:\n___\nFamily History:\nHer family history is notable for a mother dying at age ___ of \nheart disease. Her father died of myocardial infarction when he \nwas ___. Her brother had coronary artery disease status post 4 \nvessel CABG. \n \nPhysical Exam:\nPre op exam\nHR: 64. BP Right: 160/77. RR: 18. O2 sat: 100% RA\nHeight: 65\" Weight: 171 lbs\n\nGeneral:\nSkin: Dry [X] intact [X]\nHEENT: PERRLA [X] EOMI [X]: Wearing glasses\nNeck: Supple [X] Full ROM [X]\nChest: Upper bilateral Rhonchi [X] Lungs clear bilaterally []\nHeart: RRR [X] Irregular [] Murmur [] \nAbdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds \n[X]\nExtremities: Warm [X], well-perfused [X]Balloon pump right groin \n Edema [] \nVaricosities: None [X]\nNeuro: Grossly intact [X]\nPulses:\nFemoral Right: Balloon pump Left: 2+ \nLeft:DP Right: 1+ Left: 2+\n___ Right: 1+ Left:2+\nRadial Right: 1+ Left:2+\n\nCarotid Bruit: negative \n \nPertinent Results:\nLabs:\n\n___ WBC-4.3 RBC-3.66* Hgb-11.2 Hct-33.9* MCV-93 MCH-30.6 \nMCHC-33.0 RDW-12.9 RDWSD-43.9 Plt ___\n\n___ WBC-19.5*# RBC-2.17*# Hgb-6.8*# Hct-21.2*# MCV-98 \nMCH-31.3 MCHC-32.1 RDW-12.8 RDWSD-45.7 Plt ___\n\n___ ___ PTT-32.5 ___\n___ Plt ___\n___ Glucose-117* UreaN-17 Creat-0.8 Na-139 K-3.9 Cl-105 \nHCO3-20* AnGap-18\n\n___ UreaN-14 Creat-0.8 Cl-110* HCO3-20* AnGap-13\n___ Calcium-7.7* Phos-4.3 Mg-3.6*\n.......\nDischarge Labs:\n___ 05:10AM BLOOD WBC-7.7 RBC-2.46* Hgb-7.5* Hct-23.3* \nMCV-95 MCH-30.5 MCHC-32.2 RDW-14.7 RDWSD-50.2* Plt ___\n___ 11:46AM BLOOD Hct-21.6*\n___ 05:10AM BLOOD Plt ___\n___ 05:10AM BLOOD Glucose-78 UreaN-20 Creat-1.1 Na-139 \nK-4.2 Cl-95* HCO3-30 AnGap-18\n___ 05:10AM BLOOD Mg-2.7*\n\n..........\nCardiac Cath ___ ___\nDominance: Right\nLMCA: distal irregular 70% stenosis extending into the origin of \nthe LCX and LAD \nLAD: widely patent proximal stent beginning just after the short \nostial segment of left main disease extending into the LAD\nLCX: ostial at least 70% disease. It gives ride to a high large \nOM branch with no significant disease. The remainder of the LCX \nis a small diffusely disease vessel\nRCA: has diffuse mild irregularities\n\nTransesophageal Echocardiogram ___\nPre-CPB:\nThe left atrium is mildly dilated. No atrial septal defect is \nseen by 2D or color Doppler. Left ventricular wall thicknesses \nare normal. The left ventricular cavity size is normal. Overall \nleft ventricular systolic function is normal (LVEF>55%). The \ncalculated cardiac output by continuity equation is 3.1L/min. \nThe right ventricular cavity is mildly dilated with normal free \nwall contractility. \n\nThere are simple atheroma in the descending thoracic aorta. A \nmass of echos is seen in the descending thoracic aorta, \nconsistent with IABP. The aortic valve leaflets (3) are mildly \nthickened. Mild (1+) aortic regurgitation is seen. \n\nThe mitral valve leaflets are mildly thickened. Mild (1+) mitral \nregurgitation is seen. \n\nPost-CPB:\nBiventricular systolic function is preserved. The LVEF is >55%. \nThe calculated cardiac output is 4.4L/min. \n\nThe MR remains mild. Other valvular function remains unchanged. \nThere is no evidence of aortic dissection. \n\n___ 04:00AM BLOOD WBC-6.9 RBC-2.71* Hgb-8.2* Hct-25.9* \nMCV-96 MCH-30.3 MCHC-31.7* RDW-14.3 RDWSD-48.8* Plt ___\n___ 04:00AM BLOOD ___\n___ 04:00AM BLOOD UreaN-25* Creat-1.2* Na-143 K-4.6 Cl-100 \nHCO3-30 AnGap-18\n \nBrief Hospital Course:\n___ presented on ___ for elective cardiac \ncatheterization and was found to have severe left main disease \nand became unstable during the procedure. An IABP was placed and \nshe was taken emergently to the operating room and underwent \ncoronary artery bypass grafting x 2. Please see operative note \nfor full surgical details. She tolerated the procedure well and \nwas transferred to the CVICU in stable but critical condition \nfor recovery and invasive monitoring. \n \nShe weaned from sedation, awoke neurologically intact, and was \nextubated later that day. She was weaned from inotropic and \nvasopressor support. Beta blocker was initiated and she was \ndiuresed toward her preoperative weight. She remained \nhemodynamically stable and was transferred to the telemetry \nfloor for further recovery. Chest tubes and pacing wires were \ndiscontinued per protocol without incident. She was evaluated by \nthe physical therapy service for assistance with strength and \nmobility. Postoperatively she had transient episodes of rapid \natrial fibrillation which was self limiting. No need for \nanticoagulation. Her LFTs were elevated therefore no Amiodarone \nwas given. On ___ a RUQ ultrasound was performed which revealed: \nSmall amount of sludge in the gallbladder. No shadowing \ngallstones. No findings of acute cholecystitis. Her LFTs \nremained stable and TBili trending downward by the time of \ndischarge. \n By the time of discharge on POD #7 she was ambulating with \nassistance, the wound was healing, and pain was controlled with \noral analgesics. She was discharged to ___ in good \ncondition with appropriate follow up instructions.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Asthma \n2. amLODIPine 2.5 mg PO HS \n3. Atorvastatin 80 mg PO QPM \n4. Exemestane 25 mg PO DAILY \n5. MetFORMIN (Glucophage) 500 mg PO BID \n6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain \n7. Aspirin 325 mg PO DAILY \n8. GuaiFENesin ER 1200 mg PO Q12H \n\n \nDischarge Medications:\n1. Bisacodyl ___AILY:PRN constipation \n2. Docusate Sodium 100 mg PO BID \n3. Furosemide 40 mg PO DAILY Duration: 10 Days \n4. Metoprolol Tartrate 6.25 mg PO BID \n5. Polyethylene Glycol 17 g PO DAILY \n6. Potassium Chloride 20 mEq PO Q12H Duration: 10 Days \n7. Ranitidine 150 mg PO BID \n8. Senna 8.6 mg PO BID:PRN constipation \n9. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *tramadol 50 mg 1 tablet(s) by mouth q6h prn Disp #*15 Tablet \nRefills:*0 \n10. Aspirin EC 81 mg PO DAILY \n11. Albuterol Inhaler 2 PUFF IH Q6H:PRN Asthma \n12. Atorvastatin 80 mg PO QPM \n13. Exemestane 25 mg PO DAILY \n14. GuaiFENesin ER 1200 mg PO Q12H \n15. MetFORMIN (Glucophage) 500 mg PO BID \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nCoronary artery disease\nSecondary:\nHLD\nHTN\nType 2 DM\nBreast CA Right ___\nAsthma\n\n \nDischarge Condition:\nAlert and oriented x3 nonfocal\n Ambulating, gait steady\n Sternal pain managed with oral analgesics\n Sternal Incision - healing well, no erythema or drainage\n\nEdema\n\n \nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild \nsoap, no baths or swimming, and look at your incisions\n \nPlease NO lotions, cream, powder, or ointments to incisions\n \nEach morning you should weigh yourself and then in the evening \ntake your temperature, these should be written down on the chart\n \nNo 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 \nNo lifting more than 10 pounds for 10 weeks\n \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 \nFemales: Please wear bra to reduce pulling on incision, avoid \nrubbing on lower edge\n \nFollowup Instructions:\n___\n" ]

[ "I25110", "I2582", "E119", "I9789", "D62", "E785", "I10", "J45909", "Z853", "I9581", "I252", "R05", "Z87891", "Y838", "Y92239" ]

[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "I2582: Chronic total occlusion of coronary artery", "E119: Type 2 diabetes mellitus without complications", "I9789: Other postprocedural complications and disorders of the circulatory system, not elsewhere classified", "D62: Acute posthemorrhagic anemia", "E785: Hyperlipidemia, unspecified", "I10: Essential (primary) hypertension", "J45909: Unspecified asthma, uncomplicated", "Z853: Personal history of malignant neoplasm of breast", "I9581: Postprocedural hypotension", "I252: Old myocardial infarction", "R05: Cough", "Z87891: Personal history of nicotine dependence", "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", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]

[ "E119", "D62", "E785", "I10", "J45909", "I252", "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:\nNeoplastic mucinous cyst\n \nMajor Surgical or Invasive Procedure:\n___\n1. Exploratory laparoscopy.\n2. Robot-assisted minimally invasive distal pancreatectomy and \nsplenectomy.\n\n \nHistory of Present Illness:\nMs. ___ initially began experiencing some nausea in ___ \nassociated with bloating and epigastric discomfort, and \noccasional emesis. She also endorsed occasional night sweats, \nflushing, and GERD symptoms. She denied urrent abdominal pain \nor history of jaundice, fevers, chills, weight loss, changes in \nappetite, ascites, or diarrhea (though she does endorse floating \nstools at times).\n\nDue to her symptoms, her primary physician sent her for an \nabdominal sonogram on ___ which showed an bilobed cystic \nlesion in the pancreatic body/tail measuring up to 2.6 x 1.9 cm. \nThis was further characterized by MRCP on ___ which showed a \n2.7 x 2.0 x 1.8 cm cystic lesion in the pancreatic body as well\nas liver cysts and a duplicated IVC. Further workup was done by \nERCP with EUS on ___ and a septated lesion was biopsied. \nCytopathology showed neoplastic mucinous cyst with atypia. Cyst \nfluid CEA was 194 and amylase was 27. Surgical pathology from \nthis biopsy showed only minute fibrous tissues.\n \nPast Medical History:\nHer past medical history is significant for generalized pruritus\nover many years, treated with fexofenadine 180mg daily. \n\n \nSocial History:\n___\nFamily History:\nHer family history is noncontributory. Speficially, she denies a \nfamily history of any malignancies, including pancreatic, \ncolorectal, melanoma, or any other cancers. She has no family \nhistory of gallstones, pancreatitis, or polyposis diseases.\n \nPhysical Exam:\nVS: Temp: 97.8 (Tm 98.8), BP: 135/85 (126-148/75-87), HR: 65\n(61-72), RR: 18 (___), O2 sat: 96% (95-98), O2 delivery: Ra\n \nGen: resting upright in bed, NAD, smiling\nCV: RRR, soft ___ systolic murmur over right ___ interspace \nPulm: clear to auscultation b/l, no r/r/w, no tachypnea or \nsplinting \nAbdomen: soft, non-distended with minimal tenderness, no tap or\nshake tenderness, incisions covered with dermabond without \nerythema. ___ to bulb sxn with thickened serosanguinous \noutput, previous ___ drain site with minimal drainage of serous \nfluid\nExtremities: WWP, no edema or calf tenderness \n \nPertinent Results:\n___ 09:40AM BLOOD WBC-15.9* RBC-3.94 Hgb-11.7 Hct-35.8 \nMCV-91 MCH-29.7 MCHC-32.7 RDW-12.9 RDWSD-42.7 Plt ___\n\n___ 06:15AM BLOOD Glucose-282* UreaN-5* Creat-0.7 Na-139 \nK-4.3 Cl-101 HCO3-25 AnGap-13\n___ 06:15AM BLOOD Calcium-8.5 Phos-1.9* Mg-1.7\n___ 06:39AM BLOOD ALT-21 AST-20 AlkPhos-58 TotBili-0.7\n \nBrief Hospital Course:\nThe patient was admitted to the General Surgical Service on \n___ for treatment of Cystic mass of pancreatic body. On \n___, the patient underwent Exploratory laparoscopy followed \nby Robot-assisted minimally invasive distal pancreatectomy\nand splenectomy. The operation proceeded without complications \nand the patient was transferred to the PACU in stable condition, \nthen to the floor that evening. \nThe following morning, she reported mild lower chest and \nepigastric pain. The pain was mild, did not radiate and \nself-resolved within a couple of hours. She had no other \nassociated symptoms. A chest radiograph showed no abnormalities \nand an EKG showed a left bundle branch block, unchanged from her \npre-op EKG. She started a clear liquid diet and was ambulating \nminimally around her room. Overnight into POD2 she developed \nworsening abdominal pain and spiked a fever to 102.9 and \ntachycardia to the 130s. She remained hemodynamically stable and \nher abdominal exam was non-peritonitic. A urinalysis was \nunremarkable and two blood cultures were drawn, both of which \nshowed no growth at time of discharge 5 days later. Her JP \namylase was found to be elevated to 1,397. A stat abdominal CT \nshowed a fluid collection adjacent to the tip of her ___ \ndrain, not effectively being drained. Her WBC was elevated to \n30.2. She was started on IV Zosyn and on POD3 she underwent \nrepositioning of her drain to terminate within the fluid \ncollection. 30cc of non-purulent fluid immediately returned and \nwere sent for culture, which showed no growth at time of \ndischarge 4 days later. \n\nShe was started on octreotide to decrease her drain output. \nEarly morning on POD4, the patient again became febrile and \ntachycardic overnight in the post-procedure period, but remained \nclinically and hemodynamically stable. Her WBC was elevated to \n34.6. She was maintained on telemetry monitoring and vancomycin \nwas added to her antibiosis. Her fever defervesced over the \ncourse of the day, and by POD5 she was afebrile, tolerating oral \nintake, and ambulating. Her vancomycin was discontinued and she \nwas started on pantoprazole. Her blood sugars were noted to be \nelevated to the low 200s, and her insulin sliding scale was \nadjusted to a higher basal dose with good effect. Her drain \namylase was re-checked and found to be 976, but output continued \nto be minimal. Her abdominal exam had significantly improved and \nshe reported minimal pain. \n\nOn POD6 her diet was advanced and she tolerated good oral \nintake. The infectious disease service was consulted to advise \non her post-discharge antiobiotic selection, and recommended \nCipro/Flagyl. On POD7 Ms. ___ was ambulating normally and was \nadvanced to a regular low-fat diet, which she tolerated well. \nHer post-splenectomy vaccines were administered. She was \ndischarged home with plans to follow up with Dr. ___ in clinic \non ___. \n\nHer ___ drain will remain in place until then and she will \ncontinue her antibiotic regimen of Cipro/Flagyl at home to \nfinish out a total course of 2 weeks. The patient was \ndischarged home with ___ services. The patient received \ndischarge teaching and follow-up instructions with understanding \nverbalized and agreement with the discharge plan.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. fexofenadine 180 mg oral DAILY \n2. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain \n3. Diazepam 5 mg PO QHS:PRN insomnia \n \nDischarge Medications:\n1. Ciprofloxacin HCl 500 mg PO Q12H \nPlease take twice per day until you follow up with Dr. ___ \n___ *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day \nDisp #*36 Tablet Refills:*0 \n2. MetroNIDAZOLE 500 mg PO BID \nPlease take twice per day until you follow up with Dr. ___ \n___ *metronidazole 500 mg 1 tablet(s) by mouth twice a day Disp \n#*36 Tablet Refills:*0 \n3. Pantoprazole 40 mg PO Q24H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n4. fexofenadine 180 mg oral DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nCystic mass of pancreatic body\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 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, \ndiarrhea, or other reasons. Signs of dehydration include dry \nmouth, rapid heartbeat, 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\n.\n Please get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. \n Avoid driving or operating heavy machinery while taking pain \nmedications.\n Please follow-up with your surgeon and Primary Care Provider \n(PCP) as advised.\n.\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\nJP Drain Care:\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 in the drain. \nCall the doctor, ___, or ___ nurse if the amount \nincreases significantly or changes in 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 in \nwater.\n *Make sure to keep the drain attached securely to your body to \nprevent pulling or dislocation.\n \nFollowup Instructions:\n___\n" ]

[ "C251", "Z23", "L299", "R000", "R509" ]

[ "C251: Malignant neoplasm of body of pancreas", "Z23: Encounter for immunization", "L299: Pruritus, unspecified", "R000: Tachycardia, unspecified", "R509: Fever, unspecified" ]

[]

[]

[ " \nName: ___ ___ 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:\nS/p thoracoscopy, pleural biopsy, pleural catheter placement\n \nMajor Surgical or Invasive Procedure:\nflexible broncoscopy with endobronchial ultrasound\nthoracoscopy and pleuroscopy\ntunneled pleural catheter placement\nfine needle aspiration\npleural biopsy\n\n \nHistory of Present Illness:\n___ with a PMH of bronchoalveolar carcinoma s/p RUL lobectomy \n___, recent diagnosis of RUL lung adenocarcinoma with recurrent \nright pleural effusion, RLE DVT on apixiban who presents s/p \nplanned thoracoscopy, pleural biopsy and repeat right pleural \ncatheter placement ___.\nPt was recently admitted ___ for streptococcus \npneumonia bacteremia with right empyema and right pleural \neffusion s/p right thoracentesis ___ in addition to pleural \ncatheter placement ___ and again ___, discharged with chest \ntube in place draining to gravity and on 2 week course of IV \nceftriaxone.\nOn ___ pt underwent a right thoracoscopy under MAC. Multiple \nright pleural biopsies were obtained and a right TPC was placed. \nOf note, apixiban was held prior to procedure.\nOn arrival to the floor, patient reports mild right sided chest \npain.\n\n \nPast Medical History:\n- Bronchoalveolar carcinoma s/p RUL lobectomy in ___ without \nadjuvant chemo or radiation\n- HTN\n- HLD\n- Intermittent claudication\n- Seborrheic keratosis\n- Cataract removal at ___\n \nSocial History:\n___\nFamily History:\nMother- DM\nFather- MI\nBrother- deceased, accident\nSister- ___ palsy\n \nPhysical Exam:\nADMISSION EXAM\n==============\nVS: 98.7 PO 156 / 67 R Lying 96 18 93 4L\nGENERAL: NAD\nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, \nMM dry\nNECK: supple, no LAD, no JVD\nHEART: RRR, S1 + S2 present, SEM ___ loudest RUSB\nLUNGS: Decreased breath sounds R lung up to mid-lung, left CTA. \nNo wheezes/crackles. Breathing comfortably on O2, no accessory \nmuscles\nABDOMEN: SNTND, +BS, no rebound/guarding\nEXTREMITIES: Trace ___ edema b/l, WWP, PPP\nNEURO: A&Ox3, CNII-XII intact, ___ strength in ___ b/l\nSKIN: Right arm bruise\n\nDISCHARGE EXAM\n==============\nVITALS: 98.3 152 / 65 94 18 94 Ra \nGENERAL: Chronically ill-appearing, in no apparent distress\nEYES: EOMI, PERRL\nCV: Regular rate and rhythm, no murmurs, rubs, or gallops\nRESP: Diminished breath sounds at the right base. Tunneled\npleural catheter in place with bandage overlying, some\nserosanguineous output. No increased work of breathing\nGI: Soft, nontender, nondistended, positive bowel sounds\nMSK: Trace pitting edema to bilateral lower extremities, no\nchange from yesterday.\nNEURO: No nerves II through XII grossly intact, moving all\nextremities spontaneously and with purpose \nPSYCH: Alert and oriented ×3, thoughts are linear and\ngoal-directed,\n \nPertinent Results:\nADMISSION LABS\n==============\n\n___ 04:59AM BLOOD WBC-14.7* RBC-3.01* Hgb-9.2* Hct-29.2* \nMCV-97 MCH-30.6 MCHC-31.5* RDW-15.3 RDWSD-52.8* Plt ___\n___ 04:59AM BLOOD ___ PTT-23.2* ___\n___ 04:59AM BLOOD Glucose-90 UreaN-22* Creat-1.2* Na-142 \nK-4.5 Cl-105 HCO3-22 AnGap-15\n___ 04:59AM BLOOD ALT-23 AST-22 LD(LDH)-198 AlkPhos-105 \nTotBili-0.2\n___ 04:59AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.0\n___ 04:59AM BLOOD\n\nPERTINENT LABS\n==============\n___ 05:03AM BLOOD WBC-11.5* RBC-2.89* Hgb-8.5* Hct-28.0* \nMCV-97 MCH-29.4 MCHC-30.4* RDW-15.5 RDWSD-53.1* Plt ___\n___ 07:15PM PLEURAL TNC-250* ___ Polys-49* \nLymphs-45* Monos-4* Eos-1* Plasma-1* Other-0\n___ 07:15PM PLEURAL TotProt-LESS THAN Glucose-LESS THAN \nLD(LDH)-40 Amylase-LESS THAN Albumin-LESS THAN \n\nDISCHARGE LABS\n==============\n___ 05:27AM BLOOD WBC-9.4 RBC-2.70* Hgb-7.9* Hct-26.1* \nMCV-97 MCH-29.3 MCHC-30.3* RDW-15.4 RDWSD-53.1* Plt ___\n___ 05:27AM BLOOD ___ PTT-56.0* ___\n___ 05:27AM BLOOD Glucose-92 UreaN-18 Creat-0.9 Na-145 \nK-3.9 Cl-107 HCO3-22 AnGap-16\n___ 05:27AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.9\n\nMICROBIOLOGY\n============\n___ 4:34 pm TISSUE RIGHT PARIETAL PLEURA. \n\n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n\n TISSUE (Final ___: NO GROWTH. \n\n ANAEROBIC CULTURE (Preliminary): NO GROWTH. \n\n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. \n\n ACID FAST CULTURE (Preliminary): \n\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. \n\n POTASSIUM HYDROXIDE PREPARATION (Final ___: \n NO FUNGAL ELEMENTS SEEN. \n\n___ 5:46 pm TISSUE\n RIGHT HILAR MASS CHECK FOR ACTYNOMYCES, NORCARDIA. \n\n GRAM STAIN (Final ___: \n 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n\n TISSUE (Preliminary): \n Reported to and read back by ___ ___ 9:14AM. \n\n VIRIDANS STREPTOCOCCI. RARE GROWTH. \n STAPHYLOCOCCUS, COAGULASE NEGATIVE. \n Isolated from broth media only, INDICATING VERY LOW \nNUMBERS OF\n ORGANISMS. \n\n ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. \n\n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. \n\n ACID FAST CULTURE (Preliminary): \n\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. \n\n POTASSIUM HYDROXIDE PREPARATION (Final ___: \n NO FUNGAL ELEMENTS SEEN. \n\n NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. \n\n___ 4:23 pm PLEURAL FLUID RIGHT PLEURAL EFFUSION. \n\n GRAM STAIN (Final ___: \n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. \n NO MICROORGANISMS SEEN. \n\n FLUID CULTURE (Final ___: NO GROWTH. \n\n ANAEROBIC CULTURE (Preliminary): NO GROWTH. \n\n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. \n\n ACID FAST CULTURE (Preliminary): \n\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. \n\n POTASSIUM HYDROXIDE PREPARATION (Final ___: \n NO FUNGAL ELEMENTS SEEN. \n\nIMAGING\n=======\nCXR ___\nIMPRESSION: \n1. Small right apical pneumothorax, unchanged. \n2. Interval insertion of a new right pleural catheter, which \nappears kinked. \n3. Left lower lobe atelectasis. \n\nCXR ___\nIMPRESSION: \n \n1. Interval improvement in right apical pneumothorax, which is \nnow tiny, if \nany. The right pleural catheter is no longer kinked. \n2. Interval improvement in left lower lobe atelectasis. \n\nCXR ___\nIMPRESSION: \n \n1. Interval increase in size of the moderate right pleural \neffusion and \nassociated atelectasis. \n2. Left lower lobe pulmonary edema. Despite the mild \nradiographic \nappearance, this may have more clinical significance given the \npatient's \nlimited pulmonary reserve. \n\nPATHOLOGY REPORTS:\n=================\nPLEURAL FLUID ___\nCYTOLOGY REPORT - Final\nSPECIMEN(S) SUBMITTED: PLEURAL FLUID, RIGHT\nDIAGNOSIS:\nPLEURAL FLUID, RIGHT:\nNEGATIVE FOR MALIGNANT CELLS.\n\nFNA ___\nSPECIMEN(S) SUBMITTED: FINE NEEDLE ASPIRATION, 7 LYMPH NODE EBUS \nTBNA\nDIAGNOSIS:\nENDOBRONCHIAL ULTRASOUND-GUIDED TRANSBRONCHIAL NEEDLE \nASPIRATION, LYMPH\nNODE, LEVEL7:\nNEGATIVE FOR MALIGNANT CELLS.\nPolymorphous lymphocytes consistent with lymph node sampling.\n\nFNA ___\nSPECIMEN(S) SUBMITTED: FINE NEEDLE ASPIRATION, RIGHT HILAR MASS\nDIAGNOSIS:\nFINE NEEDLE ASPIRATION, LUNG, RIGHT HILAR MASS:\nPOSITIVE FOR MALIGNANT CELLS.\nConsistent with patient's known adenocarcinoma of lung \n___ reviewed).\n\nPLEURAL BIOPSY/EXCISION ___\nRESULT PENDING AT DISCHARGE\n\nLymphocytes, histiocytes, neutrophils, and red blood cells\n\n \n\n \nBrief Hospital Course:\nBRIEF SUMMARY\n=============\nMrs. ___ is an ___ with a PMH of bronchoalveolar carcinoma\ns/p RUL lobectomy ___, recent diagnosis of RUL lung\nadenocarcinoma with recurrent right pleural effusion, RLE DVT on\napixiban who presented s/p planned thoracoscopy, pleural biopsy\nand repeat right pleural catheter placement on ___.\n\nACUTE ISSUES:\n=============\n# Loculated R Pleural Effusion: The patient underwent a planned \nthoracoscopy, pleural biopsy, and tunneled pleural catheter \nplacement on ___ in the setting of a recurrent right \npleural effusion likely due to a recent diagnosis of lung \nadenocarcinoma. She tolerated the procedure well. Effusion was \na transudate, the pleural fluid analysis was negative for \nmalignancy. A right hilar mass was biopsied and was positive \nfor adenocarcinoma cells. At the time of discharge, the pleural \nbiopsy results were still pending. She did experience a \ndecrease in her hemoglobin, however interventional pulmonology \ndid not feel that this was significant, and was likely a result \nof minor blood loss in combination with dilution. She was set \nup with a ___ to do daily drainages, and will follow up with \ninterventional pulmonology as an outpatient 2 weeks after \ndischarge.\n\n# Lung Adenocarcinoma. Large right suprahilar mass seen on CT\nChest ___ with ipsilateral mediastinal adenopathy and \npossible\nLLL metastasis. Lung biopsy ___ demonstrated KRAS wild type,\nPDL1 0%, no EGFR mutation. Pleural fluid cytology negative to\ndate. Staging indicates likely stage IV disease, though pt has\nbeen resistant to further imaging studies. Hilar mass biopsy \nduring this admission showed evidence of adenocarcinoma, however \npleural fluid studies were again negative and as above pleural \nbiopsy cytology was pending at the time of discharge\nWas previously followed by Dr. ___ she does not want to \nsee him again and is looking for another oncologist at present. \nShe will coordinate interventional pulmonology and her primary \ncare physician regarding future treatment options for her \ncancer.\n\n# RLE DVT: RLE DVT in femoral vein extending into\npopliteal/posterior tibial/peroneal vein noted on U/S ___. \nPt\ninitiated on apixiban during last admission, apixiban and \nlovenox\nheld prior to IP procedure (last dose lovenox ___. Post \nprocedurally, she was trialed on a heparin drip and tolerated \nthis well. She was restarted on her apixaban prior to discharge \n(did not want Lovenox despite improved efficacy in setting of \ncancer).\n\n# Streptococcal Bacteremia. Diagnosed with streptococcal\npneumonia bacteremia from presumed respiratory source during \nlast\nadmission. L midline place and pt receiving IV CTX at home. \ncontinued her CTX 2 g q24h. \n- Continue CTX 2 g IV Q24H (___).\n- F/u with ID as outpatient (scheduled ___\n- Per last DC summary, likely transition to 4 weeks levofloxacin\n500 mg PO QD (___)\n\n# Acute on chronic anemia: Pt with falling hemoglobin, from a \nbase of 10.5 down to 7.9 on day of discharge. IP felt that the \ndrop was due to mild procedural blood loss in combination with \ndilutional effect. She was counseled extensively on the signs \nand symptoms of further bleeding, and instructed to proceed to \nthe ED if these symptoms should occur. \n\nCHRONIC ISSUES:\n===============\n\n# HTN: \n- Cont home amlodipine 10 mg QD \n- held atenolol (per last d/c summary. HR and BP stable this \nadmission)\n\n# HLD: \n- Held home atorvastatin 10 mg QPM (held upon last discharge iso\ntransaminitis)\n- Held home ASA 81 mg QD per last DC summary held iso apixiban\n\n# Gout: \n- Cont home allopurinol ___ mg QD \n\n# Dry Eyes\n- Cont home eye drops\n\nTRANSITIONAL ISSUES\n===================\n[ ] will need repeat CBC on ___ given dropping H/H in the \nsetting of recent pleural catheter placement. \n-will need daily drainage of her tunneled pleural catheter. ___ \nwill help with this.\n[ ] will need to follow up with an oncologist to discuss further \ncare regarding her lung adenocarcinoma\n[ ] will need to continue antibiotics: \n- Continue CTX 2 g IV Q24H (___).\n- F/u with ID as outpatient (scheduled ___\n- Per last DC summary, likely transition to 4 weeks levofloxacin\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Apixaban 5 mg PO BID \n2. Allopurinol ___ mg PO DAILY \n3. amLODIPine 10 mg PO DAILY \n4. Artificial Tear Ointment 1 Appl BOTH EYES QHS dry eyes \n5. Artificial Tears ___ DROP BOTH EYES PRN dry eye \n6. Atenolol 50 mg PO DAILY \n7. Atorvastatin 10 mg PO QPM \n8. Aspirin EC 81 mg PO DAILY \n9. Chlorpheniramine Maleate Dose is Unknown PO Frequency is \nUnknown \n10. CefTRIAXone 2 gm IV Q24H \n11. Enoxaparin Sodium 90 mg SC QHS \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \nRX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6) \nhours Disp #*60 Tablet Refills:*0 \n2. Apixaban 5 mg PO BID \nRX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0 \n3. Allopurinol ___ mg PO DAILY \n4. amLODIPine 10 mg PO DAILY \n5. Artificial Tear Ointment 1 Appl BOTH EYES QHS dry eyes \n6. Artificial Tears ___ DROP BOTH EYES PRN dry eye \n7. CefTRIAXone 2 gm IV Q24H \nRX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 g IV q24h Disp \n#*3 Intravenous Bag Refills:*0 \n8. HELD- Aspirin EC 81 mg PO DAILY This medication was held. Do \nnot restart Aspirin EC until told by your doctor\n9. HELD- Atenolol 50 mg PO DAILY This medication was held. Do \nnot restart Atenolol until told by your doctor\n10. HELD- Atorvastatin 10 mg PO QPM This medication was held. \nDo not restart Atorvastatin until told by your doctor\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___ \n \nDischarge Diagnosis:\nlung adenocarcinoma\nright pleural effusion\ndeep vein thrombosis (right leg)\nstreptococcal bacteremia\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 medicine service after you underwent a \nthoracoscopy, pleural biopsy, and repeat pleural catheter \nplacement given your right pleural effusion (fluid collection \naround the lung). \n\nYou tolerated the procedure well. We held your apixaban around \nthe procedure and then started you on a heparin drip (another \ntype of blood thinner) to see if you could tolerate \nanticoagulation. You did, and were restarted on your apixaban. \nYour blood counts did fall a little bit, but IP was not overly \nconcerned but want you to have labs drawn on ___ to recheck \nyour blood level. You will follow up with interventional \npulmonology in two weeks.\n\nWe continued your antibiotics for your lung/blood infection. You \nwill follow up with the infectious disease doctors as ___ \noutpatient on ___.\n\nYou were discharged home with services to help take care of your \nnew tunneled pleural catheter. They will drain this every day. \nYou should follow up with your physicians as below.\n\n***On ___ after infectious disease appointment and before you \nsee Dr. ___ go to the lab in the ___ building to \nhave your blood drawn. Just let them know your name and that you \nhave a lab draw waiting***\n\nWe wish you the best,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "J90", "C3411", "R7881", "B953", "I10", "Z902", "E785", "Z87891", "Z86718", "Z7901", "D500", "M109", "H579", "R0902" ]

[ "J90: Pleural effusion, not elsewhere classified", "C3411: Malignant neoplasm of upper lobe, right bronchus or lung", "R7881: Bacteremia", "B953: Streptococcus pneumoniae as the cause of diseases classified elsewhere", "I10: Essential (primary) hypertension", "Z902: Acquired absence of lung [part of]", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "Z86718: Personal history of other venous thrombosis and embolism", "Z7901: Long term (current) use of anticoagulants", "D500: Iron deficiency anemia secondary to blood loss (chronic)", "M109: Gout, unspecified", "H579: Unspecified disorder of eye and adnexa", "R0902: Hypoxemia" ]

[ "I10", "E785", "Z87891", "Z86718", "Z7901", "M109" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nCeclor\n \nAttending: ___.\n \nChief Complaint:\nAcute appendicitis\n \nMajor Surgical or Invasive Procedure:\n___: Laparoscopic appendectomy\n\n \nHistory of Present Illness:\n___ man with history of hepatitis C and alcohol-induced\ncirrhosis, leading to decompensated liver disease and \nhepatorenal\nsyndrome requiring dialysis, who underwent a combined liver and\nkidney transplantation on ___. His immediate post op\ncourse was c/b bleeding for which he was taken back on POD1\nduring which he also had a ventral hernia repair with mesh .\n\nThe patient's post-transplant course was complicated by CMV\ninfection that was treated with Valcyte and mild acute cellular\nrejection of his liver. He also developed an autoimmune \nhemolytic\nanemia and pancytopenia for which he is being followed by\nHematology/Oncology and is on a very slow prednisone taper. He\nalso had a mild acute cellular rejection. He is off MMF due to\nhistory of leukopenia. \nHe presented to OSH yesterday with abdominal pain for 3 days s/w\nn/v no chills or fever. no urinary or other GI symptoms\nat the OSH he had a CT scan which show Ac appendicitis with\nappendicolith at the base. he was transferred to ___ for\nfurther care.\n\nROS negative other than the HPI\n \nPast Medical History:\n1. Hepatitis C, genotype 1A, status post Harvoni/ribavirin \n2. Alcohol abuse \n3. Cirrhosis, requiring liver and kidney transplant ___ \n4. History of depression and suicidal ideation \n5. Ventral hernia and umbilical hernia repair (___) \n6. Temporary portacaval shunt \n7. Portal vein thrombectomy (___) \n8. CMV viremia (___) \n9. Mild acute cellular liver graft rejection (___) \n10. Abdominal exploration with repair of leaking recurrent \numbilical hernia on (___) \n \nSocial History:\n___\nFamily History:\nNo family history of liver disease. \nFather had CHF. Sister had breast cancer in her ___. \n \n \nPhysical Exam:\nOn Admission:\nGeneral: well developed, overweight, seems painful\nEyes: no scleral icterus \nMouth: moist mucous membranes\nResp: breathing comfortably no wheeze\n___: He has a systolic heart murmur. mild edema.\nAbdomen: soft, obese and non disteneded. tender TP mid and RLQ\nabdomen with local peritoneal signs he has well\nhealing wounds. slight bulge in his mid abdomen that is\nconcerning for a recurrent hernia.\nExtremities: warm, well perfused, \nNeuro: grossly intact, AAOx3, \nPsych: appropriate affect.\n.\nExam at Discharge:\n 4 HR Data (last updated ___ @ 2344)\n Temp: 97.7 (Tm 99.1), BP: 112/77 (103-112/70-78), HR: 95\n(92-97), RR: 18 (___), O2 sat: 96% (94-97), O2 delivery: Ra,\nWt: 259.26 lb/117.6 kg\n\nFluid Balance (last updated ___ @ 2233)\n Last 8 hours Total cumulative 946ml\n IN: Total 946ml, PO Amt 620ml, IV Amt Infused 326ml\n OUT: Total 0ml, Urine Amt 0ml\n Last 24 hours Total cumulative -65ml\n IN: Total 2560ml, PO Amt 720ml, IV Amt Infused 1840ml\n OUT: Total 2625ml, Urine Amt 2625ml\n\nGENERAL: [x ]NAD [x ]A/O x 3 \nCARDIAC: [x ]RRR \nLUNGS: [x ]no respiratory distress \nABDOMEN: x]soft [x ]appropriately tender\n[ ]nondistended [ x]no rebound/guarding \nWOUND: [x] intact with steris in place\nEXTREMITIES: [ x]no CCE \n \nPertinent Results:\nLabs on Admission ___ \nWBC-7.1 RBC-4.21* Hgb-12.4* Hct-38.1* MCV-91 MCH-29.5 MCHC-32.5 \nRDW-15.4 RDWSD-49.2* Plt ___ PTT-31.1 ___\nGlucose-116* UreaN-10 Creat-1.1 Na-140 K-4.4 Cl-103 HCO3-23 \nAnGap-14\nALT-41* AST-21 AlkPhos-90 TotBili-3.5*\nAlbumin-3.5 Calcium-7.4* Phos-2.3* Mg-1.4*\ntacroFK-9.8\nLabs at Discharge ___ \nWBC-4.6 RBC-3.20* Hgb-9.3* Hct-29.6* MCV-93 MCH-29.1 MCHC-31.4* \nRDW-15.4 RDWSD-52.2* Plt Ct-78*\n___\nALT-26 AST-9 AlkPhos-82 TotBili-1.3\nCalcium-7.8* Phos-2.7 Mg-2.4\ntacroFK-11.___ Year old male with history of liver/kidney transplant who \npresents with abdominal pain and diagnosed with acute \nappendicitis.\n.\nPatient was taken urgently to the OR with Dr. ___ a \nlaparoscopic appendectomy. There were no complications reported \nduring the surgery. ___ antibiotics were continued for 24 \nhours.\n.\nLFTs were mildly elevated on POD 1, these were checked serially \nfor the next ___ hours and had returned to normal by day of \ndischarge on POD 2\n.\nPatient had considerable initial pain, but improved by POD 2 and \nwas ready for discharge to home.\n.\nPatient on immunosuppression with Tacro, prednisone. Levels were \nchecked on this admission and adjusted lower to 1.5 BID for \ndischarge.\nOther medications resumed as indicated\n.\nPatient to have follow up labs on ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. FoLIC Acid 1 mg PO DAILY \n2. Gabapentin 300 mg PO BID \n3. Pantoprazole 40 mg PO Q24H \n4. PredniSONE 7 mg PO EVERY OTHER DAY \n5. PredniSONE 8 mg PO EVERY OTHER DAY \n6. Tacrolimus 2 mg PO Q12H \n7. TraZODone 50 mg PO QHS:PRN insomnia \n8. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild/Fever \n9. Calcium Carbonate 1500 mg PO DAILY \n10. Vitamin D ___ UNIT PO 1X/WEEK (FR) ___ \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \nWhile taking narcotic pain medication\nOver the counter \n2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nNo driving if taking this medication, taper as tolerated. \nPartial fill on patient request \nRX *oxycodone 5 mg 1 tablet(s) by mouth Every 4 hours as needed \nDisp #*40 Tablet Refills:*0 \n3. Tacrolimus 1.5 mg PO Q12H \nLabs ___ with trough tacro level \n4. Acetaminophen 325-650 mg PO Q8H:PRN Pain - Mild/Fever \nMaximum 6 of the 325 mg tablets daily \n5. Calcium Carbonate 1500 mg PO DAILY \n6. FoLIC Acid 2 mg PO DAILY \n7. Gabapentin 300 mg PO BID \n8. Pantoprazole 40 mg PO Q24H \n9. PredniSONE 7 mg PO EVERY OTHER DAY \n10. PredniSONE 8 mg PO EVERY OTHER DAY \n11. TraZODone 50 mg PO QHS:PRN insomnia \nAvoid combining with narcotics \n12. Vitamin D ___ UNIT PO 1X/WEEK (FR) ___ \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAcute Appendicitis\nHistory of liver/kidney transplant\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 the transplant clinic at ___ for fever of \n101 or greater, chills, nausea, vomiting, diarrhea, \nconstipation, inability to tolerate food, fluids or medications, \nyellowing of skin or eyes, increased abdominal pain, incisional \nredness, drainage or bleeding, dizziness or weakness, decreased \nurine output or dark, cloudy urine, swelling of abdomen or \nankles, weight gain of 3 pounds in a day or any other concerning \nsymptoms.\n.\nPlease get labs on ___, with results to the transplant \nclinic. (Fax ___ . CBC, Chem 10, AST, ALT, Alk Phos, T \nBili, Trough Tacro level, Urinalysis.\n.\n*** On the days you have your labs drawn, do not take your \nTacrolimus until your labs are drawn. Bring your Tacrolimus with \nyou so you may take your medication as soon as your labwork has \nbeen drawn.\n.\nFollow your medication card, keep it updated with any dosage \nchanges, and always bring your card with you to any clinic or \nhospital visits.\n.\nBring your list of current medications to every clinic visit.\n.\nYou may shower. Allow the water to run over your incisions and \npat area dry. No rubbing, no lotions or powder near the \nincisions. You may leave the incisions open to the air. \n.\nNo tub baths or swimming\n.\nNo driving if taking narcotic pain medications\n.\nNo lifting over 10 pounds for 6 weeks after surgery to avoid \nhernia formation\n \nFollowup Instructions:\n___\n" ]

[ "K3580", "Z944", "Z940", "D591", "Z86718", "I10", "E785", "K219", "Z87891", "E663", "Z6834" ]

[ "K3580: Unspecified acute appendicitis", "Z944: Liver transplant status", "Z940: Kidney transplant status", "D591: Other autoimmune hemolytic anemias", "Z86718: Personal history of other venous thrombosis and embolism", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "Z87891: Personal history of nicotine dependence", "E663: Overweight", "Z6834: Body mass index [BMI] 34.0-34.9, adult" ]

[ "Z86718", "I10", "E785", "K219", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nZithromax\n \nAttending: ___.\n \nChief Complaint:\nLow Back Pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with history of\nrecently diagnosed multiple myeloma who presents with acute on\nchronic back pain.\n\nShe had back pain in ___ that led to work-up and diagnosis\nof her multiple myeloma. She reports worsening back pain and is\nnow unable to walk due to the pain. She has been taking tylenol\nand oxycodone for the pain. She also reports urinary \nincontinence\nfor the past 2 weeks. She also notes worsening shortness of\nbreath for the past few days. Due to her worsening pain she\ncalled EMS. While she was being carried down the stairs in a\nchair stretcher, the chair slipped and hit the ground. She did\nnot fall out of the chair. She denies that her pain is worse\nafter this incident. She denies fecal incontinence. She denies\nfevers or chills. She denies trauma and falls.\n\nShe has been followed by Dr. ___ at ___ for her myeloma.\nUnfortunately the Atrius quick link is not working so unable to\nview outpatient records a this time. She does though have an\nappointment with Dr. ___ on ___.\n\nOn arrival to the ED, initial vitals were 99.8 107 154/87 18 98%\nRA. Labs were notable for WBC 5.8, H/H 8.4/26.6, Plt 285, INR\n1.4, Na 144, K 4.3, BUN/Cr ___, LFTs wnl, LDH 664, Ca ___, \nMg\n1.3, BNP 668, hapto 409, tropT < 0.01, and UA negative. Code \ncord\nwas called. MRI C/T/L-Spine showed T12 compression fracture with\nretroplusion into the canal without cord compression. CTA chest\nshowed left lower lobe PE and pathologic rib fractures. Spine \nwas\nconsulted who recommended TLSO brace and no surgical\nintervention. Patient was given IV heparin, Tylenol 1g IV x 2,\nmagnesium 2g IV, calcitonin 80 units SC, and 1L NS. PVR was \n10cc.\nPrior to transfer vitals were 98.7 96 155/69 22 98% 4L.\n\nOn arrival to the floor, patient reports ___ lower back pain.\nShe denies fevers/chills, night sweats, headache, vision \nchanges,\ndizziness/lightheadedness, weakness/numbness, cough, hemoptysis,\nchest pain, palpitations, abdominal pain, nausea/vomiting,\ndiarrhea, hematemesis, hematochezia/melena, dysuria, hematuria,\nand new rashes.\n\n \nPast Medical History:\n- Multiple Myeloma\n- Hypertension\n- Hyperlipidemia\n- Hyperlipidemia\n- Anxiety\n- s/p hysterectomy\n\n \nSocial History:\n___\nFamily History:\nBrother with leukemia.\n \nPhysical Exam:\nADMISSION EXAM:\n===============\nVS: Temp 98.1, BP 143/79, HR 97, RR 19, O2 sat 94% 4L.\nGENERAL: Very pleasant woman, appears in pain, lying in bed.\nHEENT: Anicteric, PERLL, OP clear.\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: Appears in moderate respiratory distress, clear to\nauscultation bilaterally.\nABD: Soft, non-tender, non-distended, positive bowel sounds.\nEXT: Warm, well perfused, no lower extremity edema.\nMSK: Thoracic and lumbar midline tenderness to palpation.\nNEURO: A&Ox3, good attention and linear thought, CN II-XII\nintact. Strength full throughout but bilateral hip flexion\nlimited due to pain. Sensation to light touch intact.\nSKIN: No significant rashes.\n\nDISCHARGE EXAM:\n===============\n98.8 105/67 101 18 96 RA \nGENERAL: Lying comfortably in bed, in no acute distress\nHEENT: Anicteric sclerae\nCARDIAC: Normal rate and rhythm. Normal S1 and S2. Grade ___\nsystolic murmur.\nLUNG: Decreased breath sounds at the bases. Faint crackles\nbilaterally in lower lung fields.\nABD: Soft, non-tender, non-distended.\nEXT: Warm, well perfused, no lower extremity edema.\nNEURO: A&Ox3. Motor and sensory function grossly intact\nthroughout.\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 11:16AM WBC-5.8 RBC-2.55* HGB-8.4* HCT-26.6* MCV-104* \nMCH-32.9* MCHC-31.6* RDW-14.8 RDWSD-56.9*\n___ 11:16AM PLT COUNT-285\n___ 11:16AM NEUTS-56.4 ___ MONOS-8.9 EOS-0.9* \nBASOS-0.5 NUC RBCS-0.7* IM ___ AbsNeut-3.25 AbsLymp-1.82 \nAbsMono-0.51 AbsEos-0.05 AbsBaso-0.03\n___ 11:16AM RET AUT-1.1 ABS RET-0.03\n___ 11:16AM GLUCOSE-119* UREA N-13 CREAT-0.9 SODIUM-144 \nPOTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-28 ANION GAP-12\n___ 07:45PM ___ PTT-21.8* ___\n___ 11:16AM ALT(SGPT)-27 AST(SGOT)-36 LD(LDH)-664* ALK \nPHOS-87 TOT BILI-0.4\n___ 11:16AM LIPASE-16\n___ 11:16AM cTropnT-<0.01 proBNP-668*\n___ 11:16AM ALBUMIN-3.8 CALCIUM-11.9* PHOSPHATE-4.4 \nMAGNESIUM-1.3*\n___ 11:16AM HAPTOGLOB-409*\n\nDISCHARGE LABS:\n================\n___ 06:05AM BLOOD WBC-3.9* RBC-2.36* Hgb-7.8* Hct-24.9* \nMCV-106* MCH-33.1* MCHC-31.3* RDW-17.0* RDWSD-64.2* Plt ___\n___ 06:05AM BLOOD Glucose-99 UreaN-27* Creat-1.0 Na-141 \nK-4.3 Cl-101 HCO3-27 AnGap-13\n___ 06:00AM BLOOD ALT-36 AST-19 LD(LDH)-332* AlkPhos-107* \nTotBili-0.3\n___ 06:05AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.2\n\nMICROBIOLOGY:\n=============\n__________________________________________________________\n___ 1:37 pm MRSA SCREEN SOURCE: NASAL SWAB. \n\n **FINAL REPORT ___\n\n MRSA SCREEN (Final ___: No MRSA isolated. \n__________________________________________________________\n___ 2:47 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___ 1:35 pm BLOOD CULTURE 1 OF 2. \n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n\nIMAGING:\n========\nRIB UNILAT, W/ AP CHEST LEFT Study Date of ___ \nIMPRESSION: \nNo prior chest radiographs are available. \nStudy is read in conjunction with chest CTA ___. \nCardiomegaly is severe, pulmonary edema is mild. No \npneumothorax or pleural effusion. In addition healed rib \nfractures there are acute fractures of the posterolateral left \nseventh rib and perhaps the lateral fourth. \n\nCTA CHEST Study Date of ___ \nIMPRESSION: \n1. Left lower lobe acute lobar and segmental pulmonary embolism. \n No evidence of acute right heart strain. \n2. Chronically dilated main pulmonary artery, correlate for \npulmonary arterial hypertension. \n3. Several small bilateral pleural effusions and scattered \nbilateral \nsubsegmental atelectasis. \n4. Innumerable lytic bony lesions consistent with known multiple \nmyeloma. T12 pathologic compression fracture, appears acute, \nbetter assessed and same-day MR exam \n5. Multiple pathologic rib fractures, some of which are new from \nprior, \ndetailed above. \n\nMR ___ W/O CONTRAST Study Date of ___ \nIMPRESSION: \n1. Diffusely abnormal bone marrow signal consistent with \nmyelomatous \ninfiltration given the clinical history. \n2. T2 vertebral body demonstrates mild-to-moderate anterior \nwedging and mild left-sided retropulsion, new compared to ___ut likely not acute with only minimal \nedema. The left ventral thecal sac is mildly indented without \nmass effect on the spinal cord. \n3. T3 superior endplate deformity with minimal loss of height \nand T11 superior endplate deformity without significant loss of \nheight are new compared to ___ but not acute \nwithout marrow edema. No retropulsion. \n4. New severe compression of T12 vertebral body with 7 mm \nretropulsion appears subacute, with only mild edema along the \nmain fracture line. Moderate associated spinal canal narrowing \nwith minimal ventral cord remodeling, but no cord compression or \ncord signal abnormality. Moderate to severe bilateral T11-T12 \nneural foraminal narrowing. \n5. Chronic L1 compression fracture with minimal retropulsion and \nno spinal \ncanal narrowing, similar to ___. \n6. No evidence for pathologic fractures in the cervical spine. \nAt C4-C5, mild retrolisthesis and degenerative changes cause \nmild spinal canal stenosis with minimal ventral cord remodeling \nbut no evidence for cord signal abnormalities. \n7. Multiple right rib deformities related to fractures are \ngrossly similar to the ___ CT. Some of the left \nposterior ribs appear mildly \nirregular without frank deformities, not well evaluated. Please \nnote that the ribs are not fully imaged on this exam. \n8. Small left pleural effusion with intermediate T2 signal, \nwhich may indicate complexity. \n\nCT HEAD W/O CONTRAST Study Date of ___ \nIMPRESSION: \n1. Innumerable lucent lesions scattered throughout the calvarium \nconsistent with known multiple myeloma. \n2. No evidence of intraparenchymal mass or hemorrhage. \n\nCHEST (PORTABLE AP) Study Date of ___ \nIMPRESSION: \nFindings consistent with persistent mild pulmonary edema and \nmultifocal \natelectasis in each lower lung. \n\nTransthoracic Echocardiogram Report Date: ___\nIMPRESSION: Hyperdynamic biventricular systolic function. Mild \nresting left ventricular outflow tract gradient due to high \nstroke volume ___ explains murmur. Dilated left atrium and \nleft ventricular hypertrophy most consistent with hypertensive \nheart disease. Given history of multiple\nmyeloma if there is no history of hypertension, investigation \nfor amyloid should be considered.\n\nCT CHEST W/O CONTRAST Study Date of ___ \nIMPRESSION: \n1. Motion artifact severely limits evaluation of the lung \nparenchyma. Within these limitations, peripheral ground-glass \nopacities and interlobular septal thickening suggest volume \noverload. \n2. Bibasilar linear opacities are favored to represent \nsubsegmental \natelectasis. \n3. Trace left pleural effusion, which is decreased. \n4. Extensive lytic osseous lesions in keeping with multiple \nmyeloma. \n5. Pathologic compression deformities of the T2 and T12 \nvertebral bodies have progressed since ___. The L1 \ncompression deformity appears similar to minimally progressed \nsince the ___ MR spine, accounting for differences \nin imaging modality. \n\n \nBrief Hospital Course:\n==================\nSUMMARY STATEMENT:\n================== \nMs. ___ is a ___ female with history of \nrecently diagnosed multiple myeloma who presents with acute on \nchronic back pain found to have T12 compression fracture, acute \nPE, and hypercalcemia who started multiple myeloma treatment. \n\n==============\nACTIVE ISSUES:\n==============\n# Acute Hypoxic Respiratory Failure\n# Acute Pulmonary Embolism\nPatient found to have left lower lobe acute lobar and segmental \nPE without evidence of acute right heart strain. BNP mildly \nelevated and troponin negative. During the beginning of her \nhospitalization had O2 requirement between ___ NC. Also has an \nelevated JVP elevated on exam. TTE without evidence of right \nheart strain, but did have mild LVH and dilated LA. She was \ninitially on heparin gtt, followed by lovenox, and eventually \ntransitioned to rivaroxaban. During the evening of ___ \novernight she was hypoxic to high ___ and CXR with \npulmonary edema/atelectasis and increased BNP. She was given low \ndose Lasix with a goal to be slightly net negative to optimize \nrespiratory status given likely HFpEF (see below). In addition, \nshe had low grade fevers and had a CT scan that showed possible \npneumonia. She finished a course of cefepime that was \ntransitioned to augmentin. Repeat CXR revealed improvement in \nvolume status but atelectasis remained likely secondary to \nsplinting. On discharge she was maintaining O2 sat of low-mid \n___ on RA.\n\n#Multiple Myeloma\nOn bone marrow biopsy, aspirate with 71% plasma cells. \nCytogenetics with normal female karyotype. FISH positive for \ndeletion of 13q14, deletion of TP53. Gain of chromosomes 5,9,15, \nand rearrangement of MYC. No indication for radiation therapy. \nConsidered kyphoplasty, but deferring for now iso PE and pain \nstarted to improve with opioids. It was decided that starting \nand stopping AC was contraindicated during acute PE. Will follow \nup with Dr. ___ to discuss initiation of lenolidomide once \napproved by insurance followed by a follow up with Dr. \n___ to discuss transplant. Regimen thus far as below:\n- Dexamethasone 40mg weekly (Finished Dexamethasone load 40mg x4\ndays ___ Most recent dose ___ of 20mg\n- Bortezomib ___ and finished first cycle while inpatient)\n- Lenolidomide once approved (Discuss with primary oncologist)\n- Ppx with acyclovir and Bactrim \n- Pamidronate as below \n- Consider cardiac pyrophosphate scan or CMR for cardiac amyloid \n\n\n#HFpEF (EF>70%)\nTTE with LVH and given myeloma with increased free light chains, \nrequested bone marrow stain for ___ red and can consider \n99mTc-Pyrophosphate scintigraphy or CMR if concern remains for \namyloid cardiomyopathy. ___ red stain pending upon discharge.\n\n#Acute on Chronic Cancer-Related Back Pain:\n#T12 Compression Fracture:\nPatient found to have T12 compression fracture with retroplusion \ninto the canal without cord compression. Neuro exam intact. \nEvaluated by Neurosurgey and no plan for surgical intervention, \nbut put in TLSO brace for when sitting and standing/walking. \nShould follow up with neurosurgery in ~2 weeks from discharge. \nPain control with managed with MS ___, oxycodone, and \nlidocaine patch. Can consider weaning off opioids as pain \nimproves.\n\n#Pathologic Rib Fractures\nSeen by acute care surgery in the ED. Pain control as above and \nencourage to use incentive spirometer.\n\n========================\nCHRONIC/RESOLVED ISSUES:\n========================\n#Pneumonia\n#Low grade fever\nOn initial presentation sent BCx, U/A, UCx, CT-chest, B-Glucan, \nGalactomannin, and empirically started on ceftriaxone. Fungal \ncultures, BCx, and UCx negative. CT chest showed ground glass \nopacities, likely atelectasis, but could possibly represent \npneumonia so was started on broad spectrum antibiotics cefepime. \nVancomycin was discontinued given clinical stability and with \nnegative MRSA swab. On ___, switched from cefepime to \naugmentin for 2 more days to finish 7 day course. Respiratory \nstatus vastly improved and on RA without signs of infection. \n\n#Hypercalcemia: Secondary to malignancy. Received calcitonin in \nthe ED followed by 60mg IV pamidronate on the floor (___). \nRequired intermittent PO calcium carbonate to prevent \novercorrection. Calcium stable on discharge.\n\n#Anemia: Likely secondary to myeloma. Did not require \ntransfusions.\n\n#Anxiety: Continued on home Venlafaxine and home Perphenazine\n\n#Hypertension: Initially held HCTZ, but re-started prior to \ndischarge.\n\n#Hyperlipidemia: Held home statin given contraindication with \nchemotherapy. \n\n====================\nTRANSITIONAL ISSUES:\n====================\n[] Consider amyloid cardiomyopathy workup with CMR vs \n99mTc-Pyrophosphate scintigraphy\n[] Has had intermittent diuresis with between ___ IV Lasix \nfor volume overload. Please assess volume status and weights \nregularly and diurese as necessary. Weight at discharge was \n166.2 lbs and not sent home on lasix.\n[] F/u ___ red BM stain from ___ path lab\n[] Held statin in setting of initiating chemotherapy and mild \ntransaminitis. Please re-start when OK by oncologist.\n[] Check CBC and chemistry panel at follow up appointment.\n[] Consider kyphoplasty to help with pain management if does not \ncontinue to improve \n[] Discharged on rivaroxaban 15mg BID for acute PE treatment. \nThis should be transitioned to rivaroxaban 20mg daily on ___.\n[] Will need follow up with spine in 2 weeks (spine clinic \nshould call patient, but given number in case they do not)\n[] Wean opioids as tolerated \n\nDischarge Hgb 7.8\nDischarge WBC 3.9\nDischarge Platelets 272\nDischarge Creatinine 1.0\n\nContact: ___ (husband) ___\nCode: Full\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. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate \n\n2. Venlafaxine XR 75 mg PO DAILY \n3. Hydrochlorothiazide 25 mg PO DAILY \n4. Atorvastatin 20 mg PO QPM \n5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n6. meloxicam 15 mg oral DAILY \n7. Perphenazine 4 mg PO QHS \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q12H \n2. Lidocaine 5% Patch 1 PTCH TD QAM \nPatch on for 24 hours and off for 24 hours \n3. Morphine SR (MS ___ 30 mg PO Q12H \nRX *morphine 30 mg 1 tablet(s) by mouth Twice daily Disp #*28 \nTablet Refills:*0 \n4. Polyethylene Glycol 17 g PO BID:PRN Constipation - Second \nLine \n5. Rivaroxaban 15 mg PO BID \n6. Senna 8.6 mg PO BID:PRN Constipation - First Line \n7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n8. Hydrochlorothiazide 25 mg PO DAILY \n9. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate Duration: 7 Days \nRX *oxycodone 5 mg 1 tablet(s) by mouth Every 6 hours Disp #*20 \nTablet Refills:*0 \n10. Perphenazine 4 mg PO QHS \n11. Venlafaxine XR 75 mg PO DAILY \n12. HELD- Acetaminophen 650 mg PO Q6H:PRN Pain - Mild This \nmedication was held. Do not restart Acetaminophen until talking \nwith your oncologist at follow up\n13. HELD- Atorvastatin 20 mg PO QPM This medication was held. \nDo not restart Atorvastatin until talking with your oncologist \nat follow up\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis:\n==================\nPulmonary embolism\nMultiple myeloma\n\nSecondary Diagnosis:\n====================\nT12 compression fracture\nRib fracture\nHypercalcemia\nAnemia\nAnxiety\nHTN\nHLD\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\nIt was a pleasure taking care of you at ___!\n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n- You had severe back pain that made you unable to move and \ndifficulty breathing \n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n- You were found to have fractures in your spine bone and your \nrib that was likely causing your severe pain\n- A CT scan of your chest found a blood clot in one of the blood \nvessels to your lungs\n- You were put on a blood thinning medication to treat the blood \nclot\n- You were given a back brace to prevent damage to your spinal \ncord and this should be worn until you follow up with the spine \nsurgeons\n- The broken rib and vertebrae caused you a lot of pain, which \ndid not allow your lungs to expand enough so you were encouraged \nto use the incentive spirometer 10 times per hour and given pain \nmedication \n- Your broken bones were caused by a blood cancer called \nmultiple myeloma \n- You were started on chemotherapy for the multiple myeloma\n- Multiple myeloma caused you to have high calcium, so you were \ntreated with a medication to lower your calcium\n\nWHAT SHOULD I DO WHEN I GO HOME?\n- Please follow up with your oncologist Dr. ___ to \ncontinue your chemotherapy as scheduled\n- Please follow up with Dr. ___ to discuss the next steps \nin your multiple myeloma treatment\n- Also follow up with the spine surgeon to assess your fractures \nand your brace\n- Please continue taking your medication as prescribed \n\nWe wish you the best,\n\nYour ___ care team\n \nFollowup Instructions:\n___\n" ]

[ "I2699", "J9601", "J189", "C9000", "J9811", "I5030", "M8458XA", "E8352", "E785", "G893", "D630", "F419", "E8342", "I110" ]

[ "I2699: Other pulmonary embolism without acute cor pulmonale", "J9601: Acute respiratory failure with hypoxia", "J189: Pneumonia, unspecified organism", "C9000: Multiple myeloma not having achieved remission", "J9811: Atelectasis", "I5030: Unspecified diastolic (congestive) heart failure", "M8458XA: Pathological fracture in neoplastic disease, other specified site, initial encounter for fracture", "E8352: Hypercalcemia", "E785: Hyperlipidemia, unspecified", "G893: Neoplasm related pain (acute) (chronic)", "D630: Anemia in neoplastic disease", "F419: Anxiety disorder, unspecified", "E8342: Hypomagnesemia", "I110: Hypertensive heart disease with heart failure" ]

[ "J9601", "E785", "F419", "I110" ]

[]

[ " \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:\nDyspnea on exertion\n \nMajor Surgical or Invasive Procedure:\n___ - 1. Coronary artery bypass grafting x3 with the \nleft internal mammary artery to left anterior descending artery, \nreverse\nsaphenous vein graft to the posterior descending artery and \ndiagonal artery. 2. Mitral valve replacement with a 31 mm St. \n___ tissue valve.\n \nHistory of Present Illness:\nMr. ___ is a ___ year old man with a past medical history of \nchronic obstructive pulmonary disease, congestive heart failure, \ncoronary artery disease, ischemic cardiomyopathy (EF ___, \nmitral regurgitation, and prior myocardial infarction. He has \nbeen followed with serial echocardiograms. Over the past year he \nhas noted progressive dyspnea on exertion. He still works as a \n___ and notes shortness of breath when he climbs \na flight of stairs. He also reports increased fatigue. He denies \n___ edema, chest pain, syncope. He was seen in clinic on ___ \nby Dr ___. Given his significant medical comorbidities, he was \nreferred to the structural heart team for consideration of \nmitraclip. Dr. ___ his echocardiogram and determined \nthat he would not be suitable for mitralclip. He was referred \nback to Dr. ___ surgical consultation in ___ and \naccepted for mitral valve repair vs replacement. He underwent \ncardiac catheterization which revealed significant coronary \nartery disease. He was admitted post cath to the cardiac surgery \nservice for CABG/MVR vs replacement tomorrow. \n \nPast Medical History:\nChronic Obstructive Pulmonary Disease\nCongestive Heart Failure, chronic systolic \nCoronary Artery Disease, s/p PCI ___\nDyspepsia\nGastroesophageal Reflux Disease\nH-Pylori\nHyperlipidemia \nMelanoma\nMitral Regurgitation\nMonomorphic Ventricular Tachycardia s/p ICD\nMyocardial Infarction, ___\nPulmonary Nodules \n\nSurgical History:\nKnee arthroscopy, bilateral\n \nSocial History:\n___\nFamily History:\nFather drowned at ___. \nMother died of cancer at ___. \nSister with lung disease. \nBrother with heart disease and diabetes.\n \nPhysical Exam:\nAdmission Exam:\nBP: 118/60 (left arm ). HR: 60. O2 Sat%: 93 (RA). RR: 16. Pain \nScore: 0.\nHeight: 70\" Weight: 101.4kg\n\nGeneral:x\nSkin: Dry thin [x] intact []\nHEENT: PERRLA [] EOMI [x]\nNeck: Supple [x] Full ROM [x]\nChest: Lungs clear bilaterally [x] Diminished BS\nHeart: RRR [x] Irregular [] Murmur [x] grade ___ pansystolic \nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds \n+ [x]\nExtremities: Warm [x], well-perfused [x] Edema []none \nVaricosities: None []left lower leg\nNeuro: Grossly intact [x]\nPulses:\n___ Right: + Left:+\nRadial Right:+ Left:+\nCarotid Bruit: none\n\nDischarge Exam:\nTM 98.1 TC 98.0 131/65 66 16 92% RA\nPhysical Examination:\nGeneral: NAD [x] \nNeurological: A/O x3 [x] Moves all extremities [x] Follows\ncommands [x] \nCardiovascular: RRR [x] Irregular [] \nRespiratory: clear bilaterally, No resp distress, scattered \nwheezes [x] \nGI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]\nExtremities: \nRight Upper extremity Warm [] Edema \nLeft Upper extremity Warm [] Edema \nRight Lower extremity Warm [x] Edema 1+ \nLeft Lower extremity Warm [x] Edema 1+ \nPulses:\nDP Right: Left:\n___ Right:+ Left:+\nRadial Right:+ Left:+\nSkin/Wounds: Dry [x] intact [x]\nSternal: CDI [x] no erythema [x] scant yellow drainage at \nsuperior pole, well approximated \n Sternum stable [x] Prevena []\nLower extremity: Right [x]Left[] CDI [x]\n\n \nPertinent Results:\nAdmission Labs:\n___ 04:51PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE \nEPI-0\n___ 04:51PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-NEG\n___ 05:17PM ___ PTT-28.3 ___\n___ 05:17PM PLT COUNT-153\n___ 05:17PM WBC-7.1 RBC-4.68 HGB-14.5 HCT-44.6 MCV-95 \nMCH-31.0 MCHC-32.5 RDW-12.8 RDWSD-44.4\n___ 05:17PM %HbA1c-5.5 eAG-111\n___ 05:17PM TOT PROT-6.6 ALBUMIN-4.3 GLOBULIN-2.3 \nMAGNESIUM-2.2\n___ 05:17PM LIPASE-109*\n___ 05:17PM ALT(SGPT)-16 AST(SGOT)-19 ALK PHOS-63 \nAMYLASE-74 TOT BILI-0.5\n___ 05:17PM GLUCOSE-97 UREA N-20 CREAT-0.8 SODIUM-143 \nPOTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-27 ANION GAP-10\n\nDischarge Labs:\n___ 09:44AM BLOOD WBC-12.2* RBC-3.06* Hgb-9.3* Hct-29.8* \nMCV-97 MCH-30.4 MCHC-31.2* RDW-13.1 RDWSD-46.7* Plt ___\n___ 04:35AM BLOOD Hct-29.1*\n___ 06:45AM BLOOD WBC-7.7 RBC-2.88* Hgb-8.8* Hct-28.8* \nMCV-100* MCH-30.6 MCHC-30.6* RDW-12.7 RDWSD-46.0 Plt ___\n___ 01:51AM BLOOD WBC-8.0 RBC-2.86* Hgb-8.8* Hct-28.1* \nMCV-98 MCH-30.8 MCHC-31.3* RDW-12.7 RDWSD-45.5 Plt Ct-84*\n___ 04:10AM BLOOD UreaN-20 Creat-0.9 K-4.3\n\nCardiac cath ___: \nThe coronary circulation is right dominant.\nLM: The Left Main, arising from the left cusp, is a large \ncaliber vessel. This vessel bifurcates into the Left Anterior \nDescending and Left Circumflex systems. There is a 50% stenosis \nin the mid and distal\nsegments.\nLAD: The Left Anterior Descending artery, which arises from the \nLM, is a large caliber vessel. There is a 3.5mm X 13mm bare \nmetal stent (___) in the proximal segment. There is a 50% \nstenosis in the\nproximal segment.\nThe Diagonal, arising from the proximal segment, is a medium \ncaliber vessel.\nCx: The Circumflex artery, which arises from the LM, is a large \ncaliber vessel. The ___ Obtuse Marginal, arising from the \nproximal segment, is a medium caliber vessel. The ___ Obtuse \nMarginal, arising from the mid segment, is a medium caliber \nvessel.\nRCA: The Right Coronary Artery, arising from the right cusp, is \na large caliber vessel. There is a 100% stenosis in the proximal \nsegment. Collaterals from the distal segment of the Cx connect \nto the distal\nsegment. The Acute Marginal, arising from the proximal segment, \nis a very small caliber vessel. The Right Posterior Descending \nArtery, arising from the distal segment, is a small caliber \nvessel. There are moderate irregularities in the ostium \nextending to the distal segment. The Right Posterolateral \nArtery, arising from the distal segment, is a small caliber \nvessel.\n\nEcho ___: \nMEASUREMENTS:\nLEFT ATRIUM ___ ATRIUM (RA)\n___ Ejection Velocity: 0.50m/sec (>0.55)\nTHORACIC AORTA/PULMONARY ARTERY (PA)\nAnnulus: 2.4cm\nSinus: 3.6cm (nl M<4.1;F<3.7)\nSinus Index: 1.6cm/m2 (nl M<2.2;F<2.3)\nSinotubular Junction: 2.9cm\nAscending: 3.8cm (nl M<3.9;F<3.6)\nAscending Index: 1.7cm/m2 (nl M<2.0;F<2.3)\nArch: 3.7cm (nl<=3.0)\nAORTIC VALVE (AV)\nLV Outflow Tract (LVOT) Diam: 2.4cm\nFINDINGS:\nPre-bypass: Severe MR with ___ complex pathology as evidenced by 2 \neccentric jets and one central jet. There is a moderate to \nseverely depressed LV function with global hypokinesis\nPost -bypass: There is a well tissue prosthetic valve in the \nmitral position. There is no obvious paravalvular leak. There is \na mean gradient of 3mmHg across the valve. The RIGHT ventricular \nfunction is low normal. The LEFT ventricular function is similar \nto pre-bypass and is visually estimated at ___.\nADDITIONAL FINDINGS: No TEE related complications.\nPRE-OPERATIVE STATE: Pre-bypass assessment. Sinus rhythm.\nLeft Atrium ___ Veins: Dilated ___. No spontaneous \necho contrast is seen in the ___.\nRight Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC): \nNormal interatrial septum. No atrial septal defect by 2D/color \nflow Doppler.\nLeft Ventricle (LV): Moderately dilated cavity. Moderate to \nsevere regional systolic dysfunction \nRight Ventricle (RV): Low normal free wall motion.\nAorta: Normal sinus diameter. No dissection. No sinus atheroma.\nAortic Valve: Mildly thickened (3) leaflets. Mild (>1.5cm2) \nstenosis. Trace regurgitation.\nMitral Valve: Mildly thickened leaflets. SEVERE [4+] \nregurgitation. Eccentric jets x 2, anterior and posteriorly \nfacing and also a central jet. The etiology is uncertain but \nmixed restrictive posterior leaflet and prolapse of anterior \nleaflet is suspected\nTricuspid Valve: Normal leaflets. Trace regurgitation.\nPericardium: No effusion.\nPOST-OP STATE: The patient is DOO paced. Infusions are Milrinone \n0.25, Vaso 1.2, NOR 0.1 and EPI 0.05 There is a well tissue \nprosthetic valve in the mitral position.\nThere is no obvious paravalvular leak. There is a mean gradient \nof 3mmHg across the valve. The RIGHT ventricular function is low \nnormal. The LEFT ventricular function is similar to pre-bypass \nand is visually estimated at ___.\n___ MD ___ \n \nRadiology Report CHEST (PA & LAT) Study Date of ___ 1:09 \n___ \nFINDINGS: AP upright and lateral views of the chest provided. \nThere has been interval improvement in lung volumes. There are \nsmall \nbilateral pleural effusions, stable on the left and decreased on \nright. There is minimal, if any, residual pulmonary edema of the \nlung bases. There is borderline cardiomegaly. There is no \nmediastinal widening or pneumothorax. The tip of a right IJ \ncentral venous catheter terminates in the upper SVC, unchanged \nin position. Left chest wall dual lead AICD is unchanged in \nposition. Sternal wires are re-demonstrated. \nIMPRESSION: Small bilateral pleural effusions, stable on the \nleft and decreased on the right. Minimal residual bibasilar \ncongestion. No mediastinal widening or pneumothorax. \n \n___ CXR\nIMPRESSION: \n \nSmall bilateral pleural effusions, stable on the left and \ndecreased on the \nright. Minimal residual bibasilar edema and congestion. No \nmediastinal \nwidening or pneumothorax. \n\n \nBrief Hospital Course:\nMr. ___ underwent a cardiac cath on ___. Cath revealed \ntwo-vessel coronary artery disease. Post-cath he was admitted \nfor surgical work-up. On ___ he was taken to the operating \nroom where he underwent a coronary artery bypass graft x 2 and \nmitral valve repair. Please see operative note for surgical \ndetails. In summary he had: 1. Coronary artery bypass grafting \nx3 with the left internal mammary artery to left anterior \ndescending artery, reverse saphenous vein graft to the posterior \ndescending artery and diagonal artery.\n2. Mitral valve replacement with a 31 mm ___ tissue \nvalve, reference number is ___, serial number is \n___, with preservation of the subvalvular apparatus.\nHe tolerated the operation and following surgery he was \ntransferred to the CVICU for invasive monitoring. He was \nsomewhat vasoplegic and came out of the operating room on \nMilrinone, epinepherine, levophed, and vasopressin infusions. \nOver the next several hours he was weaned off the milrinone, \nlevophed and vasopressin infusions but remained on epinephrine. \nHe awoke neurologically intact and was extubated on POD1. \nFollowing extubation he weaned of his epinephrine infusion, \nstarted on ACE inhibitor and Beta blockers. Aspirin and a statin \nwere also resumed. He stayed in the ICU because of hypoxia \nrequiring hiflo oxygen to maintain O2sat. He was diuresed \ntowards his postoperative weight, and ultimately came off the \nhigh flow oxygen. On POD4 he was transferred to the step down \nunit for further recovery. All tubes, lines and drains were \nremoved per cardiac surgery protocol w/o complication. Once on \nthe step down floor he worked with nursing and physical therapy \nfor assistance with his postoperative strength and mobility. He \nwas noted to have some ventricular tachycardia and EP was \nconsulted. His Toprol XL was resumed at his home dose and follow \nup was arranged with EP. ICD was interrogated by EP on ___. He \nhas a history of COPD - room air saturation was 92% and \nambulatory sats were 89-94%, which was patient's baseline. Preop \ninhalers and Symbicort were resumed. The remainder of his \npost-op course was uneventful. He was discharged home with ___ \nand home ___ on POD 8.\nHe will follow-up with Dr ___ in 4 weeks and with EP in 8 weeks. \nHe did have a scant amount of drainage at upper sternal pole and \nwound check was moved up to ___. His WBC was increased slightly \nand is to be rechecked ___ with results to be called to cardiac \nsurgery office. Patient remained afebrile without signs of \nactive infection. He was discharged POD 8 in stable condition. \n \nMedications on Admission:\nALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation \naerosol inhaler. 2 puffs inh Every 4 hours as needed for cough \nor shortness of breath\nBUDESONIDE-FORMOTEROL [SYMBICORT] - Symbicort 160 mcg-4.5 \nmcg/actuation HFA aerosol inhaler. 2 PUFFS inhaled twice daily\nEZETIMIBE [ZETIA] - Zetia 10 mg tablet. 1 tablet(s) by mouth \nonce daily - (Prescribed by Other Provider)\nFUROSEMIDE - furosemide 40 mg tablet. 1 tablet(s) by mouth daily \n- (Prescribed by Other Provider)\nLOSARTAN - losartan 50 mg tablet. 1 tablet(s) by mouth once \ndaily - (Prescribed by Other Provider)\nMETOPROLOL SUCCINATE - metoprolol succinate ER 100 mg \ntablet,extended release 24 hr. 1 tablet(s) by mouth Once a day\nNITROGLYCERIN - nitroglycerin 0.4 mg sublingual tablet. 1 \ntablet(s) sublingually PRN chest pain - (Prescribed by Other \nProvider)\nPANTOPRAZOLE - pantoprazole 40 mg tablet,delayed release. \ntablet(s) by mouth daily - (Prescribed by Other Provider)\nROSUVASTATIN - rosuvastatin 40 mg tablet. 1 tablet(s) by mouth \nonce daily - (Prescribed by Other Provider)\n \nMedications - OTC\nASPIRIN - aspirin 81 mg tablet,delayed release. 1 tablet(s) by \nmouth once a day - (Prescribed by Other Provider)\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H \n2. Docusate Sodium 100 mg PO BID \n3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ___ capsule(s) by mouth Q 4 hours Disp #*45 \nCapsule Refills:*0 \n4. Polyethylene Glycol 17 g PO DAILY \n5. Potassium Chloride 20 mEq PO DAILY Duration: 10 Days \nCheck with cardiologist about continuing KCL if Lasix continues \nRX *potassium chloride 20 mEq 1 tablet(s) by mouth once a day \nDisp #*10 Tablet Refills:*0 \n6. Aspirin 81 mg PO DAILY \n7. Ezetimibe 10 mg PO DAILY \n8. Furosemide 40 mg PO DAILY \nCheck with cardiologist re: need to continue Lasix \nRX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth once a day \nDisp #*10 Tablet Refills:*0 \n9. Losartan Potassium 50 mg PO DAILY \n10. Metoprolol Succinate XL 100 mg PO DAILY \nRX *metoprolol succinate [Toprol XL] 100 mg 1 tablet(s) by mouth \nonce a day Disp #*30 Tablet Refills:*1 \n11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n12. Pantoprazole 40 mg PO Q24H \n13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQ4H:PRN cough, sob \nRX *albuterol sulfate [ProAir HFA] 90 mcg 1 INH INH Q 4 hours \nDisp #*1 Inhaler Refills:*0 \n14. Rosuvastatin Calcium 40 mg PO QPM \n15. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nCoronary artery disease s/p Coronary artery bypass graft \nMitral regurgitation s/p mitral valve repair\nPast medical history:\nS/p inferior and apical myocardial infarction ___\ns/p LAD PCI stent ___\nSystolic heart failure\nValvular heart disease; mild aortic stenosis, mitral\nregurgitation\nMonomorphic ventricular tachycardia\nS/p ICD implant greater than ___ years ago\nCOPD on inhalers\nHyperlipidemia\nMelanoma w removal\nGERD\nPulmonary nodules \nDyspepsia \nH-pylori \nbilateral knee arthroscopy\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\n1+ lower extremity edema bilaterally \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\n \nFollowup Instructions:\n___\n" ]

[ "I2510", "I5022", "D62", "I472", "Z9861", "Z87891", "J449", "Z006", "I255", "K219", "E785", "Z85820", "Z95810", "I252", "R918", "I080", "D6959", "R0902", "I493" ]

[ "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I5022: Chronic systolic (congestive) heart failure", "D62: Acute posthemorrhagic anemia", "I472: Ventricular tachycardia", "Z9861: Coronary angioplasty status", "Z87891: Personal history of nicotine dependence", "J449: Chronic obstructive pulmonary disease, unspecified", "Z006: Encounter for examination for normal comparison and control in clinical research program", "I255: Ischemic cardiomyopathy", "K219: Gastro-esophageal reflux disease without esophagitis", "E785: Hyperlipidemia, unspecified", "Z85820: Personal history of malignant melanoma of skin", "Z95810: Presence of automatic (implantable) cardiac defibrillator", "I252: Old myocardial infarction", "R918: Other nonspecific abnormal finding of lung field", "I080: Rheumatic disorders of both mitral and aortic valves", "D6959: Other secondary thrombocytopenia", "R0902: Hypoxemia", "I493: Ventricular premature depolarization" ]

[ "I2510", "D62", "Z87891", "J449", "K219", "E785", "I252" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nchlorhexidine\n \nAttending: ___.\n \nChief Complaint:\nDehydration\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ male who was recently\ndischarged following a complicated hospital stay following\nsimultaneous liver kidney transplant. He was ultimately found \nto\nhave malignant mastocytosis and is post transport course was\ncomplicated by recurrent mastocytosis in the transplant liver. \nThe patient failed a trial of Midostaurin as treatment for\nmastocytosis and ultimately underwent ___ shunt for control\nof refractory ascites. He was recently discharged and seen in\nclinic for routine follow-up today. In clinic he was noted to \nbe\nhypotensive and his outpatient labs revealed an elevated\ncreatinine to 2.6 from a baseline of 1.3-1.5. He did report \npoor\np.o. intake of food and liquids. Therefore he was referred to\nthe emergency department for further evaluation. Apart from the\nweakness in the setting of dehydration and poor p.o. intake, the\npatient actually reports she has been feeling very well at home\nsince discharge. He denies all other complaints.\n\nROS: positive as per HPI, otherwise complete review of systems \nis\nnegative\n\n \nPast Medical History:\nCryptogenic cirrhosis complicated by HE, diuretic refractory \nascites. \nMastocytosis\n.\nPSH:\n___ Liver transplant with temporary portacaval shunt. \n___ Deceased donor kidney transplant as part of a\nsimultaneous liver/kidney transplant.\nLiver biopsy\n- ___ Open Tracheostomy\n- ___ Bone marrow biopsy\n- ___ ___ guided drainage of anterior fluid collection\n- ___ EGD with duodenal biopsy\n- ___ R Thoracentesis\n- ___ R 14 ___ chest tube placement\n- ___ ___ guided attempted drainage of anterior fluid \ncollection\n- ___ R Thoracentesis\n-___ ___ shunt placement\n \nSocial History:\n___\nFamily History:\nHe has three brothers without any history of liver disease or \ncolon cancer. \n \nPhysical Exam:\nVS: 98.4 88 109/60 18 100% RA\nGeneral: cachectic but overall well-appearing in NAD\nHEENT: NC/AT, EOMI, no scleral icterus\nResp: breathing comfortably on room air\nCV: mildly tachycardic but regular\nAbd: mildly distended but soft, non-tender. Well-healed surgical\nincisions. \nExt: no edema\n.\nWeight at Discharge: 60.8 kg\n \nPertinent Results:\nLabs on Admission: ___\nWBC-5.0# RBC-3.02* Hgb-8.4* Hct-27.0* MCV-89 MCH-27.8 MCHC-31.1* \nRDW-18.5* RDWSD-59.7* Plt Ct-50*\nUreaN-85* Creat-2.7* Na-130* K-4.3 Cl-97 HCO3-17* AnGap-20 \nGlucose-143*\nALT-48* AST-43* AlkPhos-294* TotBili-0.5\nLipase-22\nAlbumin-3.6 Calcium-8.4 Phos-5.1* Mg-2.0\nLactate-1.4\n.\nLabs at Discharge: ___\nWBC-4.6 RBC-2.60* Hgb-7.4* Hct-23.1* MCV-89 MCH-28.5 MCHC-32.0 \nRDW-17.4* RDWSD-55.2* Plt Ct-36*\nGlucose-102* UreaN-82* Creat-2.2* Na-135 K-3.7 Cl-101 HCO3-17* \nAnGap-21*\nALT-30 AST-21 AlkPhos-247* TotBili-1.6*\nCalcium-8.8 Phos-4.8* Mg-1.7\ntacroFK-9.___ y/o male with history of liver/kidney transplant, found to \nhave biopsy proven mastocytosis following transplant, extended \nhospital course who was discharged to home on ___.\n\nIn routine clinic follow up the patient was found to be \nhypotensive and have elevated creatinine so he was admitted for \nhydration. Also hematocrit was 22%\n\nOn admission the patient received one unit of blood as well as \nalbumin. Hematocrit in the morning was 23.1, so an additional \nunit of RBCs was given.\n\nAbdominal incision was noted to have area mid incision, where \nthe old opening and underlying hematoma was, that appeared to \nrequire debridement. Using local, a small incision was made to \ndrain and then pack this area. ___ inch Nu-Gauze packing was \nused with overlying DSD. There was some initial increased \ndrainage. There is still likely liquefying old hematoma still \nlocated under this portion of the incision.\n\nLFTs were stable with the exception of the bilirubin which \nincreased to 1.6 (in the setting of blood transfusion) \nCreatinine was also noted to be 2.2 from baseline around 1.0. \nAll values will be rechecked on ___.\n\nImmunosuppression was kept the same with Tacro 1.5 mg BID and \nPrednisone 5 mg daily. \n\n___ shunt sites are healing well, and patient has been able \nto pump with good results, abdominal exam showed significant \nreduction in ascites. He does note pain after bowel movements \nonly, and this has been reported in other patients with the \n___ shunt, and patient was apprised of this.\n\nBowel movements remain loose, he has not been using stool \nsoftener or fiber.\nDr ___ the patient on Bicitra during this admission. \nAs well the Lasix has been discontinued.\n\nHe will discharge to home with ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild \n2. Atovaquone Suspension 1500 mg PO DAILY \n3. BuPROPion XL (Once Daily) 150 mg PO DAILY \n4. Cetirizine 10 mg PO DAILY:PRN Itching or flushing \n5. DiphenhydrAMINE 25 mg PO Q6H:PRN Itching or flushing \n6. Docusate Sodium 100 mg PO BID \n7. Senna 8.6 mg PO BID:PRN constipation \n8. Simethicone 80 mg PO QID:PRN gas pain \n9. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate \n10. Lidocaine 5% Patch 1 PTCH TD QPM \n11. Montelukast 10 mg PO DAILY \n12. PredniSONE 5 mg PO DAILY \n13. Ranitidine 150 mg PO BID \n14. Tacrolimus 1.5 mg PO Q12H \n15. Furosemide 80 mg PO DAILY \n\n \nDischarge Medications:\n1. Bicitra 30 mL PO BID \nRX *sodium citrate-citric acid ___ mg-500 mg/5 mL 30 ml by mouth \ntwice a day Disp #*1800 Milliliter Refills:*1 \n2. Vitamin D 1000 UNIT PO DAILY \n3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild \nMaximum 4 of the 500 mg tablets daily \n4. Atovaquone Suspension 1500 mg PO DAILY \n5. BuPROPion XL (Once Daily) 150 mg PO DAILY \n6. Cetirizine 10 mg PO DAILY:PRN Itching or flushing \n7. DiphenhydrAMINE 25 mg PO Q6H:PRN Itching or flushing \n8. Docusate Sodium 100 mg PO BID:PRN constipation \n9. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate \n10. Lidocaine 5% Patch 1 PTCH TD QPM \n11. Montelukast 10 mg PO DAILY \n12. PredniSONE 5 mg PO DAILY \n13. Ranitidine 150 mg PO BID \n14. Senna 8.6 mg PO BID:PRN constipation \n15. Simethicone 80 mg PO QID:PRN gas pain \n16. Tacrolimus 1.5 mg PO Q12H \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___ \n \nDischarge Diagnosis:\nDehydration\nAcute kidney injury\nHistory of liver/ kidney transplant\n___ shunt in place for ascites control\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:\nDischarge to resume services with All Care ___ ___, \nfax ___ \n\nPlease call the transplant clinic at ___ for fever > \n101, chills, nausea, vomiting, diarrhea, constipation, inability \nto tolerate food, fluids or medications, yellowing of skin or \neyes, increased abdominal pain, incisional redness, drainage or \nbleeding, dizziness or weakness, decreased urine output or dark, \ncloudy urine, swelling of abdomen or ankles, or any other \nconcerning symptoms.\n\nBring your pill box and list of current medications to every \nclinic visit.\n\nYou will have labwork drawn every ___ and ___ as \narranged by the transplant clinic, with results to the \ntransplant clinic (Fax ___ . CBC, Chem 10, AST, ALT, \nAlk Phos, T Bili, Trough Tacro level, Urinalysis.\n\n*** On the days you have your labs drawn, do not take your Tacro \nuntil your labs are drawn. Bring your Tacro with you so you may \ntake your medication as soon as your labwork has been drawn.\n\nFollow your medication card, keep it updated with any dosage \nchanges, and always bring your card with you to any clinic or \nhospital visits.\n\nYou may shower. Allow the water to run over your incision and \npat area dry. No rubbing, no lotions or powder near the \nincision. You may leave the incision open to the air. \n\nChange the dressing once a day to small opened area of the \nincision. Pack lightly with Nu-Gauze if available.\n\nPump the ___ shunt as you are lying flat, ***Lie flat three \ntimes a day for 15 minutes then pump the ___ shunt valve 20 \ntimes as instructed by Dr. ___. \n\nNo tub baths or swimming\n\nNo driving if taking narcotic pain medications\n\nAvoid direct sun exposure. Wear protective clothing and a hat, \nand always wear sunscreen with SPF 30 or higher when you go \noutdoors.\n\nDrink enough fluids to keep your urine light in color. Your \nappetite will return with time. Eat small frequent meals, and \nyou may supplement with things like carnation instant breakfast \nor Ensure.\n\nCheck your blood sugars and blood pressure at home. Report \nconsistently elevated values to the transplant clinic\n\nDo not increase, decrease, stop or start medications without \nconsultation with the transplant clinic at ___. There \nare significant drug interactions with anti-rejection \nmedications which must be considered in medication management \nfollowing transplant.\n\nConsult transplant binder, and there is always someone on call \nat the transplant clinic with any questions that may arise\n\n \nFollowup Instructions:\n___\n" ]

[ "N179", "T8649", "C962", "I959", "R188", "Z944", "Z940", "C802", "L7632", "E860", "Y838", "Y92018", "K7469" ]

[ "N179: Acute kidney failure, unspecified", "T8649: Other complications of liver transplant", "C962: Malignant mast cell neoplasm", "I959: Hypotension, unspecified", "R188: Other ascites", "Z944: Liver transplant status", "Z940: Kidney transplant status", "C802: Malignant neoplasm associated with transplanted organ", "L7632: Postprocedural hematoma of skin and subcutaneous tissue following other procedure", "E860: Dehydration", "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", "Y92018: Other place in single-family (private) house as the place of occurrence of the external cause", "K7469: Other cirrhosis of liver" ]

[ "N179" ]

[]

[ " \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:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\nEUS with biopsy\n \nHistory of Present Illness:\nPatient is a ___ year old man with history of DM, obesity, NAFLD \ndiverticulosis, sleep apnea, s/p ___ bariatric roux-en-y and \nremote cholecystectomy who was transferred from ___ \n___ with 3 days of abdominal pain and findings of a \npancreatic mass.\n\nOf note, in ___ patient was found to have an incidental \npancreatic mass on CT scan after presenting with an episode of \ndiverticulitis. MRI showed 1.3cm mass hypoenhancing mass in \npancreatic tail and RP lymphadenopathy. EUS found a cyst with \ncytology that was nondiagnostic, no atypical, suspicious or \nmalignant cells were identified. Eventually thought to be a \nmucinous or serous cyst.\n\nHe reports for the past 1 month he has had his usual \"gas pain\" \nwhich he describes as cramping diffuse pain with bloating. For \nthe past 3 days, he has been experiencing worsening pain, \nparticularly in the left subcostal region radiating to LLQ. ROS \n+ 10lbs weight loss in past month. This morning, he woke up with \nnausea, worsening abdominal pain, mostly LLQ/LUQ. He initially \npresented to ___ where his VSS. Labs notable for Tbili 3.2, alk \nphos 195. CT a/p showed a mass like lesion of the pancreatic \nparenchyma at level of tail measuring up to 6.7cm, DDx including \nchronic focal pancreatitis vs neoplastic mass. The case was \ndiscussed with Dr. ___ at ___ who asked for transfer for \nERCP and bx by Dr. ___.\n \n In the ED, initial VS were: 97.9 73 154/74 14 99% RA \n \n ED physical exam was recorded as:\nWell-appearing, resting comfortably in bed.\nAbd: Guarding LLQ/LUQ. Mildly tender LUQ/LLQ. Protuberant at \nbaseline. No fluid wave.\n\nED labs were notable for: \nAP: 184 Tbili: 3.2 \nLactate:1.9\n\nTransfer VS were: 64 138/64 16 99% RA \n When seen on the floor, he denies headache, chest pain, \nshortness of breath\n\nREVIEW OF SYSTEMS: \n A ten point ROS was conducted and was negative except as above \nin the HPI.\n\n \nPast Medical History:\nObesity\nNAFLD\nDiverticulosis\nBilateral renal cyst\n\nSurgical History:\nappendectomy \ncholecystectomy\nroux-en-y gastric bypass\n \nSocial History:\n___\nFamily History:\nBrother had pancreatic cancer, passed away last year\n\n \nPhysical Exam:\n Gen: NAD, lying in bed\n Eyes: EOMI, sclerae anicteric \n ENT: MMM, OP clear\n Cardiovasc: RRR, II/VI SEM at RUSB, full pulses, no edema \n Resp: normal effort, no accessory muscle use, lungs CTA ___.\n GI: soft, non tender, non distended +BS, no rebound or \nguarding, no organomegaly\n MSK: No significant kyphosis. No palpable synovitis.\n Skin: No visible rash. No jaundice.\n Neuro: AAOx3. No facial droop.\n Psych: Full range of affect\n \nPertinent Results:\n___ 03:53PM LACTATE-1.9\n___ 03:45PM GLUCOSE-113* UREA N-7 CREAT-0.7 SODIUM-139 \nPOTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15\n___ 03:45PM estGFR-Using this\n___ 03:45PM ALT(SGPT)-38 AST(SGOT)-33 ALK PHOS-184* TOT \nBILI-3.2*\n___ 03:45PM LIPASE-44\n___ 03:45PM ALBUMIN-3.8\n___ 03:45PM ___ PTT-34.2 ___\n\nLABS: Reviewed in OMR.\n___ transfer labs:\nUA 5 ketones otherwise neg\nWBC 4.9\nHgb 15.6 MCV 93\nPlt 92\nChem7 WNL\nTBili 3.2 AP 195 AST 39 ALT 44 Lipase 48\n\nCT at OSH:\nNew lobulated hypodense mass likel lesion involving the \npancreatic tail. Differentiual considerations include chronic \nfocal pancreatitis but neoplastic mass such as adenocarcinoma is \nalos consideration. Consider further evaluation with endoscopic \nultrasound or elective contrast enhanced MR of the abdomen\n\n___ is new narrowing of the adjacent central aspects of \nsplenic vein possibly related to extrinsic compression from the \nmass r chronic non occlusive thrombosis\nChanges of cirrhosis. Multifocal varices and splenomegaly and \nnew moderate free intraperitoneal fluid and a small lobule of \nlocalized fluid right lower quadrant. these findings may be \nrelated to sequelae of portal hypertension associated with \nchronic hepatic disease. \nNew finding in central mesentery which could related to \nmesenteric panniculitis.\nAbdominal lymphadenopathy \nChanges of prior antecolic Roux en Y gastric bypass procedure \nwithout evidence of post surgical complication\n\nMRCP:\nModerate volume ascites. \n Nodular hepatic parenchyma, consistent cirrhosis. \n The CBD is within normal limits. No intrahepatic biliary \nductal dilatation. \n A 2.9 x 1.2 cm mass in the body the pancreas is T1 hypointense \nand \nhypoenhancing. Numerous small cystic lesions distal to the mass \nin the body may represent side branch IPMNs or alternatively \ndilated pancreatic duct and side branches. \n Moderate splenomegaly. \n Multiple simple hepatic cysts are noted. \n The patient is status post Roux-en-Y gastric bypass. \n\n___ EUS\n\n Minimal exam of the esophagus was normal with the \nechoendoscope.\n Evidence of a previous Roux-en-Y anastomosis was seen. \n Duodenum was not examined.\n EUS was performed using a linear echoendoscope at ___ MHz \nfrequency\n EUS examination was markedly limited due to patient's \naltered anatomy.\n The body and tail were imaged from the gastric body and \nfundus.\n Mass: A 2 cm X 3.6 cm ill-defined mass was noted in the body \nof the pancreas.\n The mass was hypoechoic and heterogenous in echotexture. The \nborders of the mass were irregular and poorly defined.\n Contrast: Per institution protocol, Lumason contrast was \ngiven [2ml X 1 dose]. There was no enhancement of the pancreas \nmass with contrast injection.\n FNA was performed of the mass. Color doppler was used to \ndetermine an avascular path for needle aspiration. A 25-gauge \nneedle with a stylet was used to perform aspiration. Five needle \npasses were made into the mass.\n Small amounts of ___ ascites was noted. A \n25-gauge needle with a stylet was used to perform aspiration. 2 \ncc of clear fluid was aspirated. Aspirate was sent for cytology.\n\n \nBrief Hospital Course:\nMr. ___ is a ___ year old gentleman with a history of \nNAFLD/cirrhosis, DM, obesity, s/p bariatric surgery,and remote \nCCY admitted to ___ with 3 days of abdominal \npain, found to have a pancreatic mass and transferred\nto ___ for further workup.\n\n# Pancreatic mass: Patient with a history of cystic mass in the \npancreatic tail. He was sent for FNA in ___ though adequate \nsample could not be obtained as a splenic vessel was \nseentraversing through the cyst (per patient's outpatient \nhepatologist). Current mass is separate from the cystic lesion \nisolated in ___ and is concerning for malignancy. He underwent \nEUS with biopsy of the lesion. CA ___ and IgG4 levels sent. He \nis instructed to call the GI clinic for results of the biopsy. \nPain manage with tylenol and oxycodone as needed. \n\n# Cirrhosis\n# NAFLD\n# Thrombocytopenia\n# Coagulopathy\nPatient with known history of cirrhosis secondary to NAFLD, with \nlaboratory evidence of thrombocytopenia and coagulopathy \n(elevated INR). MRCP reveals splenomegaly and moderate ascites. \nPatients outpatient hepatologist was contacted (Dr. \n___) who confirmed that the patient has no \nknown history of ascites as of his last follow up. He has not \nbeen on diuretics in the past. No evidence of HCC on MRCP ___. \nPatient without a safe pocket for diagnostic paracentesis. \nPatient will need to follow up with Dr. ___ discharge \nfor\nongoing management/screening for esophageal varices\n\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 Disposition:\nHome\n \nDischarge Diagnosis:\nPancreatic mass\n\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 to the hospital because of abdominal pain. \nYour workup at an outside facility revealed a pancreatic mass. \nYou were transferred to ___ for biopsy of this \nmass. The results of the biopsy are still pending but you should \ncall Dr. ___ ___ next week for the \npathology results. The next steps in your management will depend \non the results of this biopsy.\n\nWe wish you all of the best,\nYour ___ treatment team\n \nFollowup Instructions:\n___\n" ]

[ "C252", "D689", "D6959", "K7581", "E119", "Z87891", "Z980", "Z808", "E669", "Z6837" ]

[ "C252: Malignant neoplasm of tail of pancreas", "D689: Coagulation defect, unspecified", "D6959: Other secondary thrombocytopenia", "K7581: Nonalcoholic steatohepatitis (NASH)", "E119: Type 2 diabetes mellitus without complications", "Z87891: Personal history of nicotine dependence", "Z980: Intestinal bypass and anastomosis status", "Z808: Family history of malignant neoplasm of other organs or systems", "E669: Obesity, unspecified", "Z6837: Body mass index [BMI] 37.0-37.9, adult" ]

[ "E119", "Z87891", "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / iodine / latex\n \nAttending: ___.\n \nChief Complaint:\neye pain\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ no significant PMH p/w L ocular pain, upper eyelid swelling,\nfever and diplopia as a referral from ___ with an MRI\nshowing preseptal cellulitis.\n\nShe reports that her eye pain began approximately 4 days ago,\nwith mild redness in the left lateral corner of the eye. At \nthat\ntime, she thought it could be pinkeye. When she developed\nworsening redness, she went to her PCP, who prescribed\nclindamycin, which she has been taking. However, the pain and\nswelling continued to worsen. On the day of admission she began\nto have significant blurry vision, diplopia, worsening pain. \nShe\nreports that she had an episode of fever. She developed\nsignificant nausea. She originally went to her PCP, was\nsubsequently sent to ___, her MRI was notable for\npreseptal periorbital cellulitis. She was subsequently\ntransferred here for ophthalmology workup and further \nevaluation.\n\nIn the ED, initial vital signs were 98.3, 58, 101/66, 16, 99% on\nRA\nLabs notable for WBC of 10.1, CBC otherwise unremarkable. BMP\nunremarkable. She received 25 mg IV fentanyl.\nOphthalmology was made aware in the ED. However given imaging\nconsistent with preseptal cellulitis, they recommended admission\nto medicine, with optho to consult to see in the AM.\n\nUpon arrival to the floor, the patient confirms the story as\nabove. She denies recent history of sinus infection, sore\nthroat, ear infection. She denies shortness of breath or chest\npain. Denies abdominal pain.\n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n\n \nPast Medical History:\n- Rhabdomyosarcoma S/P chemo/radiation (approximately ___ years\nago)\n- Cervical cancer status post surgery versus colposcopy\n- Bipolar disorder\n\n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY: \n+ DM, cervical cancer (mother)\n+ rhabdomyosarcome (maternal relative)\n \nPhysical Exam:\nVITALS: Afebrile and vital signs stable (see eFlowsheet)\nGENERAL: Alert and in no apparent distress\nEYES: Swelling of the upper left and lower left eyelid with\ncorresponding erythema, pupils equally round and reactive, pain\nof the left eye with lateral and inferior deviation, gross\nperipheral field testing with defects in middle/inferior vision,\nable to identify number of fingers with significant difficulty\n___ reported diplopia\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate\nMucous membranes moist \nCV: Heart regular, no murmur\nRESP: Lungs clear to auscultation with good air movement\nbilaterally\nGI: Abdomen soft, non-distended, non-tender 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, CN II through XII intact\nPSYCH: pleasant, appropriate affect\n\n \nPertinent Results:\n___ 06:54AM BLOOD WBC-5.3 RBC-3.23* Hgb-11.1* Hct-33.7* \nMCV-104* MCH-34.4* MCHC-32.9 RDW-12.1 RDWSD-46.0 Plt ___\n___ 06:40AM BLOOD WBC-9.0 RBC-3.17* Hgb-11.1* Hct-33.1* \nMCV-104* MCH-35.0* MCHC-33.5 RDW-12.3 RDWSD-47.4* Plt ___\n___ 06:51AM BLOOD WBC-11.0* RBC-3.55* Hgb-12.1 Hct-36.8 \nMCV-104* MCH-34.1* MCHC-32.9 RDW-12.2 RDWSD-46.7* Plt ___\n___ 08:58PM BLOOD WBC-10.1* RBC-3.55* Hgb-12.6 Hct-36.8 \nMCV-104* MCH-35.5* MCHC-34.2 RDW-12.5 RDWSD-47.0* Plt ___\n___ 06:54AM BLOOD Glucose-75 UreaN-10 Creat-0.7 Na-142 \nK-4.1 Cl-103 HCO3-25 AnGap-14\n___ 08:58PM BLOOD Glucose-77 UreaN-13 Creat-0.6 Na-138 \nK-3.9 Cl-105 HCO3-23 AnGap-10\n___ 10:30AM BLOOD Vanco-16.5\n\nMRI brain OSH:\nMRI BRAIN ___\nFINDINGS: There is left periorbital and infraorbital soft \ntissue\nedema and enhancement. No edema signal or enhancement is\ndemonstrated in the retrobulbar fat to suggest postseptal\nextension. There is symmetrical and unremarkable appearance of\nthe orbital globes. Orbital nerves appear unremarkable. \nThere is minimal mucosal thickening noted in the posterior right\nethmoid air cells. There is no significant additional paranasal\nsinus disease. \n\nVisualized portions of the brain appear unremarkable. There is \nunremarkable appearance of the pituitary gland. There is no\nevidence of abnormal parenchymal or meningeal enhancement\nfollowing contrast \nadministration. \n\nIMPRESSION: \nLEFT PERIORBITAL AND INFRAORBITAL CELLULITIS WITHOUT EVIDENCE OF \n\nPOSTSEPTAL EXTENSION\n \nBrief Hospital Course:\n___ otherwise healthy woman presenting with left eye \npain, found to have left preseptal cellulitis.\n\nACUTE/ACTIVE PROBLEMS:\n#Preseptal cellulitis\n#Infected chalazion: MRI significant for left periorbital and\ninfraorbital soft tissue edema, without evidence of post septal\nextension. Given concern for severe preseptal cellulitis\nbegan with broad-spectrum antibiotics with \nvancomycin/ctx/flagyl. Ophthalmology was consulted and followed \nalong. Pt did not have any signs of orbital cellulitis by \nimaging or exam. She markedly improved on IV therapy and with \nophthalmology approval was converted to PO Bactrim on ___. She \ncontinued to improve on this therapy and was discharged ___ \nwith plans to continue abx through ___ to complete a 7 day \ncourse. Ophthalmology recommended a f/u in ___ weeks which was \narranged prior to DC. BCX NGTD during admission. \n\nCHRONIC/STABLE PROBLEMS:\n# Bipolar disease: continued Seroquel\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. QUEtiapine Fumarate 100 mg PO TID \n\n \nDischarge Medications:\n1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild \nyou may purchase over the counter and take only as directed \n2. Sulfameth/Trimethoprim DS 2 TAB PO BID \nRX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by \nmouth twice a day Disp #*7 Tablet Refills:*0 \n3. QUEtiapine Fumarate 100 mg PO TID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\npreseptal cellulitis \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 evaluation of redness and swelling around \nyour left eye. You had an MRI and were evaluated by \nophthalmology who recommended initially IV antibiotics for \n\"preseptal cellulitis\" or an infection in the skin and soft \ntissues around your eye. Given your improvement, your \nantibiotics were changed to pill antibiotics (Bactrim) on ___. \nYou will need to continue your antibiotics through ___ and \nfollow up with the eye doctor in ___ weeks. \n \nFollowup Instructions:\n___\n" ]

[ "L03213", "H00026", "H532", "Z8541", "Z8589", "F319", "Z720", "F1290" ]

[ "L03213: Periorbital cellulitis", "H00026: Hordeolum internum left eye, unspecified eyelid", "H532: Diplopia", "Z8541: Personal history of malignant neoplasm of cervix uteri", "Z8589: Personal history of malignant neoplasm of other organs and systems", "F319: Bipolar disorder, unspecified", "Z720: Tobacco use", "F1290: Cannabis use, unspecified, uncomplicated" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \ncodeine / Percocet\n \nAttending: ___.\n \nChief Complaint:\nC10 D8-12 MUC1/Decitabine\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ year old female with a history of HTN and HLD recently \ndiagnosed with AML NK CEBPA positive who is admitted for C10 \nMUC1/Decitabine. \n\n \nPast Medical History:\nSTUDY TREATMENT HISTORY\n- ___ Cycle 1 Plan: GO-203-2C 18 mg/m2 IV on days ___ and\n___ of 28 day cycle. Decitabine 20 mg/m2 IV on days ___ of 28\nday cycle.\n- ___ Cycle 2 Plan: GO-203-2C 18 mg/m2 IV on days ___ and\n___ of 28 day cycle. Decitabine 20 mg/m2 IV on days ___ of 28\nday cycle.\n- ___: Cycle 3 delayed to allow for neutropenia recovery.\n- ___ Cycle 3 Plan: GO-203-2C 18 mg/m2 IV on days ___ and\n___ of 28 day cycle. Decitabine 20 mg/m2 IV on days ___ of 28\nday cycle.\n- ___: Cycle 4 delayed d/t perirectal abscess.\n- ___: Cycle 4 delayed to allow for recovery of perirectal\nabscess.\n- ___ Cycle 4 Plan: GO-203-2C 18 mg/m2 IV on days ___ and\n___ of 28 day cycle. Decitabine 20 mg/m2 IV on days ___ of 28\nday cycle.\n- ___ Cycle 5 Plan: GO-203-2C 18 mg/m2 IV on days ___ and\n___ of 28 day cycle. Decitabine 20 mg/m2 IV on days ___ of 28\nday cycle.\n___ Cycle 5 Day 8 treatment with GO-203-2c and decitabine \nHELD\ndue to ANC 610.\n- ___ Cycle 6 Plan: GO-203-2C DOSE REDUCED TO 12.5 mg/m2 IV\non days ___ and ___ of 28 day cycle for grade 3 neutropenia\nresulting in days ___ missed doses of GO-203-2c of cycle 5\nthought related to GO-203-2c and decitabine. Decitabine 20 mg/m2\nIV on days ___ of 28 day cycle.\n- ___ Cycle 7 Plan: GO-203-2C 12.5 mg/m2 IV on days ___ and\n___ of 35 day cycle. Decitabine 20 mg/m2 IV on days ___ of 35\nday cycle.\n- ___ Cycle 8 Plan: GO-203-2C 12.5 mg/m2 IV on days ___ and\n___ of 35 day cycle. Decitabine 20 mg/m2 IV on days ___ of 35\nday cycle.\n- ___ Cycle 9 Plan: GO-203-2C 12.5 mg/m2 IV on days ___ and\n___ of 35 day cycle. Decitabine 20 mg/m2 IV on days ___ of 35\nday cycle.\n- ___ Cycle 10 Plan: GO-203-2C 12.5 mg/m2 IV on days ___ and\n___ of 35 day cycle. Decitabine 20 mg/m2 IV on days ___ of 35\nday cycle.\n\n*Dosing based on Day 1 of each cycle height and weight*\n- C10D1 ___ wt 163.21 ht 64 BSA 1.79 m2\n\nPAST MEDICAL HISTORY: \n- Diverticulosis ___\n- Hypertension ___\n- Hyperlipidemia ___\n- ?Takutsubo syndrome ___\n- Hx of UTIs\n \nSocial History:\n___\nFamily History:\nSiblings: brother died of lung cancer (smoker) at age ___\nMother: died of pancreatic cancer at age ___\nFather: died at ___, healthy\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nGEN: NAD, awake and alert x 3\nVS: TC 98.1 128/88 66 18 98%RA \nWT: 163.39 lbs.\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, or\nxillary adenopathy, no thyromegaly\nCV: RR, NL S1/S2; no S3/S4 MRG\nPULM: Non-labored. CTAB\nABD: BS+, soft, NT/ND, no masses or hepatosplenomegaly\nLIMBS: No edema. Mild clubbing with cracking of several\nfingernails, no obvious onychomycosis.\nSKIN: No rashes or skin breakdown\nNEURO: Cranial nerves II-XII are within normal limits excluding\nvisual acuity which was not assessed, no nystagmus; strength is\n___ of the proximal and distal upper and lower extremities; gait\nis normal, coordination is intact.\nACCESS: L POC without erythema, tenderness, or discharge \n\nDISCHARGE PHYSICAL EXAM:\nGEN: NAD, awake and alert x 3\nVS: TC 98.5 ___ 94-99%RA\nWT: 161.6 lbs.\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, or\nxillary adenopathy, no thyromegaly\nCV: RR, NL S1/S2; no S3/S4 MRG\nPULM: Non-labored. CTAB\nABD: BS+, soft, NT/ND, no masses or hepatosplenomegaly\nLIMBS: No edema. Mild clubbing with cracking of several\nfingernails, no obvious onychomycosis.\nSKIN: diffuse erythema/sun burn anterior chest face arms b/l,\nimproving. Thick crusting macular region aprox 2mm in diameter \non\nR anterior shoulder, no bleeding/irregularity/ growth\nNEURO: Cranial nerves II-XII are within normal limits excluding\nvisual acuity which was not assessed, no nystagmus; strength is\n___ of the proximal and distal upper and lower extremities; gait\nis normal, coordination is intact.\nACCESS: L POC without erythema, tenderness, or discharge \n \nPertinent Results:\nADMISSION LABS:\n___ 11:40AM BLOOD WBC-6.1 RBC-3.51* Hgb-9.9* Hct-30.7* \nMCV-88 MCH-28.2 MCHC-32.2 RDW-18.1* RDWSD-57.9* Plt ___\n___ 11:40AM BLOOD Neuts-59.3 ___ Monos-11.0 \nEos-0.3* Baso-2.6* Im ___ AbsNeut-3.61# AbsLymp-1.59 \nAbsMono-0.67 AbsEos-0.02* AbsBaso-0.16*\n___ 11:40AM BLOOD UreaN-20 Creat-0.9 Na-138 K-4.1 Cl-105 \nHCO3-24 AnGap-13\n___ 11:40AM BLOOD ALT-26 AST-29 LD(___)-203 AlkPhos-89 \nTotBili-0.2 DirBili-<0.2 IndBili-0.2\n___ 11:40AM BLOOD Albumin-3.9 Calcium-8.9 Phos-4.1 Mg-1.9\n\nDISCHARGE LABS:\n___ 12:22AM BLOOD WBC-6.0 RBC-3.46* Hgb-9.6* Hct-30.0* \nMCV-87 MCH-27.7 MCHC-32.0 RDW-17.4* RDWSD-55.1* Plt ___\n___ 12:22AM BLOOD Neuts-71.1* Lymphs-18.2* Monos-8.2 \nEos-0.3* Baso-1.7* Im ___ AbsNeut-4.23 AbsLymp-1.08* \nAbsMono-0.49 AbsEos-0.02* AbsBaso-0.10*\n___ 12:22AM BLOOD Plt ___\n___ 12:22AM BLOOD Glucose-87 UreaN-17 Creat-1.0 Na-143 \nK-4.4 Cl-105 HCO3-24 AnGap-18\n___ 12:22AM BLOOD ALT-28 AST-27 LD(___)-168 AlkPhos-75 \nTotBili-0.3\n___ 12:22AM BLOOD Albumin-3.6 Calcium-8.4 Phos-4.3 Mg-2.___SSESSMENT AND PLAN: ___ year old female with a history of HTN \nand HLD with diagnosis of AML CEBPA positive s/p C9 of MUC I \ntrial presenting now for C10 to receive D8-D12.\n\n#AML: Tolerated C10 of MUC 1 inhibitor and Decitabine trial per \n___ protocol without acute complications. Most recent \nbone marrow on ___ showed no evidence of acute leukemia. \n-Appointment with study team and Dr. ___ to be arranged \nprior to next cycle (likely in ___ weeks).\n\n#HTN: Stable currently. Continue losartan 100mg daily, recently \nadded amlodipine 5mg PO daily outpatient during ___ visit \ngiven concern for HTN exacerbation. Disharged wtih a lower dose \nof amlodipine daily (2.5mg) at discharge\n\n#Actinic Keratosis: diagnosis through clinical assessment, stuck \non appearing crusting horn/macular area on R shoulder, There is \nlow suspicion for malignancy, monitor sxs outpatient. \n\n#Constipation: Continue with home bowel regimen prn. Stooling \ndaily during hospital course. \n\n#Infectious PPX: continue acyclovir\n\n#ACCESS: POC placed ___\n#CODE STATUS: presumed full \n#CONTACT INFORMATION: ___ (brother, HCP) - \n___\n#DISPO: Discharged ___. Follow up outpatient to be arranged. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. amLODIPine 5 mg PO DAILY \n3. Losartan Potassium 100 mg PO DAILY \n4. LORazepam 0.25-0.5 mg PO Q6H:PRN nausea anxiety insomnia \n5. Docusate Sodium 100 mg PO BID:PRN constipation \n6. Senna 8.6 mg PO BID:PRN constipation \n\n \nDischarge Medications:\n1. amLODIPine 2.5 mg PO DAILY \n2. Acyclovir 400 mg PO Q12H \n3. Docusate Sodium 100 mg PO BID:PRN constipation \n4. LORazepam 0.25-0.5 mg PO Q6H:PRN nausea anxiety insomnia \n5. Losartan Potassium 100 mg PO DAILY \n6. Senna 8.6 mg PO BID:PRN constipation \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAML\nHTN\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\nYou were admitted to receive D8-12 of cycle 10 of your \nMUCI/Dacogen Trial. You tolerated this well and will be \ndischarged home today. You will follow up in clinic as stated \nbelow. Please call in the meantime with any questions or \nconcerns. It was a pleasure taking care of you.\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C92Z0", "I10", "L570", "K5900", "Z87891" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C92Z0: Other myeloid leukemia not having achieved remission", "I10: Essential (primary) hypertension", "L570: Actinic keratosis", "K5900: Constipation, unspecified", "Z87891: Personal history of nicotine dependence" ]

[ "I10", "K5900", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: ORTHOPAEDICS\n \nAllergies: \nLamictal\n \nAttending: ___.\n \nChief Complaint:\nright hip pain\n \nMajor Surgical or Invasive Procedure:\nRight total hip arthroplasty\n\n \nHistory of Present Illness:\nright hip pain\n \nPast Medical History:\nRefractory complex partial seizure\nSeasonal depression\nL broken ankle s/p fixation with plate and screws\nL knee bone spurs\n \nSocial History:\n___\nFamily History:\nMother: high cholesterol, hypothyroid\nFather: high cholesterol, HTN, bladder cancer\nPaternal grandmother: ?heart disease/stroke\nMaternal grandmother: cancer, unknown origin\nMaternal aunt x2: cancer, unknown origin\nYoungest son: neuroblastoma of the adrenal gland.\n \nPhysical Exam:\nDischarge PE:\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* Incision healing well with staples \n* Scant serosanguinous drainage \n* Thigh full but soft \n* No calf tenderness \n* ___ strength \n* SILT, NVI distally \n* Toes warm\n \nPertinent Results:\n___ 06:35AM BLOOD WBC-8.0 RBC-3.57*# Hgb-10.0*# Hct-29.9*# \nMCV-84 MCH-28.0 MCHC-33.4 RDW-13.6 RDWSD-41.2 Plt ___\n___ 06:35AM BLOOD Glucose-98 UreaN-15 Creat-0.9 Na-138 \nK-4.3 Cl-102 HCO3-26 AnGap-14\n___ 06:35AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.8\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:\n\n#Hypotension, POD#0-> SBP in ___ while working with ___ \nasymptomatic, returned SBP ___ when back to bed, given 1L bolus \nwith good effect. Cleared ___ without reoccurrence of hypotension \non POD#1\n\nOtherwise, pain was controlled with a combination of IV and oral \npain medications. The patient received aspirin 325mg BID for \nDVT prophylaxis starting on the morning of POD#1. The foley was \nremoved and the patient was voiding independently thereafter. \nThe surgical dressing was changed on POD#2 and the surgical \nincision was found to be clean and intact without erythema or \nabnormal drainage. The patient was seen daily by physical \ntherapy. Labs were checked throughout the hospital course and \nrepleted accordingly. At the time of discharge the patient was \ntolerating a regular diet and feeling well. The patient was \nafebrile with stable vital signs. The patient's hematocrit was \nacceptable and pain was adequately controlled on an oral \nregimen. The operative extremity was neurovascularly intact and \nthe wound was benign. \n\nThe patient's weight-bearing status is weight bearing as \ntolerated on the operative extremity with posterior precautions. \n\n \nMrs ___ is discharged to home with services in stable \ncondition.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Betamethasone Dipro 0.05% Cream 1 Appl TP BID \n2. Ranitidine 150 mg PO DAILY \n3. Multivitamins 1 TAB PO DAILY \n4. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild \n\n \nDischarge Medications:\n1. Aspirin 325 mg PO BID Duration: 28 Days \ntake with pantoprazole and food \n2. Docusate Sodium 100 mg PO BID \n3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain \n4. Pantoprazole 40 mg PO Q24H \n5. Senna 8.6 mg PO BID \n6. Acetaminophen 1000 mg PO Q8H \n7. Betamethasone Dipro 0.05% Cream 1 Appl TP BID \n8. Multivitamins 1 TAB PO DAILY \n9. Ranitidine 150 mg PO DAILY \n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nright hip arthritis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\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. Please DO NOT take any non-steroidal \nanti-inflammatory medications (NSAIDs such as Celebrex, \nibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by \nyour physician.\n\n8. ANTICOAGULATION: Please continue your Aspirin 325 twice daily \nwith food and pantoprazole or omeprazole for four (4) weeks to \nhelp prevent deep vein thrombosis (blood clots). If you were \ntaking Aspirin prior to your surgery, take it at the above dose \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 five days after surgery but no tub baths, \nswimming, or submerging your incision until after your four (4) \nweek checkup. Please place a dry sterile dressing on the wound \neach day if there is drainage, otherwise leave it open to air. \nCheck wound regularly for signs of infection such as redness or \nthick yellow drainage. Staples will be removed by the visiting \nnurse or rehab facility in two (2) weeks.\n \n10. ___ (once at home): Home ___, dressing changes as \ninstructed, wound checks, and staple removal at two weeks after \nsurgery.\n \n11. ACTIVITY: Weight bearing as tolerated on the operative \nextremity. Posterior precautions. No strenuous exercise or heavy \nlifting until follow up appointment. Mobilize frequently.\n\nPhysical Therapy:\nWBAT RLE\nPosterior hip precautions x 2 months\nMobilize frequently\n\nTreatments Frequency:\ndaily dressing changes as needed for drainage\nwound checks daily\nice\nstaple removal and replace with steri-strips on POD14 at \n___ \n \nFollowup Instructions:\n___\n" ]

[ "M1631", "Q043", "I959", "R569", "E669", "Z6831", "F17210" ]

[ "M1631: Unilateral osteoarthritis resulting from hip dysplasia, right hip", "Q043: Other reduction deformities of brain", "I959: Hypotension, unspecified", "R569: Unspecified convulsions", "E669: Obesity, unspecified", "Z6831: Body mass index [BMI] 31.0-31.9, adult", "F17210: Nicotine dependence, cigarettes, uncomplicated" ]

[ "E669", "F17210" ]

[]

[ " \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:\n___- BRONCHOSCOPY FLEXIBLE AND RIGID, ELECTROCAUTERY, \nBALLOON DILATION \nattach\n \nPertinent Results:\nADMISSION LABS:\n==================\n___ 12:03AM BLOOD WBC-4.7 RBC-3.70* Hgb-12.3 Hct-38.0 \nMCV-103* MCH-33.2* MCHC-32.4 RDW-12.0 RDWSD-45.1 Plt ___\n___ 12:03AM BLOOD Neuts-69.4 ___ Monos-4.9* \nEos-0.0* Baso-0.0 Im ___ AbsNeut-3.26 AbsLymp-1.20 \nAbsMono-0.23 AbsEos-0.00* AbsBaso-0.00*\n___ 12:03AM BLOOD Plt ___\n___ 12:03AM BLOOD Glucose-134* UreaN-13 Creat-0.8 Na-142 \nK-4.9 Cl-105 HCO3-23 AnGap-14\n___ 05:30AM BLOOD Calcium-9.1 Phos-3.7 Mg-1.7\n___ 05:29AM BLOOD ___ pO2-36* pCO2-60* pH-7.32* \ncalTCO2-32* Base XS-2\n___ 12:20AM BLOOD Lactate-3.6*\n\nPERTINENT LABS:\n==================\n___ 04:31AM BLOOD ANCA-NEGATIVE B\n___ 04:31AM BLOOD ___\n___ 01:28PM BLOOD ___ pO2-56* pCO2-55* pH-7.35 \ncalTCO2-32* Base XS-2\n___ 05:29AM BLOOD ___ pO2-36* pCO2-60* pH-7.32* \ncalTCO2-32* Base XS-2\n___ 01:28PM BLOOD Lactate-1.1\n___ 12:20AM BLOOD Lactate-3.6*\n\nMICRO:\n======\n___ 3:50 pm BRONCHIAL WASHINGS Site: TRACHEA\n TRACHEAL WASH. \n\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 COCCI. \n ___ PAIRS AND SINGLY. \n\n RESPIRATORY CULTURE (Final ___: \n Commensal Respiratory Flora Absent. \n STREPTOCOCCUS PNEUMONIAE. >100,000 CFU/mL. \n Note: For treatment of meningitis, penicillin G MIC \nbreakpoints\n are <=0.06 ug/ml (S) and >=0.12 ug/ml (R). \n Note: For treatment of meningitis, ceftriaxone MIC \nbreakpoint are\n <=0.5 ug/ml (S), 1.0 ug/ml (I), and >=2.0 ug/ml (R). \n For treatment with oral penicillin, the MIC break \npoints are\n <=0.06 ug/ml (S), 0.12-1.0 (I) and >=2 ug/ml (R). \n\n SENSITIVITIES: MIC expressed ___ \nMCG/ML\n \n_________________________________________________________\n STREPTOCOCCUS PNEUMONIAE\n | \nCEFTRIAXONE-----------<=0.06 S\nERYTHROMYCIN---------- =>1 R\nLEVOFLOXACIN---------- 1 S\nPENICILLIN G----------<=0.06 S\nTETRACYCLINE---------- <=1 S\nTRIMETHOPRIM/SULFA---- <=0.5 S\nVANCOMYCIN------------ <=1 S\n\n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. \n\n ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. \n\n\n FUNGAL CULTURE (Final ___: \n YEAST. \n\n POTASSIUM HYDROXIDE PREPARATION (Final ___: \n TEST CANCELLED, PATIENT CREDITED. \n PATIENT CREDITED. \n This is a low yield procedure based on our ___ \nstudies. \n if pulmonary Histoplasmosis, Coccidioidomycosis, \nBlastomycosis,\n Aspergillosis or Mucormycosis is strongly suspected, \ncontact the\n Microbiology Laboratory (___). \n\n___ 12:03 am BLOOD CULTURE **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: \n STAPHYLOCOCCUS, COAGULASE NEGATIVE. \n Isolated from only one set ___ the previous five days. \n SENSITIVITIES PERFORMED ON REQUEST.. \n\n Anaerobic Bottle Gram Stain (Final ___: \n GRAM POSITIVE COCCI ___ PAIRS AND CLUSTERS. \n Reported to and read back by ___,RN(CC5B) AT 0312 ON \n___. \n\nIMAGING:\n=========\nCXR ___\nFINDINGS: There is no evidence of subcutaneous emphysema. No \nfocal consolidation, pleural effusion or pneumothorax. The size \nof the cardiac silhouette is enlarged but unchanged.\nIMPRESSION: No subcutaneous emphysema visualized.\n\nDISCHARGE EXAM:\n================\nVITALS: ___ 0833 Temp: 97.9 PO BP: 146/84 L Lying HR: 81 \nRR:\n18 O2 sat: 93% O2 delivery: 1L \nGENERAL: Alert and interactive. ___ no acute distress.\nHEENT: Normocephalic, atraumatic. Pupils equal, round, and\nreactive bilaterally, extraocular muscles intact. Sclera\nanicteric and without injection. Moist mucous membranes, good\ndentition. Oropharynx is clear.\nNECK: No JVD.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: Inspiratory wheezes bilaterally, mild tracheal stridor.\nABDOMEN: Normal bowels sounds, non distended, non-tender except\n___ epigastric area. No organomegaly.\nEXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial \n2+\nbilaterally.\nSKIN: Warm. Cap refill <2s. No rash.\nNEUROLOGIC: AOx3. CN2-12 intact. ___ strength throughout. Normal\nsensation. \n\nDISCHARGE LABS:\n===============\n___ 05:40AM BLOOD WBC-6.2 RBC-3.29* Hgb-10.7* Hct-34.0 \nMCV-103* MCH-32.5* MCHC-31.5* RDW-12.1 RDWSD-45.9 Plt ___\n___ 05:40AM BLOOD Plt ___\n___ 05:40AM BLOOD Glucose-92 UreaN-13 Creat-0.6 Na-146 \nK-3.6 Cl-105 HCO3-31 AnGap-10\n___ 05:40AM BLOOD Calcium-8.6 Phos-5.0* Mg-1.8\n \nBrief Hospital Course:\nSUMMARY:\n====================\nMs. ___ is a ___ year old woman with a history of mild \nintermittent asthma, mood disorder, and inhalation burn injury \nfrom a house fire (1 mo ago) who underwent prolonged intubation \nat ___ c/b subglottic tracheal stenosis, s/p dilation with \n___ IP on ___, with recurrence of stridor and now s/p repeat \ntracheal dilation\n___, initially ___ the TSICU for airway monitoring and then \ntransferred to medicine for further management. She remained \nhemodynamically stable on room air with SpO2 94-96% while \nwalking and at rest. She has oxygen and nursing services at home \nand was discharged home with instructions to follow-up \noutpatient with thoracic surgery.\n\nTRANSITIONAL ISSUES:\n====================\n[ ] Thoracic surgery working on scheduling her an outpatient \nappointment for pre-op eval/consent. Patient should call \n___ to schedule an appointment if she does not hear \nfrom them ___ ___ business days.\n[ ] ___ and ANCA pending at time of discharge to rule out \nautoimmune disease as component of tracheal stenosis.\n\nACUTE/ACTIVE ISSUES:\n====================\n#Stridor\n#Tracheal stenosis\n#S/p rigid bronch, electrocautery and balloon dilation ___\nShe first underwent dilation ___ at ___. CT at ___ \nfrom ___ showed tracheal inflammation and narrowing. She \nunderwent rigid bronch/electrocautery/balloon dilation with IP \non ___ without complication and with improvement ___ her stridor \nand she received a short course of steroids and unasyn. She \nremained stable on ___, which is her home O2 requirement, and \nwas discharged home on a regular diet.\n\n#Mild intermittent asthma\nShe was continued on her home albuterol nebs Q6hours PRN and \nhome budenoside 0.5mg IH BID without incident.\n\nCHRONIC/STABLE ISSUES:\n======================\n#Glaucoma\nHer home lumigan drops were non-formulary and she was \ntransitioned to timolol 1 drop ___ each eye BID and then \ntransitioned back to her home lumigan drops at discharge.D\n\n#Unspecified mood d/o\n#Anxiety\nShe was continued on her home carbamazepine 400mg BID, doxepin \n150mg qHS, perphenazine 24mg qHS, Seroquel XR 600mg qHS, \nhydroxyzine 50mg q6 PRN, clonidine 0.1mg qHS PRN for anxiety, \nand ramelteon 5mg qHS PRN and her home diazepam 10mg TID was \nheld without incident.\n\n#HTN\nHer blood pressure remained under good control (<150) with her \nhome amlodipine 10mg daily. Her home lisinopril 20 daily was \nheld given airway concerns but she remained stable after \ntracheal dilation and she was re-started on lisinopril at \ndischarge.\n\n#CAD\nShe was continued on her home ASA 81 daily\n\n#GERD\nShe was continued on her home ranitidine 150mg BID\n\n#Chronic back pain\nShe was continued on her home gabapentin 300mg TID\n\nICU COURSE ___:\n======================\n___ PMHx inhalation burn injuries and intubation c/p tracheal \nstenosis s/p tracheal dilation on ___ p/w ___, CT \ndemonstrating tracheal narrowing, admitted to ICU for \nrespiratory watch. IP was consulted on presentation, and per \nthere recommendations she was started on hydrocortisone 40 mg q8 \nhr and unasyn on ___ for edema seen on CT scan from ___. \n___. She remained on ___ L NC throughout her \nhospitalization. Patient initially NPO. She underwent a \nbronchoscopy and tracheal balloon dilation by IP on ___, and \nshe remained ___ the ICU for >24 hours post procedure on \nrespiratory watch. She remained stable and she was deemed stable \nfor the floor. She was restarted on clears to regular diet, \nwhich was well tolerated. Hydrocortisone and unasyn was \ndiscontinued on ___ per IP. \nHer home meds were restarted and continued throughout her \nhospitalization\nShe was transferred to the medical floor on ___ for additional \nmanagement\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Gabapentin 300 mg PO TID \n2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB \n3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \n4. amLODIPine 10 mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. Budesonide 0.5 mg IH BID \n7. CarBAMazepine 400 mg PO BID \n8. CloNIDine 0.1 mg PO QHS:PRN insomnia/anxiety \n9. Cyanocobalamin 500 mcg PO DAILY \n10. Diazepam 10 mg PO TID \n11. Doxepin HCl 150 mg PO HS \n12. FoLIC Acid 1 mg PO DAILY \n13. GuaiFENesin ___ mL PO Q6H:PRN cough \n14. HydrOXYzine 50 mg PO Q6H:PRN anxiety \n15. Lisinopril 20 mg PO DAILY \n16. Lumigan 0.03% Ophth (*NF*) 1 drop Other QHS \n17. Ramelteon 5 mg PO QPM:PRN insomnia \n18. Multivitamins 1 TAB PO DAILY \n19. Perphenazine 8 mg PO QAM \n20. Perphenazine 24 mg PO QHS \n21. Polyethylene Glycol 17 g PO DAILY \n22. QUEtiapine extended-release 600 mg PO QHS \n23. Ranitidine 150 mg PO BID \n24. Timolol Maleate 0.5% 1 DROP BOTH EYES BID \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \n2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB \n3. amLODIPine 10 mg PO DAILY \n4. Aspirin 81 mg PO DAILY \n5. Budesonide 0.5 mg IH BID \n6. CarBAMazepine 400 mg PO BID \n7. CloNIDine 0.1 mg PO QHS:PRN insomnia/anxiety \n8. Cyanocobalamin 500 mcg PO DAILY \n9. Diazepam 10 mg PO TID \n10. Doxepin HCl 150 mg PO HS \n11. FoLIC Acid 1 mg PO DAILY \n12. Gabapentin 300 mg PO TID \n13. GuaiFENesin ___ mL PO Q6H:PRN cough \n14. HydrOXYzine 50 mg PO Q6H:PRN anxiety \n15. Lisinopril 20 mg PO DAILY \n16. Lumigan 0.03% Ophth (*NF*) 1 drop Other QHS \n17. Multivitamins 1 TAB PO DAILY \n18. Perphenazine 8 mg PO QAM \n19. Perphenazine 24 mg PO QHS \n20. Polyethylene Glycol 17 g PO DAILY \n21. QUEtiapine extended-release 600 mg PO QHS \n22. Ramelteon 5 mg PO QPM:PRN insomnia \nShould be given 30 minutes before bedtime \n23. Ranitidine 150 mg PO BID \n24. Timolol Maleate 0.5% 1 DROP BOTH EYES BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis:\n=====================\n#Stridor\n#Tracheal stenosis\n#Tracheal balloon dilation\n\nSecondary Diagnosis:\n=====================\n#Asthma\n#Glaucoma\n#Mood disorder\n#Anxiety\n#Hypertension\n#Coronary artery disease\n#Gastroesophageal reflux disease\n#Chronic back pain\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 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 trouble \nbreathing \n\nWHAT HAPPENED WHILE I WAS ___ THE HOSPITAL?\n==========================================\n- Your airway (windpipe) was injured ___ a fire and now it is \nvery narrow and small and can make it hard for you to breath\n\n- You had a procedure to open up your airway (windpipe) and your \nbreathing got better after\n\n- You were discharged home and should make a follow-up \nappointment ___ clinic with the thoracic (airway) surgeons to \nhelp fix your airway\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" ]

[ "J398", "Z6841", "R0902", "I10", "I2510", "F419", "F39", "J4520", "H409", "G8929", "K219", "R000", "Y848", "Y929", "E669" ]

[ "J398: Other specified diseases of upper respiratory tract", "Z6841: Body mass index [BMI]40.0-44.9, adult", "R0902: Hypoxemia", "I10: Essential (primary) hypertension", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "F419: Anxiety disorder, unspecified", "F39: Unspecified mood [affective] disorder", "J4520: Mild intermittent asthma, uncomplicated", "H409: Unspecified glaucoma", "G8929: Other chronic pain", "K219: Gastro-esophageal reflux disease without esophagitis", "R000: Tachycardia, unspecified", "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", "E669: Obesity, unspecified" ]

[ "I10", "I2510", "F419", "G8929", "K219", "Y929", "E669" ]

[]

[ " \nName: ___ Unit ___: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nErythromycin Base / Doxycycline / Amoxicillin / Clindamycin / \nBactrim DS / Niaspan Starter Pack / Levofloxacin / Advil / \nSalsalate / Colchicine / Pletal / Penicillins / Nitrofurantoin / \nLisinopril / Influenza Virus Vacc,Specific / Spiriva with \nHandiHaler\n \nAttending: ___\n \nChief Complaint:\nmelena\n \nMajor Surgical or Invasive Procedure:\nColonoscopy ___ and ___\n\n \nHistory of Present Illness:\nMs. ___ is a ___ female with the past medical\nhistory of HFpEF, CAD s/p CABG x2, HTN, DMII, HLD, afib s/p PPM\nplacement, pHTN, AAA s/p EVAR, COPD, CKD, GERD, and small bowel\nangioectasias and colonic dieulafoy lesions c/b recurrent GI\nbleeding who presents for melena x2 days. \n\nPt has hx of recurrent bleeds, ___ on ___, at which time\nafter discussion with GI patient opted to not pursue aggressive\nintervention and instead manage conservatively with regular\ntransfusions as outpt in response to the melena. At the time, \npatient said she would prefer not to undergo \ncolonoscopies for smaller bleeds, however, if she noticed a \nlarge bleed, she would be amenable to intervention in order to \nstop. She was ___ admitted ___ for R hip fx and went to rehab;\nshe was started on lovenox at night at the time and has now been\noff for a few weeks per pt.\nPt ___ received a blood transfusion 2 days ago on ___ when \nher\nHb dropped to 7 from 9.2 after a melanotic BM. Pt reported that\nshe has had 2 melanotic BMs today and ___ yesterday so she came to\nthe ED. \n\nIn the ED, vitals were afebrile, HR 68, BP 131/60, RR 16, and\n100% on RA. Her Hb had dropped to 6.8. Started on iv ppi. She \nwas\neval by GI who will re-eval whether she needs to be scoped. They\nrecommend PPI Bid and clear liquid diet for now. \n\nPt says that she does not have fevers, chills, cp, sob, n/v,\ndysuria, weakness, falls. She says she does not feel more tired\nthan usual. Denies syncope or lightheadedness/dizziness.\nDescribes her stool as black and then tinged with blood on the\nsides. She would like to avoid a colonoscopy if possible but if\nnecessary, she would consider it. \n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n\n \nPast Medical History:\n# COPD: ___ PFTs mild obstructive defect with FEV1 70% \n# Large ventral hernia \n# Diverticulosis\n# Segmental colitis\n# Colonic AVM\n# Cholelithiasis\n# Hx of GIB\n# CHF\n# Pulmonary hypertension: ___ ___: Dilated RV cavity. Mild \nglobal RV free wall hypokinesis. 3+ TR, moderate PAH (PASP 53 mm \nHg above RA) with eccentric jet, causing underestimation\n# Atrial fibrillation with very slow ventricular response and \nunderwent pacemaker placement on ___ \n# Abdominal Aortic Aneurysm: s/p endovascular aneurysm repair \n___ \n# Asthma \n# Hypertension \n# Hyperlipidemia \n# Hypothyroidism \n# ASD: Secundum ASD with left to right flow at rest ___ ___\n# Coronary artery disease s/p quadruple bypass in ___ and again \nin ___ with ?stent placement \n# Colonic polyps and large colonic adenoma seen on colonoscopy \n___, patientt elected not to have more colonoscopy \n- Small and Large Bowel AVMs\n# GERD \n# Sleep Apnea, on BIPAP \n# Insomnia \n# Iron deficiency anemia \n# Migraine headaches \n# Osteoarthritis \n# Renal insufficiency: patient born with atrophic right kidney, \nhas stent in left for patency \n# Venous insufficiency \n \nSocial History:\n___\nFamily History:\nMom: CHF \nDad: CVA \nSister: dementia, stroke\n \nPhysical Exam:\nGENERAL: Elderly female, Alert and in ___ apparent distress, \nthin,\nanxious\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, grade ___ systolic murmur heard ___ of LLSB. \n\nRESP: Bilat LL crackles, ___ resp distress\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. +abd hernia, is reducible\nGU: ___ suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities, bilat 1+ pitting edema\nin ___\nSKIN: ___ rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric, gaze conjugate with \nEOMI,\nspeech fluent, moves all limbs\nPSYCH: pleasant, appropriate affect\n\n \nPertinent Results:\n___ 08:50AM BLOOD WBC-7.5 RBC-3.05* Hgb-9.1* Hct-29.8* \nMCV-98 MCH-29.8 MCHC-30.5* RDW-17.2* RDWSD-60.5* Plt ___\n___ 08:50AM BLOOD Glucose-118* UreaN-11 Creat-1.0 Na-143 \nK-3.5 Cl-106 HCO3-27 AnGap-10\n___ 08:50AM BLOOD Calcium-10.2 Phos-2.4* Mg-1.9\n\nColonoscopy ___\nAborted due to poor prep\n\nColonoscopy ___\nMultiple diverticula with mixed openings were seen in the whole \ncolon. Diverticulosis appeared to be severe with predominance in \nsigmoid\nNormal mucosa noted in terminal ileum without blood\nSeveral polyps were found but not removed given acute bleed\nBlood found throughout the colon\nA single bleeding Dieulafoy lesion was found in the distal \nascending colon, proximal to the hepatic flexure. THe area was \nwashed and inspected carefully. 8ccs of epinephrine ___ \ninfection was successfully applid for hemostasis. 2 endoclips \nwere successfully applied for the purpose of hemostasis.\n \nBrief Hospital Course:\n___ female with the past medical history\nof HFpEF, CAD s/p CABG x2, HTN, DMII, HLD, afib s/p PPM\nplacement, pHTN, AAA s/p EVAR, COPD, CKD, GERD, and small bowel\nangioectasias and colonic dieulafoy lesions c/b recurrent GI\nbleeding who presents for melena x2 days found to have another\nbleeding dieulafoy lesion.\n\nACTIVE/ACTIVE ISSUES ISSUES\n=============\n#Acute on chronic blood loss anemia\n#Melena\n#LGIB\nrepeat dieulafoy bleed found in colon, clipped via ___. She \nneeded 2 colonoscopies due to the first one with poor prep. I \nhad a\nconversation probing her receptiveness of colon resection. She \nis\nvery risk averse and would like to avoid surgery. She states she\nhas been living like this with frequent transfusions and would\nlike to keep it this way.\nBaseline Hgb approx ___. She is s/p 3u transfusion, now hgb 9.1 \non discharge.\nI expect that she will still need periodic transfusions once\ndischarged. Hgb stable for 24 hours. I spoke with GI, ok to \ndischarge with close follow up\n-appreciate GI consult\n-CBC BID\n-revert to PO PPI\n-advance to full diet\n\n#Anxiety\nrequired occasional Ativan with bowel prep, but since then it \nhas been reasonably controlled\n\nCHRONIC/STABLE PROBLEMS: \n=============== \n#Chronic diastolic congestive heart failure\n#Pulmonary HTN\n#Mitral valve regurgitation\n#ASD\n#CAD s/p multiple interventions, CABGx2, possible ___ evidence of ACS/HF. Notable blowing murmur on exam consistent \n\nwith MR. ___ ___. \n- resume torsemide 60mg\n- resumed home losartan and imdur\n- c/w home ranolazine, digoxin 0.0625mg PO qd (for RV support),\nandrosuvastatin 40mg qPM\n-will continue ASA in s/o cardiac hx unless GI feels otherwise\n\n#Atrial fibrillation s/p PPM for slow ventricular response\nNot on anticoagulation secondary to chronic bleeds other than\nASA. Rates appear well controlled with PPM. \n-continue digoxin\n-deferring AC in setting of bleed\n\n#COPD\n#Asthma\n-continue ipratropium, start advair BID in place of home\nSymbicort\n\n#Restless Leg Syndrome\n-Continue home pramipexole.\n\n#Insomnia\n-Continue on home zolpidem\n-hold home Belsomra as non-formulary\n\n#OSA\n-Continue home BiPAP at night\n\n#Hypothyrodism\n-Continue home levothyroxine\n\n#DM:\n-held lantus due to poor PO\n-ISS\n \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Calcitriol 0.25 mcg PO DAILY \n2. Digoxin 0.0625 mg PO DAILY \n3. FoLIC Acid 1 mg PO DAILY \n4. Levothyroxine Sodium 88 mcg PO DAILY \n5. Pramipexole 0.125 mg PO QHS \n6. Ranolazine ER 500 mg PO BID \n7. Rosuvastatin Calcium 40 mg PO QPM \n8. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN cough \n9. Aspirin 81 mg PO DAILY \n10. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation DAILY \n11. Montelukast 10 mg PO DAILY \n12. Zolpidem Tartrate 5 mg PO QHS \n13. Torsemide 60 mg PO DAILY \n14. Potassium Chloride 20 mEq PO DAILY \n15. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n16. Losartan Potassium 25 mg PO DAILY \n17. Omeprazole 20 mg PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Calcitriol 0.25 mcg PO DAILY \n3. Digoxin 0.0625 mg PO DAILY \n4. FoLIC Acid 1 mg PO DAILY \n5. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN cough \n6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n7. Levothyroxine Sodium 88 mcg PO DAILY \n8. Losartan Potassium 25 mg PO DAILY \n9. Montelukast 10 mg PO DAILY \n10. Omeprazole 20 mg PO DAILY \n11. Potassium Chloride 20 mEq PO DAILY \nHold for K > 5 \n12. Pramipexole 0.125 mg PO QHS \n13. Ranolazine ER 500 mg PO BID \n14. Rosuvastatin Calcium 40 mg PO QPM \n15. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation DAILY \n16. Torsemide 60 mg PO DAILY \n17. Zolpidem Tartrate 5 mg PO QHS \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nLower GI bleed due to dieulafoy lesion\n\n \nDischarge Condition:\nstable\nA/Ox3\nambulatory with minimal assist\n\n \nDischarge Instructions:\nYou were admitted to the hospital again for lower GI bleeding. \nWe performed colonoscopy, which showed another bleeding \ndieulafoy lesion and it was clipped. Your bleeding seems to have \nslowed. Please follow up with your PCP ___ 1 week for another \nhemoglobin level check.\n\nWe discussed the option of partial colectomy, but you prefer not \nto go that route. We respect your wishes, but should continue to \nconsider this.\n\nWeigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n \nFollowup Instructions:\n___\n" ]

[ "K6381", "D62", "I130", "I5032", "Q211", "E1122", "N182", "Z794", "E785", "J449", "K219", "I2510", "E039", "G2581", "I4891", "I2720", "G4733", "G4700", "F419", "M1990", "Z66", "I340", "K5730", "I872", "Z951", "Z950", "Z87891" ]

[ "K6381: Dieulafoy lesion of intestine", "D62: Acute posthemorrhagic anemia", "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", "Q211: Atrial septal defect", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N182: Chronic kidney disease, stage 2 (mild)", "Z794: Long term (current) use of insulin", "E785: Hyperlipidemia, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E039: Hypothyroidism, unspecified", "G2581: Restless legs syndrome", "I4891: Unspecified atrial fibrillation", "I2720: Pulmonary hypertension, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "G4700: Insomnia, unspecified", "F419: Anxiety disorder, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "Z66: Do not resuscitate", "I340: Nonrheumatic mitral (valve) insufficiency", "K5730: Diverticulosis of large intestine without perforation or abscess without bleeding", "I872: Venous insufficiency (chronic) (peripheral)", "Z951: Presence of aortocoronary bypass graft", "Z950: Presence of cardiac pacemaker", "Z87891: Personal history of nicotine dependence" ]

[ "D62", "I130", "I5032", "E1122", "Z794", "E785", "J449", "K219", "I2510", "E039", "I4891", "G4733", "G4700", "F419", "Z66", "Z951", "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:\nTIPS\n \nMajor Surgical or Invasive Procedure:\nArteriogram ___\nTIPS ___\n \nHistory of Present Illness:\n___ w/ PMHx including APLS w/ DVT & portal/splenic/SMA venous \nthrombosis ___, leading to portal htn with varices, portal \ncholangiopathy and biliary strictures with recurrent cholangitis \nwho was diagnosed with liver absesses in ___ due to the \ndevelopment of abdominal pain, fevers, and transaminitis. ERCP \nin ___ showed a dislodged metal stent, and CT revealed \nnotable multiple hepatic abscesses that were drained by ___. \nPatient completed a 2 week course of PO flagyl and 4 week course \nof IV CTX, with improvement in abscesses noted on subsequent \nimaging. \n\nIn early ___, he developed worsening fatigue, malaise and \nabdominal pain. At his follow-up on ___, he had a worsening \nleukocytosis and hyperbilirubinemia c/f cholangitis. He was \nadmitted with repeat ERCP with stent exchange and cystic duct \nstone removal. \n\nPatient's symptoms resolved completely after ERCP. However, BCx \nfrom ___ grew Strep anginosus in ___ bottles an repeat CT \nshowed two new liver collections, distinct from those seen in \n___. ___ drained the larger lesion, and cultures were notable \nfor pan-sensitive Strep anginosus, MDR E coli & K pneumo \nsensitive to meropenem, Avycaz, colistin.\n\nThe patient was treated with meropenem for these organisms and \nhepatic abscess since ___. He is now in his ___ week of \ntreatment without evidence of active infection currently. He is \nclosely followed by ID who is tentatively planning to \ndiscontinue the meropenem and discontinue the PICC line (L arm, \nplaced at time of antibiotic initiation) provided that a repeat \nRUQ ultrasound this admission is without evidence of recurrent \ndisease.\n\nHe had a drain into a hepatic abscess (in R dome) that was \nplaced last admission and which was removed approximately 5 days \nafter last discharge.\n\nThe patient was referred in by Dr. ___ elective TIPS \nprocedure.\n\nHis last dose of meropenem was at 12.30PM. He manages his own \nantibiotic infusions at home. He also has ___ ___ to change \ndressing on PICC line.\n\nID note from ___ comments that they would like meropenem 500mg \nIV Q6H ___ for any invasive procedure that risks \nseeding biliary flora into the bloodstream.\n\n \nPast Medical History:\n- JAK2 mutation indicative of myeloproliferative syndrome\n- CBD stones and cholangitis s/p ERCP in ___, grade 3 varices \nseen at that time.\n- Portal vein thrombosis in ___, thought to be secondary to\nantiphospholipid antibody syndrome, recently switched to Lovenox\nafter recurrent thrombosis while on therapeutic coumadin therapy\n- Status post cholecystectomy ___\n- 3 cords of grade 1 varices\n- Portal gastropathy in the stomach\n- Periampullary varix\n- Hemorrhoids\n \nSocial History:\n___\nFamily History:\nThere is no family history of hypercoagulable disorders, no \nhistory of coronary disease or early MIs. Father with history of \nhypertension. There is no history of diabetes. There is no \nhistory of prostate or colon cancer. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n==========================\nVS: T 98.2, BP 95/51, P 71, RR 18, O2sat 95% on RA\nGEN: pleasant, chronically-ill appearing but comfortable and in\nno acute distress\nCARD: RRR, normal S1, S2, no murmurs / rubs / gallops \nPULM: clear to auscultation bilaterally w/o wheezes / rhonchi /\nrales \nGI: mildly distended & tympanic without significant fluid wave\nappreciated, normoactive bowel sounds, non-tender\nMSK: no joint swelling or erythema \nEXTR: no edema \nSKIN: no rashes, no jaundice \nACCESS: L UE PICC c/d/i (dressing just changed in ED)\n\n \nPertinent Results:\nAll other relevant labs in ___\n\nADMISSION LABS:\n====================\n___ 09:00PM BLOOD WBC-3.1* RBC-3.19* Hgb-9.5* Hct-29.3* \nMCV-92 MCH-29.8 MCHC-32.4 RDW-15.2 RDWSD-51.2* Plt ___\n___ 09:00PM BLOOD Neuts-69.6 Lymphs-15.2* Monos-9.7 Eos-4.2 \nBaso-1.0 Im ___ AbsNeut-2.15# AbsLymp-0.47* AbsMono-0.30 \nAbsEos-0.13 AbsBaso-0.03\n___ 09:00PM BLOOD ___ PTT-36.5 ___\n___ 09:00PM BLOOD Glucose-188* UreaN-15 Creat-0.5 Na-137 \nK-3.3 Cl-99 HCO3-27 AnGap-14\n___ 09:00PM BLOOD ALT-25 AST-28 AlkPhos-282* TotBili-1.3\n___ 09:00PM BLOOD Calcium-7.8* Phos-3.2 Mg-1.9\n___ 09:20PM URINE Color-AMBER Appear-Clear Sp ___\n___ 09:20PM URINE Blood-NEG Nitrite-NEG Protein-TR \nGlucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.5 Leuks-SM \n___ 09:20PM URINE RBC-2 WBC-2 Bacteri-FEW Yeast-NONE Epi-<1\n\nOTHER RELEVANT LABS/STUDIES:\n========================\nRUQ US ___\nIMPRESSION: \n \n1. Previously seen left lobe hepatic abscess is no longer \nvisualized. No new fluid collection identified. Unchanged \nmoderate biliary duct dilation with pneumobilia. \n2. Cirrhosis with splenomegaly and small amount of perihepatic \nascites. \n3. Cavernous transformation of the portal vein. \n\nMesenteric arteriogram ___\nIMPRESSION: \nSuccessful planning study for attempted portal vein \nrecanalization / \nportosystemic shunt placement consisting of splenic and \nmesenteric \narteriograms with delayed venograms. \n\n___BD & PELVIS WITH CO \nIMPRESSION: \n \n1. Fluid-filled, dilated loops of small bowel with new \nmesenteric swirling in the mid abdomen is concerning for slow \nflow mesenteric ischemia or partial volvulus. There is no \ndefinite filling defect seen within the mesenteric vessels. \nClose clinical and imaging follow-up are recommended. \n2. The PTBD is in appropriate position with expected pneumobilia \nin the left intrahepatic bile ducts. CBD stents are in stable \nposition, with unchanged biliary ductal dilatation in hepatic \nsegment VII bile ducts. \n3. Nonocclusive thrombus remains in the main portal and splenic \nvein. \n4. Layering in pelvic ascites is similar to ___, \nand remains \nconcerning for hemorrhage. \n5. Cirrhotic liver with splenomegaly measuring up to 23 cm and \nextensive \nsplenic, gastric and esophageal varices are unchanged compared \nto ___. \n\n___ Peritoneal fluid: \n_________________________________________________________\n ENTEROCOCCUS FAECIUM\n | ESCHERICHIA COLI\n | | \nAMPICILLIN------------ =>32 R =>32 R\nAMPICILLIN/SULBACTAM-- =>32 R\nCEFAZOLIN------------- =>64 R\nCEFEPIME-------------- =>64 R\nCEFTAZIDIME----------- =>64 R\nCEFTRIAXONE----------- =>64 R\nCIPROFLOXACIN--------- =>4 R\nDAPTOMYCIN------------ S\nGENTAMICIN------------ 4 S\nLINEZOLID------------- 2 S\nMEROPENEM------------- 4 R\nPENICILLIN G---------- =>64 R\nTOBRAMYCIN------------ =>16 R\nTRIMETHOPRIM/SULFA---- <=1 S\nVANCOMYCIN------------ =>32 R\n\n ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. \n\n\n FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED. \n\nCT abd/pel ___: \nIMPRESSION: \n1. One of the patient's common bile duct stents has become \ndislodged and now sits within a small bowel loop in the right \nmid abdomen. \n2. Periductal biliary enhancement compatible with cholangitis. \n3. Patent TIPS point thrombus again seen in the main portal \nvein, unchanged from prior exam. \n4. Moderate to large volume of abdominal and pelvic ascites. \n5. Diffuse small bowel dilatation compatible with ileus. \n\n \nBrief Hospital Course:\nMr. ___ is a ___ w/ PMHx significant for myeloproliferative \ndisorder ___ JAK2 mutation and resulting hypercoagulable state \nc/b DVT & portal/splenic/SMA venous thrombosis, leading to \nportal cholangiopathy and biliary strictures with multiple \nepisodes of cholangitis. He was admitted for a planned TIPS \nprocedure, which was c/b hypoxic respiratory failure, SBP, MDR \nE. coli bactermia, and VRE SBP. His clinical status continued to \nworsened and he was made comfort measures only in the setting of \na refractory ileus and persistent infections despite prolonged \nantibiotic courses. \n\nPalliative care and spiritual care were very involved in his \ncase and several goals of care conversations were had with the \npatient and his family. He was transitioned to comfort measures \nonly on ___ and died on ___. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ferrous Sulfate 325 mg PO BID \n2. Lactobacillus acidophilus 1 unit oral DAILY \n3. Enoxaparin Sodium 100 mg SC DAILY \nStart: ___, First Dose: Next Routine Administration Time \n4. Furosemide 40 mg PO BID \n5. Nadolol 20 mg PO EVERY OTHER DAY \n6. Omeprazole 20 mg PO BID \n7. Spironolactone 50 mg PO BID \n8. Sucralfate 1 gm PO QID \n9. Ursodiol 600 mg PO BID \n10. Meropenem 1000 mg IV Q8H \n11. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line \nflush \n\n \nDischarge Medications:\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nPatient deceased. \n \nDischarge Condition:\nDeceased. \n \nDischarge Instructions:\nN/A\n \nFollowup Instructions:\n___\n" ]

[ "K830", "K831", "J9601", "E43", "K652", "R7881", "E872", "D6861", "I82891", "I8510", "R188", "K766", "C946", "K922", "D696", "Z66", "Z515", "D649", "B952", "B965", "Z1621", "Z6820" ]

[ "K830: Cholangitis", "K831: Obstruction of bile duct", "J9601: Acute respiratory failure with hypoxia", "E43: Unspecified severe protein-calorie malnutrition", "K652: Spontaneous bacterial peritonitis", "R7881: Bacteremia", "E872: Acidosis", "D6861: Antiphospholipid syndrome", "I82891: Chronic embolism and thrombosis of other specified veins", "I8510: Secondary esophageal varices without bleeding", "R188: Other ascites", "K766: Portal hypertension", "C946: Myelodysplastic disease, not classified", "K922: Gastrointestinal hemorrhage, unspecified", "D696: Thrombocytopenia, unspecified", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "D649: Anemia, unspecified", "B952: Enterococcus as the cause of diseases classified elsewhere", "B965: Pseudomonas (aeruginosa) (mallei) (pseudomallei) as the cause of diseases classified elsewhere", "Z1621: Resistance to vancomycin", "Z6820: Body mass index [BMI] 20.0-20.9, adult" ]

[ "J9601", "E872", "D696", "Z66", "Z515", "D649" ]

[]

[ " \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 \n___ Complaint:\nSmall bowel obstruction\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ prior hx of right colectomy (___) for colonic polyp \nc/bleak, requiring resection of ileocolic anastomosis diverting \nileostomy, with subsequent ileostomy take-down, ileocolic \nanastomosis, small bowel resection, along with ventral hernia \nrepair with component ___ who underwent \nendoscopic dilation of anastomotic stricture on ___ c/b \nperforation managed non-operatively s/p ___ drainage and \nconservative management who now re-presents with abdominal pain \nconcerning for SBO. Of note, patient had recurrently SBOs after \nhis multiple operations spanning ___. On ___, patient \nunderwent colonoscopic dilation of an anastomotic stricture. \nThis was complicated by a operation which was non-operatively \nmanaged,\nbut required ICU stay ( Free air on CT). On ___, patient had a \n___ placed pigtail for a LUQ abdominal pain. Patient was \nre-hospitalized for malaise and a partial SBO (___).\nDuring that hospital admission, patient was found to have a \nbladder tumor. He underwent a cystoscopy and transurtheral \nresection on ___. Patient was recently admitted ___ for \nmalaise. CT A/P demonstrates extensive fat-stranding and small \nbowel wall thickening proximal to the entero-colonic anastomosis\nconcerning for contained perforation similar to prior CT scans. \nPatient was started on TPN and continued on antibiotics. Initial \nplan was for patient to receive antibiotics until the \ninflammation improves, and then to undergo elective resection \nalong with plastic surgery.\nSince discharge on ___, patient initially presented to ___ \nwith hypotension and received IV hydration. He was discharged \nthe same day. At home patient was not tolerating oral intake. 4 \ndays ago, patient started to experience worsening abdominal \npain, nausea, with ___ episodes of emesis. Patient continued to \npass\ngas and have bowel function as of ___. However, given \nworsening pain, he initially presented to ___ where a CT A/P was \nperformed demonstrating ongoing stranding in the RUQ, with \ndilated loops of small bowel. \nHe was trasferred to ___ for further evaluation\n \nPast Medical History:\nBladder Tumor - non-invasive, papillary urothelial carcinoma \nHepatitis C s/p treatment \nCoronary artery disease\nHTN \nColonic polyps \ns/p VF arrest\ns/p PEA arrest\nAtrial fibrillation in the setting of bowel perforations\nRecurrent bowel obstructions \nPast Surgical History: \nLiver bx in ___ \nLap chole in ___ \nL hip replacement \n___ ileostomy takedown, v hernia repair + comp. sep.+mesh \n___: Exploratory laparotomy, resection of ileocolic \nanastomosis, abdominal washout, placement of ABThera VAC. \n___: Laparoscopic right colectomy and colonoscopy. \n___: Ileostomy takedown, extensive lysis of adhesions, \nsmall bowel resection, ileocolic anastomosis, ventral hernia \nrepair with component separation and mesh\n___: Cystoscopy, bilateral retrograde pyelogram,\nbipolar transurethral resection of bladder tumor, intravesical\ninstillation of gemcitabine\n \nSocial History:\n___\nFamily History:\nNoncontributory \n \nPhysical Exam:\nDischarge Physical Exam:\n\nVS: 97.5, 127/78, 70, 18, 94%/RA \nGEN: NAD\nCV: hemodynamically stable\nPULM: normal excursion, no respiratory distress\nABD: soft, tender to palpation in epigastric region and right \nlower quadrant, granulation tissue at drain insertion site, \ndrain to LLQ with feculent output\nEXT: WWP, no CCE, 2+ B/L radial\nNEURO: A&Ox3, no focal neurologic deficits\n\n \nPertinent Results:\n___ 05:34AM BLOOD WBC-11.8* RBC-3.32* Hgb-10.5* Hct-32.0* \nMCV-96 MCH-31.6 MCHC-32.8 RDW-14.4 RDWSD-50.8* Plt ___\n___ 05:37PM BLOOD WBC-8.5 RBC-3.33* Hgb-10.2* Hct-33.2* \nMCV-100* MCH-30.6 MCHC-30.7* RDW-14.6 RDWSD-53.0* Plt ___\n___ 05:37PM BLOOD Neuts-72.5* Lymphs-9.8* Monos-16.4* \nEos-0.4* Baso-0.2 Im ___ AbsNeut-6.19* AbsLymp-0.84* \nAbsMono-1.40* AbsEos-0.03* AbsBaso-0.02\n___ 05:37PM BLOOD ___ PTT-31.7 ___\n___ 10:30AM BLOOD Glucose-97 UreaN-16 Creat-0.6 Na-139 \nK-4.6 Cl-104 HCO3-26 AnGap-9*\n___ 05:34AM BLOOD Glucose-95 UreaN-16 Creat-0.7 Na-136 \nK-5.5* Cl-101 HCO3-24 AnGap-11\n___ 05:37PM BLOOD Glucose-96 UreaN-17 Creat-0.7 Na-136 \nK-5.4 Cl-102 HCO3-24 AnGap-10\n___ 05:37PM BLOOD ALT-18 AST-24 AlkPhos-96 TotBili-0.2\n___ 10:30AM BLOOD Calcium-8.4 Phos-4.4 Mg-1.9\n___ 08:56AM BLOOD Calcium-8.1* Phos-11.6* Mg-3.2*\n___ 05:34AM BLOOD Albumin-2.7* Calcium-8.0* Phos-3.9 Mg-2.0 \nIron-12___ 05:37PM BLOOD Albumin-2.7* Calcium-8.3* Phos-4.0 Mg-1.7\n___ 05:34AM BLOOD calTIBC-152* TRF-117*\n___ 05:34AM BLOOD Triglyc-125\n___ 05:51PM BLOOD Lactate-0.9\n \nBrief Hospital Course:\nMr. ___ presented to ___ on ___ with symptoms and \nimaging concerning for recurrent small bowel obstruction. He was \nadmitted to the colorectal surgery service for conservative \nmanagement. The patient was given bowel rest, maintained on his \nhome TPN and antibiotics were switched to IV. His abdominal \nsymptoms improved with conservative management. Initially he was \nkept on his home antibiotic regimen converted to IV. However, \nbased on his recurrent obstructive symptoms and lack of response \nraised our concern about absorption. The infectious disease team \nwas consulted and with their recommendations, the patient was \ntransitioned to IV ceftriaxone and flagyl while he was \ninpatient. On the day of discharge, the patient was then given a \nchallenge dose and dose of ertapenem to continue as an \noutpatient per the recommendations of the infectious disease \nteam. His pain was well controlled on Tylenol and tramadol for \nbreakthrough pain. The patient remained stable from a \ncardiovascular standpoint; vital signs were routinely monitored. \nThe patient remained stable from a pulmonary standpoint; oxygen \nsaturation was routinely monitored. The patient was voiding \nwithout difficulty throughout hospitalization, urine output was \nmonitored as indicated. On ___, the patient was discharged \nhome. At discharge, he was passing flatus, voiding, and \nambulating independently. He will follow-up in the clinic in \n___ to discuss surgery. He will continue the ertapenem at \nhome with weekly labs, continue TPN, and may continue to eat for \ncomfort. This information was communicated to the patient \ndirectly prior to discharge.\n\n \nMedications on Admission:\n1. Acetaminophen 1000 mg PO Q8H \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO QPM \n4. Lisinopril 2.5 mg PO DAILY \n5. Tamsulosin 0.4 mg PO QHS \n6. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n7. TraZODone 50 mg PO QHS:PRN insomnia \n8. Ciprofloxacin HCl 500 mg PO BID \n9. Metoprolol Succinate XL 25 mg PO DAILY \n10. MetroNIDAZOLE 500 mg PO Q8H \n11. Melatin (melatonin) 3 mg oral QHS \n12. Multivitamins 1 TAB PO DAILY \n13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nBID:PRN \n14. Vitamin D 1000 UNIT PO DAILY \n15. Saline Wound Wash (sodium chloride) 0.9 % Drain Q24H \n\n \nDischarge Medications:\n1. Ertapenem Sodium 1 g IV ONCE Duration: 1 Dose \nRX *ertapenem 1 gram 1 g IV once a day Disp #*30 Vial Refills:*1 \n\n2. Acetaminophen 1000 mg PO Q8H \n3. Aspirin 81 mg PO DAILY \n4. Atorvastatin 80 mg PO QPM \n5. Lisinopril 2.5 mg PO DAILY \n6. Melatin (melatonin) 3 mg oral QHS \n7. Metoprolol Succinate XL 25 mg PO DAILY \n8. Multivitamins 1 TAB PO DAILY \n9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nBID:PRN \n10. Saline Wound Wash (sodium chloride) 0.9 % Drain Q24H \n11. Tamsulosin 0.4 mg PO QHS \n12. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n13. TraZODone 50 mg PO QHS:PRN insomnia \n14. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nSmall bowel obstruction\nContained perforation\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 a symptoms suggestive of \nsmall bowel obstruction. You were given bowel rest and \nintravenous fluids and keep NPO. Your obstruction has \nsubsequently resolved after conservative management. We are \nsending you home with new intravenous antibiotics to treat your \ninfection. Please continue your TPN at home and eat for \ncomfort. \n\nIf you have any of the following symptoms, please call the \noffice or go to the emergency room (if severe): increasing \nabdominal distension, increasing abdominal pain, nausea, \nvomiting, inability to tolerate food or liquids, prolonged loose \nstool, or extended constipation.\n\nThank you for allowing us to participate in your care, we wish \nyou all the best! \n \nFollowup Instructions:\n___\n" ]

[ "K56609", "K631", "Z8551", "Z86010", "I10", "Z87891", "I2510", "Z96642", "I4891", "Z8674" ]

[ "K56609: Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction", "K631: Perforation of intestine (nontraumatic)", "Z8551: Personal history of malignant neoplasm of bladder", "Z86010: Personal history of colonic polyps", "I10: Essential (primary) hypertension", "Z87891: Personal history of nicotine dependence", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z96642: Presence of left artificial hip joint", "I4891: Unspecified atrial fibrillation", "Z8674: Personal history of sudden cardiac arrest" ]

[ "I10", "Z87891", "I2510", "I4891" ]

[]

[ " \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, hyperkalemia\n \nMajor Surgical or Invasive Procedure:\n- Tunneled right IJ catheter placement (removed ___\n- Left thoracentesis (800cc)\n\n \nHistory of Present Illness:\n___ male history of COPD diabetes chronic kidney disease \npresents emergency room for evaluation of elevated potassium and \ndyspnea.\n\nPer report, he presented to routine appointment at his ___ \n___ when it was noted that he was hyperkalemic at 6.2 \nwith some associated shortness of breath. He reported this SOB \nstarted somewhat suddenly 1 month prior. He denies any fever or \ncough. No lower leg edema. No nausea no vomiting. No chest pain \nshortness of breath. He was sent to the emergency department for \nfurther evaluation. Reported BP 152/92, HR 72, 99% before \nleaving clinic.\n\nIn the ED, initial vitals: 97.3 80 256/62 22 99% RA \n\nPer report, exam notable for tachypnea.\n\nLabs: K 6.3>6.2 pH 7.25 pCO2 59 pO2 ___levations in V2 V3 repeat EKG v2 and v3 ste 1 mm\n\nCXR IMPRESSION: Moderate to large left and small right pleural \neffusions. \n\n \n\nPt given:\n\n___ 13:40 IV Insulin Regular 10 units \n\n___ 13:40 IV Dextrose 50% 25 gm \n\n___ 13:40 IV Calcium Gluconate 1 gm \n\n___ 14:01 PO Aspirin 324 mg \n\n___ 15:35 IV DRIP Nitroglycerin Started 0.35 mcg/kg/min \n\n___ 15:35 IV Furosemide 80 mg \n\n___ 15:52 IV DRIP Nitroglycerin Confirmed Rate Changed \nto 1 mcg/kg/min \n\n___ 17:48 IV Furosemide 120 mg \n\n \n\nInitiated on BiPAP with concern for increased work of breathing. \nLowest recorded O2 93% on RA. Repeat VBG: pH 7.31 pCO2 45 pO2 \n36, K before arrival 5.2. Patient reliably urinating in \ncollection bottle, adamantly refusing foley. Total UOP during ED \nvisit 400ccs\n\n \n\nAdmitted with concern for respiratory distress and potential \nneed for dialysis intiation. \n\n \n\nOn transfer, vitals were: 80 122/57 (noted to be spurious by ED \nprovider, SBP 170 on his read in room) 16 98% Bipap\n\n \n\nOn arrival to the MICU, pt breathing comfortably with BiPap in \nplace. Denies current dyspnea/CP/N/V/F/C/jaw pain/arm pain. \nDenies history of heart failure, but cannot recall if he's had \nECHO in past. Reports fistula placed but pt did not want to \nintiate given he was continuing to urinate. Reports \nunderstanding he will likely now need to initiate. Reports hx of \nchest pain leading to diagnosis of heart attack in ___ but was \nmonitored overnight in hospital in ___, ___ not undergoing \ncardiac catheterization then or thereafter. He reports having a \ncardiologist but does not know his name. Reports he no longer \nhas primary care physician. Reports no major weight gain. Pt \nreports holding meds, not eating since ___ due to scheduled \ncolonoscopy on ___ (not underwent because of snow). \n\n \n\nPer discussion with outpatient nephrologist, fistula placed in \n___ ___. Has needed dialysis, but had refused \nin the past.\n\n \n\nPer notes, seen pulmonologist ___ for SOB, who recommended \ninitiation of dialysis. CXR ___ described in office visit \nshowed hyperinflated lungs c small b/l pleural effusions \n(unclear date of CXR). ___ PFTs show restrictive pattern.\n\n \nPast Medical History:\nDM c/b retinitis, nephropathy\nESRD s/p fistula placement at ___ ~___\nHTN\nHLD\nCOPD\nCAD s/p MI ___ requiring hospitalization and overnight \nobservation in ___, ___, no prior hx of catheterization. (per \npt)\n \nSocial History:\n___\nFamily History:\nNegative for renal disease. Reports father died of heart attack \nat ___\n \nPhysical Exam:\nADMISSION:\nVitals: 97.6 82 166/71 15 98% on BiPaAP\nGENERAL: Alert, oriented, no acute distress on BiPAP mask \nHEENT: Sclera anicteric, MMM, oropharynx clear\nNECK: supple, JVP not elevated, no LAD \nLUNGS: decreased breath sounds on L \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. 1+ \npitting edema b/l \n\nDISCHARGE:\nVS - 98 154/56 80 16 98 r/a\nGeneral: Elderly male, laying in hospital bed, no acute \ndistress\nCV: RRR, s1 and s2 heard, ___ systolic murmur heard best at \nLUSB\nLungs: CTABL, no wheezes, rhonci or crackles\nAbdomen: NABS, non tender to palpation in all 4 quadrants, no \nrebound or guarding\nExt: No ___ edema\n\n \nPertinent Results:\nADMISSION:\n___ 12:40PM BLOOD WBC-7.9 RBC-3.27* Hgb-8.8* Hct-30.6* \nMCV-94 MCH-26.9 MCHC-28.8* RDW-16.7* RDWSD-57.4* Plt ___\n___ 12:40PM BLOOD Neuts-86.0* Lymphs-5.9* Monos-6.3 \nEos-0.9* Baso-0.5 Im ___ AbsNeut-6.82* AbsLymp-0.47* \nAbsMono-0.50 AbsEos-0.07 AbsBaso-0.04\n___ 12:40PM BLOOD ___ PTT-32.0 ___\n___ 12:40PM BLOOD Plt ___\n___ 12:40PM BLOOD Glucose-218* UreaN-69* Creat-7.4* Na-138 \nK-6.2* Cl-101 HCO3-23 AnGap-20\n___ 12:40PM BLOOD ALT-13 AST-16 CK(CPK)-212 AlkPhos-60 \nTotBili-0.3\n___ 12:40PM BLOOD Lipase-34\n___ 12:40PM BLOOD CK-MB-5\n___ 12:40PM BLOOD cTropnT-0.12*\n___ 12:40PM BLOOD Albumin-4.2 Calcium-8.1* Phos-7.2* Mg-2.0\n___ 03:41PM BLOOD ___ pO2-25* pCO2-59* pH-7.25* \ncalTCO2-27 Base XS--3\n___ 05:56PM BLOOD ___ PEEP-5 O2 Flow-2 pO2-36* pCO2-45 \npH-7.31* calTCO2-24 Base XS--3 Intubat-NOT INTUBA \nVent-SPONTANEOU\n___ 12:46PM BLOOD Lactate-1.8 Na-140 K-6.3*\n___ 05:56PM BLOOD K-5.2*\n___ 03:41PM BLOOD O2 Sat-29\n\nDISCHARGE:\n\n___ 07:50AM BLOOD WBC-10.9* RBC-3.08* Hgb-8.5* Hct-28.0* \nMCV-91 MCH-27.6 MCHC-30.4* RDW-15.5 RDWSD-50.4* Plt ___\n___ 07:50AM BLOOD Plt ___\n___ 07:50AM BLOOD Glucose-113* UreaN-36* Creat-5.1*# Na-136 \nK-4.2 Cl-94* HCO3-30 AnGap-16\n___ 07:50AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.1\n\nMICRO:\n___ 03:55PM URINE Color-Straw Appear-Clear Sp ___\n___ 03:55PM URINE Blood-TR Nitrite-NEG Protein-300 \nGlucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG\n___ 03:55PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0\n\nOTHER LABS:\n\n___ 12:40PM BLOOD cTropnT-0.12*\n___ 10:32PM BLOOD CK-MB-5 cTropnT-0.12*\n___ 02:36AM BLOOD CK-MB-4 cTropnT-0.12*\n___ 06:11AM BLOOD CK-MB-4 cTropnT-0.12*\n___ 08:27AM BLOOD %HbA1c-6.1* eAG-128*\n___ 10:32PM BLOOD calTIBC-259* ___ Ferritn-143 \nTRF-199*\n___ 04:23AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE \nHBcAb-NEGATIVE\n___ 04:23AM BLOOD HCV Ab-NEGATIVE\n\nIMAGING:\n___, CARDIAC ECHO\nThe left atrium is elongated. No atrial septal defect is seen by \n2D or color Doppler. The estimated right atrial pressure is ___ \nmmHg. Left ventricular wall thickness, cavity size and \nregional/global systolic function are normal (LVEF >55%). The \nestimated cardiac index is normal (>=2.5L/min/m2). Right \nventricular chamber size and free wall motion are normal. The \nascending aorta and aortic arch are mildly dilated. The aortic \nvalve leaflets (3) are mildly thickened but aortic stenosis is \nnot present. Trace aortic regurgitation is seen. The mitral \nvalve leaflets are mildly thickened. Mild (1+) mitral \nregurgitation is seen. There is moderate pulmonary artery \nsystolic hypertension. There is no pericardial effusion. \n\nIMPRESSION: Normal biventricular cavity sizes with preserved \nregional and global biventricular systolic function. Moderate \npulmonary artery systolic hypertension. Mild mitral \nregurgitation. \n\n CLINICAL IMPLICATIONS: \n Based on ___ AHA endocarditis prophylaxis recommendations, the \necho findings indicate prophylaxis is NOT recommended. Clinical \ndecisions regarding the need for prophylaxis should be based on \nclinical and echocardiographic data. \n \n___, CXR\nIMPRESSION: \nIn comparison with the study of ___, the large left \npleural effusion with underlying compressive atelectasis is \nunchanged. Some hazy opacification at the right base is most \nlikely reflecting a layering pleural effusion with some \natelectatic changes. \nThe cardiac silhouette is difficult to assess but is probably \nenlarged. There is increased indistinctness of engorged \npulmonary vessels, consistent with increase in the degree of \npulmonary edema. \n\n___, Doppler fistula eval\nIMPRESSION: \nPatent left upper extremity radiocephalic AV fistula with access \nvolume flow means as shown above \n\n___, Fistulogram\n\nIMPRESSION: \n1. Successful placement of a 19 cm tip-to-cuff length tunneled \ndialysis line. The tip of the catheter terminates in the right \natrium. The catheter is ready for use. \n2. Patent left radiocephalic fistula with adequate flow, depth, \nand diameter. \n \nRECOMMENDATION(S): Dialysis may be attempted via the left AV \nfistula, which is patent and appears matured. If dialysis is not \nsuccessful via the fistula, the tunneled HD line can be used for \ndialysis and the fistula can be reassessed for potential coiling \nor surgical ligation of venous collaterals which may augment \nflow through the fistula. \n\n___, CXR\nIMPRESSION: \nMild pulmonary edema has improved. Right pleural effusion now \nis small. \nLarge Left pleural effusion has increased. There is no \npneumothorax. Right HD catheter is in standard position. \nCardiomegaly cannot be assessed. There are moderate \ndegenerative changes in the thoracic spine. \n\n___, CXR\nModerate left pleural effusion slightly smaller. Left lower \nlobe still \ncollapsed. Large cardiac silhouette could include pericardial \neffusion. \nSmall pleural effusion and right basal consolidation have \nworsened. No \npneumothorax. Dual channel dialysis catheter ends low in the \nright atrium, as before. \n\n___, CXR\nIMPRESSION: \n\nPrevious pulmonary edema has cleared, left lower lobe collapse \nhas improved substantially and left pleural effusion is much \nsmaller. Heart size normal. No pneumothorax. \n\n___, CT without contrast\nIMPRESSION: \n1. Small right pleural effusion with no remaining left pleural \neffusion. \nExtensive ground-glass opacity, interstitial thickening, and \nsubsegmental \natelectasis at the left lung base may represent fibrotic changes \nrelated to chronic relaxation atelectasis. \n2. Extensive vascular calcifications including aortic valvular \nand mitral \nannular calcifications, could be hemodynamically significant. \n3. CT evidence of anemia, correlate with lab values. \nRECOMMENDATION(S): Cardiovascular evaluation for valvular \nfunction, if not \nalready performed. \n\n \nBrief Hospital Course:\n___ y/o M w/ ESRD c L AVF (not yet initiated on dialysis upon \nadmission), DM2, HTN, reported CAD s/p MI ___ p/w subacute \ndyspnea and hyperkalemia found to be in hypertensive emergency \nwith b/l pleural effusions of unknown etiology with respiratory \ndistress now stabilized on BiPAP\n\n# CKD stage V causing respiratory distress and volume overload: \nHe was initiated on bipap for respiratory support upon admission \nand was started on aggressive diuresis with metolazone + Lasix \nbolus (200mg IV) + Lasix gtt @ 20mg/hr in the ICU. He was \nquickly weaned off bipap. He was followed closely by the \nnephrology team who recommended initiation of dialysis \nnon-urgently during this admission. Transplant was consulted, \nand there were initial concerns for fistula patency. He \nunderwent ultrasound imaging of his fistula which revealed \nadequate diameter but >1cm depth and low flow. Patient underwent \ntunneled line dialysis placement as well as fistulagram on \n___. During the fisulogram, AVF appeared to have good flow. \nAfter discussion with Transplant surgery, nephrology agreed \nfistula maybe trialed Dialysis intiaited on ___. Patient had \nthree successful sessions of dialysis using the fistula. His \ntemporary dialysis line was pulled prior to discharge. Pt has \noutpatient dialysis set up on ___, and ___ at \n12:30 pm ___ Dialysis ___).\n\n#Hypertension Emergency: He presented with SBPs in 250s to the \nED. He was started on nitro gtt with improvement in his SBPs. He \nwas transitioned to amlodipine and lisinopril and blood \npressures remained within normal limits. \n\n#Pleural effusion: Patient had pleural effusions on CXR upon \nadmission. Pleural effusions remained after dialysis. We \nbelieved these to be related to volume overload in the setting \nof ESRD. After pleural effusions did not resolve, interventional \npulm was consulted. Left thoracentesis was performed. Upon \ndischarge, labs were pending. Labs later revealed elevated \nprotein, LDH and cholesterol more consistent with an exudative \npattern vs. transudative. A CT did not reveal clear evidence of \nmalignancy or clear consolidation. The patient should have close \nfollow up with outpatient pulm for further work up. \n\n#Elevated cardiac enzymes: \nMB flat, troponin elevated upon admission. ST in V3/V4 which \nimproved. Echo w/o evidence of focal wall motion abnormality. \nLikely related to demand ischemia in setting of hypertension and \npoor clearance given renal function\n\n#Bradycardia\nPatient found to be bradycardic to ___ and asymptomatic over \nnight. EP was consulted and noted PR prolongation (in setting of \nAV delay at baseline) with resultant Wenchebach and then 2:1 \nblock without need for PPM. Patient should have follow up for \nobstructive sleep apnea as an outpatient.\n\n#HYPOXIA\nPatient mildly hypoxic with room air sats in the high ___ to low \n___ be a component of V/Q mismatch with COPD vs. \nobstructive sleep apnea with more desaturations in the evening. \nAlso pt apparently scheduled for outpatient sleep study. Pt did \nnot tolerate CPAP while in the hospital but was treated with 2 L \nat night. Continued to have desats to the ___ in the evening, \nlikely related to OSA.\n\n#Anemia:\nNormocytic. Iron of 26. TIBC and TF on lower end of normal \nrange. Likely both iron deficiency anemia as well as CKD. No \nevidence of hemolysis. Patient was started on IV iron with \ndialysis. ___ require outpatient colonoscopy.\n\n#DM2\nPt reports history of Diabetes. Had been treated with insulin in \nthe past and also reports weight loss. Says Diabetes resolved \nand upon admission was not on any treatment. A1c 6% in hospital. \nWas treated with insulin sliding scale while in the hospital.\n\n#COPD\nDulera not on formulary, switch to advair 100/50 while \ninpatient. No evidence of exacerbation.\n\n#BPH\nContinued on home tamsulosin\n\nTRANSITIONAL ISSUES\n\n-Thoracentesis results and CT chest results were pending at time \nof discharge but have been added to the discharge summary. \nPleural fluid results concerning for exudative effusion given \nelevated LDH, protein and cholesterol. Patient should have \ncontinued outpatient work up with pulm.\n-Pt reported history of DM. Had been taking insulin and lost \nweight and DM improved. Prior to hospitalization, pt not taking \nany meds. A1c in hospital was 6.1%\n-Noted to have thrombocytopenia. Should be worked up as \noutpatient\n-Also noted to have iron deficiency anemia. Consider outpatient \ncolonoscopy\n-Pt should follow up OSA work up and have sleep study\n-Discontinued metoprolol. Initiated Lisinopril and amlodipine.\n-Uptitrated sevelamer to 2400mg TID\n-Increased atorvastatin to 80mg daily given known CAD\n-Pt needs to be vaccinated for HBV\n\n# Communication: HCPs: ___ (HCP/son) ___, ___ \n(HCP/son) ___ \n# Code: Full (confirmed) \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY \n2. Tamsulosin 0.4 mg PO DAILY \n3. Sodium Bicarbonate 650 mg PO TID \n4. sevelamer CARBONATE 800 mg PO TID W/MEALS \n5. Multivitamins 1 TAB PO DAILY \n6. Metoprolol Tartrate 25 mg PO BID \n7. Atorvastatin 10 mg PO DAILY \n8. Aspirin 81 mg PO DAILY \n9. Dulera (mometasone-formoterol) 100-5 mcg/actuation inhalation \nBID \n\n \nDischarge Medications:\n1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO DAILY \nRX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*28 \nTablet Refills:*0\n4. sevelamer CARBONATE 2400 mg PO TID W/MEALS \nRX *sevelamer carbonate [___] 800 mg 3 tablet(s) by mouth \nthree times per day Disp #*90 Tablet Refills:*0\n5. Tamsulosin 0.4 mg PO DAILY \n6. Tiotropium Bromide 1 CAP IH DAILY \n7. Amlodipine 10 mg PO DAILY \nRX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*28 Tablet \nRefills:*0\n8. Lisinopril 5 mg PO DAILY \nRX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*28 Tablet \nRefills:*0\n9. Nephrocaps 1 CAP PO DAILY \nRX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1 \ncapsule(s) by mouth daily Disp #*28 Capsule Refills:*0\n10. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose \ninhalation DAILY \n11. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\n- CKD stage V c/b volume overload, pleural effusions, and \npulmonary edema\n- OSA c/b nocturnal hypoxemia and bradycardia\n- Hypertensive emergency\n\nSecondary:\n- Hypertension\n- Diabetes mellitus type II\n- Hyperlipidemia\n- COPD\n- CAD (MI in ___ in ___\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 I come to the hospital?\n-You were admitted with difficulty breathing and abnormal labs\n\nWhat happened while I was in the hospital?\n-You started dialysis \n-We also changed some of your medicines for your blood pressure. \nWe discontinued your metoprolol and added Lisinopril and \namlodipine.\n-You also had fluid taken out of your lungs\n\nWhat should I do after I leave the hospitalization?\n-Continue taking your medicines\n-Go to your dialysis appointments\n-We were unable to schedule a PCP appointment for you, you will \nneed to establish care with a PCP of your choosing on ___ \n___\n\nThanks,\n\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "I120", "N186", "J810", "N179", "E872", "J90", "E1121", "I441", "I248", "D696", "E875", "E8770", "Z794", "E11319", "E785", "Z87891", "I2510", "I252", "E8339", "E8351", "J449", "R001", "D631", "N400", "G4733" ]

[ "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N186: End stage renal disease", "J810: Acute pulmonary edema", "N179: Acute kidney failure, unspecified", "E872: Acidosis", "J90: Pleural effusion, not elsewhere classified", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "I441: Atrioventricular block, second degree", "I248: Other forms of acute ischemic heart disease", "D696: Thrombocytopenia, unspecified", "E875: Hyperkalemia", "E8770: Fluid overload, unspecified", "Z794: Long term (current) use of insulin", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I252: Old myocardial infarction", "E8339: Other disorders of phosphorus metabolism", "E8351: Hypocalcemia", "J449: Chronic obstructive pulmonary disease, unspecified", "R001: Bradycardia, unspecified", "D631: Anemia in chronic kidney disease", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "G4733: Obstructive sleep apnea (adult) (pediatric)" ]

[ "N179", "E872", "D696", "Z794", "E785", "Z87891", "I2510", "I252", "J449", "N400", "G4733" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / erythromycin base / Ceclor / doxycycline / \nTetracyclines / Sulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\nAMS, SOB\n \nMajor Surgical or Invasive Procedure:\n___: Pericardial Drain Placement\n___: R Thoracentesis\n___: L thoracentesis with pigtail catheter placement\n\n \nHistory of Present Illness:\n___ PMH stage IV lung cancer s/p chemo/wedge resection with \nrecurrence now on nivolumab q2 weeks, COPD, tobacco dependence, \ndepression, previous suicide attempt, hx anal cancer, chronic \nhyponatremia/SIADH who was brought by EMS to ___ for AMS and SOB \n(EMS called by boyfriend). \n\nOf note, the patient was recently admitted to ___ ___ - \n___ for hyponatremia ___ SIADH. Following discharge, \npatient has had persistent AMS. She is somnolent most of the day \nand not always oriented. Additionally she has had lower \nextremity edema which has been treated with po lasix. Her po \nintake has been poor, with only sips of fluids with pills. Today \nthe patient was found down by boyfriend and was shaking and \nminimally responsive. Eyes were closed and she appeared to be \nshivering. \n\nAs the patient was altered on arrival to ___ she was unable to \nprovide history. On arrival her vitals were BP 100/77, HR110, \nRR26, 99% on 3LNC. She was reportedly following commands but was \nunable to give history. Her initial labs at ___ were remarkable \nfor (see below). She had a CT head done which showed no acute \nintracranial process, and a CT Chest w/contrast which ruled out \nPE but showed a large pericardial effusion. They were unable to \nget an echo as they did not have echo staff on site at that time \nso transfer to ___ was initiated. Prior to transfer she was \ngiven Cipro 400mg IV x1, 2L NS, Magnesium 2gm IV x1. \n\nUpon Arrival to ___ the patient was brought to the cath lab \nfor placement of a pericardial drain. 580cc serous fluid was \ndrained and echo showed resolution of the effusion; however she \nremained hypotensive. Right heart catheterization showed \n\"effusive-constrictive physiology of the right ventricle and \nright atrium and underfilling of the left ventricle with a PCWP \n5mmHg.\" She required levophed for BP support. \n\nVitals on arrival to CCU: T99.5, HR100s, BP100s/50s-60s (on 0.25 \nlevo), 98% on 4LNC, RR ___\n \nOn arrival to the CCU she is responding to her name but is \nunable to provide history. \n \nPast Medical History:\n- Reccurent lung cancer (previously stage 1b), s/p resection, RT \nand CT, currently on Nivolumab, follows with Dr. ___ at ___ \nin ___\n- Depression, suicide attempt in ___ (stab to neck)\n- epidermoid carcinoma of the anus T3N0 \n- COPD\n- SIADH\n- ? Auto-immune disease\n\n \nSocial History:\n___\nFamily History:\nFamily denies and history of malignancies. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION: \n===================================\nVS: T99.5, HR100s, BP100s/50s-60s (on 0.25 levo), 98% on 4LNC, \nRR ___ \nGENERAL: appears uncomfortable, thin, rigoring\nHEENT: Normocephalic, atraumatic, EOMI\nNECK: Supple. Swan-Ganz catheter in place\nCARDIAC: Tachycardic, regular rhythm, split S2\nLUNGS: NC in place, no chest wall deformities, Port-cath on R \nside of chest wall, breath sounds clear anteriorly and laterally \n(pt unable to follow commands and sit up)\nABDOMEN: soft, non-tender, non-distended\nEXTREMITIES: Warm, well perfused, no peripheral edema \nSKIN: No significant skin lesions or rashes. \nPULSES: DP pulses palpable bilaterally\nNeuro: AAOx2 (self and hospital), not following commands \n\nDISCHARGE PHYSICAL EXAM\n===============================\nPHYSICAL EXAMINATION: \nVS: 98.3 113/71 87 16 98% on 3L\nI/O: (16h) 1010/4600\nWeight: 51kg\nGENERAL: appears comfortable, thin\nHEENT: Normocephalic, atraumatic, EOMI\nCARDIAC: RRR\nLUNGS: Port-cath on R side of chest wall, Lungs clear b/l, \nslightly diminished at bases\nABDOMEN: soft, non-tender, non-distended\nEXTREMITIES: Warm, well perfused, ___ b/l ___ edema\nSKIN: No significant skin lesions or rashes. \nPULSES: DP pulses palpable bilaterally\nNeuro: AAOx2-3 \n \nPertinent Results:\nLABS ON ADMISSION:\n==========================\n___ 03:36PM BLOOD WBC-3.4* RBC-2.81* Hgb-8.6* Hct-26.3* \nMCV-94 MCH-30.6 MCHC-32.7 RDW-13.3 RDWSD-45.9 Plt ___\n___ 03:36PM BLOOD Neuts-78.0* Lymphs-10.1* Monos-10.7 \nEos-0.0* Baso-0.9 Im ___ AbsNeut-2.61 AbsLymp-0.34* \nAbsMono-0.36 AbsEos-0.00* AbsBaso-0.03\n___ 03:36PM BLOOD ___ PTT-45.6* ___\n___ 03:36PM BLOOD Glucose-97 UreaN-4* Creat-0.3* Na-127* \nK-4.1 Cl-94* HCO3-24 AnGap-13\n___ 03:36PM BLOOD ALT-7 AST-40 AlkPhos-69 TotBili-0.4\n___:25PM BLOOD CK(CPK)-1634*\n___ 03:36PM BLOOD cTropnT-0.16*\n___ 07:25PM BLOOD CK-MB-14* MB Indx-0.9 cTropnT-0.19*\n___ 05:06AM BLOOD CK-MB-10 cTropnT-0.15*\n___ 03:36PM BLOOD Albumin-2.4*\n___ 07:25PM BLOOD Calcium-7.5* Phos-2.4* Mg-1.4* Iron-16*\n___ 07:25PM BLOOD calTIBC-122* Ferritn-459* TRF-94*\n___ 03:48PM BLOOD Lactate-1.1\n___ 11:07AM BLOOD freeCa-1.12\n\nPERTINENT INTERVAL LABS\n========================\n___ 07:25PM BLOOD calTIBC-122* Ferritn-459* TRF-94*\n___ 06:19AM BLOOD TSH-3.9\n___ 05:00AM BLOOD TSH-7.1*\n___ 07:25PM BLOOD TSH-2.9\n___ 04:40AM BLOOD PTH-82*\n___ 06:19AM BLOOD T4-4.6 T3-59* calcTBG-0.95 TUptake-1.05 \nT4Index-4.8\n___ 06:42AM BLOOD 25VitD-36\n___ 01:32PM BLOOD Cortsol-26.0*\n___ 11:22AM BLOOD Cortsol-16.6\n___ 05:00AM BLOOD Cortsol-6.1\n___ 04:40AM BLOOD CRP-59.0*\n\nMICRO\n=================\n___ 5:47 pm FLUID,OTHER PERICARDIAL FLUID. \n GRAM STAIN (Final ___: \n 2+ ___ 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 (Final ___: NO GROWTH. \n ANAEROBIC CULTURE (Final ___: NO GROWTH. \n___ 10:25 pm MRSA SCREEN Site: NASOPHARYNX\n Source: Nasal swab. **FINAL REPORT ___\n MRSA SCREEN (Final ___: \n POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. \n___ 11:07 am PLEURAL FLUID PLEURAL FLUID. \n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n FLUID CULTURE (Final ___: NO GROWTH. \n ANAEROBIC CULTURE (Final ___: NO GROWTH. \n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. \n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. \n ACID FAST CULTURE (Pending):\n___ 11:53 am PLEURAL FLUID **FINAL REPORT ___\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 FLUID CULTURE (Final ___: NO GROWTH. \n ANAEROBIC CULTURE (Final ___: NO GROWTH. \n\nAll Blood Cultures: No Growth\nAll Urine Cultures: No Growth\nC. Diff Amplification Assay: Negative \nStool Culture, Ova and Parasites: Negative \nLegionella Urine Antigen: Negative \n\nIMAGING/OTHER STUDIES\n========================\n___ Imaging CHEST (PORTABLE AP) \n1. Bibasilar opacities, concerning for pneumonia on the right. \n2. Spiculated contour of the left upper mediastinal border for \nwhich an \nunderlying lesion cannot be excluded. Correlation with prior \nimaging is \nrecommended and if none available, further evaluation with \ncross-sectional \nimaging is recommended. \n\n___ Cardiovascular ECHO \nThe estimated right atrial pressure is at least 15 mmHg. The \nleft ventricle is not well seen. Overall left ventricular \nsystolic function is low normal (LVEF 50-55%). The right \nventricular cavity is mildly dilated with depressed free wall \ncontractility. The mitral valve leaflets are structurally \nnormal. There is a large pericardial effusion. The effusion \nappears circumferential. There is right ventricular diastolic \ncollapse, consistent with impaired fillling/tamponade \nphysiology. There is significant, accentuated respiratory \nvariation in mitral/tricuspid valve inflows, consistent with \nimpaired ventricular filling. \n\n___ Cardiovascular ECHO \nThe estimated right atrial pressure is at least 15 mmHg. Overall \nleft ventricular systolic function is moderately depressed \n(LVEF= 35 %) secondary to direct ventricular interaction. The \nright ventricular cavity is mildly dilated with severe global \nfree wall hypokinesis. There is abnormal septal motion/position \nconsistent with right ventricular pressure/volume overload. The \nmitral valve leaflets are structurally normal. There is mild \npulmonary artery systolic hypertension. There is a small \npericardial effusion. There are no echocardiographic signs of \ntamponade. \n\n___ Imaging CHEST (PORTABLE AP) \nIn comparison with the study of ___, the ___-Ganz \ncatheter is been \nremoved and a right IJ sheath remains in place. Retrocardiac \nopacification is again consistent with volume loss in left lower \nlobe and small pleural effusion. Less prominent changes are \nseen on the right. \nStriking spiculated contour of the left upper mediastinal border \nis unchanged. \n\n___ Imaging MR HEAD W & W/O CONTRAST\n1. No evidence of acute infarction, intracranial hemorrhage, \nmass, or abnormal enhancement. No evidence for intracranial \nmetastatic disease at this time. \n2. Mild paranasal sinus disease with partial opacification of \nbilateral \nmastoid air cells, which may be inflammatory. \n\n___ Imaging CHEST (PORTABLE AP) \nNo significant interval change since the prior radiograph.\n\n___ Imaging CHEST (PORTABLE AP) \nIn comparison with the study of ___, there is little \noverall change \nexcept for slightly lower lung volumes which may explain the \nincreased \nbilateral pulmonary opacifications. \n\n___ Cardiovascular ECHO \nLeft ventricular wall thicknesses are normal. The left \nventricular cavity size is normal. Overall left ventricular \nsystolic function is mildly depressed (LVEF= 45 %). The right \nventricular free wall thickness is normal. The right ventricular \ncavity is moderately dilated with severe global free wall \nhypokinesis. There is abnormal septal motion suggestive of \npericardial constriction. The aortic valve leaflets (3) appear \nstructurally normal with good leaflet excursion and no aortic \nstenosis or aortic regurgitation. The mitral valve appears \nstructurally normal with trivial mitral regurgitation. Moderate \n[2+] tricuspid regurgitation is seen (may be significantly \nunderestimated). There is mild pulmonary artery systolic \nhypertension. There is a trivial/physiologic pericardial \neffusion. There are no echocardiographic signs of tamponade. \n\n___ Imaging CTA CHEST \n1. No pulmonary embolism. \n2. Abnormal soft tissue along the left upper and mid \nmediastinum, may \nrepresent posttreatment change, residual recurrent tumor cannot \nbe excluded, comparison to more distant imaging would be helpful \nif available. \n3. Areas of mucous plugging. \n4. Worsening extensive bilateral lung opacities. The perihilar \ndistribution suggestive of pulmonary edema, however hemorrhage \nor ARDS should also be considered. \n5. Worsening bilateral nonhemorrhagic pleural effusions, large \non the right and moderate on the left. \n6. Small residual pericardial effusion. \n7. Mild dilation of the main pulmonary artery could reflect \npulmonary hypertension. \n\n___ Imaging CHEST (PORTABLE AP) \nThere is interval improvement in the right lung consolidations, \nsubstantial. \n\n___ Imaging VENOUS DUP UPPER EXT UN \nNo evidence of deep vein thrombosis in the left upper extremity.\n\n___ TTE\nOverall left ventricular systolic function is normal (LVEF>55%). \nRight ventricular chamber size is normal with mild global free \nwall hypokinesis. There is a moderate sized pericardial \neffusion. The effusion appears circumferential. IMPRESSION: \nModerate pericardial effusion without signs of tamponade. Mild \nright ventricular systolic dysfunction. Bilateral pleural \neffusions. Compared with the prior study (images reviewed) of \n___, biventricular systolic function has improved. \nPericardial effusion is larger. \n\n___ TTE\nThe estimated right atrial pressure is ___ mmHg. Overall left \nventricular systolic function is low normal (LVEF 50-55%). with \nborderline normal free wall function. There is abnormal septal \nmotion/position. Mild (1+) mitral regurgitation is seen. There \nis moderate pulmonary artery systolic hypertension. There is a \nsmall to moderate sized circumferential pericardial effusion \nlocated predominantly adjacent to the right heart and \nposteriorly. Stranding is visualized within the pericardial \nspace c/w organization. There are no echocardiographic signs of \ntamponade. Echocardiographic signs of tamponade may be absent in \nthe presence of elevated right sided pressures. \nIMPRESSION: Small to moderate sized pericardial effusion located \npredominantly adjacent to the right heart and posteriorly. \nBorderline biventricular systolic function. Mild mitral \nregurgitation. Moderate pulmonary hypertension.\nCompared with the prior study (images reviewed) of ___, \nthe size of the pericardial effusion is similar. The heart rate \nis slower and left ventricular function slightly less vigorous, \nand moderate pulmonary hypertension is detected. \n\n___ CXR\nFINDINGS: \nStable spiculated mass above left hilum. Volume loss left \nchest. Right \nPort-A-Cath tip in the right atrium. Mildly improved right \nbasilar opacity. Stable mild right pleural effusion. Improved \nleft basilar opacity. Improved left pleural effusion. Stable \nheart size, pulmonary vascularity. Improved interstitial \nmarkings. No pneumothorax. \nIMPRESSION: Interval mild improvement \n\nLABS ON DISCHARGE:\n========================\n___ 04:58AM BLOOD WBC-5.4 RBC-2.77* Hgb-8.5* Hct-26.1* \nMCV-94 MCH-30.7 MCHC-32.6 RDW-15.9* RDWSD-53.7* Plt ___\n___ 04:58AM BLOOD ___ PTT-28.1 ___\n___ 04:58AM BLOOD Glucose-81 UreaN-3* Creat-0.3* Na-135 \nK-3.9 Cl-97 HCO3-30 AnGap-12\n___ 04:58AM BLOOD Albumin-2.9* Calcium-8.2* Phos-3.2 Mg-1.___SSESSMENT AND PLAN: ___ ___ stage IV lung cancer s/p \nchemo/wedge resection with recurrence now on nivolumab q2 weeks, \nCOPD, tobacco dependence, depression, previous suicide attempt, \nhx anal cancer, chronic hyponatremia/SIADH who presented to ___ \nwith AMS and SOB, found to have pericardial effusion with \ntamponade, transferred to ___ for further workup and \nmanagement of her tamponade, shock, and AMS. \n\n# Pericardial effusion with tamponade physiology:\nPatient initially found to have a large pericardial effusion on \nCTA done for suspicion of PE at OSH. Patient transferred to \n___, and underwent pericardial drain placement on ___. \n580cc serous fluid was drained and echo showed resolution of the \neffusion; however patient remained hypotensive. Right heart \ncatheterization showed effusive-constrictive physiology of the \nright ventricle and right atrium and underfilling of the left \nventricle. Patient was started on levophed and transferred to \nthe CCU. She continued to be hypotensive requiring significant \npressor support initially. Pericardial drain continued to have \noutput >200cc a day until ___. CT surg consulted for \npalliative pericardial window, but felt patient would not a \ncandidate with her potential underlying pneumonia currently and \nunclear prognosis of her lung cancer. After >24h without \nsignificant output and ECHO showing minimal effusion, decision \nwas made to remove the drain on ___ and follow-up daily Vscans \nfor reaccumulation. Repeat echo performed on ___ showed \nre-accumulation of pericardial fluid with no evidence of \ntamponade. Heme/onc was consulted and determined that nivolumab \ncan cause autoimmune inflammatory effects which may have caused \nthe effusions. The patient was started on 60mg IV \nmethylprednisone q24 hrs. Repeat echo on ___ showed no \nprogression of the pericardial effusion, and CXR showed interval \nimprovement in the pleural effusions. She was HDS and on ___ O2 \n(her home dose) at the time of discharge. Patient was discharged \nwith 80mg PO prednisone with atovaquone for PCP prophylaxis with \n___ plan to followup with her outpatient heme/onc doctor for \ndetermination of course and taper. She will have a repeat echo \n___ days after discharge. She would prefer to have this done by \nher primary oncologist in ___.\n\n# Shock\nInitially thought to be related to the pericardial effusion, \nespecially given improvement with pericardial fluid drainage and \nweaning of pressors. However, patient became hypotensive again \ndespite significant improvement on ECHO requiring pressor \nsupport. DDx included septic shock vs. constrictive pericarditis \nvs. adrenal insufficiency. Pt was treated for HCAP, but no \ndefinitive infectious source was identified, as all cultures \nwere negative. Labwork was not consistent with adrenal \ninsufficiency. Pt was weaned from pressors in the CCU and \nsubsequently remained hemodynamically stable. When her \npericardial fluid recurred, she did not have any hemodynamic \ncompromise. \n\n#AMS: Likely multifactorial - shock, hypoxia, hyponatremia, \ntoxic metabolic encephalopathy. Patient w/ previous suicide \nattempt and known depression however serum tox screen was \nnegative, and LFTs normal. Had recent admission to ___ for \nhyponatremia and has known SIADH. MRI w/ no evidence of acute \ninfarction, intracranial hemorrhage, mass, or abnormal \nenhancement. She was antibiosed due to c/f infection w/ \nimprovement in mental status. \n\n#Hypoxemic respiratory failure \n#COPD:\n#Pleural effusion\n#Recurrent Lung cancer: per ___ records, patient is on nivolumab \nq2 weeks. Respiratory dysfunction most likely due to underlying \nlung cancer and known COPD with element of pulmonary edema. Over \nthe course of her hospitalization, the patient developed \nbilateral pleural effusions initially thought to be ___ \nobstructive shock from tamponade. She had a R-sided \nthoracentesis on ___, and a L-sided thoracentesis with \nplacement of L pigtail catheter on ___. Fluid studies were \nconsistent with a transudative etiology. She was diuresed with \n20 mg IV Lasix boluses. As detailed above, the heme/onc team was \nultimately of the opinion that the pleural effusions may also \nhave been related to nivolumab, and they improved with IV \nsteroids. She was on her home ___ of O2 on discharge. \n\n#HCAP: treated with Vanc and ___ ___ - ___.\n\n# Normocytic anemia:\n# Leukopenia: Most likely BM suppression (on palliative chemo) \nvs anemia of chronic disease. No signs of active bleeding \nthroughout hospitalization\n\n# Hyponatremia: has known SIADH, Na 126 on presentation. \nPatient's Na improved w/ no intervention, 135 on day of \ndischarge. \n\n# Coagulopathy: As of ___ pt was not on any systemic \nanticoagulation so unlikely to be medication effect. Pt is thin \non exam and has low albumin (2.4) and low Cr (0.3) so likely due \nto malnutrition. Pt's meals were supplemented with Ensure. \nAlbumin improved to 2.9.\n\n# Depression: Home citalopram initially held iso AMS, resumed w/ \nimprovement of mental status. Home clonazepam held iso AMS.\n\n# Klebsiella UTI: Culture positive on ___ urine Cx. \nPansensitive. Completed 7d course of abx. Urine cultures at \n___ were all negative.\n\n====================\nTRANSITIONAL ISSUES:\n====================\nMEDICATIONS STARTED: Calcium Carbonate 1000 mg PO/NG TID, \nVitamin D 1000 UNIT PO/NG DAILY, Prednisone 80 mg PO daily, \nAtovaquone 1500 mg PO daily\n- Patient to continue current dose of steroids to treat \npericardial effusion presumably caused by opdivo until she \nfollows up with heme/onc and is started on a prolonged taper\n- Continue at___ for PCP ppx while on high doses of \nsteroids\n- Please arrange to have repeat TTE within ___ days to check for \ninterval change in pericardial effusion. Patient prefers to \nfollow-up with oncologist for this.\n- Patient to pick up rollator on ___. Unable to be \narranged before discharge and patient preferred to come back to \npick it up, understanding risks. She will have full-time assist \nfrom boyfriend in meantime.\n- Spoke with the patient at the time of discharge to fill out a \nMOLST form, and she expressed her wish to be listed as a full \ncode at this time.\n\n# CODE: Full (confirmed at time of discharge)\n# CONTACT/HCP: Brother ___: ___\nSignificant other: ___ ___\n# DISCHARGE WEIGHT: 51 kg\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Citalopram 20 mg PO DAILY \n2. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q4H:PRN \ndyspnea \n3. ClonazePAM 1 mg PO TID \n4. Ondansetron 4 mg PO Q4H:PRN nausea \n5. Pantoprazole 40 mg PO Q24H \n6. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation \ninhalation BID \n7. Sodium Chloride 2 gm PO BID \n8. TraZODone 300 mg PO QHS \n9. Nicotine Polacrilex 2 mg PO Q1H:PRN nicotine withdrawal \n10. Furosemide 20 mg PO DAILY \n11. Levothyroxine Sodium 25 mcg PO DAILY \n\n \nDischarge Medications:\n1. Atovaquone Suspension 1500 mg PO DAILY \nRX *atovaquone 750 mg/5 mL 10 mL by mouth daily Refills:*1 \n2. Calcium Carbonate 1000 mg PO TID \nRX *calcium carbonate 500 mg calcium (1,250 mg) 2 tablet(s) by \nmouth three times a day Disp #*180 Tablet Refills:*0 \n3. PredniSONE 80 mg PO DAILY \nRX *prednisone 20 mg 4 tablet(s) by mouth daily Disp #*120 \nTablet Refills:*0 \n4. Vitamin D 1000 UNIT PO DAILY \nRX *ergocalciferol (vitamin D2) 2,000 unit 0.5 (One half) \ntablet(s) by mouth daily Disp #*30 Tablet Refills:*0 \n5. Citalopram 20 mg PO DAILY \n6. ClonazePAM 1 mg PO TID \n7. Furosemide 20 mg PO DAILY \n8. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q4H:PRN \ndyspnea \n9. Levothyroxine Sodium 25 mcg PO DAILY \n10. Nicotine Polacrilex 2 mg PO Q1H:PRN nicotine withdrawal \n11. Ondansetron 4 mg PO Q4H:PRN nausea \n12. Pantoprazole 40 mg PO Q24H \n13. Sodium Chloride 2 gm PO BID \n14. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation \ninhalation BID \n15. TraZODone 300 mg PO QHS \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis: Pericardial and pleural effusions, cardiac \ntamponade, hypoxic respiratory failure, pneumonia\n\nSecondary Diagnoses: Malnutrition, lung adenocarcinoma, anemia, \ndepression, UTI\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 taking care of ___ at ___. \n\nWHY DID ___ COME TO THE HOSPITAL?\n___ were feeling short of breath, and ___ were confused.\n\nWHAT HAPPENED WHILE ___ WERE HERE?\nWe discovered that ___ had fluid around your heart that was \nmaking it difficult for your heart to pump correctly. ___ also \nhad fluid around your lungs that was affecting your breathing. \nWe drained the fluid around both your heart and your lungs, and \ngave ___ medications to support your blood pressure. We \nsupported your breathing with oxygen. After exploring different \nreasons why ___ might have developed this fluid around your \nheart and lungs, we decided that it is most likely a side effect \nof your Opdivo. For this we treated ___ with steroids, and ___ \nimproved.\n\nWHAT SHOULD ___ DO WHEN ___ LEAVE THE HOSPITAL?\n___ should be sure to continue to take all of your medications \nas directed, and to follow up with all of your doctors. ___ will \nneed to have a follow-up heart ultrasound within the next ___ \ndays, and this may be done by your oncologist per your \npreference. It's very important to continue taking prednisone \nand all of your other meds. If ___ have any increased shortness \nof breath, chest pain, dizziness, or syncope, return immediately \nto the ED.\n\nAgain, it was a pleasure taking care of ___!\n\nSincerely, \n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "I319", "R570", "I314", "J9691", "G92", "J90", "J189", "E222", "D684", "I248", "E46", "C3412", "C799", "N390", "Z66", "F329", "Z85048", "J449", "Z538", "D638", "D72819", "Z6821", "E039", "F17211", "B961", "E8770", "E211", "T451X5A", "Y929" ]

[ "I319: Disease of pericardium, unspecified", "R570: Cardiogenic shock", "I314: Cardiac tamponade", "J9691: Respiratory failure, unspecified with hypoxia", "G92: Toxic encephalopathy", "J90: Pleural effusion, not elsewhere classified", "J189: Pneumonia, unspecified organism", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "D684: Acquired coagulation factor deficiency", "I248: Other forms of acute ischemic heart disease", "E46: Unspecified protein-calorie malnutrition", "C3412: Malignant neoplasm of upper lobe, left bronchus or lung", "C799: Secondary malignant neoplasm of unspecified site", "N390: Urinary tract infection, site not specified", "Z66: Do not resuscitate", "F329: Major depressive disorder, single episode, unspecified", "Z85048: Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus", "J449: Chronic obstructive pulmonary disease, unspecified", "Z538: Procedure and treatment not carried out for other reasons", "D638: Anemia in other chronic diseases classified elsewhere", "D72819: Decreased white blood cell count, unspecified", "Z6821: Body mass index [BMI] 21.0-21.9, adult", "E039: Hypothyroidism, unspecified", "F17211: Nicotine dependence, cigarettes, in remission", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "E8770: Fluid overload, unspecified", "E211: Secondary hyperparathyroidism, not elsewhere classified", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y929: Unspecified place or not applicable" ]

[ "N390", "Z66", "F329", "J449", "E039", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics) / Amoxicillin / Clindamycin / \nVenofer / adhesive / Macrobid / Lamictal / vancomycin\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nnone\nattach\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 08:51PM BLOOD WBC-9.0 RBC-5.17 Hgb-15.4 Hct-47.0 MCV-91 \nMCH-29.8 MCHC-32.8 RDW-13.9 RDWSD-46.5* Plt ___\n___ 08:51PM BLOOD Neuts-52.9 ___ Monos-7.0 Eos-1.9 \nBaso-0.4 Im ___ AbsNeut-4.74 AbsLymp-3.37 AbsMono-0.63 \nAbsEos-0.17 AbsBaso-0.04\n___ 08:51PM BLOOD Glucose-96 UreaN-11 Creat-1.1 Na-140 \nK-4.2 Cl-102 HCO3-25 AnGap-13\n___ 06:23AM BLOOD ALT-15 AST-16 AlkPhos-48 TotBili-0.3\n___ 08:51PM BLOOD cTropnT-<0.01\n___ 06:28AM BLOOD cTropnT-<0.01\n___ 08:51PM BLOOD Calcium-9.6 Phos-3.2 Mg-2.2\n\nOTHER PERTINENT LABS:\n=====================\nTime Taken Not Noted Log-In Date/Time: ___ 11:35 pm\n URINE ON GREY TOLD HOLD ___. \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___ 01:13PM BLOOD Testost-___\n___ 08:51PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n\nIMAGING:\n========\nCXR ___:\nNo acute cardiopulmonary findings. \n\nRIGHT FOOT XRAY ___: \nNote is again made of an intra-articular fracture involving the \nbase of the distal phalanx of the great toe with mild increased \nswelling surrounding the great toe. Tiny pockets of air are \nseen within the soft tissue. No erosions are seen. No \nsignificant degenerative changes. Mineralization is normal. \n \nGASTRIC EMPTYING STUDY ___: \nFINDINGS: Residual tracer activity in the stomach is as \nfollows: \nAt 1 hour 13% of the ingested activity remains in the stomach \nAt 2 hours 1% of the ingested activity remains in the stomach \n \nRapid emptying. \n \nIMPRESSION: Abnormally rapid gastric emptying with 13% of the \ningested activity \nremaining in the stomach at 1 hour. (Values lower than 30% \nsuggest abnormally \nrapid gastric emptying). \n\nDISCHARGE LABS:\n===============\nnone\n\n \nBrief Hospital Course:\nTRANSITIONAL ISSUES\n===================\n\n[] please try to wean patient off dilaudid with improvement in \nmood disorder (s), now on daily:prn\n[] will need colorectal surgery follow up on discharge with Dr. \n___\n[] will need GI follow up on discharge for possible ED/colon and \nto decide on utility of Creon \n[] podiatry follow up outpatient for right toe fracture\n\n#CODE: Full (presumed)\n#CONTACT: ___\n Relationship: OTHER\n Phone: ___\n\n___ year old transgender man with past medical history of \nulcerative colitis in complete remission, chronic abdominal \npain/bloating and diarrhea of unclear etiology, PTSD, and MDD \nwho presented with persistent N/V, anorexia, and weight loss as \nwell as active SI/HI due to ongoing symptoms. Course complicated \nby right toe pain iso prior fracture, chronic perineal \ndiscomfort, and depressive symptoms. \n\nACUTE ISSUES:\n=============\n# SI/HI\n# MDD\n# PTSD:\nEvaluated by psychiatry and given active SI/HI, recommended \n___. He has endorsed symptoms of depression, anxiety, \npassive SI/HI, and is experiencing depersonalization symptoms. \nHe will be discharged to inpatient psychiatry at ___ for \nfurther management. Continued Hydroxyzine 25mg TID PRN for \nanxiety/insomnia, Zyprexa prn nausea/anxiety, and is taking \ndiazepam per rectum for pelvic floor pain. \n\n# Perineal pain:\nConcern for an enterocele based on imaging done at ___. Was seen \nby OB/GYN here and recently referred to outpatient colorectal \nsurgery to review surgical options. Has been prescribed baclofen \nand gabapentin by outside providers with thought being pain \ncould be pudendal nerve irritation with some improvement in \npain. He was recently prescribed dilaudid by his PCP for pain \ncontrol as well. Colorectal surgery consulted in patient to \nreview the case and images were uploaded from ___ to our system. \nThey will discuss his case and elective surgical options during \noutpatient visit. Will need to follow up with Dr. ___. \nContinued baclofen, Tylenol, and ibuprofen for pain control. \nContinued diazepam per rectum (PR) as prescribed by outpatient \npain provider (Dr. ___, to help with pelvic floor \ndysfunction. Started dilaudid for refractory pain and weaned \nfrom BID to daily:prn, but will need to continue to wean this \nmedication\n\n# Abdominal Pain\n# Nausea/vomiting\n# Anorexia:\nPatient has had ongoing abdominal bloating/discomfort, N/V, and \nloose stools for at least the past ___ years. He has had multiple \nED visits and has seen multiple providers for his symptoms and \nis frustrated with lack of clear diagnosis. He has been \nevaluated for celiac disease and had ___ several years ago \nwhich were unremarkable. He does have a history of UC as well \nthat as of ___ has been in complete remission. He recently saw \nhis GI specialist who considered gastroparesis as a possible \ncause of his N/V and recommended a gastric emptying study and \nrepeat ___ to further evaluate symptoms, especially with \nintermittent bloody/mucousy stools and history of UC. While a \ndiagnosis of exclusion, it is also possible his abdominal pain \nand diarrhea could be due to IBS and would likely benefit from \ntreatment of underlying PTSD and depression. Gastric emptying \nstudy was performed here ___ that showed rapid gastric \nemptying, which has unclear clinical significance. Started creon \nTID w/meals to see if any improvement if some component of \nexocrine pancreatic insufficiency. Continued dronabinol TID, \nPPI, and simethicone, and Zyprexa prn. Improved symptoms on \ndischarge\n\n# Chest pain:\nPatient endorsing atypical chest pain. Not exertional, not \nimproved with rest, and radiates to the right shoulder. Troponin \nnegative x2, with EKG showing stable TWI in lead III. Chest pain \nintermittent iso distress and anxiety. Occurred again ___ with \nleft sided chest pain radiating to back and worse with deep \ninspiration. EKG showed new TWI in lead aVF (stable TWI lead \nIII) but resolved on a repeat study. Unlikely anginal pain and \nno evidence of pericarditis on EKG so continued to monitor. \nLikely anxiety/MSK related. \n\n# Right great toe fracture:\nOn admission patient endorsed worsened pain in the right big toe \nradiating to the shin with throbbing pain in the second toe. \nRepeat xray with good healing. Podiatry curb-sided and they were \ncontent with the images, with recommendations for patient to \ncontinue using his boot and non-weight bearing status to help \nreduce pain \n\nCHRONIC ISSUES:\n===============\n# Testosterone Replacement Therapy:\nTestosterone level in 749 on ___, last dose received ___. \nReceiving 140mg every ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Omeprazole 20 mg PO BID \n2. Diazepam 5 mg PO QHS per rectum \n3. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n4. Propranolol 60 mg PO TID anxiety/nightmares \n5. testosterone enanthate 140 mL injection 1X/WEEK \n6. Dronabinol 5 mg PO BID \n7. Baclofen 10 mg PO BID \n8. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild \n9. Loratadine 10 mg PO DAILY \n\n \nDischarge Medications:\n1. Calcium Carbonate 500 mg PO QID:PRN heart burn \n2. Creon 12 1 CAP PO TID W/MEALS \n3. HYDROmorphone (Dilaudid) 2 mg PO BID:PRN Pain - Moderate \n4. Multivitamins W/minerals 1 TAB PO DAILY \n5. OLANZapine (Disintegrating Tablet) 5 mg PO BID:PRN \nnausea/anxiety \n6. Polyethylene Glycol 17 g PO DAILY \n7. Psyllium Powder 1 PKT PO TID \n8. Senna 8.6 mg PO BID \n9. Simethicone 40-80 mg PO QID:PRN bloating \n10. Diazepam 5 mg po/pr BID \n11. Baclofen 10 mg PO BID \n12. Dronabinol 5 mg PO BID \n13. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n14. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild \n15. Loratadine 10 mg PO DAILY \n16. Omeprazole 40 mg PO BID \n17. Propranolol 60 mg PO TID anxiety/nightmares \n18. testosterone enanthate 140 mL injection 1X/WEEK \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES\n==================\nAbdominal pain\nPerineal pain\nSuicidal/homicidal ideation\n\nSECONDARY DIAGNOSES\n====================\nDepression\nRight toe fracture\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 YOU WERE HERE\n- You were having abdominal pain, nausea, and vomiting\n- You expressed thoughts of hurting yourself and hurting others\n\nWHAT WE DID FOR YOU\n- You were evaluated by the psychiatry team and given immediate \ndanger to yourself and your debilitating mood symptoms, you were \nreferred for an inpatient psychiatric admission\n- You had a gastric emptying study that showed rapid emptying. \nWe trialed you on a medication called creon to try to help with \nsymptoms\n- Your pain was treated with multiple medications including \ndilaudid, which we will have to wean you off of\n\nWHAT YOU SHOULD DO WHEN YOU LEAVE\n- Take your medications as directed\n- Please follow up with your doctors as below (primary care, GI, \ncolorectal surgery, podiatry)\n\nIt was a pleasure caring for you!\n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "R1013", "R45851", "R102", "K458", "K623", "R112", "Z6828", "R45850", "Z87890", "Z599", "Z87898", "F4310", "F481", "F329", "F411", "R0789", "S92421D", "W19XXXD", "Z87440", "R197", "Z751", "Z23", "R630" ]

[ "R1013: Epigastric pain", "R45851: Suicidal ideations", "R102: Pelvic and perineal pain", "K458: Other specified abdominal hernia without obstruction or gangrene", "K623: Rectal prolapse", "R112: Nausea with vomiting, unspecified", "Z6828: Body mass index [BMI] 28.0-28.9, adult", "R45850: Homicidal ideations", "Z87890: Personal history of sex reassignment", "Z599: Problem related to housing and economic circumstances, unspecified", "Z87898: Personal history of other specified conditions", "F4310: Post-traumatic stress disorder, unspecified", "F481: Depersonalization-derealization syndrome", "F329: Major depressive disorder, single episode, unspecified", "F411: Generalized anxiety disorder", "R0789: Other chest pain", "S92421D: Displaced fracture of distal phalanx of right great toe, subsequent encounter for fracture with routine healing", "W19XXXD: Unspecified fall, subsequent encounter", "Z87440: Personal history of urinary (tract) infections", "R197: Diarrhea, unspecified", "Z751: Person awaiting admission to adequate facility elsewhere", "Z23: Encounter for immunization", "R630: Anorexia" ]

[ "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \n___\n \nAttending: ___.\n \nChief Complaint:\nchest discomfort and shortness of breath\n \nMajor Surgical or Invasive Procedure:\n___ artery bypass grafting x2, with the left\ninternal mammary artery to left anterior descending artery,\nand reverse saphenous vein graft to the obtuse marginal\nartery.\n\n \nHistory of Present Illness:\n___ year old ___ male who has been experiencing a\nsqueezing sensation in his chest associated with shortness of\nbreath when he goes for walks or lifts heavy objects. The pain\nlast for approximately 1 minute, and actually dissipated as he\ncontinued to walk. He had no rest pain. He was sent for a stress\nechocardiogram which was found to be positive and he was \nreferred\nfor a cardiac catheterization. Cardiac catheterization revealed\nleft main and LAD disease and is now being referred to cardiac\nsurgery for surgical revascularization. He is scheduled for CABG\ntoday.\n\n \nPast Medical History:\nStable angina by stress testing \nHypertension\nHyperlipidemia\nNon-insulin dependent diabetes\nGERD\nHyperthyroidism s/p RAI treatment\nHypothyroidism \nCataracts\nPast Surgical History: None \n\n \nSocial History:\n___\nFamily History:\nFamily History:Premature coronary artery disease- non \ncontributory\n \nPhysical Exam:\nAdmit PE:\nPhysical Exam\nPlease see Holding recordsd for Vitals]\nHeight:66\" Weight:71.7 kg\n\nGeneral: WDWN in NAD\nSkin: Dry [x] intact [x]\nHEENT: PERRLA [x] EOMI [x]\nNeck: Supple [x] Full ROM [x]\nChest: Lungs clear bilaterally [x]\nHeart: RRR [x] Irregular [] Murmur [] grade ______\nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds\n+ [x] easily reducible umbilical hernia, no ttp or color change\nExtremities: Warm [x], well-perfused [x] Edema [] _____\nVaricosities: b/l feet[x]\nNeuro: Grossly intact [x]\nPulses:\nFemoral Right: p Left: p\nDP Right: p Left: p\n___ Right: p Left: p\nRadial Right: p Left: p\n\nCarotid Bruit Right: - Left: -\n\n \nPertinent Results:\nSTUDIES:\nPA/LAT CXR ___: \nSmall left pleural effusion and bibasilar atelectasis. \n.\nTEE, Intraop, ___:\nConclusions \nPREBYPASS: Diastolic dysfunction, otherwise an essentially \nnormal exam. \n LV systolic function preserved with LVEF>55% and no wall motion \nabnormalities. The left atrium is mildly dilated. No spontaneous \necho contrast is seen in the left atrial appendage. Left \nventricular wall thicknesses and cavity size are normal. Left \nventricular wall thicknesses are normal. The left ventricular \ncavity size is normal. Right ventricular chamber size and free \nwall motion are normal. There are simple atheroma in the \ndescending thoracic aorta. The aortic valve leaflets (3) are \nmildly thickened. Mild (1+) aortic regurgitation is seen. The \nmitral valve leaflets are structurally normal. Mild (1+) mitral \nregurgitation is seen. There is no pericardial effusion. Intact \ninteratrial septum. Diastolic function consistent with \npseudonormal diastolic dysfunction with lateral mitral annular \ne' = 8 cm/sec.\n Normal coronary sinus.\n\n POSTBYPASS:\n LVEF >55% no new wall motion abnormalities following chest \nclosure. No dissection seen following removal of the aortic \ncannula. Otherwise unchanged. \n.\nCardiac Catheterization: ___ ___\nLMCA: has a distal eccentric approximately 50% stenosis\nLAD: has an ostial 90% stenosis\nCircumflex: has no significant disease.\nRCA: has minor irregularities.\n.\nCardiac ___ ___\nLeft Ventricle - Ejection Fraction: >= 55% >= 55% \nLeft Ventricle - Lateral Peak E': *0.06 m/s > 0.08 m/s \nLeft Ventricle - Septal Peak E': *0.04 m/s > 0.08 m/s \nLeft Ventricle - Ratio E/E': 10 < 13 \nAortic Valve - Peak Velocity: 1.2 m/sec <= 2.0 m/sec \nMitral Valve - E Wave: 0.5 m/sec \nMitral Valve - A Wave: 0.9 m/sec \nMitral Valve - E/A ratio: 0.56 \nMitral Valve - E Wave deceleration time: *284 ms 140-250 ms \nTR Gradient (+ RA = PASP): 18 mm Hg <= 25 mm Hg \nFindings \nLEFT VENTRICLE: Normal regional LV systolic function. Overall\nnormal LVEF (>55%). No resting LVOT gradient. \nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. \nAORTIC VALVE: No AS. Mild (1+) AR. \nMITRAL VALVE: Trivial MR. \n___: No pericardial effusion. \nConclusions \n The patient exercised for 8 minutes according to a Modified\n___ treadmill protocol ___ METS) reaching a peak heart rate of\n101 bpm and a peak blood pressure of 152/70 mmHg (with\nprogressive subsequent drop through exercise). The test was\nstopped because of anginal pain and hypotensive response. This\nlevel of exercise represents an average exercise tolerance for\nage and gender. In response to stress, the ECG showed ischemic \nST\nchanges (see exercise report for details). with an abnormal fall\nin blood pressure \n Resting images were acquired at a heart rate of 70 bpm and a\nblood pressure of 132/78 mmHg. These demonstrated normal \nregional\nand global left ventricular systolic function. Right ventricular\nfree wall motion is normal. There is no pericardial effusion.\nDoppler demonstrated mild aortic regurgitation with no aortic\nstenosis or significant mitral regurgitation or resting LVOT\ngradient.\n Echo images were acquired within 59 seconds after peak stress \nat\nheart rates of 100 - 87 bpm. These demonstrated mild global left\nventricular systolic dysfunction with somewhat more prominent\nbasal inferior hypokinesis (concerning for multivessel CAD).\nThere was augmentation of right ventricular free wall motion. \n IMPRESSION: Average functional exercise capacity. Ischemic ECG\nchanges. 2D echocardiographic evidence of inducible ishemia at\nachieved workload, concerning for multivessel CAD. Mild aortic\nregurgitation at rest. \n.\nCarotid Ultrasound: ___\nBilateral less than 40% carotid stenosis. \nLABS:\nAdmit:\n___ 04:34PM BLOOD WBC-10.6*# RBC-3.44*# Hgb-10.3*# \nHct-30.2*# MCV-88 MCH-29.9 MCHC-34.1 RDW-13.7 RDWSD-43.8 Plt \n___\n___ 04:34PM BLOOD ___ PTT-35.3 ___\n___ 01:40AM BLOOD ___ 04:34PM BLOOD UreaN-8 Creat-0.8 Na-143 K-3.8 Cl-111* \nHCO3-25 AnGap-11\n___ 04:34PM BLOOD Mg-3.5*\n___ 01:40AM BLOOD Calcium-8.2* Phos-2.6*\n\nDischarge:\n\n___ 12:10PM BLOOD WBC-9.6 RBC-3.65* Hgb-10.7* Hct-33.2* \nMCV-91 MCH-29.3 MCHC-32.2 RDW-14.5 RDWSD-47.6* Plt ___\n___ 07:23AM BLOOD WBC-9.1 RBC-3.32* Hgb-9.9* Hct-30.8* \nMCV-93 MCH-29.8 MCHC-32.1 RDW-14.1 RDWSD-47.8* Plt ___\n___ 04:51AM BLOOD WBC-10.8* RBC-3.23* Hgb-9.4* Hct-28.4* \nMCV-88 MCH-29.1 MCHC-33.1 RDW-14.2 RDWSD-45.6 Plt ___\n___ 01:40AM BLOOD ___ PTT-38.5* ___\n___ 09:00PM BLOOD ___ PTT-30.0 ___\n___ 04:34PM BLOOD ___ PTT-35.3 ___\n___ 05:47AM BLOOD Glucose-124* UreaN-13 Creat-1.0 Na-137 \nK-4.4 Cl-102 HCO3-26 AnGap-13\n___ 07:23AM BLOOD Glucose-130* UreaN-14 Creat-1.0 Na-135 \nK-4.6 Cl-99 HCO3-28 AnGap-13\n___ 04:51AM BLOOD Glucose-187* UreaN-14 Creat-1.0 Na-135 \nK-3.8 Cl-97 HCO3-31 AnGap-11\n___ 01:40AM BLOOD Glucose-98 UreaN-7 Creat-0.9 Na-140 K-3.6 \nCl-105 HCO3-27 AnGap-12\n___ 04:34PM BLOOD UreaN-8 Creat-0.8 Na-143 K-3.8 Cl-111* \nHCO3-25 AnGap-11\n \nBrief Hospital Course:\nThe patient was brought to the Operating Room on ___ where \nthe patient underwent Coronary artery bypass grafting x2, with \nthe left internal mammary artery to left anterior descending \nartery, and reverse saphenous vein graft to the obtuse marginal\nartery. Overall the patient tolerated the procedure well and \npost-operatively was transferred to the ___ in stable \ncondition for recovery and invasive monitoring. \nPOD 1 found the patient extubated, alert and oriented and \nbreathing comfortably. The patient was neurologically intact \nand hemodynamically stable, weaned from inotropic and \nvasopressor support. Beta blocker was initiated and the patient \nwas gently diuresed toward the preoperative weight. Lopressor \nwas titrated up for blood pressure and heart rate control. \nMetformin was resumed at home dose and Glipizide was added for \nadditional blood sugar control. 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 \nhome with visiting nurse services in good condition with \nappropriate follow up instructions.\n \nMedications on Admission:\n1. Atorvastatin 80 mg PO QPM \n2. MetFORMIN (Glucophage) 1000 mg PO BID \n3. Metoprolol Succinate XL 100 mg PO DAILY \n4. Naproxen 500 mg PO Q12H:PRN pain \n5. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN cp \n6. Omeprazole 20 mg PO DAILY \n7. Aspirin 81 mg PO DAILY \n8. Calcium Carbonate 500 mg PO DAILY \n9. Vitamin D 400 UNIT PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. MetFORMIN (Glucophage) 1000 mg PO BID \n4. Omeprazole 20 mg PO DAILY \n5. Acetaminophen 1000 mg PO Q6H:PRN pain \n6. Bisacodyl ___AILY:PRN constipation \n7. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*601 Capsule Refills:*0\n8. Furosemide 20 mg PO DAILY \nRX *furosemide [Lasix] 20 mg 1 tablet(s) by mouth daily Disp #*5 \nTablet Refills:*0\n9. GlipiZIDE 2.5 mg PO BID \nRX *glipizide 5 mg 0.5 (One half) tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0\n10. Metoprolol Tartrate 50 mg PO Q8H \nRX *metoprolol tartrate 50 mg 1 tablet(s) by mouth Q 8 hours \nDisp #*90 Tablet Refills:*0\n11. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain: \nmoderate/severe \nRX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth Q 4 hours Disp \n#*60 Tablet Refills:*0\n12. Calcium Carbonate 500 mg PO DAILY \n13. Vitamin D 400 UNIT PO DAILY \n14. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days \nRX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp \n#*5 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nCoronary artery disease s/p revascularization\nStable angina by stress testing \nHypertension\nHyperlipidemia\nNon-insulin dependent diabetes\nGERD\nHyperthyroidism s/p RAI treatment\nHypothyroidism \nCataracts\nPast Surgical History:None \n\n \nDischarge Condition:\nAlert and oriented x3 nonfocal\nAmbulating, gait steady\nSternal pain managed with oral analgesics\nSternal Incision - healing well, no erythema or drainage\nLeft Leg Incision - healing well, no erythema or drainage\nEdema - trace \n\n \nDischarge Instructions:\nPlease shower daily including washing incisions gently with mild \nsoap, no baths or swimming, and look at your incisions\nPlease NO lotions, cream, powder, or ointments 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, will be discussed at follow up appointment with \nsurgeon when you will be able to drive\nNo lifting more than 10 pounds for 10 weeks\nPlease call with any questions or concerns ___\n \nFollowup Instructions:\n___\n" ]

[ "I25118", "E119", "I10", "D62", "E785", "K219", "I9581" ]

[ "I25118: Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "D62: Acute posthemorrhagic anemia", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "I9581: Postprocedural hypotension" ]

[ "E119", "I10", "D62", "E785", "K219" ]

[]

[ " \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:\nAbdominal pain, diarrhea\n \nMajor Surgical or Invasive Procedure:\n___:\n1. Diagnostic laparoscopy with a conversion to exploratory \nlaparotomy with abdominal washout.\n2. Right hemicolectomy with mobilization of hepatic flexure.\n3. Partial omentectomy.\n\n \nHistory of Present Illness:\n___ M otherwise healthy with history of acute appendicitis ___ \ntreated non-operatively re-presents with 4 days abdominal pain \nand loose stools. Pain located in mid abdomen mostly in right \nlower quadrant, no other abdominal pain. Decreased oral intake \nlast few days, due to associated loose stools. Passing gas, no \nblood, no melena. Denies nausea or emesis. Now with leukocytosis \nand CTAP consistent with recurrent acute appendicitis involving \nthe cecum. \n \nPast Medical History:\nNone\n \nSocial History:\n___\nFamily History:\nNo family history of IBD, IBS, GI cancer. Mother has history of \nbreast cancer \n \nPhysical Exam:\nAdmission Physical Exam:\nVS: 99.0F 89 HR 129/81 BP 18 96% RA \nGen: affable, comfortable, NAD\nNeuro: grossly intact\nCV: RRR no MRG\nPulm: CTAB\nAbd: soft, focally tender to deep palpation RLQ, no RUQ pain,\nnegative ___, non peritoneal, no guarding\nExt: warm well perfused, no ___ edema\n\nDischarge Physical Exam:\nVS: 98.3 76 123/80 18 98% RA\nGen: Alert and interactive sitting up in bed with mother at \nbedside.\nHEENT: no deformity. PERRL, EOMI. Mucus membranes moist. Neck \nsupple, trachea midline.\nCV: RRR\nPulm: Clear to auscultation bilaterally.\nAbd: Soft, mildly tender incisionally as anticipated, mildly \ndistended. Active bowel sounds x 4 quadrants.\nExt: Warm and dry. No edema. 2+ Dp/pt pulses bilaterally\nNeuro: A&Ox3. Follows commands and moves all extremities equal \nand strong. Speech is clear and fluent. \n \nPertinent Results:\n___ 04:30AM BLOOD WBC-11.7* RBC-3.99* Hgb-11.5* Hct-35.1* \nMCV-88 MCH-28.8 MCHC-32.8 RDW-12.7 RDWSD-40.6 Plt ___\n___ 06:00AM BLOOD WBC-11.5* RBC-3.83* Hgb-11.0* Hct-34.8* \nMCV-91 MCH-28.7 MCHC-31.6* RDW-12.8 RDWSD-42.6 Plt ___\n___ 09:25AM BLOOD WBC-13.1* RBC-3.87* Hgb-11.2* Hct-34.8* \nMCV-90 MCH-28.9 MCHC-32.2 RDW-12.8 RDWSD-41.8 Plt ___\n___ 05:10AM BLOOD WBC-16.4* RBC-3.87* Hgb-11.1* Hct-35.4* \nMCV-92 MCH-28.7 MCHC-31.4* RDW-12.8 RDWSD-42.2 Plt ___\n___ 05:55AM BLOOD WBC-18.1* RBC-4.27* Hgb-12.2* Hct-37.7* \nMCV-88 MCH-28.6 MCHC-32.4 RDW-12.7 RDWSD-41.1 Plt ___\n___ 05:56AM BLOOD WBC-21.0* RBC-4.78# Hgb-14.0# Hct-41.6 \nMCV-87 MCH-29.3 MCHC-33.7 RDW-12.5 RDWSD-40.0 Plt ___\n___ 02:05AM BLOOD WBC-17.8* RBC-3.74*# Hgb-10.9*# \nHct-33.4*# MCV-89 MCH-29.1 MCHC-32.6 RDW-12.5 RDWSD-41.0 Plt \n___\n___ 12:00PM BLOOD WBC-15.7* RBC-5.11 Hgb-14.9 Hct-43.5 \nMCV-85 MCH-29.2 MCHC-34.3 RDW-12.5 RDWSD-38.5 Plt ___\n___ 12:00PM BLOOD ___ PTT-30.1 ___\n___ 06:00AM BLOOD Glucose-114* UreaN-11 Creat-0.8 Na-139 \nK-3.9 Cl-103 HCO3-29 AnGap-11\n___ 09:25AM BLOOD Glucose-113* UreaN-10 Creat-0.6 Na-139 \nK-4.0 Cl-103 HCO3-25 AnGap-15\n___ 05:10AM BLOOD Glucose-121* UreaN-8 Creat-0.7 Na-138 \nK-4.4 Cl-101 HCO3-28 AnGap-13\n___ 05:55AM BLOOD Glucose-147* UreaN-9 Creat-1.1 Na-139 \nK-4.5 Cl-104 HCO3-28 AnGap-12\n___ 05:56AM BLOOD Glucose-138* UreaN-12 Creat-1.0 Na-139 \nK-3.8 Cl-104 HCO3-22 AnGap-17\n___ 02:05AM BLOOD Glucose-126* UreaN-11 Creat-0.7 Na-121* \nK-3.7 Cl-89* HCO3-14* AnGap-22*\n___ 12:00PM BLOOD Glucose-88 UreaN-14 Creat-1.0 Na-139 \nK-5.4* Cl-101 HCO3-23 AnGap-20\n___ 12:00PM BLOOD ALT-38 AST-48* AlkPhos-79 TotBili-1.7*\n___ 06:00AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.2\n___ 09:25AM BLOOD Calcium-8.6 Phos-2.2* Mg-2.1\n___ 05:10AM BLOOD Calcium-8.6 Phos-2.1* Mg-2.3\n___ 05:55AM BLOOD Calcium-8.2* Phos-2.2*# Mg-2.5\n___ 05:56AM BLOOD Calcium-8.2* Phos-4.6* Mg-2.4\n___ 02:05AM BLOOD Calcium-7.2* Phos-3.4 Mg-1.3*\n___ 12:00PM BLOOD Albumin-4.4 Calcium-9.5 Phos-3.7 Mg-2.3\n\n___ CT AP: Findings consistent with gangrenous acute \nappendicitis. No free air or\nadjacent fluid collections. Thickening of the base of the cecum \ncompatible\nwith secondary inflammation.\n \nBrief Hospital Course:\nMr. ___ is a ___ gentleman who presented 9 months \nprior with evidence of acute appendicitis. He was treated with \nantibiotics and offered an interval appendectomy in the \noutpatient setting but did not return for follow up. On ___ \nhe presented to the emergency department with abdominal pain. He \nhad a CT scan that showed high suspicion for acute on chronic \nappendicitis. Given the concern for possible Crohn's, possible \nmalignancy, and a history of lost to followup, the patient was \noffered surgical intervention on this admission. After this \nextensive discussion regarding the risks, benefits, \nalternatives, and complications, informed consent was signed and \nthe patient was then scheduled for the operating room. On \n___ he underwent a diagnostic laparoscopy with conversion \nto open exploratory laparotomy, right hemicolectomy, and partial \nomentectomy. Please see operative report for details. He \ntolerated the procedure well, was extubated, and taken to PACU \nin stable condition. Once recovered from anesthesia, he was \ntransferred to the surgical floor for further management.\n\nOn POD1 he was kept NPO with IV fluids and a nasogastric tube in \nplace. His pain was controlled with a Dilaudid PCA. His \nnasogastric tube output was monitored and subsequently removed. \nOn POD2 his foley catheter was removed and he voided without \ndifficulty. On POD3 he had nausea and one episode of emesis. On \nPOD4 he had return of bowel function as noted by positive flatus \nand a bowel movement. On POD5 he was tolerating a regular diet, \npain was better controlled on oral pain medicine, and he was \nambulating independently. \n\nDuring this hospitalization, the patient ambulated early and \nfrequently, was adherent with respiratory toilet and incentive \nspirometry, and actively participated in the plan of care. The \npatient received subcutaneous heparin and venodyne boots were \nused during this stay.\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. Follow up appointments were \nscheduled. \n \nMedications on Admission:\nnone\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \ndo not exceed 4 grams/ 24 hours \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*30 Capsule Refills:*0\n3. Ibuprofen 400 mg PO Q8H \n4. Senna 8.6 mg PO BID:PRN constipation \nRX *sennosides 8.6 mg 1 by mouth twice a day Disp #*30 Tablet \nRefills:*0\n5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain \nRX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4) \nhours Disp #*30 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPerforated recurrent acute on chronic 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 Mr. ___,\n\nYou were admitted to the Acute Care Surgery Service on ___ \nwith abdominal pain. You had a CT scan that showed acute \nappendicitis. You were taken to the operating room and had you \nappendix and a piece of your intestine removed through an open \nincision. You are tolerating a regular diet, ambulating \nindependently, and pain is better controlled.\n\nPlease note the following discharge 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\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 \n \nFollowup Instructions:\n___\n" ]

[ "K352", "E669", "K36", "Z6835" ]

[ "K352: Acute appendicitis with generalized peritonitis", "E669: Obesity, unspecified", "K36: Other appendicitis", "Z6835: Body mass index [BMI] 35.0-35.9, adult" ]

[ "E669" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nlisinopril / watermelon / shrimp / apples / crab\n \nAttending: ___.\n \nChief Complaint:\nElevated creatinine\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\n___ PMHx DMI s/p LURT ___ and pancreas after kidney\ntransplant on ___, post-op recovery complicated by\ngastroenteritis (nausea/diarrhea/RLQ pain/low-grade fevers) for\nwhich patient was admitted on ___. After complete \nresolution\nof symptoms upon starting antibiotics, the patient was \ndischarged\nwith Augmentin on ___. Initial stool micro-organism testing\ndemonstrated possible Salmonella, and so the patient was \nswitched\nfrom Augmentin to Levaquin/Flagyl as an outpatient on ___.\nAfter the initiation of these new antibiotics, the patient\nreported feeling nauseous, acid reflux, and loss of appetite, \nfor\nwhich the patient felt that he became dehydrated and \noccasionally\ndizzy over the past few days.\n\nToday on admission, the patient reports having had a small \namount\nof emesis earlier this morning. The patient continues to report\npoor PO intake due to GI upset/nausea from the new antibiotics,\nbut otherwise denies fevers/chills, abdominal pain/back pain,\nchest pain/SOB, and reports having regular bowel \nmovements/flatus\nand making plenty of urine. He reports that his blood sugars \nhave\nbeen between 90-130 at home. Labs from ___ demonstrated Cr\nof 2.4 (baseline 1.4-1.6), amylase/lipase wnl. \n\n \nPast Medical History:\nPMH: DM1 c/b ESRD s/p LURT ___ and hypoglycemic unawareness,\n>6 hypoglycemic seizures, retinopathy\n\nPSH: LURT ___\n \nSocial History:\n___\nFamily History:\nFamily: Mother - hypothyroid; father - HTN, DM2; Brother -\nhealthy; Sister - sickle cell anemia, Paternal grandfather - DM1\n \nPhysical Exam:\nVitals: Temp 99.3 / BP 108/64 / HR 93 / RR 18 / O2sat 98%RA \nGEN: A&O, NAD, comfortable\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, no rebound or\nguarding, incision clean/dry/intact w/ staples\nExt: No ___ edema, ___ warm and well perfused\n\nLab Results ___:\ntacroFK: 8.7\n\n135 | 99 | 16 AGap=18 \n------------- \n4.8 | 23 | 2.4 \nGlu: 89 \nCa: 10.0 Mg: 1.7 P: 4.0\n\nALT: 24 AP: 91 Tbili: 0.2 Alb: 4.1 \nAST: 22 LDH: Dbili: TProt: \n___: 50 Lip: 47 \n\nOther Urine Chemistry:\nCreat:129 \nTotProt:19 \nProt/Cr:0.1\n\nWBC: 2.9 / Hgb 9.6 / Hct 29.9 / Plt 473 \n \nPRESERVED FOR UA\nColor: Yellow Appear: Clear SpecGr: 1.014 pH: 6.0 \nUrobil: Neg Bili: Neg Leuk: Neg Bld: Neg Nitr: Neg \nProt: Tr Glu: Neg Ket: Neg RBC: 0 WBC: <1 Bact: None \nYeast:\nNone Epi: 0 Amorph Rare \n\nOther Urine Counts\nCastHy: 6 \nMucous: Rare\n\nImaging Results:\nRENAL TRANSPLANT U.S. LEFT Study Date of ___ 3:01 ___ \nFINDINGS: \n \nThe left lower quadrant transplant renal morphology is normal. \nSpecifically, the cortex is of normal thickness and \nechogenicity,\npyramids are normal, there is no urothelial thickening, and \nrenal\nsinus fat is normal. There is no \nhydronephrosis and no perinephric fluid collection. \n \nThe resistive index of intrarenal arteries ranges from 0.57 to\n0.65, within the normal range. The main renal artery shows a\nnormal waveform, with prompt systolic upstroke and continuous\nantegrade diastolic flow, with peak systolic velocity of 99\ncentimeters/seconds. Vascularity is symmetric throughout \ntransplant. The transplant renal vein is patent and shows normal\nwaveform. \n \nIMPRESSION: \n \nNormal renal transplant ultrasound. \n\n___ WT 55kg. Adm wt 54.8kg\n\n \nPertinent Results:\nAdmission labs:\n\n___ 09:27AM BLOOD WBC-2.9* RBC-3.38* Hgb-9.6* Hct-29.9* \nMCV-89 MCH-28.4 MCHC-32.1 RDW-13.8 RDWSD-44.1 Plt ___\n___ 05:10PM BLOOD ___ PTT-31.9 ___\n___ 09:27AM BLOOD UreaN-16 Creat-2.4* Na-135 K-4.8 Cl-99 \nHCO3-23 AnGap-18\n___ 09:27AM BLOOD ALT-24 AST-22 AlkPhos-91 Amylase-50 \nTotBili-0.2\n___ 09:27AM BLOOD Lipase-47\n___ 09:27AM BLOOD Albumin-4.1 Calcium-10.0 Phos-4.0 Mg-1.7\n\nDischarge Labs:\n\n___ 04:51AM BLOOD WBC-2.4* RBC-2.76* Hgb-7.7* Hct-24.5* \nMCV-89 MCH-27.9 MCHC-31.4* RDW-13.7 RDWSD-44.3 Plt ___\n___ 04:51AM BLOOD ___ PTT-32.0 ___\n___ 04:51AM BLOOD Glucose-112* UreaN-7 Creat-1.7* Na-139 \nK-5.1 Cl-108 HCO3-21* AnGap-15\n___ 04:51AM BLOOD ALT-18 AST-18 LD(LDH)-142 AlkPhos-75 \nAmylase-36 TotBili-0.2\n___ 04:51AM BLOOD Amylase-34\n___ 04:51AM BLOOD Lipase-45\n___ 04:51AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.7\n___ 09:27AM BLOOD tacroFK-8.7\n___ 04:51AM BLOOD tacroFK-10.7\n\n \n \n___ 3:34 pm URINE Source: ___. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: NO GROWTH. \n\n \nBrief Hospital Course:\n___ PMH w DMI s/p LURT ___ and pancreas after kidney \ntransplant on ___, was admitted with ___ likely pre-renal \ndue to dehydration from Levaquin/Flagyl-induced GI upset and \npoor PO intake.\n\nHe was started on IV hydration and a renal U/S was normal. Per \nDr. ___, the final result of the stool \nmicro-organism grown from his ___ admission culture was not \nSalmonella, but rather E coli, and recommended discontinuation \nof all of his antibiotics (levaquin and flagyl). Creatinine \ndecreased to 1.7 from 2.4. Tacrolimus dose remained at his home \ndose of 2.5 twice daily for troughs of 8.7 to 10.7 then 8.7 on \n___. Dose was increased to 3mg twice daily on ___. Valcyte \nwas adjusted per creatinine clearance. \n\nAmylase and lipase were normal. Glucoses averaged 101 to 128. He \nfelt well and was tolerating a regular diet. He was discharged \nto home in stable condition on ___. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Famotidine 40 mg PO Q12H \n3. Mycophenolate Mofetil 1000 mg PO BID \n4. Nystatin Oral Suspension 5 mL PO QID \n5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n6. ValGANCIclovir 900 mg PO Q24H \n7. Pravastatin 40 mg PO QPM \n8. Sodium Polystyrene Sulfonate 15 gm PO ASDIR hyperkalemia \n9. Tacrolimus 2.5 mg PO Q12H \n10. Levofloxacin 500 mg PO Q24H \n11. MetroNIDAZOLE 500 mg PO TID \n\n \nDischarge Medications:\n1. Tacrolimus 3 mg PO Q12H \n2. ValGANCIclovir 450 mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Famotidine 40 mg PO Q12H \n5. Mycophenolate Mofetil 1000 mg PO BID \n6. Nystatin Oral Suspension 5 mL PO QID \n7. Pravastatin 40 mg PO QPM \n8. Sodium Polystyrene Sulfonate 15 gm PO ASDIR hyperkalemia \n9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nARF\nDehydration\npancreas after kidney transplant ___\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 the transplant clinic at ___ for fever of \n101 or greater, chills, nausea, vomiting, diarrhea, \nconstipation, inability to tolerate food, fluids or medications, \npain over graft sites, increased abdominal pain, incision \nredness, drainage or bleeding, dizziness or weakness, decreased \nurine output or dark, cloudy urine, swelling of abdomen or \nankles, increasing blood sugars or blood sugar of 180 or \ngreater, weight gain of 3 pounds in a day, or any other \nconcerning symptoms.\n\nCheck your blood sugars prior to meals and bedtime. Call if \nglucose is 180 or greater. \n\nlabwork twice weekly as arranged by the transplant clinic, with \nresults to the transplant clinic (Fax ___ . CBC, Chem \n10, AST, T Bili, Amylase, Lipase, Trough Tacro level, \nUrinalysis.\n\n****On the days you have your labs drawn, do not take your \nTacrolimus until your labs are drawn. Bring your Tacrolimus with \nyou so you may take your medication as soon as your labwork has \nbeen drawn.\n\nFollow your medication card, keep it updated with any dosage \nchanges, and always bring your card with you to any clinic or \nhospital visits.\n\nDrink enough fluids to keep your urine light in color. Your \nappetite will return with time. Eat small frequent meals, and \nyou may supplement with things like carnation instant breakfast \nor Ensure.\n\nCheck blood pressure at home daily. Report consistently elevated \nvalues over 160 systolic to the transplant clinic\n\nDo not increase, decrease, stop or start medications without \nconsultation with the transplant clinic at ___. There \nare significant drug interactions with anti-rejection \nmedications which must be considered in medication management \nfollowing transplant\n\n \nFollowup Instructions:\n___\n" ]

[ "N178", "Z9483", "E10319", "Z940", "I10", "E860", "K219" ]

[ "N178: Other acute kidney failure", "Z9483: Pancreas transplant status", "E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "Z940: Kidney transplant status", "I10: Essential (primary) hypertension", "E860: Dehydration", "K219: Gastro-esophageal reflux disease without esophagitis" ]

[ "I10", "K219" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \n___\n \nAttending: ___.\n \nChief Complaint:\nhypotension, anorexia, fatigue\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMr. ___ is an ___ year old male with a history of DLBCL\ns/p treatment s/p C4 R-mini CHOP who presents with fatigue,\ndecreased appetite and found to hypotensive at the clinic. \n \nPast Medical History:\n# Gastric ulcers \n# Anemia \n# Linear atelectasis \n# S/P Subtotal Gastrectomy \n# Status Post Nissen Fundoplication (without Gastrostomy Tube) \n# Hx. of Asbestos exposure \n# Renal stone \n# AAA\n# Chronic MAC lung disease\n \nSocial History:\n___\nFamily History:\nFather with hx. of cardiomyopathy; otherwise, no family history \nof early MI, arrhythmia, cardiomyopathies, or sudden cardiac \ndeath; otherwise non-contributory. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nGEN: NAD, cachetic, frail, appear fatigue, alert & oriented\nVS: Tc 97.8 86/60-90/60 60 18 99%RA\nPain (___): 0\nHEENT: Sclera anicteric, keyhole R pupil, MMM, dentures, OP \nclear\nNECK: Thin, JVP not elevated, no LAD \nCV: Pacemaker over L chest wall, RRR, + pansystolic murmur.\nPULM: Normal respiratory effort. Clear to auscultation\nbilaterally\nABD: Scaphoid, soft, non-tender, non-distended, bowel sounds\npresent, no rebound tenderness or guarding \nLIMBS: 2+ pitting edema on BLE. No inguinal adenopathy\nSKIN: Dry. No rashes, skin breakdown or new bruising\nNEURO: CNs2-12 intact with R sided strabismus, motor function\ngrossly normal \n\nDISCHARGE PHYSICAL EXAM:\nPHYSICAL EXAM:\nGEN: NAD, cachetic, frail, appear fatigue, alert & oriented\nVS: Tc 97.6 101/50 66 18 98%RA\nPain (___): 0\nHEENT: Sclera anicteric, keyhole R pupil, MMM, dentures, OP \nclear\nNECK: Thin, JVP not elevated, no LAD \nCV: Pacemaker over L chest wall, RRR, + pansystolic murmur.\nPULM: Normal respiratory effort. Clear to auscultation\nbilaterally\nABD: Scaphoid, soft, non-tender, non-distended, bowel sounds\npresent, no rebound tenderness or guarding \nLIMBS: 2+ pitting edema on BLE. No inguinal adenopathy\nSKIN: Dry. No rashes, skin breakdown or new bruising\nNEURO: CNs2-12 intact with R sided strabismus, motor function\ngrossly normal \n \nPertinent Results:\n___ 12:00AM BLOOD WBC-7.2 RBC-2.85* Hgb-8.4* Hct-26.5* \nMCV-93 MCH-29.5 MCHC-31.7* RDW-20.3* RDWSD-69.7* Plt ___\n___ 09:00AM BLOOD WBC-3.6* RBC-2.48* Hgb-7.6* Hct-23.8* \nMCV-96 MCH-30.6 MCHC-31.9* RDW-17.4* RDWSD-61.2* Plt ___\n___ 12:00AM BLOOD Neuts-76* Bands-2 Lymphs-11* Monos-10 \nEos-1 Baso-0 ___ Myelos-0 AbsNeut-5.62 AbsLymp-0.79* \nAbsMono-0.72 AbsEos-0.07 AbsBaso-0.00*\n___ 09:00AM BLOOD Neuts-41 Bands-8* ___ Monos-21* \nEos-6 Baso-0 ___ Myelos-0 AbsNeut-1.76 AbsLymp-0.86* \nAbsMono-0.76 AbsEos-0.22 AbsBaso-0.00*\n___ 12:00AM BLOOD Glucose-91 UreaN-14 Creat-0.7 Na-138 \nK-4.1 Cl-110* HCO3-22 AnGap-10\n___ 09:00AM BLOOD UreaN-20 Creat-0.9 Na-137 K-4.0 Cl-103 \nHCO3-24 AnGap-14\n___ 12:00AM BLOOD ALT-11 AST-25 LD(LDH)-346* AlkPhos-95 \nTotBili-0.2\n___ 09:00AM BLOOD ALT-15 AST-23 LD(LDH)-265* AlkPhos-88 \nTotBili-0.5\n___ 12:00AM BLOOD Calcium-7.6* Phos-1.8* Mg-2.1\n___ 09:00AM BLOOD ALT-15 AST-23 LD(___)-265* AlkPhos-88 \nTotBili-0.5\n___ 12:00AM BLOOD Calcium-7.6* Phos-1.8* Mg-2.1\n___ 09:00AM BLOOD Albumin-2.9*\n \nBrief Hospital Course:\nMr. ___ is an ___ year old male with a history of DLBCL s/p\ntreatment s/p C4 R-mini CHOP who presents with fatigue, \ndecreased\nappetite and found to have low blood pressures at the clinic. \n\n#Hypotension: Low to mid ___ at the clinic, patient largely\nasymptomatic but reports some weakness upon ambulation. No\nfevers, chills, rigors, dizziness, lightheadedness, syncope or\nUTI symptoms. C/o diarrhea and profound fatigue/no energy.\nEtiology unclear; however, could be multifactorial [infection vs\nhypovolemia as a result of GI loss vs anemia]. Infection \npossible\ngiven s/p C4 D10 of R-mini CHOP and at risk for infection.\nObtained UA, urine culture and blood cultures - results NTD.\nGiven exposure to sick contacts with ___ obtain CXR to\nrule out acute cardiopulmonary process. Another possible \netiology\ncould be hypovolemia as result of decreased oral intake +\ndiarrhea, has had a 10lbs weight loss in the past 2 weeks.\nReceived 2 NS boluses with fair effect on BPs. ? related to\nanemia, hgb 7.6. Received 1U prbcs. Will continue to monitor\nclosely\n-resolved with IVF and blood products\n\n#Weight Loss: Unclear etiology, 10lbs weight loss in the past 2\nweeks. Reports diminished appetite and profound fatigue. Hx of\nsubtotal gastrectomy and s/p nissen fundoplication (without\nGastrostomy Tube). Supportive care with IVF. Plan to consult\nnutrition for recommendations. rec supplements TID.\n\n#DLBCL: Patient presented initially ___ with hypotension\nand aphasia. Work up demonstrated a large abdominal mass. Biopsy\ndemonstrated B cell DLBCL with complex cytogenetics with gain of\nMYC and IGH/BCL2 translocation. Course further complicated by \nthe\npresence of a large abdominal aortic aneurysm that was repaired\n___ as below. Once he recovered from that repair, he\nstarted treatment with CHOP. Tolerated second and third cycles \nof\nR-mini CHOP w/o major toxicity. Now s/p C4 of R-mini CHOP (D1\n___, received neulasta on ___. Plan for a repeat \nstaging\nwith PET and a TTE to monitor cardiac function per primary\noncologist. Continues on Bactrim and Acyclovir PPX\n-f/u rescheduled ___ outpatient or sooner if issues arise \n\n#Diarrhea: Has had diarrhea after most recent cycle, reports \nthat\nhe was taking Imodium at home. No abdominal pain, cramping or\nfevers. Will r/o c-diff and norovirus-neg. Initiated continuous\nfluids + prn NS boluses to account for GI losses\n\n#AAA: Underwent endovascular repair on ___ without\ncomplications for a large infra-renal AAA extending into\nbilateral iliac arteries with max diameter of 5.8 cm. \n\n#Postprandial Hypotension: Initially presented with multiple \ndays of aphasia associated with color change and hypotension \nfollowing meals. Reportedly with word finding difficulties for \nmultiple days following initial incident that improved over \ntime. These episodes were thought to represent global cerebral \nhypoperfusion (perhaps with a fixed lesion, not identified on \nCTA) related to the patient's splanchnic vasodilation following \nmeals and a large shunting of bloodflow to his abdominal mass \nPrevious ECHO was negative for thrombus, carotid duplex negative\nfor focal stenosis. On midodrine TID. Consider fludricortisone \nif\npersists although has had negative cosyntropin test in the past\n \n#Broca's (expressive) Aphasia: Occurred in setting of episodic\nhypotension and resolved with improved perfusion. CTA head and\ncarotid US non-concerning for acute CVA at that time. Continues\non midodrine TID as above\n\n#Biapical consolidations with calcifications: On previous\nhospitalizations, AFP x 3 negative for TB. Positive for MAC.\n___ quant gold indeterminate. Currently, endorsing no \nactive\npulmonary symptomatology. \n\n#Chronic Hepatitis B: Core antibody positive, VL undetected c/w \ncleared prior infection. Continues on home lamuvidine.\n\n#Infectious prophylaxis:\n- PCP: ___\n- HSV/VZV: Acyclovir\n\nProphylaxes:\n# Access: R POC, placed ___\n# FEN: Regular diet\n# Pain control: prn\n# Bowel regimen: holding with diarrhea\n# ___\n# Disposition: home with symptomatic improvement with ___ \nservices\n# Code status: DNI/DNR\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ferrous Sulfate 325 mg PO DAILY \n2. Atorvastatin 40 mg PO QPM \n3. LaMIVudine 50 mg PO DAILY \n4. Midodrine 5 mg PO LUNCH \n5. Midodrine 10 mg PO BID \n6. Docusate Sodium 100 mg PO BID \n7. Cyanocobalamin 100 mcg PO DAILY \n8. Acyclovir 400 mg PO Q8H \n9. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q8H \n2. Atorvastatin 40 mg PO QPM \n3. Cyanocobalamin 100 mcg PO DAILY \n4. Docusate Sodium 100 mg PO BID \n5. Ferrous Sulfate 325 mg PO DAILY \n6. LaMIVudine 50 mg PO DAILY \n7. Midodrine 5 mg PO LUNCH \n8. Midodrine 10 mg PO BID \n9. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nlymphoma\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 due to low blood pressure lack of appetite and \nextreme fatigue. This improved with IV fluids, blood products \nand improvement in your blood counts. You will follow up in \nclinic as stated below. Please do not hesitate to call in the \nmeantime with any questions or concerns.\n \nFollowup Instructions:\n___\n" ]

[ "C8333", "R64", "B1910", "R4701", "D649", "E861", "I071", "Z681", "I714", "Z8679", "Z66", "Z77090", "Z950", "H269" ]

[ "C8333: Diffuse large B-cell lymphoma, intra-abdominal lymph nodes", "R64: Cachexia", "B1910: Unspecified viral hepatitis B without hepatic coma", "R4701: Aphasia", "D649: Anemia, unspecified", "E861: Hypovolemia", "I071: Rheumatic tricuspid insufficiency", "Z681: Body mass index [BMI] 19.9 or less, adult", "I714: Abdominal aortic aneurysm, without rupture", "Z8679: Personal history of other diseases of the circulatory system", "Z66: Do not resuscitate", "Z77090: Contact with and (suspected) exposure to asbestos", "Z950: Presence of cardiac pacemaker", "H269: Unspecified cataract" ]

[ "D649", "Z66" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nbee venom protein (honey bee) / Penicillins\n \nAttending: ___.\n \nChief Complaint:\npossible thoracic outlet syndrome, with right arm pain, numbness\n \nMajor Surgical or Invasive Procedure:\n___ first rib resection via supraclavicular right sided \napproach, neurolysis with Dr. ___\n \n___ of Present Illness:\nMr. ___ is a ___ gentleman referred by Dr.\n___ evaluation of possible thoracic outlet syndrome. \nHe has had increasing problems over the past year in the right\narm. He has pain whenever his arm is elevated it comes on\nquickly and worsens the more he uses the arm in the elevated\nposition. He has had shoulder instability surgery last ___ \nwhich\nhe needed for substantial instability in the shoulder but this\nhad no impact on the pain and numbness that he gets. The\nsymptoms affecting primarily in the ulnar distribution in the\nhand affecting the fifth and fourth digits the lateral aspect of\nthe hand and the forearm. He has had an EMG which was normal \nand\nMRI which was normal and plain films show no cervical rib or\nother abnormalities. He has been through extensive physical\ntherapy. Right handed, no problems with the left side. \n \nPast Medical History:\nasthma\n\nallergy to penicillin- hives\n \nSocial History:\n___\nFamily History:\nGrandfather- stroke, CHF, \nuncle- MI\ngrandfather and uncle with renal failure \nmaternal and paternal grandmothers with cancer\nasthma \n\n \nPhysical Exam:\nDischarge Physical Exam: \nGeneral: NAD, AAOx3. Clear and fluent speech, speaking in full \nsentences with normal affect. \nHEENT: MMM, no scleral icterus or injection. Facial symmetry. \nCV: RRR, normal S1 and S2\nPULM: CTAB/L, no adventitious sounds, good aeration throughout. \nSymmetric expansion. \nDermabond on right lateral neck incision at the base of the \nneck. JP drain in the right mid superior aspect of shoulder, \nwith serosanguine output, holding suction without evidence of \nair leak. JP is intraplueral. \nABD: soft, nontender, nondistended. No rebound or guarding. \nExtremities: Moves all 4 extremnities spontaneously. Opposition \nand sensation intact x3 nerve distrubtion on bilateral upper \nextremities. Strength ___ in lower extremities, upper at elbow \nflexion and extension, wrists. Rapid alternating motion and \nfinger tapping amplitude intact. \nArm size symmetric, no edema in hands or feet. Strength is \nsymmetric, with no noted swelling or cyanosis. He had a minimal \narea of rash- erythema, small lesions. Nonblanching, no raised \nareas, non pruritic- on right lateral chest, with the appearance \nof heat rash. \nGait normal\n \nPertinent Results:\n___ 06:50AM BLOOD WBC-8.3# RBC-5.15 Hgb-16.1 Hct-45.2 \nMCV-88 MCH-31.3 MCHC-35.6 RDW-11.7 RDWSD-37.7 Plt ___\n___ 02:40PM BLOOD WBC-5.2 RBC-5.89 Hgb-18.4* Hct-50.9 \nMCV-86 MCH-31.2 MCHC-36.1 RDW-11.4 RDWSD-36.0 Plt ___\n___ 06:50AM BLOOD Plt ___\n___ 02:40PM BLOOD ___ PTT-33.2 ___\n___ 06:50AM BLOOD Glucose-114* UreaN-18 Creat-1.0 Na-136 \nK-4.3 Cl-98 HCO3-26 AnGap-16\n___ 02:40PM BLOOD UreaN-17 Creat-0.9 Na-141 K-3.8 Cl-99 \nHCO3-26 AnGap-20\n___ 02:40PM BLOOD Glucose-86\n___ 06:50AM BLOOD Phos-4.6* Mg-2.0\n___ 02:40PM BLOOD %HbA1c-4.9 eAG-94\n___ 02:40PM URINE Color-Straw Appear-Clear Sp ___\n___ 02:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-TR\n___ 02:40PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0\n\n___ Pathology: pending upon discharge \nReport on ___: bone right first rib resection: WNL, \ntrilineage hematopoietic bone marrow\nmuscle, anterior scalene, resection: WNL\nmuscle middle scalene, resection: WNL\n\n___: CXR: \nFINDINGS: \nRight first rib resection, postoperative changes in the soft \ntissues. \nAdjacent drain. No pneumothorax. Normal heart size, pulmonary \nvascularity. No edema. Lungs are clear. No pleural effusion. \n \nIMPRESSION: \nRight first rib resection. No pneumothorax. \n\n___: CXR:\n FINDINGS: \nCompared to the prior study, no gross change is detected. Again \nseen is \nabsence of the right first rib, consistent with the history of \nresection. \nMild soft tissue swelling is noted nearby. Also again seen is a \nchest tube overlying the right lung apex. No pneumothorax is \ndetected. The \ncardiomediastinal silhouette is unchanged, within normal limits. \n No CHF, \nfocal infiltrate, or effusion is identified. \nIMPRESSION: \nStatus post resection of right first rib. Right apical chest \ntube in place. No pneumothorax or focal infiltrate identified. \nNo acute pulmonary process detected. Probable soft tissue \nswelling along the right neck, best correlated with physical \nexam. \n\n \nBrief Hospital Course:\nMr. ___ was admitted prior to operation on ___ after \nevaluation and presentation with multiple symptoms consistent \nwith neurogenic right sided thoracic outlet syndrome. He was \ntaken to the operating room on ___ with Dr. ___ \n___ first rib resection via supraclavicular right sided approach \nand neurolysis for a neurogenic right thoracic outlet syndrome. \nPlease see the operative note for more details. A ___ drain \nwas inserted into the surgical wound and into small plueral \nholes, which was then kept on suction. After a brief and \nuneventful stay in the PACU, he was transferred to the floor for \ncontinued care. He had minimal postoperative nausea, which \nresolved by changing his pain control from oxycodone to \ndilaudid. He had a small pneumothorax secondary to the ___ \ndrain as seen on chest xray, consistent with his procedure. On \nPOD 1, he was seen by therapy services, and occupational therapy \nrecommended he continued to move as tolerated but keep his \nabduction below 90 degrees abduction. His JP output continued to \nbe serosanguinous. His JP output remained a high volume of \n178cc, and a repeat CXR on ___ was stable with no \npneumothorax. He was not kept in a sling, to prevent frozen \nshoulder. He was encouraged to continue ambulation and gently \nusing his arm. He tolerated a regular diet, and his blood labs \nwere stable and appropriate, with minimal reactive leukocytosis. \nHe was able to maintain his hydration after IV hydration was \ndiscontinued. He was discharged to ___ with ___ services and \ninstructions for how to empty his JP drain while keeping suction \nand negative pressure to prevent air entry and pneumothorax. He \nand his parents were counseled on this, and were shown how to \nproperly empty the drain as well as instructed on what to do if \nsuction were lost. He and his parents expressed understanding. \n___ services were unable to be obtained for POD2 in ___ \nwhere he resides and his JP output was high, which improved and \nhe was discharged ___ on POD3. The family states they have a \nneighbor who is an ICU ___ who expressed she would help with \nJP drain care the night of POD3 and ___ services were confirmed \nfor POD4. The patient and his family preferred this care plan. \nHe was tolerating regular diet, his pain was well controlled \nwith acetaminophen, he had bowel function, and he was ambulating \nwithout assistance. \nHe was given a prescription for outpatient physical therapy with \na copy of the OT note attached for range of motion and sensory \nre-integration. Mother and patient were able to ask questions \nand all were answered to their satisfaction. He declined a \nprescription for oxycodone, and his pain had been well \ncontrolled. He was given instructions for care and warning \nsigns, as well as follow up with Dr. ___ at his clinic \non ___ if his drain output was less than 50cc for 24 hours, \nor ___ if his drain output was greater than 50cc per day by \n___. \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Multivitamins 1 TAB PO DAILY \n2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \nRX *acetaminophen 325 mg 1 to 2 tablet(s) by mouth every six (6) \nhours Disp #*45 Tablet Refills:*0 \n2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing \n3. Multivitamins 1 TAB PO DAILY \n4.Outpatient Occupational Therapy\nRight shoulder range of motion, sensory re-integration\n\n \nDischarge Disposition:\n___ With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nneurogenic thoracic outlet syndrome\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 here at ___ \n___. You were admitted to our hospital for \nsurgical intervention for your neurogenic thoracic outlet \nsyndrome. You had a first rib resection via supraclavicular \nright sided approach and neurolysis with Dr. ___ on \n___, without complications. You tolerated the procedure well \nand are walking, tolerating a regular diet, your pain is \ncontrolled with Tylenol, and you have had bowel functioning. \nYou are now ready to be discharged to ___. Please follow the \nrecommendations below to ensure a speedy and uneventful \nrecovery. \n\nACTIVITY:\n- Do not drive until feel you could respond in an emergency and \nyour motion is no longer limited. Wait until cleared by your \nsurgeon at your follow up appointment.\n- You may climb stairs. You should continue to walk several \ntimes a day. \n- You may go outside, but avoid traveling long distances until \nyou see your surgeon at your next visit. \n- You may start some light exercise when you feel comfortable. \nSlowly increase your activity back to your baseline as \ntolerated. No heavy lifting (10 pounds or more) until cleared by \nyour surgeon. \n- Follow the recommendations from the therapists you saw in the \nhospital. You should continue to move your shoulder in the \nexercises they taught you to prevent frozen shoulder. You are \nbeing given a prescription for outpatient occupational therapy \nto work on your range of motion and sensory re-integration. \n\nHOW YOU MAY FEEL: \n- You may feel weak or \"washed out\" for 6 weeks. You might want \nto nap often. Simple tasks may exhaust you.\n- You may have a sore throat because of a tube that was in your \nthroat during the surgery.\n\nYOUR BOWELS:\n- Constipation is a common side effect of narcotic pain medicine \nsuch as oxycodone. If needed, you may take a stool softener \n(such as Colace, one capsule) twice a day. You can get this \nmedicine without a prescription.\n- If you go 48 hours without a bowel movement, or have pain \nmoving the bowels, call your surgeon.\n\nPAIN MANAGEMENT:\n- You are being discharged with a prescription for acetaminophen \n(Tylenol) for pain control. You have declined a prescription for \noxycodone and your pain has been well controlled without it. You \nmay take Tylenol as directed, not to exceed 3000mg in 24 hours. \nFor example, you can take a)325 to 650 mg acetaminophen every 6 \nhours OR b)1000mg (two extra strength 500mg tablets of tylenol) \nup to every 8 hours. You should take these regularly for a few \ndays after surgery but you may skip a dose or increase time \nbetween doses if you are not having pain until you no longer \nneed it. \n- Your pain should get better day by day. If you find the pain \nis getting worse instead of better, please contact your surgeon.\n\nIf you experience any of the following, please contact your \nsurgeon: \n- sharp pain or any severe pain that lasts several hours\n- chest pain, pressure, squeezing, or tightness\n- cough, shortness of breath, wheezing, difficulty breathing, \ntightness in your chest, or air filling up the bulb of your \ndrain that does not go away after clamping the drain, emptying \nthe bulb, re-establishing suction, and unclamping as shown to \nyou and your mother. If you have any questions or problems, call \nthe office and go to the Emergency Room. \n- numbness, tingling, swelling, feeling your arm/hand/finger is \ncold or changing color\n- pain that is getting worse over time or pain with fever\n- shaking chills, fever of more than 101\n- a drastic change in nature or quality of your pain\n- nausea and vomiting, inability to tolerate fluids, food, or \nyour medications\n- if you are getting dehydrated (dry mouth, rapid heart beat, \nfeeling dizzy or faint especially while standing)\n-any change in your symptoms or any symptoms that concern you\n\nMEDICATIONS:\n- Take all the medicines you were on before the operation just \nas you did before, unless you have been told differently.\n- If you have any questions about what medicine to take or not \nto take, please call your surgeon. \n\nWOUND CARE: \n- You may use a washcloth or rinse off your body below your \nupper chest, as discussed with you. Do not get your shoulder \nwet, and do not soak, bathe, or swim until your drain is removed \nand you are cleared by your surgeon. \n- You have Dermabond (skin glue) on your incisions, which will \nflake and fall off by itself in ___ weeks. \n- You will have visiting nurses to help you take care of your \ndrain and change the dressing every day. They will help assess \nyour incisions as well. \n-Notify your surgeon is you notice abnormal (foul smelling, \nbloody, pus, etc) or increased drainage from your incision site, \nopening of your incision, or increased pain or bruising. Watch \nfor signs of infection such as redness, streaking of your skin, \nswelling, increased pain, or increased drainage. \n\nDRAIN CARE:\nYou are being discharged with a pleural JP drain in place, \nmeaning a drain that is inside your chest cavity by your lung. \nDrain care is a clean procedure. Wash your hands with soap and \nwarm water before performing your drain care, which you should \ndo ___ times a day. Try to empty the drain at the same time each \nday. Put a clamp on the drain tubing. Pull the stopper out of \nthe bottle and empty the drainage fluid into the measuring cup. \nRe-establish drain suction by squeezing the bulb and putting the \nstopper back in. Then unclamp the tubing. Record the amount of \nfluid on the record sheet. A visiting nurse ___ help you with \nyour drain care.\nIf you get air through the tubing (the clamp falls off, the bulb \nkeeps filling up with air after you reestablish suction, etc), \nempty the drain as you have been (clamp, empty, reestablish \nsuction, unclamp) until no more air is filling the bulb and it \nis holding suction. Call the office and go to the emergency room \nif this happens. \n\n- Clean around the drain site(s) where the tubing exits the skin \nwith soap and water. Be sure to secure your drains so they don't \nhang down loosely and pull out. \n- Clamp the drain tubing\n-Empty the bulb(s), reestablish suction, and then remove the \nclamp and record the output ___ times a day as described above. \n-Keep a written record of the daily amount from each drain and \nbring this to every follow up appointment. Your drains will be \nremoved once the output tapers off to an acceptable amount. \n\nPlease call with any questions or concerns. Thank you for \nallowing us to participate in your care. We hope you have a \nquick return to your usual life and activities. \n-- Your ___ Care Team\n\n \nFollowup Instructions:\n___\n" ]

[ "G540", "J45909" ]

[ "G540: Brachial plexus disorders", "J45909: Unspecified asthma, uncomplicated" ]

[ "J45909" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nBactrim / Flagyl / Levaquin / Wellbutrin / Amitriptyline / \nTrazodone / erythromycin / Subutex / Omeprazole / Fioricet / \nTricyclic Compounds / Sudafed / Caffeine / Gluten / Cymbalta / \nlisinopril / Seroquel / Lyrica / clindamycin / Topamax\n \nAttending: ___.\n \nChief Complaint:\nDyspnea\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ male\nwith a history of nonischemic cardiomyopathy status post ICD in\n___, paroxysmal atrial fibrillation, and blood history of\nventricular tachycardia status post ablation ×2 who presents \nfrom\nhome today after a 8 pound weight gain and increasing dyspnea on\nexertion for the past week.\n\nHe is followed closely by Dr. ___ and ___\nNP. He is on very high doses of torsemide. He was seen earlier\nthis month. At that time, his weight was stable and no changes\nwere made to his regimen. His dry weight at home is around 209\npounds. Over the past week his weight is crept up to about 217\npounds. He has tried to increase the dose of torsemide without\nany improvement. He has no paroxysmal nocturnal dyspnea. He\nsleeps with the head of the bed elevated a little elevated and\nhas no orthopnea. He does have some leg edema. He has some\nabdominal bloating, but his appetite is good. He has no\npresyncope or syncope. He has no exertional lightheadedness. \nHe\nhas not had any dietary indiscretion.\n\n \nPast Medical History:\nPAST MEDICAL HISTORY:\n1. CARDIAC RISK FACTORS\n- No Diabetes\n- No Hypertension\n+ Dyslipidemia\n\n2. CARDIAC HISTORY\n# Cardiomyopathy nonischemic ___ s/p ICD implant ___, \nrevised 2 weeks ago, ejection fraction of ___ \n# Atrial Fibrillation \n# H/o tachycardia, s/p VT ablation x2\n# S/p cath ___ with clean coronaries \n\n3. OTHER PAST MEDICAL HISTORY\n# Hypodensity in the pancreas consistent with a cystic lesion \ncurrently being worked up - EUS ___ Simple 4X4 mm cyst in the \nbody of the pancreas. \n# Depressive disorder \n# GERD \n# Celiac disease \n# Cervical Spondylosis and Cervical Radiculitis \n# Myofascial pain syndrome \n# Cholecystitis s/p lap-chole ___ \n# Chronic pancreatitis ___ \n# Fatty liver elevated LFT's \n# Ventral Hernia needing repair \n# Umbilical hernia repair as a child \n# Chronic sinus infection on augmentin \n# Suprascapular nerve entrapment \n# IBS \n# HSV \n# Hepatitis A and B - ___ years ago in his late ___ \n# Tonsillectomy/ adenoids as a child \n\n \nSocial History:\n___\nFamily History:\nFather died of an MI at ___. Mother died of ___ disease at \n___. His younger sister has familial polyposis, other sister is \nhealthy. Mother's sister has COPD and emphysema. Maternal aunt \ndied of lung cancer. Paternal uncle died in World War ___. \nPaternal and maternal grandfather died young. Paternal and \nmaternal grandmothers died old. \n\n \nPhysical Exam:\nADMISSION:\nVital signs: Temp 97.9, blood pressure 106/73, heart rate 98,\noxygen saturation 97% on room air. His weight is 219.4 pounds.\nGeneral: pleasant male sitting on exam table, no distress\nHEENT: anicteric sclerae, clear oropharynx\nNeck: jugular venous pressure 16 cm water, carotids 3+ with\nnormal upstroke and without bruits\nCardiac: regular rate and rhythm, normal S1 and split S2, soft\nII/VI systolic murmur at the apex, no rubs or gallops\nPulm: clear lungs bilaterally\nAbdomen: soft, non-tender, no masses or bruits\nExtremities: warm and well perfused, 2+ leg edema, 3+ pulses\nthroughout\nNeuro: CNs ___ intact\nPsych: mood is good and affect appropriate\n\nDISCHARGE:\nVS:\n___ 0450 Temp: 98.1 PO BP: 95/59 HR: 66 RR: 18 O2 sat: 94%\nO2 delivery: RA \n___ Total Intake: 720ml PO Amt: 720ml \n___ Total Intake: 240ml PO Amt: 240ml \n___ Total Output: 775ml Urine Amt: 775ml \n___ Total Output: 575ml Urine Amt: 575ml \n\nWeight: dry weight 206lbs\n___ 96.2 212.08 Standing ___ \n\nGENERAL: NAD \nHEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM. \nNECK: JVP not elevated\nHEART: RRR, split S1, absent S2, no MRG.\nLUNGS: Bibasilar crackles, no wheeze. \nABDOMEN: Nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly. \nEXTREMITIES: WWP, no ___.\nPULSES: 2+ radial pulses bilaterally. \nNEURO: A&Ox3, moving all 4 extremities with purpose. \n\n \nPertinent Results:\nADMISSION:\n___ 04:30PM proBNP-4274*\n___ 04:30PM ALT(SGPT)-71* AST(SGOT)-79* LD(LDH)-585* ALK \nPHOS-48 TOT BILI-0.9\n___ 07:40PM ALBUMIN-4.5 CALCIUM-8.9 PHOSPHATE-3.7 \nMAGNESIUM-2.1\n\nDISCHARGE:\n___ 07:00AM BLOOD WBC-6.9 RBC-5.22 Hgb-16.0 Hct-46.6 MCV-89 \nMCH-30.7 MCHC-34.3 RDW-13.0 RDWSD-42.4 Plt ___\n___ 07:00AM BLOOD Glucose-110* UreaN-54* Creat-1.7* Na-138 \nK-3.2* Cl-95* HCO3-25 AnGap-18\n___ 07:00AM BLOOD Calcium-9.4 Phos-4.6* Mg-3.1*\n\nCARDIAC IMAGING:\n-TTE (___):\nThe left atrial volume index is SEVERELY increased. There is no \nevidence for an atrial septal defect by 2D/color Doppler. There \nis normal left ventricular wall thickness with a SEVERELY \nincreased/dilated cavity. There is SEVERE global left \nventricular hypokinesis. Quantitative biplane left ventricular \nejection fraction is 17 %. Left ventricular cardiac index is \ndepressed. There is no resting left ventricular outflow tract \ngradient. No thrombus or mass is seen in the left ventricle. \nMildly dilated right ventricular cavity with moderate global \nfree wall hypokinesis. The aortic sinus diameter is normal. The \naortic arch is mildly dilated. The aortic valve leaflets (3) are \nmildly thickened. There is no aortic valve stenosis. There is \ntrace aortic regurgitation. The mitral leaflets\nappear structurally normal with no mitral valve prolapse. There \nis moderate [2+] mitral regurgitation. The tricuspid valve \nleaflets appear structurally normal. There is mild [1+] \ntricuspid regurgitation. The pulmonary artery systolic pressure \ncould not be estimated. There is no pericardial effusion.\nIMPRESSION: Adequate image quality. Severely dilated left \nventricular cavity with SEVERE global hypokinesis in a pattern \nmost consistent with a non-ischemic cardiomyopathy. Moderate \nmitral regurgitation. Compared with the prior TTE (images \nreviewed) of ___ , LV cavity is more dilated and \nbiventricular systolic function slightly less vigorous. Other \nfindings are similar.\n \nBrief Hospital Course:\n___ with a background history of non-ischemic cardiomyopathy \nwith HFrEF (EF 21% ___, paroxysmal atrial fibrillation (on \napixiban, CHADS2VASC 2), ventricular tachycardia S/P ablation \nx2/ICD placement (___), GERD, dyslipidemia, depression, and \nchronic migraines who initially presented to the ___ ___ with \n8lbs weight gain and increasing dyspnea on exertion c/w CHF \nexacerbation w/course complicated by overdiuresis and ___.\n\n#Acute on chronic congestive heart failure exacerbation:\nUnclear trigger. Patient presented to ___ with x8lb weight \ngain, abdominal distension, and SOB. Pro-BNP was elevated 4274 \n(4621 on recheck), TTE showed worsening in systolic function. He \nreceived IV diuresis with associated weight loss and improvement \nin his symptoms. After diuresis, his Cr uptrended thought to be \ndue to overdiuresis and his medications were held x24 hours. He \nwas restarted on reduced dose losartan at 25mg daily due to \nrelative hypotension in the hospital, along with torsemide 60mg \ndaily.\n\n___:\nBaseline Cr 1.5; in the setting of aggressive diuresis, Cr \nuptrended to peak 2.3. FeUrea 19.7%, consistent with prerenal \nazotemia, no evidence of obstruction. With holding of further \ndiuretics or nephrotoxic agents, his Cr improved.\n-Repeat lab work on ___\n\nCHRONIC ISSUES:\n================\n# Diarrhea \nChronic, due to pancreatic insufficiency \nHe was continued on his home creon \n\n# VT s/p ablation x2, ICD placement \nHe was continued on his home metoprolol \n\n# Paroxysmal atrial fibrillation (CHADS2VASC 2)\nHe was continued on his home apixaban 5mg BID\nHe was continued on his home metoprolol \n\n# Dyslipidemia\nHe was continued on his home pravastatin 10mg qPM\n\n# GERD\nHe was continued on his home pantoprazole 40mg Q12H\nHe was continued on his home ranitidine at renal dosing\nHe was continued on his home sucralfate ___ qhs prn \n\n# Myofascial pain syndrome\nHe was continued on his home gabapentin 200mg TID\nHe was continued on his home hydrocodone-APAP 5mg-325mg Q6H:PRN\n\n# History of HSV:\nAcyclovir was substituted for his home valacyclovir while \ninpatient due to formulary.\n\n# Depression/Anxiety\nHe was continued on his home lorazepam ___ daily:PRN\n\n# Allergies\nHe was continued on his home fluticasone, guaifenesin, \nloratadine\n\nTRANSITIONAL ISSUES:\n[] Discharge weight: 96.2 kg (212.08 lb)\n[] Discharge Cr: 1.7\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Losartan Potassium 50 mg PO DAILY \n2. Gabapentin 200 mg PO TID:PRN pain \n3. umeclidinium 62.5 mcg/actuation inhalation DAILY \n4. LORazepam ___ mg PO DAILY:PRN anxiety \n5. Metoprolol Succinate XL 75 mg PO DAILY \n6. Methocarbamol 250-500 mg PO BID:PRN muscle spasms \n7. Apixaban 5 mg PO BID \n8. Ranitidine 300 mg PO DAILY \n9. Pravastatin 10 mg PO QPM \n10. Torsemide 80-120 mg PO DAILY \n11. Eplerenone 25 mg PO DAILY \n12. ValACYclovir 500 mg PO Q24H \n13. Fluticasone Propionate 110mcg 2 PUFF IH BID \n14. Sucralfate ___ gm PO QHS:PRN PRN \n15. Pantoprazole 40 mg PO Q12H \n16. Magnesium Oxide 500 mg PO DAILY \n17. Potassium Chloride 40-60 mEq PO DAILY \n18. HYDROcodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN \nPain - Moderate \n19. azelastine 137 mcg (0.1 %) nasal DAILY:PRN \n20. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN \nhemorrhoid \n21. Creon ___ CAP PO TID W/MEALS \n22. Metolazone 2.5 mg PO TWICE PER WEEK PRN weight gain \n23. Vitamin D 5000 UNIT PO DAILY \n24. Docusate Sodium 200 mg PO DAILY:PRN constipation \n25. GuaiFENesin ER 600 mg PO BID:PRN cough \n26. Loratadine 10 mg PO DAILY \n27. Vitamin B Complex w/C 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Losartan Potassium 25 mg PO DAILY \n2. Torsemide 60 mg PO DAILY \n3. Apixaban 5 mg PO BID \n4. azelastine 137 mcg (0.1 %) nasal DAILY:PRN \n5. Creon ___ CAP PO TID W/MEALS \n6. Docusate Sodium 200 mg PO DAILY:PRN constipation \n7. Fluticasone Propionate 110mcg 2 PUFF IH BID \n8. Gabapentin 200 mg PO TID:PRN pain \n9. GuaiFENesin ER 600 mg PO BID:PRN cough \n10. HYDROcodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN \nPain - Moderate \n11. Hydrocortisone (Rectal) 2.5% Cream ___ID:PRN \nhemorrhoid \n12. Loratadine 10 mg PO DAILY \n13. LORazepam ___ mg PO DAILY:PRN anxiety \n14. Methocarbamol 250-500 mg PO BID:PRN muscle spasms \n15. Metoprolol Succinate XL 75 mg PO DAILY \n16. Pantoprazole 40 mg PO Q12H \n17. Potassium Chloride 40-60 mEq PO DAILY \nHold for K > \n18. Pravastatin 10 mg PO QPM \n19. Ranitidine 300 mg PO DAILY \n20. Sucralfate ___ gm PO QHS:PRN PRN \n21. umeclidinium 62.5 mcg/actuation inhalation DAILY \n22. ValACYclovir 500 mg PO Q24H \n23. Vitamin B Complex w/C 1 TAB PO DAILY \n24. Vitamin D 5000 UNIT PO DAILY \n25. HELD- Eplerenone 25 mg PO DAILY This medication was held. \nDo not restart Eplerenone until you follow up with Dr. ___\n26. HELD- Magnesium Oxide 500 mg PO DAILY This medication was \nheld. Do not restart Magnesium Oxide until you follow up with \nDr. ___\n27. HELD- Metolazone 2.5 mg PO TWICE PER WEEK PRN weight gain \nThis medication was held. Do not restart Metolazone until you \nfollow up with Dr. ___\n\n \n___ Disposition:\nHome\n \nDischarge Diagnosis:\nAcute on chronic systolic heart failure \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 ADMITTED TO THE HOSPITAL?\nYou had shortness of breath and weight gain due to your heart \nfailure\n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n-You received aggressive IV diuresis to remove the excess fluid\n-Your kidney function worsened due to removal of so much fluid, \nand it was monitored until it improved\n\nWHAT SHOULD I DO WHEN I GO HOME?\n-Take torsemide 60mg daily starting tomorrow, ___\n-Take potassium 40meq tomorrow, ___\n-Do not take your eplerenone \n-Your losartan dose was decreased to 25mg\n-Please continue to weigh yourself tonight and tomorrow morning \nand report any changes to your heart failure team. \n\n \nFollowup Instructions:\n___\n" ]

[ "I5023", "N179", "K861", "I429", "I472", "I480", "E785", "K219", "M791", "F329", "F419", "Z87891", "Z7902", "Z95810", "R197", "J329", "G43809" ]

[ "I5023: Acute on chronic systolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "K861: Other chronic pancreatitis", "I429: Cardiomyopathy, unspecified", "I472: Ventricular tachycardia", "I480: Paroxysmal atrial fibrillation", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "M791: Myalgia", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "Z87891: Personal history of nicotine dependence", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z95810: Presence of automatic (implantable) cardiac defibrillator", "R197: Diarrhea, unspecified", "J329: Chronic sinusitis, unspecified", "G43809: Other migraine, not intractable, without status migrainosus" ]

[ "N179", "I480", "E785", "K219", "F329", "F419", "Z87891", "Z7902" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nCaptopril / infed / Motrin / Aleve\n \nAttending: ___.\n \nChief Complaint:\n___\n \nMajor Surgical or Invasive Procedure:\nEGD: ___\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old M w/ PMH HTN, CAD s/p stent\nplacement (___), IDDM s/p renal transplant (___) and pancreas\ntransplant (___) with course c/b pancreatic artery to small\nbowel fistula requiring pancreas explant (___) and CKD stage \nIII\nwho presents to the ED from OSH with elevated BUN/Cr.\n\nHe is managed on prednisone and tacrolimus. He presents to the \nED\nfrom OSH with persistently elevated BUN/Cr. He reports that he\nwas at a discharge facility and continued to have an elevated\nBUN. He was also reporting a dull epigastric pain that was worse\nwhen he was swallowing. Because of this, he was taken to OSH\nwhere his creatinine was 3.4 (baseline 2.0). He was transferred\nto ___. Upon arrival the patient c/o a dull epigastric\nabdominal pain but denies fever, chest pain, SOB, vomiting,\ndiarrhea, dysuria, or other complaints.\n\nIn the ED, initial VS were: 98.8 61 137/61 14 95% RA.\n\nExam notable for: General - ill-appearing\nCardiovascular - RRR, systolic murmur\nRespiratory - CTA bilaterally, no wheezing\nGI - abdomen soft, epigastric tenderness with palpation, no\nrebound, no guarding, bowel sounds active\nGU - left flank scar, no CVAT\nSkin - warm, flushed\nMusculoskeletal - no peripheral edema\n\nECG: sinus rhythm, normal axis, T wave inversions V5-V6. T wave\nflattening I-II.\n\nLabs showed: WBC 10.9, PMNs 90%, Hgb 10.1, BUN 114, Cr 3.4, HCO3\n19, trop 0.05. \n\nImaging showed: Renal ultrasound: 1. Absent diastolic flow \nwithin\nthe main renal artery and intrarenal arteries,\nas seen previously.\n2. Patent main renal vein.\n3. No hydronephrosis or definite abscess.\n\nCT A/P: 1. Anasarca with small bilateral pleural effusions,\nmesenteric edema, trace\nmesenteric fluid and trace perihepatic ascites.\n2. Atrophic native kidneys and unremarkable appearing left lower\nquadrant\ntransplanted kidney.\n \nRenal transplant was consulted and reported: In ___\ninitially underwent a thoracentesis for a left pleural effusion\nwhich was complicated by a hemothorax requiring an ICU \nadmission.\nSubsequently had a re-admission for pneumonia and heart failure\nexacerbation in ___ and ___. His hospital course was\ncomplicated by C. diff infection as well. Eventually discharged\nto rehab but was readmitted at the end of ___ for\nnausea, vomiting and elevated LFTs which were attributed to\nTamiflu. Seen in ___ clinic in ___ and at the time he\nwas not on Lasix. Reportedly, he has now had several CHF\nexacerbations and per coordinator note he was in fluid overload\nand received aggressive diuresis at ___. Last Echo\nin our system in ___. \n\nRenal consult recommended TTE and ACS rule out. Also recommended\nUA with urine lytes and culture and transplant surgery consult\nand to continue immunosuppression.\n\nTransplant surgery was consulted: Ongoing odynophagia present \nfor\n>1 month, unchanged from baseline. Tolerating a diet at time of\nexam. CT unremarkable. No transplant surgery needs. Agree with\nadmission to ET for ___, consideration of GI consult for\nodynophagia.\n\nPatient received: Tacrolimus 1.5 mg\n\nTransfer VS were: 98.1 147/61 65 19 98% RA.\n\nOn arrival to the floor, patient reports that he is having some\nepigastric pain but that it has improved a lot since he started\ngetting treatment for esophagitis. He denies fevers/chills, \nchest\npressure, SOB, diarrhea/constipation, lower extremity swelling.\nHe reports that he has been feeling more tired and lethargic \nthan\nusual.\n\nOf note, he was discharged on ___ from the OSH per the \nrecords\nsent with him. During that admission he had CHF\nexacerbationdiuresis but required ICU transfer for non-invasive\nventilation. He was discharged at weight 54.3 kg. Was discharged\nwith Cr 2.2-2.5 range after diuresis inpatient. He also had\nepigastric pain with odynophagia. He was treated with PPI for\npossible GERD but then also given voriconazole for possible\n___ esophagitis given chronic immunosuppression. EGD was\ndeferred given acute medical issues. Tacrolimus was reduced in\ndose due to voriconazole interaction. His home Flomax was held\ndue to interaction with voriconazole. He was also started on a\nstatin for primary prevention of cardiac disease.\n \nPast Medical History:\nDiabetes s/p failed pancreas transplant \nRenal failure s/p LURT \nGI bleed from pancreas transplant related fistula\nCeliac sprue \nDepression \nDiabetic retinopathy \nOA \nOsteoporosis \nDiabetic neuropathy \nCAD \nhx TIA ___ \nhx Afib \n \nPSH: \nTonsillectomy \nRemoval bladder tumor ___ \nLap chole ___ \nB/L cataracts ___ \nLURT ___ \nPAK ___ \nEx lap/pancreatic graft explantation/SBR/bl chest tubes ___ \nabdominal closure ___ \n\n \nSocial History:\n___\nFamily History:\nNoncontributory.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n\nVS: 98.31 66 / 76 65 18 96 Ra \nGENERAL: NAD, sleepy, not responding to questions without being\nwoken up multiple times, but AAOX3, does days of week backwards\ncorrectly.\nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,\nMMM \nNECK: supple, no LAD, no JVD \nHEART: RRR, S1/S2, II/VI systolic murmur, gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: nondistended, mild tenderness in epigastric area, no\nrebound/guarding, no hepatosplenomegaly \nEXTREMITIES: no cyanosis, clubbing, or edema. Left arm fistula\nwith thrill. \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===================\nDISCHARGE PHYSICAL EXAM:\n\nVS: ___ 0711 Temp: 98.5 PO BP: 168/66 R Lying HR: 62 RR: 18\nO2 sat: 96% O2 delivery: Ra \nGENERAL: NAD, tired-appearing\nHEENT: AT/NC, EOMI, PERRL, anicteric sclera \nNECK: supple, no LAD, no JVD \nHEART: RRR, S1/S2, ___ SEM heard best at the RUSB, no gallops or\nrubs \nLUNGS: CTAB, no wheezes, rales, rhonchi\nABDOMEN: +BS, S, NT, ND, no rebound/guarding\nEXTREMITIES: no cyanosis, clubbing, or edema. Left arm fistula\nwith thrill. \nNEURO: Alert, moving all 4 extremities, no facial asymmetry \nSKIN: warm and well perfused, no rashes \nPSYCH: Poor eye contact, +Dysthymic, flat affect\n \nPertinent Results:\nADMISSION LABS:\n\n___ 07:40PM BLOOD WBC-10.9* RBC-3.58* Hgb-10.1* Hct-33.3* \nMCV-93 MCH-28.2 MCHC-30.3* RDW-18.4* RDWSD-62.1* Plt ___\n___ 07:40PM BLOOD Neuts-90.9* Lymphs-3.6* Monos-4.9* \nEos-0.0* Baso-0.3 Im ___ AbsNeut-9.91* AbsLymp-0.39* \nAbsMono-0.53 AbsEos-0.00* AbsBaso-0.03\n___ 07:40PM BLOOD ___ PTT-39.8* ___\n___ 07:40PM BLOOD Glucose-196* UreaN-114* Creat-3.4* Na-137 \nK-5.3 Cl-101 HCO3-19* AnGap-17\n___ 07:40PM BLOOD ALT-13 AST-25 CK(CPK)-28* AlkPhos-117 \nAmylase-37 TotBili-0.2\n___ 07:40PM BLOOD Lipase-14\n___ 07:40PM BLOOD CK-MB-2 cTropnT-0.05*\n___ 04:38AM BLOOD CK-MB-2 cTropnT-0.06*\n___ 07:46PM BLOOD Lactate-0.4*\n\n=====================\n\nIMAGING/STUDIES:\n\nRenal ultrasound ___: \n1. Absent diastolic flow within the main renal artery and \nintrarenal arteries, as seen previously.\n2. Patent main renal vein.\n3. No hydronephrosis or definite abscess.\n\nCT A/P ___: \n1. Anasarca with small bilateral pleural effusions, mesenteric \nedema, trace\nmesenteric fluid and trace perihepatic ascites.\n2. Atrophic native kidneys and unremarkable appearing left lower\nquadrant transplanted kidney.\n\nEGD ___:\n\nFindings: \n\nEsophagus: \n\n Mucosa: Moderate esophagitis with contact bleeding was seen in \nthe middle third of the esophagus and lower third of the \nesophagus. Cold forceps biopsies were performed for histology at \nthe random (mid) esophagus. \n\nStomach: Normal stomach. \n\nDuodenum: Normal duodenum. \n\nImpression: Moderate esophagitis in the middle third of the \nesophagus and lower third of the esophagus (biopsy)\nOtherwise normal EGD to third part of the duodenum \n\nTTE ___:\n\nFindings \nThis study was compared to the prior study of ___. \nLEFT ATRIUM: Normal LA volume index. \n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Lipomatous \nhypertrophy of the interatrial septum. No ASD by 2D or color \nDoppler. Normal IVC diameter (<=2.1cm) with <50% decrease with \nsniff (estimated RA pressure ___ mmHg). \n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild \nregional LV systolic dysfunction. TDI E/e' >13, suggesting \nPCWP>18mmHg. No resting LVOT gradient. No VSD. \n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. \n\nAORTA: Focal calcifications in aortic root. Normal descending \naorta diameter. No 2D or Doppler evidence of distal arch \ncoarctation. \n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild \nAS (area 1.2-1.9cm2). No AR. \n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild \nmitral annular calcification. Calcified tips of papillary \nmuscles. \n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial \nTR. Mild PA systolic hypertension. \n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. \nNo PS. Physiologic PR. \n\nPERICARDIUM: No pericardial effusion. \n\nGENERAL COMMENTS: Left pleural 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 The left atrial volume index is normal. No atrial septal defect \nis seen by 2D or color Doppler. The estimated right atrial \npressure is ___ mmHg. Left ventricular wall thicknesses and \ncavity size are normal. There is mild regional left ventricular \nsystolic dysfunction with very mild hypokinesis of the distal \ninferior wall and septum. The remaining segments contract \nnormally (LVEF = 50-55 %). Tissue Doppler imaging suggests an \nincreased left ventricular filling pressure (PCWP>18mmHg). There \nis no ventricular septal defect. Right ventricular chamber size \nand free wall motion are normal. The aortic valve leaflets (3) \nare mildly thickened. There is mild aortic valve stenosis (valve \narea 1.2-1.9cm2). No aortic regurgitation is seen. The mitral \nvalve leaflets are mildly thickened. There is mild pulmonary \nartery systolic hypertension. There is no pericardial effusion. \n\n IMPRESSION: Normal biventricular cavity sizes with very mild \nregional eft ventricular systolic dysfunction most suggestive of \nunderlying CAD. Mild aortic valve stenosis. Mild pulmonary \nartery systolic hypertension. Increased PCWP. \n\n Compared with the prior study (images reviewed) of ___, \nthe very mild distal septal and inferior hypokinesis is new and \nc/w interim ischemia. \n\n CLINICAL IMPLICATIONS: \n The patient has mild aortic valve stenosis. Based on ___ \nACC/AHA Valvular Heart Disease Guidelines, a follow-up \nechocardiogram is suggested in ___ years. A left pleural \neffusion is present. \n\n \n====================\n\nDISCHARGE LABS:\n\n___ 05:00AM BLOOD WBC-7.6 RBC-3.38* Hgb-9.8* Hct-31.2* \nMCV-92 MCH-29.0 MCHC-31.4* RDW-16.2* RDWSD-55.6* Plt ___\n___ 05:00AM BLOOD ___ PTT-40.3* ___\n___ 05:00AM BLOOD Glucose-233* UreaN-57* Creat-2.6* Na-144 \nK-4.2 Cl-109* HCO3-22 AnGap-13\n___ 05:00AM BLOOD ALT-15 AST-15 LD(LDH)-153 AlkPhos-110 \nTotBili-0.2\n___ 05:00AM BLOOD Albumin-2.6* Calcium-8.5 Phos-3.3 Mg-2.2\n___ 05:00AM BLOOD tacroFK-6.___RIEF HOSPITAL COURSE:\n========================\n___ w/ ___ S/p living unrelated renal transplant ___ DM), \nCKD3, IDDM, HTN, CAD s/p stent placement (___), who presented \nto the ED from ___ with nausea, \nepigastrical discomfort, odynophagia, found to have ___. His ___ \nwas felt to likely be pre-renal in setting of decreased PO \nintake due to pain with swallowing. His ___ resolved to his \nbaseline Cr with gentle IVF and holding his home diuretics. He \nwas monitored for several days and Cr stayed at baseline. \nTherefore he was discharged off of diuretics, but if gaining \nweight as outpatient, this will need to be restarted. In terms \nof odynophagia, EGD ___ showed esophagitis with biopsy showing \nacute neutrophilic inflammation, likely fungal. He was started \non empiric fluconazole with plan for 21 days (___). On \nfluconazole, his tacrolimus levels were monitored and the dose \nadjusted accordingly. This will need to be re-adjusted once off \nfluconazole. His hospital course was complicated by C. diff, \nwhich was treated with PO vancomycin with improvement in \nsymptoms. Planning for ___fter antibiotics (last day \n___. \n\nACUTE ISSUES:\n===============\n#S/p renal transplant\n___, resolved: Baseline Cr ___, on admission was found to be \n3.4 iso increased furosemide and several month history of poor \nPO intake. Less likely post-renal given no hydronephrosis on \nCT/US. Was found to have a bland urine sediment, thus less \nlikely intrinsic. As such, was felt to be most representative of \npre-renal - particularly given a FEUrea 30.5% and subsequent \nimprovement with after IVF and holding his home diuretic. He was \nmonitored for several days and remained at his baseline Cr and \nappeared euvolemic therefore diuretics were held at discharge. \nHis will need to continue to have weights monitored daily and if \nincreases by >3lbs, his diuretics should be restarted likely at \nlower dose of furosemide 40 mg. He was continued on his home \nimmunosuppressants (Prednisone and Tacrolimus). He had daily \nTacro levels, with subsequent dose adjustments as needed. On \ndischarge, his Tacro level was 6.7 and he is being discharged on \na dose of 1 mg q12 hours. \n\n#Esophagitis: Pt presented with chronic epigastric pain and \nodynophagia. Was felt to be less likely cardiac in origin given \nstable troponin on admission (0.05 -> 0.06) with flat MB (iso \n___ on CKD), EKGs not significantly changed from prior, and TTE \nw/o new drastic ___ abnormality. Ultimately, GI was consulted and \nhe had an EGD which showed moderate acute neutrophilic \nesophagitis concerning for fungal infection (despite negative \nfungal stain). He was started on a BID PPI and magic mouthwash. \nHe was treated empirically with Fluconazole and improved. At \ndischarge he was taking good PO. He will continue PO Fluconazole \n400mg x 21 days (___). \n\n#C. Difficile colitis: Developed diarrhea after starting \nfluconazole. Found to be +C. Difficile. Started on PO Vancomycin \nq6 hours with improvement. Plan to continue for 14d following \nfluconazole. \n\n#Type I DM: Initially continued on his home insulin regimen, \nhowever was found to be hyperglycemic. As such, titrated his \nhome Lantus. He is being discharge on Lantus 10U qAM, 6U qPM, \nHumalog 6U w/ meals, as well as a ISS. This will need to be \ntitrated further while at rehab and as an outpt as PO status \nchanges\n\n___ OSH BCx with Coag negative staph - ultimately found to be \nstaph epi. He was initially placed on Vancomycin until \nspeciation resulted. \n\n#Moderate Malnutrition: Nutrition was consulted, who recommended \nsupplementation with Nepro TIDWM.\n\nCHRONIC ISSUES: \n================ \n#BPH: Restarted Flomax (previously held due to Voriconazole).\n\n#CAD\n#Aortic Stenosis\n#HFpEF: Continued home metoprolol succinate 25 mg XL, \nAtorvastatin 40mg QHS, and Aspirin 81mg qd. As per above, had \nreassuring troponin/CKMB, ECG, and TTE on admission.\n\n#HTN: Continued home Amlodipine at increased dose 10 mg daily as \nheld home Valsartan iso ___.\n\n#Depression: Continued home Sertraline 200mg daily and started \nMirtazapine 7.5mg QHS given reports of depressed mood, poor \nappetite, and difficulty sleeping. Patient denied SI. SW was \nconsulted for further support.\n\n#Hypothyroidism: Continued home Levothyroxine 137 mcg daily\n\n#Polyarthritis: Continued home Hydroxychloroquine 200 mg PO BID \nand prednisone 4 mg.\n\nTRANSITIONAL ISSUES:\n=========================\n- New Meds: Fluconazole (___), Vancomycin PO (last day \n___, Mirtazipine\n- Changed Meds: Amlodipine 10 mg, Omeprazole 40mg BID\n- Held/stopped Meds: Valsartan, furosemide given ___\n\n- F/u Appointments: PCP, ___, GI, renal transplant\n- F/u labs: Tacrolimus level and Chem10 on ___ and \nfax to ___ Renal ___ ___ \n\n- Immunosuppression: discharged on Tacro 1 mg BID, last level \n6.7 on ___. Will need to be titrated as outpt, especially once \noff of fluconazole (last day ___. \n- Volume status: Discharge wt 56.93 kg, 125.5 lbs. Follow \nweights daily and if >3 lbs, consider restarting Lasix at 40 mg\n- Insulin/DM: Titrated as inpt given changes in PO intake. \nContinue to monitor with ACHS finger sticks and adjust as \nneeded.\n- Repeat Chem 10, Tacro on ___ to follow up Cr and tacro level, \nsend to ___ Renal ___ ___ \n- Pt started on Mirtazipine given depression during \nhospitalization. Consider uptitration and referral to outpt \npsych.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Succinate XL 25 mg PO DAILY \n2. Atorvastatin 40 mg PO QPM \n3. amLODIPine 5 mg PO DAILY \n4. Furosemide 60 mg PO DAILY \n5. Calcitriol 0.5 mcg PO EVERY OTHER DAY \n6. Tamsulosin 0.4 mg PO QHS \n7. PredniSONE 4 mg PO DAILY \n8. Valsartan 320 mg PO DAILY \n9. Sertraline 200 mg PO DAILY \n10. Levothyroxine Sodium 137 mcg PO DAILY \n11. Hydroxychloroquine Sulfate 200 mg PO BID \n12. Tacrolimus 2.5 mg PO Q12H \n13. Omeprazole 20 mg PO DAILY \n14. Glargine 4 Units Breakfast\nGlargine 5 Units Bedtime\nHumalog 6 Units Breakfast\nHumalog 6 Units Lunch\nHumalog 6 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin\n15. Aspirin 81 mg PO DAILY \n16. Vitamin D 3000 UNIT PO DAILY \n\n \nDischarge Medications:\n1. Fluconazole 200 mg PO Q24H \n2. Maalox/Diphenhydramine/Lidocaine ___ mL PO TID W/MEALS \n3. Mirtazapine 7.5 mg PO QHS \n4. Vancomycin Oral Liquid ___ mg PO QID \n5. amLODIPine 10 mg PO DAILY \n6. Glargine 10 Units Breakfast\nGlargine 6 Units Bedtime\nHumalog 6 Units Breakfast\nHumalog 6 Units Lunch\nHumalog 6 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin \n7. Omeprazole 40 mg PO BID \n8. Tacrolimus 1 mg PO Q12H \n9. Aspirin 81 mg PO DAILY \n10. Atorvastatin 40 mg PO QPM \n11. Calcitriol 0.5 mcg PO EVERY OTHER DAY \n12. Hydroxychloroquine Sulfate 200 mg PO BID \n13. Levothyroxine Sodium 137 mcg PO DAILY \n14. Metoprolol Succinate XL 25 mg PO DAILY \n15. PredniSONE 4 mg PO DAILY \n16. Sertraline 200 mg PO DAILY \n17. Tamsulosin 0.4 mg PO QHS \n18. Vitamin D 3000 UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___ \n \nDischarge Diagnosis:\nPRIMARY:\nAcute kidney injury\nEsophagitis\nC. difficile colitis\n\nSECONDARY: \nModerate Malnutrition\nType I Diabetes\nCoronary artery disease\nAortic stenosis\nHeart failure with preserved ejection fraction\nHypertension\nDepression\nHypothyroidism\nPolyarthritis\nBenign prostate hypertrophy\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 to the hospital for an abnormal kidney \nfunction and trouble swallowing. We believe your kidney function \nwas abnormal because you had not been eating much and you were \ntaking Lasix - which essentially dehydrated you. We held your \nLasix initially and gave you fluids through the IV, and your \nkidney function returned to normal. For your trouble swallowing, \nwe involved our GI specialists who looked at your esophagus with \na camera, and found that it was very irritated. We believe you \nhave an infection of your esophagus, and that this caused your \npain. We started you on a stomach acid-reducing medicine and \nstarted you on an anti-fungal medicine. You were also having \ndiarrhea and were found to have an infection of your colon \ncalled C diff. You were started on an antibiotic for C diff and \nyour diarrhea improved. \n\nWHAT TO DO ONCE DISCHARGED:\n- Please attend all of your appointments as scheduled\n- Please take all of your medications as prescribed\n- The Gastroenterology department is working on an appointment \nfor you and will call you at home with an appointment. If you do \nnot hear from the office within two business days please call \nthem directly to book call ___.\n- We attempted to make a follow-up appointment with your kidney \ndoctor below. If you do not hear from them by ___, please call \ntheir office to make an appointment.\n\nWe wish you the best going forward!\n-Your ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "N179", "Z940", "E440", "B3781", "E872", "A0472", "R7881", "I130", "I5032", "E1022", "E1040", "E10319", "L8992", "I350", "I129", "N183", "E875", "R601", "R627", "I2510", "K900", "M810", "N400", "F329", "E039", "M130", "Z955", "Z9885", "Z8673", "Z794", "Z6823", "S0081XA", "W500XXA", "Y92238" ]

[ "N179: Acute kidney failure, unspecified", "Z940: Kidney transplant status", "E440: Moderate protein-calorie malnutrition", "B3781: Candidal esophagitis", "E872: Acidosis", "A0472: Enterocolitis due to Clostridium difficile, not specified as recurrent", "R7881: Bacteremia", "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", "E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease", "E1040: Type 1 diabetes mellitus with diabetic neuropathy, unspecified", "E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "L8992: Pressure ulcer of unspecified site, stage 2", "I350: Nonrheumatic aortic (valve) stenosis", "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)", "E875: Hyperkalemia", "R601: Generalized edema", "R627: Adult failure to thrive", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "K900: Celiac disease", "M810: Age-related osteoporosis without current pathological fracture", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "F329: Major depressive disorder, single episode, unspecified", "E039: Hypothyroidism, unspecified", "M130: Polyarthritis, unspecified", "Z955: Presence of coronary angioplasty implant and graft", "Z9885: Transplanted organ removal status", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z794: Long term (current) use of insulin", "Z6823: Body mass index [BMI] 23.0-23.9, adult", "S0081XA: Abrasion of other part of head, initial encounter", "W500XXA: Accidental hit or strike by another person, initial encounter", "Y92238: Other place in hospital as the place of occurrence of the external cause" ]

[ "N179", "E872", "I130", "I5032", "I129", "I2510", "N400", "F329", "E039", "Z955", "Z8673", "Z794" ]

[]

[ " \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:\nTwo episodes of transient visual loss in the right eye.\n \nMajor Surgical or Invasive Procedure:\nR CEA ___\n\n \nHistory of Present Illness:\nOn ___ while cooking dinner, the patient experienced \ncomplete vision loss in his R eye. He did not recall any issues \nwith the L eye. When closing the R eye he reported that he saw \nwhat looked like \"water pulsating\", though was completely \nblacked out. This lasted about ___ minutes and then resolved. \nHe did note a very mild pain/pressure around the R temple/eye at \nthis time. He has a ten year history of ocular migraines, \nalthough he stated this was different than his usual migraines, \nhe thought this may have been what he was experiencing so he \njust continued with his evening with a plan to let his PCP know \nthe next day. He experienced no further issues until ___ at around 1030, when symptoms recurred, with an acute onset \ntransient vision in the R eye. With both of these events, \npatient denied associated focal weakness, sensory \nloss/paresthesias, changes in speech, or confusion. Mr. ___ \nwent to his PCPs office and was ultimately referred to the ED. \nAt the OSH ED he had a CT/CTA Head/Neck which showed \natherosclerotic plaque with critical focal stenosis of the R ICA \norigin. He was subsequently transferred to ___ for further \nevaluation. \n\n \nPast Medical History:\nOcular migraines, hypothyroidism, hyperlipidemia and Crohn's \ndisease.\n \nSocial History:\n___\nFamily History:\nFather with history of carotid stenosis requiring surgery; also \nwith history of lymphoma.\nBrother and sister with HLD.\nNo family history of strokes. \n\n \nPhysical Exam:\nVS: T: 98.5 f HR 94 Sr BP: 114/68 02: 94% RA\n\nGeneral: Well appearing male, in NAD\n\nHEENT: A traumatic, normocephalic. Neck supple. R CEA incision \nis well approximated with mild induration to the incisional \nridge and no ecchymosis or hematoma.\n\nNeuro: AAOx3, PERRLA 3>2, EOMI, ___, no nystagmus, no pronation \ndrift, no dysmetria, ___ motor strength BUE/BLE\n\nCV: RRR, WWP\n\nPulm: LSCTAbilaterally, chest expansion symmetrical, no \nincreased wob noted\n\nGI: Abd. s/nt, nd, +flatus\n\nGU: Voiding small amounts on commode\n\nExt: No cyanosis or clubbing noted, no ulcers, cap refill <3 \nsec, palpable distal pulses\n\n \nPertinent Results:\n___ MR Head: Non-diagnostic examination with only sagittal T1 \nsequences of the head obtained. No gross mass lesion or \nanatomic abnormality. Repeat examination when clinically \nfeasible will be required for any \nfurther analysis. \n\n___ Carotid series: Duplex evaluation was performed on both \ncarotid arteries. Significant heterogeneous plaque is identified \non the right. On the right velocities are 355/152, 55/17, 124 in \nthe ICA, CCA, ECA \nrespectively. The ratio is 6.4. This is consistent with an \n80-99% stenosis. The left velocities are 118/65, 91/43, 173 in \nthe ICA, CCA, ec respectively the ratio is 1.5. This is \nconsistent with a 40-59% stenosis. There is antegrade flow in \nboth vertebral arteries Impression on the right there is \nsignificant plaque with an 80-99% carotid stenosis, on the left \nthere is a 40-59% stenosis. \n\n___ 04:22AM BLOOD Glucose-113* UreaN-8 Creat-1.0 Na-138 \nK-4.0 Cl-105 HCO3-23 AnGap-14\n___ 04:22AM BLOOD Plt ___\n___ 04:22AM BLOOD WBC-6.6 RBC-4.00* Hgb-12.2* Hct-36.0* \nMCV-90 MCH-30.5 MCHC-33.9 RDW-13.2 RDWSD-43.1 Plt ___\n\n \nBrief Hospital Course:\nPatient presented to ___ from OSH ED on ___ with critical R \ncarotid stenosis after two episodes amaurosis fugax.\n\nNon-Contrast CT of Head/CTA showed atherosclerotic plaque with \ncritical stenosis of the R ICA origin. Diffuse R ICA intimal \nthickening with reduced luminal caliber, without other focal \nstenosis or dissection. Normal L ICA and vertebral and basilar \narteries. MRA was not tolerated by patient related to \nclaustrophobia.\n\nHe was initially admitted to Neurology. Vascular Surgery and \nOphthalmology were consulted. No optic pathology noted on \nfundascopic exam. He was placed on a heparin drip and was then \nscheduled and taken for a R CEA on ___, please see operative \nreport for full details.\n\nPatient's vision has returned to baseline and he has no \nrecurrent symptoms and remains neurologically intact.\n\nPost-operative pain has been managed with Oxycodone. His course \nhas been notable for post-op urinary retention post-operatively \nrequiring straight catheterization and initiation of Flomax. His \npost void residuals remained elevated (270-470mL) with small \nvoided volumes (50-100), so he was ultimately discharged with a \nfoley catheter with urology followup. \n\nAt the time of discharge he is eating, drinking, independently \nambulating and denies n/v/chest pain/SOB at discharge. He is \nscheduled for a follow up with Dr. ___ with carotid duplex \nscan in 1 month. He will be contacted by Neurology for an \noutpatient MR brain and neurology follow up. He is discharged on \nASA. In the setting of atherosclerotic disease and LDL >100, \nsimvastatin is transitioned to atorvastatin 40mg with \ninstructions for PCP ___. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Levothyroxine Sodium 150 mcg PO DAILY \n2. Simvastatin 10 mg PO QPM \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \nRX *acetaminophen 325 mg 2 capsule(s) by mouth four times a day \nDisp #*50 Capsule Refills:*0 \n2. Aspirin 81 mg PO DAILY \nRX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*0 \n3. Atorvastatin 40 mg PO QPM \nStop Simvastatin. Follow up with your PCP ___ 8 weeks for repeat \nlabs \nRX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0 \n4. Docusate Sodium 100 mg PO BID:PRN constipation \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*30 Capsule Refills:*0 \n5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN pain \nDo no drive or operate heavy machinery while on this medication. \nDo not drink alcohol with this med \nRX *oxycodone 5 mg 1 capsule(s) by mouth every six (6) hours \nDisp #*20 Capsule Refills:*0 \n6. Senna 8.6 mg PO DAILY:PRN constipation \nRX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp \n#*30 Tablet Refills:*0 \n7. Tamsulosin 0.4 mg PO QHS \nPlease follow up with your PCP \n___ *tamsulosin 0.4 mg 1 capsule(s) by mouth daily Disp #*30 \nCapsule Refills:*0 \n8. Levothyroxine Sodium 150 mcg PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nSymptomatic R ICA stenosis\nTIA: resolved\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nIt was a pleasure taking care of you at ___ \n___. You were admitted to the hospital after a \ncarotid endarterectomy. This surgery was done to restore proper \nblood flow to your brain. To perform this procedure, an \nincision was made in your neck. You tolerated the procedure well \nand are now ready to be discharged from the hospital. Please \nfollow the recommendations below to ensure a speedy and \nuneventful recovery.\n\nWHAT TO EXPECT:\nBruising, tenderness, mild swelling, numbness and/or a firm \nridge at the incision site is normal. This will improve \ngradually in the next 2 weeks.\n \nYou may have a sore throat and or mild hoarseness. Warm tea, \nthroat lozenges, or cool drinks usually help.\n \nIt is normal to feel tired for ___ weeks after your surgery.\n \nMEDICATION INSTRUCTIONS:\n\nBefore you leave the hospital, you will be given a list of all \nthe medicine you should take at home. If a medication that you \nnormally take is not on the list or a medication that you do not \ntake is on the list please discuss it with the team! \n\nIt is very important that you take Aspirin every day! \n\nYou may take Tylenol ___ every 6 hours, as needed for neck \npain. If this is not enough, take your prescription pain \nmedication. You should require less pain medication each day. \nDo not take more than a daily total of 3000mg of Tylenol. \nTylenol is used as an ingredient in some other over-the-counter \nand prescription medications. Be aware of how much Tylenol you \nare taking in a day.\n\nNarcotic pain medication can be very constipating. If you take \nnarcotics, please also take a stool softener such as Colace. \nIf constipation becomes a problem, your pharmacist can suggest \nan additional over the counter laxative. \n \nCARE OF YOUR NECK INCISION:\n \nYou may shower 48 hours after your procedure. Avoid direct \nshower spray to the incision. Let soapy water run over the \nincision, then rinse and gently pat the area dry. Do not scrub \nthe incision. \n \nYour neck incision may be left open to air and uncovered unless \nyou have a small amount of drainage at the site. If drainage is \npresent, place a small sterile gauze over the incision and \nchange the gauze daily.\n \nDo not take a bath or go swimming for 2 weeks.\n \nACTIVITY:\n \nDo not drive for one week after your procedure and you are able \nto move your head freely to respond to traffic. Do not ever \ndrive after taking narcotic pain medication.\n \nYou should not push, pull, lift or carry anything heavier than 5 \npounds for the next 2 weeks. \n\nAfter 2 weeks, you may return to your regular activities \nincluding exercise, sexual activitiy and work.\n \nDIET:\n \nIt is normal to have a decreased appetite. Your appetite will \nreturn over time. Follow a well-balanced, heart healthy diet, \nwith moderate restriction of salt and fat.\n \nSMOKING:\nIt is essential that you maintain smoking cessation. \n \n \nCALLING FOR HELP\n \nIf you need help, please call us at ___. Remember your \ndoctor, or someone covering for your doctor is available 24 \nhours a day, 7 days a week. If you call during non-business \nhours, you will reach someone who can help you reach the \nvascular surgeon on call. \n\n \n ___, PHD ___\n \nCompleted by: ___\n" ]

[ "I6521", "K5090", "Z23", "G43B0", "E039", "E785", "Z87891", "F40240", "Z8249", "J45909", "N9989", "R338", "Y838", "Y92230" ]

[ "I6521: Occlusion and stenosis of right carotid artery", "K5090: Crohn's disease, unspecified, without complications", "Z23: Encounter for immunization", "G43B0: Ophthalmoplegic migraine, not intractable", "E039: Hypothyroidism, unspecified", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "F40240: Claustrophobia", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system", "J45909: Unspecified asthma, uncomplicated", "N9989: Other postprocedural complications and disorders of genitourinary system", "R338: Other retention of urine", "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", "Y92230: Patient room in hospital as the place of occurrence of the external cause" ]

[ "E039", "E785", "Z87891", "J45909", "Y92230" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nhydrochlorothiazide\n \nAttending: ___.\n \nChief Complaint:\nsyncope\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\n___ recently diagnosed with multiple myeloma diagnosed who was\nrecently admitted a month ago ___ ___ who presents to the\nemergency department for weakness. She was to begin\nvelcade/dexamethasone today per oncology. She has overall\nprogressive decline and weakness over the last few months. The\npatient felt very weak and had a brief syncopal episode which \nwas\nwitnessed by her daughter. The patient denies any chest pain or\nshortness of breath. She denies and recent fevers, nausea, \ncough,\ndiarrhea, or dysuria. She states she just feels very very weak.\n\nREVIEW OF SYSTEMS:\n- All reviewed and negative except as stated in the HPI.\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\nMultiple Myeloma\n- ___ found to have elevated creatinine after months of fatigue\nand pains.\n- Hospitalized and SPEP and UPEP done and consistent with light\nchain disease.\n- ___ Evaluated by oncology.\n- ___ Bone marrow biospy done, consistent with a plasma \ncell\nmyeloma with 10% of aspirate but 50% core cellularity.\n\nPAST MEDICAL HISTORY:\nHypertension, hyperlipidemia, tinnitus, thyroid nodule, type 2\ndiabetes, hearing loss, vision loss, insomnia, anxiety,\ndepression, osteoporosis and history of a TIA. Total abdominal\nhysterectomy and cataract surgery. The hysterectomy was done in\n___ and it was in the postoperative setting that she \ndeveloped\na stroke, which led to her vision loss.\n\n \nSocial History:\n___\nFamily History:\nFather died in ___, mother died at age ___ of CVA, brother had \nleukemia. \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nGeneral: NAD\nVITAL SIGNS: T 98 HR 83 RR 20 BP 153/61 O2 99%RA\nHEENT: MMM, no OP lesions, \nNeck: supple, no JVD\nCV: RR, NL S1S2\nPULM: CTAB\nABD: Soft, NTND, no masses or hepatosplenomegaly\nEXT: warm well perfused, no edema, Right hand/wrist in splint.\nSKIN: No rashes or skin breakdown\nNEURO: Alert and oriented, no focal deficits. CN intact. Muscle\nstrength intact.\n\nDISCHARGE PHYSICAL EXAM:\nGeneral: NAD\nVITAL SIGNS: 98.4 144/91 87 20 98%RA\nHEENT: MMM, no OP lesions, \nNeck: supple, no JVD\nCV: RR, NL S1S2\nPULM: CTAB\nABD: Soft, NTND, no masses or hepatosplenomegaly\nEXT: warm well perfused, no edema\nSKIN: No rashes or skin breakdown\nNEURO: Alert and oriented, no focal deficits. Muscle strength\nintact bilateral upper and lower extremities\n \nPertinent Results:\nMRI Cspine attempt ___\nIMPRESSION: \n \n \n1. Incomplete and limited study due to motion artifact. Very \nlimited \nevaluation reveals no cord compression. If there is ongoing \nconcern of \npossible ligamentous injury or spinal cord compromise, a repeat \nMR may be \nhelpful. \n\nRepeat Cspine attempt ___\nIMPRESSION: \n \n \n1. Patient could not tolerate complete imaging of the spine \nstudy was \nterminated following imaging of the cervical and upper thoracic \nspine. The \nsequences obtained demonstrate severe motion artifact which \nmarkedly degrades \nspatial resolution. \n2. No gross evidence of ligamentous injury or cord compression, \nwithout \ndefinitive cord compression, paravertebral edema, or cord signal \nabnormality. \nGiven the aforementioned limitations if there is ongoing concern \nfor \nligamentous injury or cord compromise, consider repeat MR when \npatient can \ntolerate. \n3. Heterogeneous T1 marrow signal within the cervical and upper \nthoracic spine \nwhich could represent infiltrative disease given history of \nmyeloma. \n\nCT head ___\n \nIMPRESSION: \n \n \n1. No acute intracranial process. Please note that MRI is more \nsensitive for \ndetection of subtle intracranial lesions. \n2. Global atrophy and chronic small vessel ischemic disease. \n3. Lucencies within the calvarium likely reflecting known \nmultiple myeloma. \n\nCT Cspine ___\ncervical lymphadenopathy. \n \nIMPRESSION: \n \n \n1. No acute fracture. Minimal anterolisthesis of C2 on C3 and \nC4 on C5 are \nlikely degenerative in nature. However, given that no prior \nstudy is \navailable, if there is focal neck tenderness, MRI may be \nobtained. \n2. Ligamentum flavum thickening, most pronounced at C1-C2 level \ncausing \nnarrowing of the spinal canal with deformity of the thecal sac. \nCorrelate \nwith symptoms and MRI of the cervical spine may be obtained for \nfurther \nevaluation. \n3. Multilevel, multifactorial degenerative changes as described \nabove. \n4. Heterogeneous thyroid gland with multiple cystic lesions. A \nnonemergent \nthyroid ultrasound is recommended for further evaluation if not \nobtained since \n___. \n5. No focal lytic or sclerotic osseous abnormality suspicious \nfor malignancy \nis identified. \n \nRECOMMENDATION(S): MRI of the cervical spine to evaluate \nligamentum flavum \nthickening. \n\nCXR ___\n \nIMPRESSION: \n \nMild pulmonary vascular congestion with patchy bibasilar \nopacities, \npotentially atelectasis though infection or contusion cannot be \nexcluded in \nthe correct clinical setting. \n\nR wrist MRI ___:\nIMPRESSION:\n \n1. Moderate tenosynovitis of the flexor compartment. The tendons \nare intact.\nThere is mild tenosynovitis of the second extensor compartment.\n \n2. Suggestion of mild widening of the scapholunate interval with \nmild\nincreased signal within the intra membranous portion which may \nbe secondary to\ndegenerative changes or prior injury. Evaluation of the \nligaments is limited\nsecondary to motion artifact.\n \n3. Multi focal areas of bone marrow edema pattern and cystic \nchange or likely\nsecondary to degenerative changes. Evaluation for marrow \nreplacing lesions is\nlimited given lack of intravenous contrast, however, there is no \ndefinite\nmarrow replacing lesion or fracture.\n \n4. Two ganglions cysts at the volar aspect of the radiocarpal \njoint.\n\nEcho ___\nFindings\nLEFT ATRIUM: Mild ___.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or \ncolor Doppler. Normal IVC diameter (<=2.1cm) with >50% decrease \nwith sniff (estimated RA pressure ___ mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. \nHyperdynamic LVEF >75%. Estimated cardiac index is high \n(>4.0L/min/m2). TDI E/e' < 8, suggesting normal PCWP (<12mmHg). \nNo resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch \nlevels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. \nNo AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild \nmitral annular calcification. Mild thickening of mitral valve \nchordae. Calcified tips of papillary muscles. No MS. ___ MR.\n\n___ VALVE: Normal tricuspid valve leaflets with trivial \nTR. Normal tricuspid valve supporting structures. No TS. \nModerate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. \nNo PS. Physiologic PR. Normal main PA. No Doppler evidence for \nPDA\n\nPERICARDIUM: No pericardial effusion.\nConclusions\nThe left atrium is mildly dilated. No atrial septal defect is \nseen by 2D or color Doppler. The estimated right atrial pressure \nis ___ mmHg. Left ventricular wall thicknesses are normal. The \nleft ventricular cavity size is normal. Left ventricular \nsystolic function is hyperdynamic (EF = 75%). The estimated \ncardiac index is high (>4.0L/min/m2). Tissue Doppler imaging \nsuggests a normal left ventricular filling pressure \n(PCWP<12mmHg). Right ventricular chamber size and free wall \nmotion are normal. 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. Trivial mitral regurgitation is seen. There is \nmoderate pulmonary artery systolic hypertension. There is no \npericardial effusion. \n\nLABS:\n___ 07:40AM BLOOD WBC-11.8* RBC-2.42* Hgb-7.3* Hct-22.1* \nMCV-91 MCH-30.2 MCHC-33.0 RDW-12.3 RDWSD-41.5 Plt ___\n___ 12:20PM BLOOD WBC-8.5 RBC-2.63* Hgb-8.0* Hct-23.8* \nMCV-91 MCH-30.4 MCHC-33.6 RDW-11.9 RDWSD-39.4 Plt ___\n___ 07:40AM BLOOD Glucose-85 UreaN-50* Creat-2.4* Na-133 \nK-3.4 Cl-102 HCO3-21* AnGap-13\n___ 12:20PM BLOOD Glucose-135* UreaN-38* Creat-2.3* Na-126* \nK-4.1 Cl-93* HCO3-20* AnGap-17\n___ 06:50AM BLOOD ALT-13 AST-15 LD(LDH)-153 AlkPhos-43 \nTotBili-0.2\n___ 12:20PM BLOOD ALT-13 AST-15 AlkPhos-43 TotBili-0.3\n___ 07:15AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.0\n___ 12:20PM BLOOD Albumin-4.0 Calcium-9.5 Phos-4.0 Mg-2.0\n___ 07:10AM BLOOD VitB12-449 Ferritn-315*\n \nBrief Hospital Course:\n___ recently diagnosed with multiple myeloma recently admitted a\nmonth ago ___ ___ who presents to the emergency department for\nweakness, syncopal episode. She did well on this hospitalization \nthough no exact etiology for weakness was found. She started \ntreatment for myeloma with velcade/dex. \n\nSyncope - unclear etiology. no further episodes in hospital. \npossibly\northostasis as dtr reports BP was 100 at time after the event. \nCT\nhead no bleed, Hct stable, BP stable here, no fevers or e/o\nsubstantial or systemic infection at this time. EKG reassuring.\nNo hypotension or tachycardia to suggest PE and ekg no changes \nc/w such.\n- trending Hct, remained stable through hospitalization\n- urine cx negative\n- BP meds on hold during admission, BP starting to rise so \nnorvasc restarted at DC, coreg still on hold\n- TTE (low suspicion for pericardial effusion however pt had\nsmall effusion on ___ echo in early ___: unremarkable\n- treatment of myeloma as below\n- appreciate ___ consult: safe for home with walker\n\n# Weakness/Cspine abnormality/thecal sac indentation:\nCT C-spine with possible change in ligamentum flavum. Some \nthecal\nsac indentation/deformity of the thecal sac. Not clear that it \nis\nrelated to metastatic involvement though that is obviously a\nconcern. No bowel/bladder incontinence. Pt has been having right\nsided arm pain for quite some time, question of whether it might\nbe related to this finding\n- MRI C-spine to further assess ligamentum flavum, attempted\ntwice on ___ but unable to hold still so suboptimal study with\nno clear evidence of cord impingement. At this time there does\nnot seem to be a significant lesion for which surgery or\nradiation would be indicated\n\n# Multiple Myeloma - started first line therapy with velcade/dex\non ___. CTs and X-rays done in ED show signs of multiple bone\nlucencies suggesting myeloma involvement.\n- Continue home acyclovir, protonix, vitamin D, and sodium\nbicarb. Will start bactrim ppx with single strength MWF due to \nrenal function.\n- halve the dose of steroids (20mg dex instead of 40mg) given \nh/o\ndiabetes. sugars remained well controlled, below 150 for the \nmost part so will not need to start a diabetes med for home\n- primary oncologist ___, pt will be set up to continue \nher treatment at ___ this ___. \n\n# pulm infiltrates - patchy bibas opacities seen on CXR c/w\natelectasis though can't r/o infection/contusion. Pt remained \nwell with no pulmonary complaints\n\n# leukocytosis: resolved\n\n# Anemia - hgb stable. C/w myeloma involvement in marrow and\nanemia of inflammatory block.\n- remained stable on serial checks.\n- ferritin 315, iron deficiency component unlikely\n\n# Diabetes - so far diet controlled. Lowering dose of dex as\nabove. Careful monitoring of FSG \n- SSI prn for now, careful FSG monitoring and titration of\ninsulin regimen. blood sugars largely less than 200 even on\ndexamethasone\n\n# CKD - creatinine 2.3-2.5 range, possibly renal dysfunction\nrelated to myeloma, stable\n\n# HTN - h/o htn but given syncope held home amlodipine and\ncarvedilol on this admission. BP starting to rise so restarted \nnorvasc, but coreg still on hold\n\n#wrist pain: xrays and MRI done. no apparent cause for pain \nthough there was some tenosynovitis which may suggest carpal \ntunnel. She will see a hand specialist to evaluate this as an \noutpatient.\n\nAnxiety\n- Continue home celexa and ativan.\n\nPAIN: PRN oxycodone.\n\nBOWEL REGIMEN: Continue home colace.\n\nDVT PROPHYLAXIS:\n- Heparin 5000 units SC BID\n\n___, MD\n___ ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN pain \n2. Aspirin 81 mg PO DAILY \n3. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS \n4. Lorazepam 0.5 mg PO DAILY \n5. Vitamin D 1000 UNIT PO DAILY \n6. Acyclovir 400 mg PO DAILY \n7. Amlodipine 5 mg PO BID \n8. Carvedilol 12.5 mg PO BID \n9. Citalopram 20 mg PO DAILY \n10. Pantoprazole 40 mg PO DAILY \n11. Docusate Sodium 100 mg PO BID \n12. Timolol Maleate 0.5% 1 DROP RIGHT EYE DAILY \n13. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE DAILY \n14. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain \n15. Sodium Bicarbonate 650 mg PO BID \n16. Azopt (brinzolamide) 1 % ophthalmic DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN pain \n2. Acyclovir 400 mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE DAILY \n5. Citalopram 10 mg PO DAILY \n6. Docusate Sodium 100 mg PO BID \n7. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS \n8. Lorazepam 0.5 mg PO QHS \n9. Pantoprazole 40 mg PO DAILY \n10. Sodium Bicarbonate 650 mg PO BID \n11. Timolol Maleate 0.5% 1 DROP RIGHT EYE DAILY \n12. Vitamin D 1000 UNIT PO DAILY \n13. Bortezomib 1.9 mg SC Days 1, 4, 8 and 11. ___, \n___ and ___\n (1.3 mg/m2 (Weight used: Actual Weight = 48.54 kg BSA: 1.47 \nm2)) \n14. Dexamethasone 20 mg PO DAYS 1, 2, 4, 5, 8, 9, 11, 12 \nTake on day of and day following chemotherapy \nRX *dexamethasone 4 mg 5 tablet(s) by mouth daily Disp #*100 \nTablet Refills:*0\n15. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (___) \nRX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by \nmouth MWF Disp #*12 Tablet Refills:*1\n16. Azopt (brinzolamide) 1 % ophthalmic DAILY \n17. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain \nRX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth \nevery ___ hours Disp #*25 Tablet Refills:*0\n18. Amlodipine 5 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nweakness\nmultiple myeloma\nR wrist pain\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 \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of ___ during your hospital stay \nat ___ were admitted for weakness and \npassing out. ___ were recently diagnosed with multiple myeloma \nand we started treatment for this. ___ had a significant amount \nof wrist pain intermittently, for which we did xrays and MRI \nwithout any obvious myeloma lesions, but some irritation perhaps \ndue to carpal tunnel syndrome. ___ will continue your \nchemotherapy treatments on ___. \n \nFollowup Instructions:\n___\n" ]

[ "C9000", "E119", "D649", "R55", "I129", "E785", "M65831", "M810", "Z8673", "H9190", "H547", "F419", "R918", "D72829", "N189" ]

[ "C9000: Multiple myeloma not having achieved remission", "E119: Type 2 diabetes mellitus without complications", "D649: Anemia, unspecified", "R55: Syncope and collapse", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "E785: Hyperlipidemia, unspecified", "M65831: Other synovitis and tenosynovitis, right forearm", "M810: Age-related osteoporosis without current pathological fracture", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "H9190: Unspecified hearing loss, unspecified ear", "H547: Unspecified visual loss", "F419: Anxiety disorder, unspecified", "R918: Other nonspecific abnormal finding of lung field", "D72829: Elevated white blood cell count, unspecified", "N189: Chronic kidney disease, unspecified" ]

[ "E119", "D649", "I129", "E785", "Z8673", "F419", "N189" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins / Ativan\n \nAttending: ___\n \nChief Complaint:\nfall\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n Ms. ___ is a medically complex ___ with PMH significant \nfor poorly controlled T1DM c/b retinopathy, ESRD s/p living \nkidney xplant in ___, neuropathy with neurogenic bladder and \ngastroparesis, CAD s/p MI in ___ and with 3 DES placed in \n___, hypothyroidism and h/o multiple MDR UTIs \n(Klebsiella, E.coli, Enterococcus), sclerodermda/CREST and \nantiphospholipid antibody syndrome with h/o PE in ___ who \npresents to the ED with intractable N/V and mechanical fall with \nhead strike. \n Patient was in her usual state of health until one week prior \nto admission when she developed nausea and vomiting. This nausea \nand vomiting seemed to occur after she took an oral antibiotic \nwhile on vacation in ___ (unclear why this was \nprescribed - clinic paperwork said for inguinal ___. She became \nconcerned that she was not able to tolerate PO intake and \nspecifically that she was not keeping down her anti-rejection \nmeds so she went to ___ urgent care. Vitals at urgent \ncare were: 97.3, 127/65, 122, 97%RA. She was given 500cc NS and \nIV Zofran 4mg x1. Labs were checked which showed an INR of 4.9. \nUrgent care recommended that she be seen at the ___ ED for \nfurther evaluation. Patient decided to drive herself to ___ \nbut unfortunately fell while exiting a restaurant (she felt \nbetter after the Zofran and stopped for food on the way to \n___. She fell down some stairs and struck her head but did \nnot lose conciousness. At this point in time, EMS was called and \nbrought her to ___. \n Initial vitals in the ED were: 97.2, 135, 168/69, 18, 100% RA \n Exam was notable for: laceration to right forehead and right \nwrist swelling. \n Labs were notable for: H/H 8.4/25.1 (recent baseline 9.5/28.8 \nbut decline is recent in last 4 months), INR 4.8, plts 292, BNP \n1547, Cr 1.4 (baseline 1.2-1.4), lactate 1.4, UA grossly \npositive. Blood and urine cultures were sent. \n Imaging showed: No acute fractures or intracranial pathology \nbut with right supraorbital soft tissue hematoma. C-spine \nintact. No fracture of the right wrist. \n Patient was given: IV ciprofloxacin 400mg x1 \n Consults: transplant nephrology who recommended medicine \nadmission. \n Vitals prior to transfer were: 98.9, 115, 153/60, 18, 95% RA \n On the floor, patient reports that she feels better and only \ncomplains of right wrist pain. She denies nausea since she \nreceived Zofran at the urgent care clinic. \n \n ROS: per HPI, denies fever, chills, night sweats, headache, \nvision \n changes, rhinorrhea, congestion, sore throat, cough, shortness \nof breath, chest pain, abdominal pain, nausea, vomiting, \ndiarrhea, constipation, BRBPR, melena, hematochezia, dysuria, \nhematuria. \n \nPast Medical History:\n- Poorly controlled DM Type 1 complicated by neuropathy, \nretinopathy, neurogenic bladder (intermittent straight \ncatherization) - most recent HgbA1c 12.4 in ___ \n- End-stage renal disease ___ diabetes s/p L-sided living kidney \ntransplant in ___ \n- Scleroderma w/ CREST syndrome \n- Antiphospholipid antibody syndrome and remote PE history on \nCoumadin ___ \n- CAD s/p MI in ___ c/ LAD PTCA; s/p PTCA ___: one vessel \ndisease with LAD 60% apical lesion and 90% ___ diagonal lesion. \n\n___ diagonal branch was treated with ballon angioplasty w/o \nstenting. Final angiography demonstrated ___ residual \nstenosis and improved flow down the diagonal branch. \n- LVH \n- Gastroparesis/GERD/Hiatal hernia \n- Hypothyroidism \n- Gout diagnosed ___ years ago \n- Herniated disk \n- OSA \n- Carpal tunnel s/p release \n- H/o multiple UTIs (Enterococcus vanc & amp sensitive, \nKlebsiella, E. Coli) \n- Hx of TIA?\n \nSocial History:\n___\nFamily History:\nMother-Multiple myeloma \nSister and ___ \nSister-RA \n___ disease \nNephewsx2-Alopecia \nDaughter ___, celiac disease, MS \n \nPhysical Exam:\nADMISSION EXAM\n VS: 98.3, 152/67, 117, 19, 97% RA wt 76.2kg. \n General: well appearing Caucasian female in NAD \n HEENT: NC, sclerae anicteric. Significant bruising and soft \ntissue swelling of the right periorbital area. PERRL, EOMI. OP \nclear without lesion or exudate. \n Neck: Supple, no ___, no thyromegaly \n CV: Tachycardic but regular. Normal s1/s2, no m/r/g \n Lungs: CTAB posteriorly, no w/r/r \n Abdomen: Distended but soft and nontender. Normal bowel sounds, \nno rebound or guarding. Unable to appreciate organomegaly. \n GU: no foley \n Ext: WWP, DP pulses 1+ bilaterally. No cyanosis, clubbing or \nedema \n Neuro: CN ___ grossly intact, moving all 4 extremities with \npurpose. Gait deferred. \n Skin: Ecchymoses around right eye, right wrist, above right \nbreast and scattered throughout lower extremities. \n\nDISCHARGE EXAM\nVitals 98.3 ___ 18 100RA\nGeneral: obese, NAD\nHEENT: swollen erythematous R eye that has overall improved but \nhas some crusting; now L eye has some ecchymoses\nHeart: borderline tachycardic, normal rhythm, no murmurs\nLungs: CTAB\nAbdomen: Obese, NT, NABS, several well-healed scars\nExtremities: 1+ pitting edema bilaterally\nSkin: bruising on stomach, R breast, R eye\n \nPertinent Results:\nADMISSION LABS\n___ 04:10PM BLOOD WBC-10.0 RBC-2.70* Hgb-8.4* Hct-25.1* \nMCV-93 MCH-31.1 MCHC-33.5 RDW-13.8 RDWSD-45.7 Plt ___\n___ 04:10PM BLOOD ___ PTT-60.1* ___\n___ 04:10PM BLOOD Glucose-114* UreaN-21* Creat-1.4* Na-136 \nK-3.7 Cl-101 HCO3-24 AnGap-15\n___ 04:10PM BLOOD ALT-16 AST-14 CK(CPK)-99 AlkPhos-85 \nTotBili-0.2\n___ 06:41AM BLOOD Calcium-9.6 Phos-2.5* Mg-1.6\n___ 06:41AM BLOOD tacroFK-7.4\n\nDISCHARGE LABS\n___ 04:42AM BLOOD WBC-5.5 RBC-2.72* Hgb-8.1* Hct-26.1* \nMCV-96 MCH-29.8 MCHC-31.0* RDW-15.3 RDWSD-53.1* Plt ___\n___ 04:42AM BLOOD ___ PTT-35.9 ___\n___ 04:42AM BLOOD Glucose-304* UreaN-24* Creat-1.5* Na-140 \nK-4.0 Cl-105 HCO3-27 AnGap-12\n___ 04:42AM BLOOD Calcium-9.5 Phos-3.3 Mg-1.8\n___ 04:42AM BLOOD tacroFK-5.6\n\nMICRO\n___ 4:57 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n YEAST. >100,000 ORGANISMS/ML.. \n___ 8:02 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n___ 7:37 pm BLOOD CULTURE\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: NO GROWTH. \n\nIMAGING\nWRIST XRAY ___\nDorsal soft tissue swelling along the wrist without underlying \nfracture. \nExtensive vascular calcification.\n\nCT HEAD ___. No acute intracranial hemorrhage.\n2. Right frontal supraorbital superficial soft tissue hematoma. \nNo underlying fracture seen.\n\nCT C-SPINE ___\nNo fracture or malalignment in the C-spine.\n\nRENAL TRANSPLANT US ___\nMildly elevated intrarenal resistive indices which are slightly \nhigher than ___.\n\nCT ABD/PELVIS ___. No intra or retroperitoneal or intramuscular hematoma noted \nin the abdomen or pelvis.\n2. Transplant kidney in the left lower quadrant demonstrates no\nhydronephrosis.\n3. Moderate amount of stool throughout the colon without bowel \nobstruction.\n\nCT HEAD ___. No acute intracranial hemorrhage.\n2. Small, residual, supraorbital, right frontal scalp hematoma.\n\nCXR ___\nIN COMPARISON WITH THE STUDY OF ___, THERE IS LITTLE \nCHANGE AND NO\nACUTE CARDIOPULMONARY DISEASE. THE CARDIAC SILHOUETTE IS \nENLARGED AND THERE IS NO EVIDENCE OF VASCULAR CONGESTION, \nPLEURAL EFFUSION, OR ACUTE FOCAL PNEUMONIA.\n\nCT HEAD ___. No evidence of fracture, infarction or intracranial \nhemorrhage.\n2. Minimal residual right frontal/supraorbital scalp swelling.\n \nBrief Hospital Course:\n___ yo F with history of T1DM and ESRD s/p living kidney \ntransplant ___ on MMF, tacro, prednisone, also with history of \nCAD s/p multiple MI's and recent ___ 3 ___, and h/o \nmultiple UTI's (mostly enterococcus, Klebsiella, coag neg staph) \nwho presents for elevated INR and a mechanical fall down some \nstairs at ___. Suffered trauma but no head bleed. \nNausea/vomiting resolved on admission. Experienced labile blood \npressures and orthostatic hypotension a/w anemia, improved after \ntransfusion of 1 unit of blood. INR drifted to <2 with improved \nnutrition and warfarin resumed prior to d/c.\n\nInvestigations/Interventions\n1. Elevated INR: patient is on coumadin for history of PE, and \nshe presented with INR 4.8 in setting of 1 week of nausea and \nvomiting. Elevated INR likely due to poor nutrition. INR was \ntrended and coumadin restarted ___ when INR was 1.8. INR 1.5 on \nday of discharge.\n\n2. Fall: patient fell down some stairs at restaurant and had no \npreceding symptoms. EKG on admission was at baseline. We felt \nfall to be mechanical in nature due to poor vision related to \ndiabetic nephropathy.\n\n3. Hypotension: patient initially presented with hypertension \nsbp in 190s, then became hypotensive when working with ___ sbp in \n___. She was orthostatic. Home anti-hypertensives discontinued. \nIn setting of fall with elevated INR there was concern for \ninternal bleeding so CT abd/pelvis, CT head, and CXR (PA & \nlateral) were obtained which were negative for evidence of \nbleeding. She refused IVF so we encouraged po intake which \nresulted in stabilization of blood pressures. Discharging home \non blood pressure medication regimen of metoprolol succinate \n12.5 mg daily and losartan 50 mg daily. Amlodipine discontinued \nin favor of increasing losartan.\n\n4. Anemia: pt has baseline anemia but Hgb downtrended to 6's in \nhouse. As this was associated with hypotension, bleeding was \nruled out with imaging described above. She was transfused 1 \nunit PRBC's with return of her hgb to baseline. No evidence of \nGI bleeding during hospitalization.\n\n5. Vitreous, retinal hemorrhage: patient reported blurry vision \nduring hospitalization. Ophthalmology consulted who diagnosed \nvitreous and retinal hemorrhage. Recommended to keep HOB \nelevated, avoid bending over or straining. Instructed to follow \nup with ___ clinic.\n\n6. Diabetes mellitus: patient followed at ___. Home regimen \ncontinued in house initially but patient experienced \nhypoglycemia into the 70's in the morning. ___ consulted and \npatient agreed to change pm Lantus from 20 units to 16 units. \nShe will also change her correction factor to 14.\n\n7. History of UTI's: patient has history of many UTI's. UA on \nadmission c/w UTI so patient placed on ciprofloxacin. UCx grew \nyeast which we did not treat. Due to her history of infection we \ndecided to discharge her on ciprofloxacin for 14 days, last day \nbeing ___.\n\n8. CKD, ESRD s/p kidney transplant: patient is s/p living donor \nkidney transplant in ___. Maintained on tacro, MMF, prednisone \nas outpt. Her graft has CKD, likely related to diabetic \nnephropathy. Serial tacro levels were within goal range and she \nwas maintained on her home regimen of 1mg q12h. Home prednisone \ndose changed from 6mg qd to 5mg qd. Patient also is on Bactrim \nDS tab qd which was changed to SS tab qd for PCP ___.\n\n9. CAD: patient with recent ___ 3 placed. Continued on Asa, \nPlavix, statin in house.\n\nTransitional Issues:\n[]Medication changes: Prednisone to 5mg qd, Bactrim to SS tab \nqd, losartan to 50 mg daily, qhs Glargine to 16 units daily. \nAmlodipine discontinued.\n[]Patient should take ciprofloxacin through ___\n[]Patient instructed by ___ attending to change her \ncarbohydrate correction factor to 14\n[]Patient is on several drugs which may not be needed, please \nconsider decreasing number of medications on an outpatient basis\n[]Patient instructed to keep HOB elevated, avoid bending over or \nstraining due to retinal hemorrhage\n[]Please follow up pending BCx\n[]Patient has follow up with PCP ___ patient also \ninstructed to call Dr. ___ for nephrology and \ndiabetes appointments\n\n#CODE: Full\n#CONTACT: Patient, HCP sister ___ ___ \n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO DAILY \n2. Amlodipine 2.5 mg PO DAILY \n3. Aspirin EC 81 mg PO DAILY \n4. Atorvastatin 40 mg PO QPM \n5. Calcitriol 0.25 mcg PO DAILY \n6. Cilostazol 50 mg PO TID \n7. DULoxetine 60 mg PO DAILY \n8. Gabapentin 100 mg PO QHS \n9. Levothyroxine Sodium 125 mcg PO DAILY \n10. Losartan Potassium 25 mg PO DAILY \n11. Metoprolol Succinate XL 12.5 mg PO DAILY \n12. Mycophenolate Mofetil 500 mg PO BID \n13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n14. Pramipexole 0.5 mg PO QHS \n15. PredniSONE 6 mg PO DAILY \n16. Promethazine 25 mg PO Q6H:PRN nausea or vomiting \n17. Ranitidine 300 mg PO QHS \n18. Sulfameth/Trimethoprim DS 1 TAB PO DAILY \n19. Tacrolimus 1 mg PO Q12H \n20. TraZODone 50 mg PO QHS \n21. Vitamin D 400 UNIT PO DAILY \n22. Warfarin 3 mg PO DAILY16 \n23. Clopidogrel 75 mg PO DAILY \n24. alpha lipoic acid ___ mg oral DAILY \n25. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic DAILY:PRN \n26. Esomeprazole Magnesium 40 mg ORAL BID \n27. Lidocaine 5% Patch 1 PTCH TD QPM \n28. Promethazine 25 mg PR Q6H:PRN nausea or vomiting \n29. HYDROcodone-acetaminophen ___ mg ORAL Q4H:PRN pain \n30. Glargine 36 Units Breakfast\nGlargine 20 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n31. melatonin 5 mg po Q24H \n\n \nDischarge Medications:\n1. Allopurinol ___ mg PO DAILY \n2. Aspirin EC 81 mg PO DAILY \n3. Atorvastatin 40 mg PO QPM \n4. Calcitriol 0.25 mcg PO DAILY \n5. Cilostazol 50 mg PO TID \n6. Clopidogrel 75 mg PO DAILY \n7. DULoxetine 60 mg PO DAILY \n8. Gabapentin 100 mg PO QHS \n9. HYDROcodone-acetaminophen ___ mg ORAL Q4H:PRN pain \n10. Levothyroxine Sodium 125 mcg PO DAILY \n11. Lidocaine 5% Patch 1 PTCH TD QPM \n12. Mycophenolate Mofetil 500 mg PO BID \n13. Pramipexole 0.5 mg PO QHS \n14. PredniSONE 5 mg PO DAILY \nRX *prednisone 5 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0\n15. Promethazine 25 mg PO Q6H:PRN nausea or vomiting \n16. Promethazine 25 mg PR Q6H:PRN nausea or vomiting \n17. Ranitidine 300 mg PO QHS \n18. Tacrolimus 1 mg PO Q12H \n19. TraZODone 50 mg PO QHS \n20. Vitamin D 400 UNIT PO DAILY \n21. Warfarin 3 mg PO DAILY16 \n22. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \nRX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by \nmouth once a day Disp #*30 Tablet Refills:*0\n23. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n24. Esomeprazole Magnesium 40 mg ORAL BID \n25. melatonin 5 mg po Q24H \n26. dextran 70-hypromellose (PF) 0.1-0.3 % ophthalmic DAILY:PRN \n27. alpha lipoic acid ___ mg oral DAILY \n28. Ciprofloxacin HCl 500 mg PO Q12H Duration: 19 Doses \nRX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day \nDisp #*19 Tablet Refills:*0\n29. Glargine 26 Units Breakfast\nGlargine 16 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n30. Losartan Potassium 50 mg PO DAILY \nRX *losartan 25 mg 2 tablet(s) by mouth once a day Disp #*60 \nTablet Refills:*0\n31. Metoprolol Succinate XL 12.5 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\nElevated INR\nMechanical fall\nAnemia\n\nSecondary:\nCAD\nDiabetes mellitus\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\nYou were hospitalized after a fall. You experienced extensive \nbruising since you are on blood thinners. You required 1 unit \nof blood to be transfused since your blood levels were low, \nlikely related to all of the bruising. We obtained extensive \nimaging of your body to ensure no internal bleeding, and this \nwas all negative.\n\nYou also developed some right eye floaters and blurry vision. \nYou were evaluated by Ophthalmology who felt that you had a mild \nvitreous hemorrhage. You should make sure to sleep with the \nhead of the bed elevated and to avoid any activities requiring \nbending over or straining. \n\nWe continued your immunosuppressive drugs and insulin. Please \nmake sure to follow up with your PCP and kidney doctor, ___. \n___. in addition, the diabetes doctors talked with ___ and \nwe changed your nightly insulin to 16 units of Glargine instead \nof 20. You should also change your correction factor to 14.\n\nIt was a pleasure taking care of you!\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "N390", "D6861", "E1040", "E1022", "K3184", "E1043", "Z940", "D62", "S8011XA", "S2001XA", "R791", "S0011XA", "H3560", "I2510", "N189", "W109XXA", "I252", "Z955", "E039", "N319", "Z86711", "E10319", "S8012XA", "K219", "G4733", "I951", "M109", "E10649", "Z87891", "Z87440", "H4311", "S60211A", "T45515A", "Z7901", "Z7902", "R112", "Y929", "E669", "Z6830" ]

[ "N390: Urinary tract infection, site not specified", "D6861: Antiphospholipid syndrome", "E1040: Type 1 diabetes mellitus with diabetic neuropathy, unspecified", "E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease", "K3184: Gastroparesis", "E1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy", "Z940: Kidney transplant status", "D62: Acute posthemorrhagic anemia", "S8011XA: Contusion of right lower leg, initial encounter", "S2001XA: Contusion of right breast, initial encounter", "R791: Abnormal coagulation profile", "S0011XA: Contusion of right eyelid and periocular area, initial encounter", "H3560: Retinal hemorrhage, unspecified eye", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "N189: Chronic kidney disease, unspecified", "W109XXA: Fall (on) (from) unspecified stairs and steps, initial encounter", "I252: Old myocardial infarction", "Z955: Presence of coronary angioplasty implant and graft", "E039: Hypothyroidism, unspecified", "N319: Neuromuscular dysfunction of bladder, unspecified", "Z86711: Personal history of pulmonary embolism", "E10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "S8012XA: Contusion of left lower leg, initial encounter", "K219: Gastro-esophageal reflux disease without esophagitis", "G4733: Obstructive sleep apnea (adult) (pediatric)", "I951: Orthostatic hypotension", "M109: Gout, unspecified", "E10649: Type 1 diabetes mellitus with hypoglycemia without coma", "Z87891: Personal history of nicotine dependence", "Z87440: Personal history of urinary (tract) infections", "H4311: Vitreous hemorrhage, right eye", "S60211A: Contusion of right wrist, initial encounter", "T45515A: Adverse effect of anticoagulants, initial encounter", "Z7901: Long term (current) use of anticoagulants", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "R112: Nausea with vomiting, unspecified", "Y929: Unspecified place or not applicable", "E669: Obesity, unspecified", "Z6830: Body mass index [BMI]30.0-30.9, adult" ]

[ "N390", "D62", "I2510", "N189", "I252", "Z955", "E039", "K219", "G4733", "M109", "Z87891", "Z7901", "Z7902", "Y929", "E669" ]

[]

[ " \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:\nBacteremia, biliary obstruction\n \nMajor Surgical or Invasive Procedure:\nERCP x 2\nPTBD x3\n\n \nHistory of Present Illness:\nMs ___ is a pleasant ___ year old woman w/ DM, HTN, hx ccy, \nremote aflutter s/p ablation recently worked up by PCP for \nweakness/poor PO/wt loss and obstructive jaundice w/ findings \nc/f cholangiocarcinoma w/ mets to liver who presented to ___ \n___ initially with syncope. Pt describes that she has \nhad decreased PO recently and woke up yesterday morning, \nambulated to the BR without her cane or walker and upon arriving \nto the bathroom, felt lightheaded. She subsequently lowered \nherself to the ground, denied headstrike or injury however was \nincontinent of urine. No LOC. While at ___, fall was felt to \nbe due to volume depletion, she was found to have \nleukocytosis/bandemia and GNR bacteremia. She was stabilized on \ncipro w/ improved leukocytosis, resolution of fever and stable \nhemodynamics. CT showed proximal obstructive picture w/ \nintrahepatic ductal dilatation and large liver mets. She was \nseen by GI at ___ who recommended EUS/ERCP, therefore \npatient was transferred to ___ on ___.\n\nVitals on transfer were T:97.7 BP:127/77 HR:75 RR: 20 O2 Sat: \n96% on RA. Labs showed CBC: WBC 8.8 (from 15.4 w/ bands); hgb \n10.3; plts nl; INR 1.3; cre 1.1 (from 1.4), AST 144 ALT 113 Alk \nP ___ TB 6.4 DB 5.0. CEA 67 AFP 14. \n \nOn the floor, currently c/o fatigue, no pain however soreness on \nbackside from lying on bed. Has mild epigastric discomfort \nwhich she attributes to her hiatal hernia. She also endorses \npoor PO intake over the last several months, dark urine. No CP, \nSOB, palps, focal weakness, prior syncopal or near syncopal \nevents. She has fallen at home which she attributes to weakness \nand clumsiness, but usually can get up on her own. No bleeding. \n She states that her incontinence was because she could not get \nto the bathroom and has not occurred since the initial episode.\n\nReview of systems:\n(+) Per HPI\n(-) Denies fevers at home, chills, night sweats. Denies \nheadache, sinus tenderness, rhinorrhea or congestion. Denies \ncough, shortness of breath. Denies chest pain or tightness, \npalpitations. Denies nausea, vomiting, diarrhea, constipation or \nabdominal pain. No recent change in bowel or bladder habits. No \ndysuria. Denies arthralgias or myalgias. 10 pt ros otherwise \nnegative.\n \nPast Medical History:\nHTN\nHL\nDM\nobesity\nOA\nremote TIA \ndepression\nremote aflutter s/p ablation not on AC\ns/p ccy\ns/p hysterectomy\nbursitis\n \nSocial History:\n___\nFamily History:\n(per chart, confirmed with pt): Mother died of CHF, father died \nof bladder CA and was an alcoholic. Sister died of liver CA\n \nPhysical Exam:\nADMISSION EXAM:\nVitals: 97.7 PO 154 / 53 91 18 98 RA \nConstitutional: Alert, oriented, no acute distress\nEYES: Sclera icteric, EOMI, PERRL\nENT: MMM, oropharynx clear,\nNeck: Supple\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops\nRespiratory: Clear to auscultation bilaterally, no wheezes, \nrales, rhonchi\nGI: Soft, mild TTP on deep palpation in epigastrium, \nnon-distended, bowel sounds present, no organomegaly, no rebound \nor guarding\nGU: No foley\nEXT: Warm, well perfused, no CCE\nNEURO: aaox3 CNII-XII and strength grossly intact \nSKIN: no rashes or lesions, jaundiced\n\nDISCHARGE EXAM:\n97.5 153 / 74 94 20 97 RA \nCONSTITUTIONAL NAD, jaundiced \nEYES: EOMI, icteric\nENT: MMM\nCV: regular rate, Nl S1/S2, no MRG\nRESP: CTA, no w/r/r, no O2\nGI: +BS, mild TTP in RUQ, biliary drains to bag, surrounding \nerythema or drainage, non-tender to palpation\nEXT: WWP, trace non-pitting edema bilat\nSKIN: jaundiced\nNEURO: aao x3, CNs ___ and strength grossly intact\nPSYCH: appropriate, normal affect, not depressed\n \nPertinent Results:\nCT A/P ___\nIMPRESSION: \n1. Markedly improved intrahepatic bile duct dilation since the\nprior MRCP following placement of a right posterior and left\npercutaneous biliary catheters, now with residual mild\nintrahepatic biliary dilation in hepatic segment VIII. \n2. Known intrahepatic cholangiocarcinoma is similar in size\ncompared to prior MRCP from ___. \n\nCXR ___:\nComparison to ___. Decreased lung volumes with\nsubsequent increase in lung density at the lung bases. The\nchanges reflect atelectasis no pneumonia. No pulmonary edema, \nno\nlarger pleural effusions. Borderline size of the cardiac\nsilhouette. \n\nCT chest with contrast ___:\nIMPRESSION: \nPulmonary embolism \nNonspecific millimetric lung nodules attention in followup\nstudies is \nrecommend. \n\nERCP ___:\n•Limited exam of the esophagus was normal \n•Limited exam of the stomach was normal \n•Limited exam of the duodenum was normal \n•The scout film revealed a previously placed plastic biliary\nstent in the RUQ. \n•A plastic stent originating in the biliary tree was emerging\nfrom the major ampulla. \n•The stent was successfully removed with a snare. \n•There was evidence of prior sphincterotomy and it appeared wide\nopen. \n•The CBD was cannulated with the CleverCut 3V sphincterotome\npreloaded with a 0.025in guidewire. \n•The guidewire was advanced into the right intraherpatic biliary\ntree. \n•Contrast injection was minimized to reduce the risk of\ncholangitis. \n•The common bile duct measured approximately 8mm. \n•Note was made of a tight, high grade common hepatic stricture\nextending to the intrahepatic ducts. \n•There was minimal filling of the intrahepatics with mild\nupstream dilation. \n•A 8mm X 100mm Wallflex Uncovered metal stent (LOT: ___ \nREF:\n___ was successfully placed across the stricture with the\nproximal end into the right intrahepatic biliary system. \n•There was excellent spontaneous drainage of bile, contrast,\nsludge and stone fragments at the end of the procedure. \n•The PD was not cannulated or injected. \n\nERCP ___:\nCannulation of the biliary duct was successful and deep with a\nsphincterotome using a free-hand technique. \n•Contrast medium was injected resulting in partial \nopacification.\nThe procedure was not difficult. \nContrast injection was minimized to reduce the risk of worsening\nthis patient's cholangitis. \nThe common bile duct measured approximately 8mm. \nNote was made of a tight, high grade common hepatic stricture\nextending to the intrahepatic ducts. \nThere was minimal filling of the intrahepatics with mild \nupstream\ndilation. \nA sphincterotomy was performed in the 12 o'clock position using \na\nsphincterotome.\nCytology samples were obtained for histology using a brush at \nthe\ncommon hepatic duct stricture.\nA ___ Fr x 10 cm biliary stent was placed successfully. \n \nMRCP ___. 10.0 x 5.2 cm hepatic mass centered at segment IV, with\nextension to segments V and VIII, capsular retraction, and\nassociated intrahepatic bile duct dilation, compatible with \nknown\nhistory of cholangiocarcinoma. \n2. Biliary stent extending from the right anterior intrahepatic\nduct through the CBD. The remaining intrahepatic bile ducts are\nmoderately dilated, unchanged in comparison to the ___\nCT. \n3. Mild cholangitis. No focal fluid collections. \n \nCT A/P ___ read:\n1. Heterogeneous hypo attenuating mass with capsular retraction\ncorresponding to the patient's known cholangiocarcinoma. \nNo definite evidence of abdominal or pelvic metastatic disease. \n \nPATHOLOGIC DIAGNOSIS:\nSeven consult slides labeled ___, received from ___ \n___, ___;\nprocedure date: ___.\nLiver, biopsy:\nAdenocarcinoma with ductal phenotype; see note.\nNon-neoplastic hepatic parenchyma is not identified.\n\nPTBD ___:\nIMPRESSION: \nSuccessful placement of the right posterior and left ___ \ninternal-external \nbiliary drain alongside the existing metal stent. \n\nPTBD ___:\nIMPRESSION: \nSuccessful exchange and upsizing of the existing percutaneous \ntranshepatic \nbiliary drainage catheters with new 12 ___ catheters \n(catheters were \ndestrung). \n\nPTBD ___:\nIMPRESSION: \nSuccessful Re placement of right 12 ___ percutaneous \ntranshepatic biliary drainage catheter. \n\nDischarge labs:\n___ 05:33AM BLOOD WBC-9.6 RBC-2.89* Hgb-9.6* Hct-29.8* \nMCV-103* MCH-33.2* MCHC-32.2 RDW-19.0* RDWSD-71.7* Plt ___\n___ 05:33AM BLOOD ___ PTT-73.9* ___\n___ 04:00AM BLOOD Glucose-136* UreaN-11 Creat-0.8 Na-135 \nK-3.8 Cl-102 HCO3-24 AnGap-13\n___ 05:33AM BLOOD ALT-49* AST-125* AlkPhos-220* \nTotBili-6.9*\n \nBrief Hospital Course:\nMs. ___ presented with obstructive jaundice and biliary \nsepsis d/t cholangiocarcinoma with liver mets. \n\n# E coli bacteremia prior to transfer from ___ on ___\n# Ascending cholangitis\n# Metastatic cholangiocarcinoma\n# Obstructive jaundice\n# Severe sepsis on ___ likely d/t draining of infected pocket \nw/in biliary system, requiring ICU transfer. \nHemodynamically stable on presentation, non-toxic appearing. \nPatient with confirmed pan-sensitive E.coli in blood at ___, \npathology showing new cholangiocarcinoma on rush biopsy \nperformed at ___. She underwent a second ERCP because of \ncontinuous bilirubin uptrending. She was placed on \nciprofloxacin for her septicemia. Oncology and ___ \nSurgery were consulted for new cholangiocarcinoma and \nrecommended further imaging, which showed potentially resectable \ndisease. Bilirubin remained in ___ range despite ERCP stent, \npossibly d/t poor expansion d/t tumor, so ___ was consulted for \nbiliary drain, placed R and L sided drains on ___. On ___ \npatient became hypoxic, tachycardic, fatigued, and drain output \nbecame more purulent concerning for cholangitis, and was \ntransferred to the ICU. Her antibiotics were broadened to \nvancomycin, aztreonam, and metronidazole. Abdomen CT confirmed \nproper drain placement and absence of abscess or hematoma, LFTs \ntrended downwards, patient improved clinically, and patient was \nsubsequently transferred to floor on ___ and transitioned to PO \nabx. Unfortunaely she did not tolerate a capping trial of her \nbiliary drains and therefore required upsizing of drains on ___. \n R biliary drain fell out overnight on ___ and was replaced \n___. Drains were capped but bilirubin continued to rise, \ndrains were opened to bag drainage on ___. Based on extensive \nimaging evaluation of her cancer the hepatobiliary surgical \nservice felt her tumor was potentially resectable and plan was \nfor discharge with drains in place with follow up with surgical \nteam as an outpatient. \n-Please leave biliary drains open to bag drainage\n-Interventional radiology team is scheduling her for a repeat \ncholangiogram in 1 week to attempt to cap drains.\n-Given significant fluid loss with drains open (about ___ \nml per day) please give 1 liter of Normal Saline daily.\n-Continue PO cipro/flagyl until ___.\n-Plan for outpatient follow-up with Dr. ___ surgical \noncology on ___ to discuss possible surgery. \n\n# Acute hypoxic respiratory failure: Pt was satting well during \nadmission until decompensation on ___ likely due to PE and \nsepsis. After starting anticoagulation her hypoxia resolved and \nshe has been stable from a respiratory perspective off \nsupplemental oxygen.\n\n# Bilateral pulmonary emboli: evident on screening CT chest \n___. Kept on hep gtt during admission due to multiple \nprcoedures and transitioned therapeutic lovenox prior to \ndischarge.\n\n# Anemia: stable hemoglobin. No evidence of active bleed, did \nnot require transfusion. \n\n# Acute kidney injury: ___ at ___ that improved with fluids and \nabx, and subsequent mild ___ that occurred in setting of \ndecompensation on ___ but improved quickly with IVFs and abx. \nCreatinine 0.8 on discharge. \n\n#Hyponatremia: likely hypovolemic in setting ___ & sepsis, \nand further exacerbated by PTBD fluid losses. Corrected with NS \nIVF.\n\n# Diabetes: held metformin while admitted, and she was \nmaintained with insulin sliding scale.\n\n# Hypertension: held home irbesartan and HCTZ given sepsis, her \nblood pressure was stable off of these, discontinued for now. \nIf hypertensive would consider restarting irbesartan first. \n\n# Depression: continued SSI\n\n# Atrial flutter: now on therapeutic heparin ISO recent PE, \nheart rates well controlled without rate control agents. \n\n#FEN: diabetic regular diet\n#DVT PROPHYLAXIS: therapeutic lovenox\n#ACCESS: ___\n#COMMUNICATION: ___, daughter, ___\n#CODE: DNR/DNI\n#DISPO: to ___ for rehab\n\nGreater than 30 minutes were spent on discharge related \nactivities on day of discharge.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Artificial Tears ___ DROP BOTH EYES PRN dry eye \n3. Vitamin D 1000 UNIT PO DAILY \n4. Fish Oil (Omega 3) 1000 mg PO DAILY \n5. Escitalopram Oxalate 10 mg PO DAILY \n6. Hydrochlorothiazide 12.5 mg PO DAILY \n7. irbesartan 300 mg oral DAILY \n8. Magnesium Oxide 200 mg PO DAILY \n9. MetFORMIN (Glucophage) 850 mg PO BID \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild \nDo not exceed 2 grams of Tylenol daily. \n2. Calcium Carbonate 500 mg PO QID:PRN heart burn \n3. Ciprofloxacin HCl 750 mg PO Q12H Duration: 2 Days \nLast day ___. Enoxaparin Sodium 110 mg SC Q12H \nStart: Today - ___, First Dose: Next Routine Administration \nTime \n5. MetroNIDAZOLE 500 mg PO Q8H Duration: 2 Days \nLast day ___. Multivitamins 1 TAB PO DAILY \n7. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours \nDisp #*30 Tablet Refills:*0 \n8. Polyethylene Glycol 17 g PO BID:PRN constipation \n9. Simethicone 40-80 mg PO QID:PRN bloating \n10. sodium chloride 0.9 % 0.9 % intravenous DAILY \nPlease give 1 L of normal saline daily. \n11. Artificial Tears ___ DROP BOTH EYES PRN dry eye \n12. Escitalopram Oxalate 10 mg PO DAILY \n13. Fish Oil (Omega 3) 1000 mg PO DAILY \n14. Magnesium Oxide 200 mg PO DAILY \n15. MetFORMIN (Glucophage) 850 mg PO BID \n16. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nCholangiocarcinoma\nBile duct obstruction \nE.coli septicemia\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 to \n___. While here, you were found to have a new cancer called \ncholangiocarcinoma. You were seen by the GI (___) team, \nSurgery team, Oncology team and Interventional Radiology team \nfor further work-up of this new problem. You had recurrent \nbiliary infections and blockage of your bile ducts requiring \nmultiple ERCP procedures and biliary drain placements. The \ninterventional radiology team are scheduling you for a repeat \nprocedure in 1 week to re-evaluate your drains. You are \nscheduled to see the surgical oncology team to discuss \nundergoing surgery. \n\nYou also were found to have a blood clot in your lungs \n(Pulmonary embolism), you were started on blood thinners to help \ntreat this. You are being discharged to rehab to work on your \nstrength and mobility.\n \nFollowup Instructions:\n___\n" ]

[ "A4151", "I2699", "J9601", "N179", "D684", "C787", "C221", "I4892", "K8030", "Z6841", "R6520", "E119", "I10", "E669", "F329", "E860", "D649", "Z8673", "Z87891", "Z794" ]

[ "A4151: Sepsis due to Escherichia coli [E. coli]", "I2699: Other pulmonary embolism without acute cor pulmonale", "J9601: Acute respiratory failure with hypoxia", "N179: Acute kidney failure, unspecified", "D684: Acquired coagulation factor deficiency", "C787: Secondary malignant neoplasm of liver and intrahepatic bile duct", "C221: Intrahepatic bile duct carcinoma", "I4892: Unspecified atrial flutter", "K8030: Calculus of bile duct with cholangitis, unspecified, without obstruction", "Z6841: Body mass index [BMI]40.0-44.9, adult", "R6520: Severe sepsis without septic shock", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "E669: Obesity, unspecified", "F329: Major depressive disorder, single episode, unspecified", "E860: Dehydration", "D649: Anemia, unspecified", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z87891: Personal history of nicotine dependence", "Z794: Long term (current) use of insulin" ]

[ "J9601", "N179", "E119", "I10", "E669", "F329", "D649", "Z8673", "Z87891", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nCompazine / Motrin / Celexa / Amitriptyline Hcl / Neurontin / \ndaptomycin / ertapenem\n \nAttending: ___.\n \nChief Complaint:\nneutropenia\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\nCC: called in by ___ clinic for leukopenia and elevated CK\n\nHPI(4): Ms. ___ is a ___ female with h/o left TKR in ___ with\nrecent revision of left knee in ___ of this year complicated by\npolymicrobial prosthetic joint infection currently on prlonged\ncourse of IV dapto / ___, PE on Coumadin recently changed from\neliquis, and anxiety who presented to the ED per ___ clinic recs\nafter she was found to have neutropenia and elevated CK on \nsafety\nlabs today.\n\nIn brief, she underwent total LT knee revision on ___ the\nexplanted LT knee sonication culture on ___ was no growth; post\nop course complicated by LT knee hematoma. no accompanying\nfevers; readmitted on ___. She underwent revision of LT knee\nwith debridement on ___ pt placed on IV vanco/cefepime; deep \nLT\nknee tissue tissue cultures isolated grp B strep; enterococcus\n(vanc/amp susceptible); SCN; diptheroids; kleb pneumo \n___\nserratia (pan- ___ and mixed bacterial flora. She was\ndischarged on ___ to home with plans to complete a 6 week \ncourse\nof IV antibiotics for polymicrobial LT knee PJI. \n\nThe pt was readmitted on ___ with fever to 103.2; LT knee wound\ndrainage. Labs demonstrated leukopenia with WBC 2.3; new ___\nwith creat of 2.8; vanco level of 46. The IV antibiotic regimen\nwas revised to meropenem 1 gram IV q12h; IV vanco was held.\nShe underwent repeat arthocenesis on ___ ; cell count of joint\nfluid demonstrated 896 WBCs (94% polys). The joint fluid culture\nwas no growth. She was switched to IV daptomycin on ___. Her\nrenal function improved with creatinine of 2.8 on ___.9; WBC was\n2.5. She was discharged on ___ with IV daptomycin 530 mg IV q24h\nand ertapenem 1 gram IV q24h. She was also started on Coumadin \nat\ndischarge. \n\nOutpatient safety labs from ___ (see OMR) showed absolute\nneutropenia with WBC 1.4 (2.8% polys; 88% lypmhs); HCT 26; plt\n3556. Serum creat has decreased 1.3; CPK now increased at 3780. \n\nPatient was also seen in ___ clinic today and dressing was\nchanged. Per ortho note: Low suspicion for knee infection as no\nactive drainage or erythema. Not acute orthopedic intervention\nnecessary. No orthopedic admission necessary. Would agree with a\nmedicine admit to work up lab abnormalities. \n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n+ for fatigue, left knee pain, decreased appetite, constipation\nand more recently low volume loose stool\n- for shortness of breath, fevers, chills, nausea, abdominal\npain, chest pain, palpitations\n\n \nPast Medical History:\n-Osteoarthritis s/p LT TKR ___ s/p RT TKR ___\n-prosthetic joint infection after revision of L knee ___\n-pulmonary embolism - ___ after left knee replacement, second \nafter stopping coumadin, currently on eliquis\n-abd wall cellulitis ___\n-fibroids s/p supracervical hysterectomy, repair of bowel serosa\ninjury, cystoscopy (___) \n-fibromyalgia, depression, anxiety \n-left leg nerve entrapment \n-ectopic pregnancy \n-obesity, OSA, migraines, GERD, chronic lower back pain\n \nSocial History:\n___\nFamily History:\n-Father's health unknown except potential h/o stomach cancer.\n-Uncle has unknown cancer.\n-Mother living at ___ with arthritis, DM, and osteoporosis.\n-Aunt recently passed at ___ ___nd heart disease.\n-Grandmother with breast cancer.\n-No siblings.\n-Children healthy.\n \nPhysical Exam:\nDISCHARGE EXAM:\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\nRESP: Lungs clear to auscultation with good air movement\nbilaterally. Breathing is non-labored\nGI: Abdomen soft, non-distended, non-tender to palpation. Bowel\nsounds present. \nGU: No suprapubic fullness or tenderness to palpation\nMSK: Neck supple, moves all extremities. Left knee with slow\nhealing clean based appearing wounds from recent TKA revisions\nPSYCH: pleasant, appropriate affect\nNEUROLOGIC:\nMENTATION: alert and cooperative. Oriented to person and place\nand time.\n \nPertinent Results:\nCOMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt \nCt \n___ 05:40 25.1* 3.17* 8.4* 26.3* 83 26.5 31.9* 17.2* \n52.6* 192 \nSource: Line-PICC \n___ 00:08 21.1* 3.12* 8.2* 25.6* 82 26.3 32.0 17.2* \n51.4* 176 \nSource: Line-Midline \n___ 04:48 15.4* 3.29* 8.5* 27.2* 83 25.8* 31.3* 17.2* \n52.5* 213 \nSource: Line-SL ___ \n___ 07:40 4.8 3.25* 8.6* 27.2* 84 26.5 31.6* 17.1* \n52.0* 240 \n___ 04:54 1.9* 2.82* 7.6* 23.9* 85 27.0 31.8* 16.8* \n52.5* 209 \nSource: Line-___ \n___ 05:44 1.5* 2.47* 6.5* 20.7* 84 26.3 31.4* 16.6* \n51.0* 2361 \nSource: Line-PICC \n___ 05:11 1.3* 2.53* 6.8* 21.3* 84 26.9 31.9* 16.6* \n51.6* 254 \nSource: Line-___ \n___ 22:30 1.5* 3.16* 8.6* 27.2* 86 27.2 31.6* 16.8* \n52.7* 309 \n___ 11:52 1.4*2 3.10* 8.2* 26.6* 86 26.5 30.8* 17.0* \n53.4* 356 \nDIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas \nMyelos Promyel Blasts NRBC ___ Other AbsNeut AbsLymp \nAbsMono AbsEos AbsBaso \n___ 05:40 58 9* 17* 5 0 0 0 4* 3* 2* 2* 2* \n16.82* 4.27* 1.26* 0.00* 0.00* \nSource: Line-___ \n___ 04:48 ___ 10 0 0 0 7* 2* 4* 4*2 4* 03 \n8.47* 2.77 1.54* 0.00* 0.00* \nSource: Line-SL ___ \n___ 07:40 17*4 7* 46 17* 1 0 1* 3* 3* 4*2 2* 1* 03 \n1.15* 2.26 0.82* 0.05 0.00* \n___ 04:54 7.5* 74.3* 16.6* 0.0* 0.5 \n1.1*5 0.14* 1.39 0.31 0.00* 0.01 \nSource: Line-___ \n___ 05:44 1* 0 94* 5 0 0 0 0 0 0.02* 1.41 \n0.08* 0.00* 0.00* \nSource: Line-___ \n___ 05:11 1* 0 93* 2* 0 1 3* 0 0 0.01* \n1.25 0.03* 0.00* 0.01 \nSource: Line-PICC \n___ 22:30 4.1* 85.1* 10.1 0.0* 0.7 \n0.06* 1.26 0.15* 0.00* 0.01 \n___ 11:52 2.8* 88.0* 8.5 0.0* 0.7 \n0.04* 1.25 0.12* 0.00* 0.01 Review \n \nRENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap \n___ 05:40 7 1.3* 146* 3.5 ___ \nSource: Line-PICC \n___ 00:08 ___ 143 3.6 ___ \n\nENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase \nTotBili DirBili \n___ 05:40 1821 \nSource: Line-PICC \n___ 04:54 4052*1 \nSource: Line-PICC \n___ 05:44 5123*1 \nSource: Line-PICC \n___ 05:11 31 113* 6545*1 106* 0.4 \nSource: Line-PICC \n___ 22:30 35 132* 140* 0.4 \n___ 11:52 24 76* 3780*1 Review \n \n\n___ Imaging CT HEAD W/O CONTRAST \nIMPRESSION: \n \nNo acute intracranial abnormalities. \n\n \nBrief Hospital Course:\nMs. ___ is a ___ female with h/o left TKR\nin ___ with recent revision of left knee in ___ of this year\ncomplicated by polymicrobial prosthetic joint infection \ncurrently\non prlonged course of IV dapto / ___, PE on Coumadin recently\nchanged from eliquis, and anxiety who presented to the ED per ___\nclinic recs after she was found to have neutropenia and elevated\nCK on routine follow up labwork.\n\n#Neutropenia (now resolved)\n#Leukocytosis now due to neupogen\n-neutropenia was attributed to ertapenem. ANC was as low as 40 \non admission. She was given neupogen for 3 days, with response. \nShe had fevers and flu like symptoms attributed to neupogen. Her \nWBC was 25.1 on discharge day.\n-Repeat CBC 1 week from discharge.\n\n#Likely had daptomycin associated myositis\n-CK was 6540 at its peak, and then downtrended and is normal on \n___ at 182.\n-No weakness on exam. Generalized myalgias/malaise persisted but \nalso was due to neupogen.\n\n#polymicrobial prosthetic joint infection (recent discharge\n___ and was started on daptomycin/meropenem).\n-Zosyn was initiated on ___ and she was immediately taken off \ndaptomycin/ertapenem on admission.\nThe plan prior to admission was to stop abx on ___. The dose of \nzosyn is 4.5 g q8h.\n\n#Anemia:\n-There were no signs of active bleeding or hypotension. \nPatient had decreased hgb<7. No evidence of hemolysis. Thought \nto be from marrow suppression related to ertapenem. She required \ntransfusion of 1 uPRBC on ___.\n\n#history of recurrent DVT/PEs \n-continue on Coumadin (recent switch from eliquis)\n-Dose changed to 2 mg once daily on discharge. Her INR was 3.8 \nbut downtrended to 2.9 on day of discharge. \n\nFinally, of note, on ___ evening, she was found to be drowsy \nand \"slurred speech\"; this recovered on its own and she had CTH \nshowing no intracranial bleed. She had insomnia the nights prior \nand the patient reported feeling not herself for that brief time \nperiod, at that time, due to being roused awake at night. \n\nMs. ___ is clinically stable for discharge today. The total \ntime spent today on discharge planning, counseling and \ncoordination of care today was 40 minutes.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ertapenem Sodium 1 g IV 1X \n2. Daptomycin 530 mg IV Q24H \n3. Atenolol 100 mg PO DAILY \n4. QUEtiapine Fumarate 400 mg PO QHS \n5. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia \n6. Albuterol Inhaler 2 PUFF IH Q6H wheezing \n7. LORazepam 1 mg PO QHS anxiety \n8. Leuprolide Acetate 11.25 mg ___ Q3MONTHS \n9. Warfarin 4 mg PO DAILY16 \n10. Ferrous Sulfate 325 mg PO BID \n11. Vitamin D 400 UNIT PO DAILY \n12. Cyclobenzaprine 10 mg PO BID:PRN spasm \n13. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN \nBREAKTHROUGH PAIN \n\n \nDischarge Medications:\n1. Piperacillin-Tazobactam 4.5 g IV Q8H \nRX *piperacillin-tazobactam 4.5 gram 4.5 gram IV every eight (8) \nhours Disp #*18 Vial Refills:*0 \n2. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line \nflush \nRX *sodium chloride 0.9 % 0.9 % ___ cc IV daily Refills:*0 \n3. Warfarin 2 mg PO DAILY16 \n4. Albuterol Inhaler 2 PUFF IH Q6H wheezing \n5. Atenolol 100 mg PO DAILY \n6. Cyclobenzaprine 10 mg PO BID:PRN spasm \n7. Ferrous Sulfate 325 mg PO BID \n8. Leuprolide Acetate 11.25 mg ___ Q3MONTHS \n9. LORazepam 1 mg PO QHS anxiety \n10. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN \nBREAKTHROUGH PAIN \n11. QUEtiapine Fumarate 400 mg PO QHS \n12. Vitamin D 400 UNIT PO DAILY \n13. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia \n14.Outpatient Lab Work\nDraw CBC on ___ with results forwarded to Dr. ___ \n(fax ___ ). D70.2\n15.Outpatient Lab Work\nDraw INR on ___ with results faxed to Dr. ___ \n(fax ___ ). I26.99\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\ndrug induced neutropenia\ndaptomycin induced myositis\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: Dear Ms. ___, \n\nIt was a pleasure to be a part of your care team at ___ \n___.\n\n====================================\nWhy did you come to the hospital? \n====================================\n\n-You had lab check that showed abnormally low white cell count. \n\n====================================\nWhat happened at the hospital? \n====================================\n\n-You had low white cell count due to your new antibiotic called \nertapenem. This drug was stopped. \n-You also had very high levels of CK, which is found from muscle \ndamage. This likely was due to your new antibiotic called \ndaptomycin. This drug was stopped.\n-You were changed to an antibiotic called Zosyn to continue \ntreatment of your joint infection.\n-You were given a drug called Neupogen to increase your white \ncell count, which was successful. \n\n==================================================\nWhat needs to happen when you leave the hospital? \n==================================================\n\n-Please follow with home services for IV Zosyn for your joint \ninfection. Last day to take is on ___.\n-Take your medications every day and have your CBC laboratory \nlevel checked as directed by your doctors, on ___.\n-Have your INR level drawn on ___. Coumadin dose may require \nadjusting as instructed by your PCP ___.\n-Please attend all of your doctor appointments. \n\nActivity: WBAT LLE, ___ brace at all times, may remove for\nphysical therapy or at night, do not bend knee past 70 degrees\n\nDressing: Apply Betadine twice daily to incision with dry\nsterile dressing changes\n\nIt was a pleasure taking care of you during your stay! \n\nSincerely, \n\nYour ___ team \n\n \nFollowup Instructions:\n___\n" ]

[ "D702", "E870", "Z6841", "I10", "T8454XD", "Y834", "Z86711", "Z7901", "G8929", "F419", "D638", "T368X5A", "Y929", "M6080", "R400", "T424X5A", "Y92239", "Z96652", "R502", "T458X5A", "D6489", "E669" ]

[ "D702: Other drug-induced agranulocytosis", "E870: Hyperosmolality and hypernatremia", "Z6841: Body mass index [BMI]40.0-44.9, adult", "I10: Essential (primary) hypertension", "T8454XD: Infection and inflammatory reaction due to internal left knee prosthesis, subsequent encounter", "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", "Z86711: Personal history of pulmonary embolism", "Z7901: Long term (current) use of anticoagulants", "G8929: Other chronic pain", "F419: Anxiety disorder, unspecified", "D638: Anemia in other chronic diseases classified elsewhere", "T368X5A: Adverse effect of other systemic antibiotics, initial encounter", "Y929: Unspecified place or not applicable", "M6080: Other myositis, unspecified site", "R400: Somnolence", "T424X5A: Adverse effect of benzodiazepines, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "Z96652: Presence of left artificial knee joint", "R502: Drug induced fever", "T458X5A: Adverse effect of other primarily systemic and hematological agents, initial encounter", "D6489: Other specified anemias", "E669: Obesity, unspecified" ]

[ "I10", "Z7901", "G8929", "F419", "Y929", "E669" ]

[]

[ " \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:\nEtOH WITHDRAWAL\n \nMajor Surgical or Invasive Procedure:\nnone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ M with PMHx Alcoholism, hx EtoH w/d c/b \nseizures w/ multiple ICU admissions, hx schizoaffective disorder \nw/ past suicide attempts, here with EtOH w/d. \n\n3 days ago (___) he decided to quit drinking from his usual \nbaseline of 40 beers per day. He then transported himself to \n___ ___ in response to nausea, diarrhea, \ntremulousness. Denies seizure, vomiting, trauma, LOC.\n\nPer ED chart, pt originally presented to outside hospital \n(___) where he is banned due to violent behavior in the \nsetting of alcohol withdrawal and delirium. Prior to arrival to \n___ ED, he received 24 mg of Ativan, 70 mg of Valium, and 5 mg \nof Haldol. At OSH, he was placed in 4 point hard restraints, \ntransferred here to court order to keep patient out of the \nhospital. \n\n On arrival to ED here, patient is unable to provide much \nhistory. He thinks his last drink was \"a couple nights ago\". \nReceived 70mg valium in ED. Access: PIV 18G right distal arm; \nTibial IO \n\n In the ED, initial vitals: 98.7 113 136/73 24 93%RA \n - Exam notable for gentleman in 4 point restraints \n - Labs were notable for: AG 22, serum EtOH 143, serum BDZ pos, \nBtox negative \n - Imaging: none \n - Patient was given: \n ___ 00:26 IV Diazepam 10 mg \n ___ 01:06 IV Diazepam 20 mg \n ___ 01:58 IV Diazepam 40 mg \n ___ 02:11 IV Diazepam 60 mg \n ___ 02:37 IV Diazepam 100 mg \n \n On arrival to the MICU, he was breathing comfortably, not in \nrestraints, lying in bed. Vitals were 99.4F 114 bpm 134/116 RR \n22 95%RA. He described a desire to \"stab himself in the femoral \nartery,\" without plan; he contracts for safety. His right thigh \nhas linear well-healed scars.\n\nHe remained tremulous and tachycardic after phenobarbital \nloading and became increasingly agitated. He was given \nhydroxyzine to little effect. He was rescue dosed on \nphenobarbital and started on a precede drip.\n \n Review 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. Denies chest pain \nor tightness, palpitations. Denies vomiting, constipation or \nabdominal pain. No recent change in bowel or bladder habits. No \ndysuria. Denies arthralgias or myalgias. \n\n \nPast Medical History:\nSignificant for multiple and frequent psychiatric \nhospitalizations as well as detoxifications. The patient has a \nlong history of alcohol and substance abuse, and has had more \nthan 20 detoxification admissions (Per ___ report), \nc/b seizures (per patient). Please see Psychiatry notes in ___ \nfor full psychiatric history and additional information from \noutpatient providers. \n Hx Etoh abuse \n Hx Etoh w/d \n Hx stimulant/bdz/opiate abuse \n \n\n \nSocial History:\n___\nFamily History:\nNo liver disease, diabetes, cardiac FH.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n========================= \n Vitals: 99.4F 114 bpm 134/116 RR 22 95%\n GENERAL: Well-appearing, tremulous man in NAD\n HEENT: Normocephalic, atraumatic\n NECK: Full ROM\n LUNGS: CTA, breathing comfortably at 15 breaths/min\n CV: RRR no m/r/g, no edema\n ABD: Non-tender, non-tympanic but protuberant abdomen, nl bs, \n EXT: Warm and well-perfused\n SKIN: No stigmata of liver disease, no rash. Well-healed \nlinear scars on right thigh.\n NEURO: Tremulous, alert and oriented, occasionally confused, \npupils 6-7mm and reactive\n ACCESS: IO, PIV\n\nPHYSICAL EXAM ON DISCHARGE FROM MEDICINE SERVICE: \n===================================================\nVS: \n98.3 PO 126 / 51 81 20 98 ra \n\nGen: Patient sleeping soundly this AM on entry to room, states \nhe is sleepy but arouses to voice. Sleeping through exam, in \nNAD, no complaints this AM.\nHEENT: NC/AT\nCV: RRR, no murmurs rubs or gallops\nPulm: CTA bilaterally in anterior fields and lateral fields, no \nwheezes, rales or rhonchi\nAbd: soft NT, ND with no organomegaly\nExt: no ___ edema noted, extremities warm and well perfused \nPsych: deferred; patient sleeping comfortably and agreeable to \nvital signs, does not appear agitated, cooperative at this time. \nHad previously been endorsing auditory hallucinations, SI but \nnot actively voicing at this time (asleep during exam)\n\nDISCHARGE PHYSICAL EXAM:\n========================\n\n \nPertinent Results:\nLABS\n====\n___ 12:05AM BLOOD WBC-12.7* RBC-5.21 Hgb-14.0 Hct-43.5 \nMCV-84 MCH-26.9 MCHC-32.2 RDW-16.4* RDWSD-49.5* Plt ___\n___ 03:28AM BLOOD WBC-9.1 RBC-4.77 Hgb-13.1* Hct-39.5* \nMCV-83 MCH-27.5 MCHC-33.2 RDW-15.6* RDWSD-46.3 Plt ___\n___ 12:05AM BLOOD Neuts-86.5* Lymphs-5.7* Monos-6.6 \nEos-0.1* Baso-0.5 Im ___ AbsNeut-10.95* AbsLymp-0.72* \nAbsMono-0.84* AbsEos-0.01* AbsBaso-0.06\n___ 04:20AM BLOOD ___ PTT-26.6 ___\n___ 03:28AM BLOOD Glucose-94 UreaN-4* Creat-0.7 Na-137 \nK-3.5 Cl-99 HCO3-28 AnGap-14\n___ 12:05AM BLOOD Glucose-98 UreaN-6 Creat-0.8 Na-139 K-4.5 \nCl-100 HCO3-22 AnGap-22*\n___ 04:19AM BLOOD ALT-26 AST-50* CK(CPK)-1881* AlkPhos-122 \nTotBili-0.9\n___ 03:29AM BLOOD ALT-25 AST-49* CK(CPK)-1562* AlkPhos-120 \nTotBili-0.7\n___ 12:05AM BLOOD Albumin-4.3 Calcium-9.2 Phos-2.7 Mg-2.1\n___ 11:25AM BLOOD D-Dimer-1261*\n___ 11:25AM BLOOD Osmolal-288\n___ 02:48PM BLOOD Phenoba-11.0\n___ 12:05AM BLOOD ASA-NEG ___ Acetmnp-NEG \nBnzodzp-POS* Barbitr-NEG Tricycl-NEG\n___ 10:46AM BLOOD Type-ART O2 Flow-4 pO2-123* pCO2-44 \npH-7.42 calTCO2-30 Base XS-4 Intubat-NOT INTUBA\n___ 03:04PM BLOOD ___ pO2-50* pCO2-37 pH-7.28* \ncalTCO2-18* Base XS--8\n___ 04:25AM BLOOD Lactate-3.2*\n___ 10:46AM BLOOD Lactate-2.2*\n___ 03:53AM BLOOD Lactate-3.2*\n___ 09:17AM BLOOD Lactate-1.2\n___ 03:04PM BLOOD Lactate-1.1\n___ 04:16AM BLOOD WBC-7.1 RBC-4.58* Hgb-12.4* Hct-39.4* \nMCV-86 MCH-27.1 MCHC-31.5* RDW-15.8* RDWSD-49.3* Plt ___\n___ 05:57AM BLOOD WBC-7.4 RBC-4.89 Hgb-13.4* Hct-42.5 \nMCV-87 MCH-27.4 MCHC-31.5* RDW-16.0* RDWSD-50.4* Plt ___\n___ 06:49AM BLOOD WBC-9.4 RBC-4.70 Hgb-12.8* Hct-40.9 \nMCV-87 MCH-27.2 MCHC-31.3* RDW-15.9* RDWSD-50.7* Plt ___\n___ 04:16AM BLOOD Glucose-114* UreaN-13 Creat-0.6 Na-136 \nK-4.2 Cl-100 HCO3-28 AnGap-12\n___ 05:57AM BLOOD Glucose-100 UreaN-14 Creat-0.7 Na-137 \nK-4.5 Cl-100 HCO3-24 AnGap-18\n___ 06:49AM BLOOD Glucose-87 UreaN-17 Creat-0.7 Na-137 \nK-4.2 Cl-100 HCO3-29 AnGap-12\n___ 04:16AM BLOOD ALT-29 AST-27 AlkPhos-93 TotBili-<0.2\n___ 04:16AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.0\n___ 05:57AM BLOOD Calcium-9.5 Phos-5.8* Mg-2.2\n___ 06:49AM BLOOD Calcium-9.3 Phos-5.1* Mg-2.1\n___ 03:53AM BLOOD Lactate-3.2*\n___ 09:17AM BLOOD Lactate-1.2\n___ 04:42PM BLOOD Lactate-1.1\n\nIMAGING\n========\nNormal chest radiograph. \n\nEKG\n=======\n___ QTc not prolonged\n___ QTc ___\n\n \nBrief Hospital Course:\n Mr. ___ is a ___ M with PMHx Alcoholism, hx EtoH w/d c/b \nsiezures w/ multiple ICU admissions, hx significant psychiatric \ndisease w/ past suicide attempts, here with EtOH w/d. Initially \nadmitted to the MICU for ETOH withdrawal requiring phenobarbital \nand precedex with course complicated by tooth infection for \nwhich he received clindamycin and severe agitation and SI on 1:1 \nsitter.\n\n #EtoH w/d: hx multiple admissions for hx EtOH w/d c/b seizures, \ns/p 24 mg Ativan, 70mg Valium, and 5 mg Haldol at OSH. Received \n70mg valium in ___ ED. Pt reports last drink \"couple nights \nago\", poor historian. In setting of high risk patient with \ncomplicated alcohol initiated phenobarbital protocol in MICU. \nCompleted phenobarbital taper and acute withdrawal resolved. \nHowever patient with agitation requiring precedex in MICU. EKG \nstable without prolonged QTc. Received thiamine, folate, and \nmultivitamin. Medically stable at this time with agitation being \ntreated as per below. \n\n# Agitation: initially required precedex gtt in MICU DCed on \n___. Has received significant amount of medications for \nagitation issues. Current regimen includes \ngabapentin TID, clonidine TID, Quetiapine (Seroquel) 250mg qAM, \n250mg qPM, 450 mg QHS and 50 BID PRN agitation which is maximum \ndaily dose. Initially getting additional Haldol for agitation \nbut also received some Zyprexa while on the floor. Aggressive \nmonitoring of K and Mag (no repletion needed on floor)\n\n# Tooth pain: Panorex showing tooth #19 w/apical abscess. \nPreviously on clindamycin; patient states he finished ___s outpatient, given 7 day course in MICU (___). \nPer phone discussion with ___ ___ could potentially remove \ntooth as inpatient if worsening pain but as there could be \nsalvage of tooth with outpatient management (root canal) might \nconsider symptomatic treatment until patient can see dentist as \noutpatient; recommend continued evaluation and downtitration of \noxycodone and oxycontin as patient tolerates. Non-urgent need \nfor extraction for 13 and 30.\n\n# Psychiatric disorder: has a diagnosis of ?bipolar disorder \nthough diagnosis confounded by significant etoh abuse and \nwithdrawal in the past. The patient has a long history of \nalcohol and substance abuse, and has had more than 20 \ndetoxification admissions per ___ records. The \npatient has a long history of mood disorder with various \ndiagnoses including bipolar disorder, schizoaffective disorder, \nand personality disorder. \n\n# Opioid withdrawal: Endorsed taking 30mg Percocet daily last \n___ weeks. Resolving diaphoresis, loose stool. Wanted to attempt \nto reach out to outpatient provider who is prescribing these \nmeds (___, ___, and check PMP. Recommend further \ndowntitration of pain medications (now oxycontin 10mg BID, \noxycodone 5mg q4hrs breakthrough) as tolerated.\n\n# Depression with SI: patient has endorsed passive SI on and off \nwhile in MICU with plan to cut femoral artery. Had recently been \nreceiving ECT at ___ prior to admission. Continued venlafaxine \n(Effexor) but held buproprion (wellbutrin) this admission. Has \n1:1 sitter.\n\n#Pure AG Metabolic Acidosis: AG 17, HCO3 22 - secondary to \nalcoholic ketosis, EtOH ~140. Resolved while in the MICU, Chem 7 \nwnl on floor. \n \n# Tachycardia: had work up with negative CTPE. Likely a \ncombination of withdrawal and agitation. Has not been \ntachycardic since arrival to floor. Will continue to monitor.\n\n# High CK: Initial concern for rhabdo, CK 1800, but OSH UA \ndipstick negative for blood, no history per patient of \nimmobilization/LOC at home, immobilized in 4-point restraints at \nOSH. Received IVF, 4 point restraints. Now resolved.\n\n#Insomnia: continued zolpidem 10 mg PO QHS.\n\n \n CORE MEASURES: \n # FEN: IVF, replete electrolytes, NPO in setting of \nagitation/violence \n # Prophylaxis: ___ \n # Access: PIV \n # Restraints: while intubated to protect patient from \naccidental removal of tubes/lines/drains and will be reassessed \nat regular intervals per hospital policy \n # Communication: Mother, HCP ___\n # Code: Full, confirmed \n # Disposition: ICU pending clinical improvement \n\nCORE MEASURES: \n================\n# FEN: regular\n# PPX: \n - bowel: senna/colace \n - DVT: heparin\n# ACCESS: midline \n# CODE: full, confirmed (from prior MICU note)\n# CONTACT: \nMother ___ \nWork ___ CALL THIS ONE FROM ___-1500 \nCell ___ \n# DISPO: CC7, pending above \n\nTRANSITIONAL ISSUES\n======================\n- patient needs follow up dental evaluation; may move to get \ninpatient dental evaluation/extraction if pain symptoms worsen \nor oral exam changes\n- recommend weaning of clonidine (now 0.2 mg TID)--recommend \nslow taper \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. BuPROPion 200 mg PO BID \n2. Venlafaxine 225 mg PO QAM \n3. QUEtiapine Fumarate 200 mg PO QHS \n4. QUEtiapine Fumarate 50-100 mg PO QID:PRN anxiety \n5. Gabapentin 800 mg PO TID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nalcohol withdrawal\nagitation\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 to the hospital because of alcohol withdrawal. \nYou needed to be treated in the Intensive Care Unit for your \nwithdrawal symptoms and for your severe agitation. While in the \nMICU and on the floor you received a lot of medications to help \nwith your agitation and anxiety. \n\nYou will be discharged to the ___ inpatient psychiatry \nunit for continued management of your agitation and psychiatric \nsymptoms. \n\nIt was a pleasure taking care of you and we wish you the best in \nyour recovery.\n\nSincerely, \nYour ___ Medicine Team\n \nFollowup Instructions:\n___\n" ]

[ "F10231", "G92", "F1123", "E872", "R45851", "K047", "F17210", "F329", "G4700", "F419", "K029", "Z781", "R0902" ]

[ "F10231: Alcohol dependence with withdrawal delirium", "G92: Toxic encephalopathy", "F1123: Opioid dependence with withdrawal", "E872: Acidosis", "R45851: Suicidal ideations", "K047: Periapical abscess without sinus", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F329: Major depressive disorder, single episode, unspecified", "G4700: Insomnia, unspecified", "F419: Anxiety disorder, unspecified", "K029: Dental caries, unspecified", "Z781: Physical restraint status", "R0902: Hypoxemia" ]

[ "E872", "F17210", "F329", "G4700", "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:\nAbdominal pain, alcohol withdrawal\n \nMajor Surgical or Invasive Procedure:\nNone \n\n \nHistory of Present Illness:\nMr ___ is a ___ with alcohol abuse, alcohol withdrawal, \nlikely alcoholic cirrhosis, prior HCV, aniridia, and relatively \nrecent admission for alcohol withdrawal and likely alcoholic \ngastritis, who presents with abdominal pain and alcohol \nwithdrawal.\n\nHe is not the very best historian. He tells me that after his \nlast admission to the hospital he took his prescribed \nmedications and avoided drinking for some time. However after a \nrelatively short period of sobriety he resumed drinking, upwards \nof ___ gallon vodka daily. He tried to remember to take his \nmedications every day but definitely missed at least a few \ndoses. It sounds like he began to have worsening abdominal pain \n___ days ago, though he is not very clear on the timeline. It \nwas epigastric though somewhat migratory about his epigastrum \nand umbilicus, characterized as \"over-eating\" type pain. \nModerate at first, it became progressively more severe. He then \ndeveloped a sensation of bug-crawling, and with both of these \nsymptoms he decided to come to the hospital.\n\nHe is unclear on what he had been doing as far as drinking, \nwhether he had tried to cut back because of the pain and then \ndeveloped bug-crawling, or whether he had continued to drink or \notherwise increased his drinking attempting to numb the pain. \nDuring the same interview he told me both of these. ED report \nsaid his last drink was >24 hours prior to admission, ~3PM on \n___.\n\nIn the ED, he had stable vital signs. Labs showed elevated LFTs, \npancytopenia, mild coagulopathy, lipase of 100. He had RUQUS \nthat was relatively unrevealing, otherwise c/w cirrhosis. He was \ngiven diazepam, benadryl, and IVF. Admission was requested.\n \nPast Medical History:\nAlcohol abuse with history of withdrawal\nCirrhosis - likely alcohol\nAlcoholic gastritis (presumptive diagnosis)\nHCV - Viral load at ___ ___ was negative\nAniridia - reports that he is \"legally blind\" and has odd eye \nmovements chronically.\nTobacco use\n \nSocial History:\n___\nFamily History:\nAniridia. No early cardiac death. \n \nPhysical Exam:\nVitals AVSS\nGen NAD, pleasant\nAbd soft, NT, ND, BS+\nCV RRR, no MRG\nLungs CTA ___\nExt WWP, no edema\nSkin few abrasions on forehead; otherwise no rash on exposed \nskin, anicteric\nGU no foley\nEyes EOMI\nHENT MMM, OP clear\nNeuro so signs of withdrawals \nPsych flat affect\n\n \nPertinent Results:\nLabs on admission\n___ 08:13PM BLOOD WBC-2.3* RBC-3.42* Hgb-11.5* Hct-34.6* \nMCV-101* MCH-33.6* MCHC-33.2 RDW-15.1 RDWSD-56.3* Plt Ct-32*\n___ 08:13PM BLOOD Neuts-56.2 ___ Monos-15.5* \nEos-1.7 Baso-0.9 Im ___ AbsNeut-1.31* AbsLymp-0.59* \nAbsMono-0.36 AbsEos-0.04 AbsBaso-0.02\n___ 08:13PM BLOOD ___ PTT-34.1 ___\n___ 08:13PM BLOOD Glucose-94 UreaN-13 Creat-0.8 Na-131* \nK-3.8 Cl-96 HCO3-26 AnGap-13\n___ 08:13PM BLOOD ALT-57* AST-130* AlkPhos-149* \nTotBili-2.8*\n___ 08:13PM BLOOD Lipase-105*\n___ 08:13PM BLOOD Albumin-3.8\n___ 08:35PM BLOOD Lactate-1.3\n\nImaging on admission\nCXR\nSlight blunting of the right costophrenic angle, trace pleural \neffusion not excluded. No focal consolidation.\n\nRUQUS\n1. Cirrhotic liver and splenomegaly consistent with underlying \nliver disease and possible portal hypertension.\n2. Contracted gallbladder likely due to recent oral ingestion.\n3. Previously identified cholelithiasis is not seen on this \nstudy.\n4. No biliary ductal dilation.\n \nBrief Hospital Course:\n___ with alcohol abuse, alcohol withdrawal, likely alcoholic \ncirrhosis, prior HCV, aniridia, and relatively recent admission \nfor alcohol withdrawal and likely alcoholic gastritis, who \npresents with abdominal pain and alcohol withdrawal.\n\n# Abdominal pain, most likely\n# Alcoholic gastritis: \nHad dull epigastric pain associated with GERD. He was given \nmaaylox, PPI, and sulcrafate. His symptoms had completely \nresolved on discharge. As we discussed he still needs a \nscreening EGD for possible varies. \n\n# Hypertension\n# Shakes, subjective fevers, sweats\n# Formication, likely due to\n# Alcohol withdrawal: Drinks 1 gallon of vodka or more per day. \nOn admission was in alcohol withdrawal. No signs of complicated \nwithdrawal. He was treated with Valium and was quickly tapered \noff. He was given multivitamin, thiamine, and folate. We had a \nlong discussion about the effect his drinking is having on his \nbody. He states he will follow up with his PCP and possibly \nattend the ___ clinic. Social work was involved to help him \nnavigate where he can go for help to stay sober. \n\n# Odd eye movements: This is the second time I have cared for \nhim. Both times he had continuous nystagmus. He states this \nfirst happened after repeat TBI. He states this has been ongoing \nfor several years. He has multiple CT scan in the last 6 months \nwithout any signs of stroke or bleed or mass that would explain \nthese findings. He states his PCP was aware of these movement. \n\n# Cirrhosis: Volume status is euvolemic. No signs of infection, \nno tappable ascites. No signs of bleeding, though has not had \nrecent EGD for variceal screening. No signs of \nencephalopathy/asterixis. Overdue for screening tests.\n- Consider initiation of vaccination series for HAV, and HBV, \npneumonia\n\n# Macrocytic anemia\n# Thrombocytopenia\n# Pancytopenia: Likely due to alcoholism, sequestration from \nsplenomegaly, and cirrhosis. Previously normal TSH, HIV, B12, \nfolate, hep serol. Copper deficiency not yet considered. Could \nconsider this as he has reported some occasional \nnumbness/tingling c/w neuropathy, though the neuropathy is most \nlikely due to chronic alcoholism.\n\n# Homelessness\n- SW consult as above\n\n# Tobacco use: ___ smoker\n- Nicotine patch \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Thiamine 100 mg PO DAILY \n2. FoLIC Acid 1 mg PO DAILY \n3. Multivitamins 1 TAB PO DAILY \n4. Pantoprazole 40 mg PO Q12H \n\n \nDischarge Medications:\n1. Sucralfate 1 gm PO QID \nRX *sucralfate [Carafate] 1 gram 1 tablet(s) by mouth four times \na day Disp #*40 Tablet Refills:*0 \n2. FoLIC Acid 1 mg PO DAILY \n3. Multivitamins 1 TAB PO DAILY \n4. Pantoprazole 40 mg PO Q12H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n5. Thiamine 100 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAlcohol Withdrawal \nCirrhosis \nTransaminase\nThrombocytopenia \n \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 alcohol withdrawal. As we \nspoke about your drinking is seriously effecting your health \nespecially your liver. For your withdrawal you were treated with \nvalium and improved significantly. You were also given several \nvitamins. We discussed possible treatment centers and you were \ngiven a list of their phone numbers. Also discussed going to see \nyour PCP in the drop in clinic at ___. \n\nYour liver shows severe scarring from ongoing alcohol use. As we \ntalked about your blood work shows that your liver is worsening \nover time. This was evidenced by slightly higher bilirubin and \nlower platelets. You had another ultrasound of the liver and it \nwas unchanged from a month ago. It still shows significant \ncirrhosis. You will need an EGD to screen for possible varices. \n\n\nOn arrival to the hospital you had some abdominal pain. This \npain completely resolved with acid blocking medication. This was \nlikely from inflammation in the stomach from ongoing drinking. \nYou can continue the acid blocking medications when you leave \nthe hospital. \n\nIt was a pleasure caring for you, \nYour ___ Doctors \n \n___ Instructions:\n___\n" ]

[ "F10239", "F1121", "D61818", "D6959", "K7030", "E871", "K2920", "K7469", "B1920", "R740", "Z720", "Z590", "R791", "H548" ]

[ "F10239: Alcohol dependence with withdrawal, unspecified", "F1121: Opioid dependence, in remission", "D61818: Other pancytopenia", "D6959: Other secondary thrombocytopenia", "K7030: Alcoholic cirrhosis of liver without ascites", "E871: Hypo-osmolality and hyponatremia", "K2920: Alcoholic gastritis without bleeding", "K7469: Other cirrhosis of liver", "B1920: Unspecified viral hepatitis C without hepatic coma", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "Z720: Tobacco use", "Z590: Homelessness", "R791: Abnormal coagulation profile", "H548: Legal blindness, as defined in USA" ]

[ "E871" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: PSYCHIATRY\n \nAllergies: \nNo Allergies/ADRs on File\n \nAttending: ___\n \n___ Complaint:\n\"My parents called for a wellness check on me\"\n\n \nMajor Surgical or Invasive Procedure:\nn/a\n \nHistory of Present Illness:\nPer Dr. ___ note from ___:\n\"Patient states that last night she intoxicated, drinking \"way\nmore\" than 10 beers and mixed drinks, and left the bar boyfriend\ngot into an argument. She is unable to recall what the fight \nwas\nabout, but knows that she had to walk to her friend and\n___ home without shoes on at 4 in the morning. She\ndenies knowing where her shoes on. Patient also reports doing a\ncouple \"sniffy's\" of cocaine last night. Denies drinking \nalcohol\nthis morning or today.\n\nShe woke up this morning at her ___ house, and \nstarted\nto have a panic attack. She called her family tell them that \nshe\nbe celebrating with her ___, and was not feeling up to\ncoming home. However her ___ told her she needed to\nleave by 6 ___ when his new girlfriend was coming over. At this\npoint she got \"mad, and so depressed\" that she attempted to take\nan electric cord from the wall, wrapped it around her neck and\nlowered her body and attempt to strangle herself. She stopped\nand undid the cord. When asked why she stopped, patient states\n\"maybe because it was ___?\" But does not really have \nan\nanswer. In the moment she \"felt so dumb, and things were going\nreally downhill with all these panic attacks.\"\"\n\nOn interview, patient corroborates history collected above. She\nwas amenable to relocating to exam room for interview. On\ninterview, she exhibited notable psychomotor agitation \n(fidgeting\nw/ upper extremities, moving lower extremities). In addition, \nher\nspeech was rapid though not pressured and she was interruptible.\nPatient denies that wrapping cord around her neck was a suicide\nattempt. It appears to have been a gesture as patient compares \nit\nto a time in middle or high school in which she took ___ Midol\ntablets as a suicide attempt and notes that she \"knew it \nwouldn't\nkill [her].\" She notes her wrapping the cord around her neck was\ntriggered by her finding out that she would have to leave her\n___ place before his new girlfriend arrived. She \nnotes\nit would be \"kind of selfish\" for her to expect him to put her\nbefore his new girlfriend but wishes he had been more\naccommodating given she was experiencing a panic attack. She\ndenies a history of SIB and currently denies SI or HI. With\nregards to SI, she states that she \"[doesn't] think [she] would\nend [her] life,\" but notes that, when she has panic attacks, she\ncan feel \"overwhelmed\" to the point of experiencing egodystonic\npassive SI.\n\nShe cites work (has been skipping for past 2 months ___ \nanxiety),\nschool (found out she is further from graduating that she had\nthought; has not been attending regularly since ___, her\nrelationship w/ her mom (of note, requests team not contact\nmother; appears to have conflict regarding parents financially\nsupporting her), and her dad's illness (brain tumor, recent\ngallbladder surgery) as stressors. She notes she has been \nfeeling\n\"really depressed\" at times but currently describes her mood as\n\"pretty happy\" noting she had just spoken w/ her boyfriend on \nthe\nphone. Her sleep appears to be poor as she notes delayed onset,\nintermittent awakenings, and early morning awakenings. She \ndenies\nexperiencing a period in which she did not feel a need for sleep\n___ increased energy or euphoria. She has been experiencing\nnightmares at times (states regarding her boyfriend cheating on\nher) but these do not appear to be worsening the quality of her\nsleep. Her appetite has been \"too good\" as she has been \"stress\neating\" more than usual. She denies AVH, TB, TI nor did she\nappear to be responding to internal stimuli. Unable to elicit\nparanoid or persecutory delusions during this interview.\n\nCollateral Contacts:\nPer Dr. ___ note from ___:\n___ EMS Run Report: ___ female found on scene with\nBPD,bupd\nand her parents. They pt reports that she became anxious today\nand wrapped a electrical cord around her neck \" end it \" but\nstopped. The pt reports she is on and off compliant with her\ncelexa. The pt reports she awoke with a lot of anxiety this am\ndue to the holiday. The pt admits to ETOH today also. The pt was\nevaluated and transported to ___ without incident.\"\n\nTriage: \"pt reports SI, was at her boyfriends house and put an\nelectrical cord around her neck and started tugging on it. \ndenies\nLOC. pt is a+OX3. pt appears anxious.\" Screens positive for IPV,\ndepression, suicidal ideation with plan; denies intent and prior\nattempts. \n\nNursing Notes: \"Pt arrives to ___ by EMS. Pt with disorganized\nthinking, appears anxious. Pt states she had argument\nwith boyfriend last night, \"we were out drinking,\" they got in a\nfight and she walked/got a ride to her exboyfriend's\nhouse and slept there. She states that she felt very panicky \nthis\nAM, realizing that it was ___ and she reports some\nfamily dysfunction, has been having increased . Pt endorses\ntaking an electrical cord and wrapped it around her neck. \"It's\nthe anxiety and the depression that's killing me right now.\" hx\nBPD, SA, anxiety, has gotten worse within the last ___ years.\"\n\nPer ___ OMR Review: \nOffice appointment on ___ with PCP ___, MD for\nanxiety. Bad anxiety, in a funk, also had in HS. Brother with\nanxiety. Got over body dysmorphia with CBT, previously saw\ntherapists. Recently worsened with panic attacks, has missed \nwork\nfor 3 weeks, grades dropping. Feeling overwhelmed and socially\nisolating herself from friends/family. Feels depressed, not\n___. Trialed breathing, bath, yoga, affirmations.\nCouldn't get in with ___ clinician, no prior Rx trials. Awakes\nfrom sleep with heart pounding. Last panic attack 2 weeks ago\nwith boyfriend, SOB, emotional, triggered by small things, more\noften when out, now staying in room. Denied SI. Started on \nCelexa\n(begin at 10mg for 8 days and then increase to 20mg daily) and\nreferred to therapy through Psychology Today and other list of\nproviders. Patient was supposed to return to clinic in 3 weeks\nfor ___, but scheduled for ___.\n\nParents: ___, and ___. Interviewed separately. Patient requested parents\nnot be involved; limited clinical information divulged but\ncollateral obtained given emergent safety evaluation. Report\npatient ___ body dysmorphia in high school, enrolled\nin ___ clinical trial for ___ year and did very well. Straight A\nstudent in college until boyfriend ___ this past ___. She\nnever gave them a last name or let them meet him. ___ years old,\nprior domestic violence charge. Prior boyfriend ___ is\nsupportive. ___ mom called them this morning, reported that\n___ had reportedly grabbed patient by ponytail and possibly\nattempted to strangle her. ___ mom was very worried patient\nwas leaving their house to attempt to kill herself. Parents\ncalled ___ for wellness check. Terrified, daughter \ndoesn't\nkeep them updated, not sure if she is going to school but not at\nwork or seeing family for several weeks. They give her $150 a\nweek for groceries and see much of it spent on alcohol. Not sure\nif this is mental illness or just a bad boyfriend driving her to\nthis. Consider dispo update, though they understand patient is \nan\nadult and can choose whether or not to involve them. She is on\ntheir insurance. Tried to get her into REST psychology group but\nnever followed up.\"\n\n \nPast Medical History:\nPAST PSYCHIATRIC HISTORY:\n- Prior diagnoses: anxiety, depression, body dysmorphia \n(improved\ns/p CBT); declined ADD evaluation offered by PCP\n- Hospitalizations: denies\n- Psychiatrist: denies\n- Therapist: denies\n- Medication trials: citalopram (not effective)\n- Suicide attempts: freshman year of high school (took ___ Midol\ntablets\", states she \"knew it wouldn't kill [her]\")\n- Harm to others: denies\n- Trauma: emotional abuse from ___ though appears to\nhave made ammends\n- Access to weapons: denies\n\nPAST MEDICAL HISTORY:\n- PCP: ___, MD, MPH\n- Acne\n- Tonsillectomy\n- Dysmenorrhea\n- Denies history of seizure\n- Head trauma w/ ___ hours loss of consciousness in ___ grade,\nfell off scooter onto pavement\n- NKDA\n\n \nSocial History:\n- Born/Raised: Grew up in ___, living in ___ for past ___\nyears. 2 older brothers. Mother is ___ and teaches language\nat ___ in addition to working at ___.\n- Relationship status/Children: Boyfriend\n- Primary Supports: current boyfriend, father, mom to a degree\nbut notes she is \"not helpful\" at times and would prefer team to\nallow patient to update mother directly\n- ___: Lives with roommate\n- Education: ___, studying psychology, ___ . Endorsed\ndifficulty with memory and focus, trouble in HS, no evaluations.\nSaw speech therapist in ___ (age ___. \n- Employment/Income: Works with mother in ___ ___\ndepartment for ___. Not in work for several weeks.\n- Spiritual: denies\n- Military History: ___\nSUBSTANCE ABUSE HISTORY:\n- Alcohol: last used ___ endorses occasional binge\ndrinking; did not score on ___ x2 while in ___ more recently \nhas\nbeen drinking up to 2 \"tall boys\" per day; denies history of\nseizure or withdrawal\n- Tobacco: 1 pack per day\n- Marijuana: endorses weekly use; buying a gram occasionally,\nmostly dab pen or shared from friends; used daily during high\nschool but quit daily use ___ THC exacerbating her anxiety \n- Opiates: none\n- Benzos: none\n- Cocaine: weekly; last used last night\n- Amphetamines/speed: none\n- Other Drugs: LSD/Shrooms (last used at some point during ___\nthough unable to recall date)\n\n \nFamily History:\n- Psychiatric Diagnoses: brother - anxiety; grandmother\nunspecified\n- ___ Attempts/Completed Suicides: denies\n- Substance Use Disorders: denies\n \nPhysical Exam:\nVITAL SIGNS\n24 HR Data (last updated ___ @ 1823)\nTemp: 98.1 (Tm 98.1), BP: 118/80, HR: 87, RR: 16, O2 sat: 99% \n\nEXAM:\n-HEENT: Normocephalic, atraumatic. Moist mucous membranes,\noropharynx clear.\n-Cardiovascular: Regular rate and rhythm, normal S1,S2, no\nmurmurs/rubs/gallops.\n-Pulmonary: No increased work of breathing. Lungs clear to\nauscultation bilaterally. No wheezes/rhonchi/rales.\n-Abdominal: Normoactive bowel sounds. Abdomen soft, nontender,\nnondistended. No guarding, no rebound tenderness.\n-Extremities: Warm and ___. No edema of the limbs.\n-Skin: No bruising, rashes or lesions noted\nNeurological:\n-Cranial Nerves:\n---I: Olfaction not tested.\n---II: pupils 3mm, equal, round, reactive to light\n---III, IV, VI: extraocular movements not tested\n---V: Masseter ___ bilaterally\n---VII: nasolabial folds symmetric bilaterally\n---VIII: Hearing intact to conversation\n---IX, X: Palate elevates symmetrically\n---XI: trapezii ___ symmetric bilaterally\n---XII: Tongue protrudes midline\n-Motor: Normal bulk and tone bilaterally. Strength ___ in\ndeltoids, biceps, triceps.\n-Sensory: deferred\n-DTRs: deferred\n___: Normal on finger to nose test, no intention tremor\nnoted.\n-Gait: narrow based, normal initiation, arm swing\nAppeared somewhat tremulous,\nAbsence of rigidity or spasticity\nAbsence of asterixis \n\nCognition:\n-Wakefulness/alertness: Awake and alert\n-Attention: DOTW backwards w/ 0 errors\n-Orientation: BI, ___ ___\n-Executive function: deferred\n-Memory: immediate memory intact\n-Fund of knowledge: deferred\n-Calculations: 7 quarters = \"$1.75\"\n-Abstraction: watch/ruler = \"numbers\" \"measure\"\n-Visuospatial: deferred\n-Language: Native ___ speaker, no paraphasic errors,\nappropriate to conversation\n\nMental Status:\n-Appearance/Behavior: woman appearing older than stated age,\ntattoos on forearm, adequate hygiene, +PMA, no PMR, wearing\nhospital gown, NAD\n-Attitude: cooperative, slightly inappropriate (mentioned her\n\"booty might be hanging out\" while discussing hospital gown)\n-Mood: \"Pretty happy\"\n-Affect: reactive, mood congruent, occasionally dysphoric while\ndiscussing SI\n-Speech: increased rate though not pressured, interruptible,\nnormal volume and tone\n-Thought process: ___\n-Thought Content:\n---Safety: denies SI, HI, SIB urge\n---Delusions: No evidence of delusions\n---Obsessions/Compulsions: No evidence based on current \nencounter\n---Hallucinations: denies AVH\n-Perceptual disturbances: does not appear to be responding to\ninternal stimuli\n-Insight: poor i.e. frequently replies \"I don't know\" when asked\nf/u questions regarding how she feels \n-Judgment: limited\n\n \nPertinent Results:\n___ 03:40PM URINE ___ \n___\n___ 03:40PM URINE GR ___\n___ 03:40PM URINE ___\n___ 03:40PM URINE ___\n___ 03:40PM URINE ___\n___ 03:40PM URINE ___\n___ 03:40PM URINE ___\n___ 04:15PM PLT ___\n___ 04:15PM ___ \n___ IM ___ \n___\n___ 04:15PM ___ \n___\n___ 04:15PM ___ \n___\n___ 04:15PM ___ this\n___ 04:15PM ___ UREA ___ \n___ TOTAL ___ ANION ___. LEGAL & SAFETY: \nOn admission, the patient signed a conditional voluntary \nagreement (Section 10 & 11) and remained on that level \nthroughout her admission. She was also placed on 15 minute \nchecks status on admission and remained on that level of \nobservation throughout while being unit restricted.\n\n2. PSYCHIATRIC:\n#) Borderline Personality Disorder\nUpon admission to the unit, patient minimized her suicidal \ngesture of placing electrical cord around her neck, as an \nunserious attempt to make her ex boyfriend angry rather than \nreflecting any true suicidal intent. Patient stated this was an \nimpulsive decision rather than a premeditated decision. Patient \ndenied suicidal ideation in the past or present including prior \nto placing electrical cord around her neck. Upon further inquiry \npatient divulged a long history of impulsive decisions made in \nthe context of extreme emotion. Patient endorsed extreme \ninterpersonal hypersensitivity contributing to relationship \ninstability, as well as extreme sensitivity to feeling \nabandoned. \n\nFor patient's reported anxiety and depressed mood, patient was \nstarted on Zoloft 25mg without evidence of adverse side effects. \nZoloft was trialed because she declined to resume taking celexa, \nbegun by her outpatient PCP, out of her concern for lack of \nefficacy.\n\nPatient's mother came in for a family meeting on day of \ndischarge. Patient stated she had been \"happy and positive\" \nthroughout the day but quickly became tearful and \"so \nfrustrated\" during a conversation with mother and treatment team \nin which treatment team discussed the borderline personality \ndisorder diagnosis and its favorable prognosis with appropriate \nDBT treatment. Patient requested to leave the room multiple \ntimes during conversation out of frustration. Patient reiterated \nher commitment to achieving sobriety from alcohol and other \nsubstances; to attend daily AA meetings; to attend ___ \nPartial ___ Program as a bridge to both family therapy and \noutpatient DBT. Ultimately patient was discharged to her \nparents' home. At this time she expressed a \"frustrated\" mood \nwith tearful affect, without evidence of thought \ndisorder/perceptual disturbance/SI/HI. Patient's insight into \nher own condition and need for DBT treatment and sobriety had \nimproved, as had her judgment as evidenced by acceding to her \nmother's request to return to the family home this evening for \nthe latter's comfort.\n\n3. SUBSTANCE USE DISORDERS:\n#) Etoh Use disorder, Cocaine Use Disorder, Cannabis Use \nDisorder, Tobacco Use, Hallucinogen Use:\nPatient received ___ motivational counseling for \netoh use disorder, cocaine use disorder, cannabis use disorder, \nand tobacco use. She declined naltrexone/Acamprosate but \naccepted a daily nicotine patch which was continued upon \ndischarge. Patient was asked to follow up with her PCP ___ \n___ for continued ___ counseling and \ntreatment.\n\n4. MEDICAL\n#) No active or chronic medical conditions.\n\n5. PSYCHOSOCIAL\n#) GROUPS/MILIEU: \nThe patient was encouraged to participate in the various groups \nand milieu therapy opportunities offered by the unit. The \npatient often attended these groups that focused on teaching \npatients various coping skills. On the milieu patient was \npleasant and social with her peers, without behavioral \ndysregulation.\n#) COLLATERAL INFORMATION AND FAMILY INVOLVEMENT\nFamily meeting with mother. Please see \"Brief Hospital Course\" \nabove for details.\n\n#) INTERVENTIONS\n- Medications: Zoloft \n- Psychotherapeutic Interventions: Individual, group, and milieu \ntherapy.\n- Coordination of aftercare: arranged follow up PCP appointment, \n___ Partial Hospital Program, DBT therapists for pt to \nreach out to. \n- Behavioral Interventions (e.g. encouraged DBT skills, ect): \nsupportive psychotherapy \n-Guardianships: n/a\n\nINFORMED CONSENT: The team discussed the indications for, \nintended benefits of, and possible side effects and risks of \nstarting Zoloft, including sexual side effects and GI upset, and \nrisks and benefits of possible alternatives, including not \ntaking the medication, with this patient. We discussed the \npatient's right to decide whether to take this medication as \nwell as the importance of the patient's actively participating \nin the treatment and discussing any questions about medications \nwith the treatment team. The patient appeared able to \nunderstand and consented to begin the medication.\n\nRISK ASSESSMENT & PROGNOSIS\n\nOn presentation, the patient was evaluated and felt to be at an \nincreased risk of harm to herself based upon history of suicidal \ngestures and recent suicidal gesture of placing electrical cord \naround neck, which prompted this admission. Her static factors \nnoted at that time include history of suicide attempts, history \nof substance abuse, age, single status, the presence of a \npersonality disorder. The modifiable risk factors were also \naddressed at that time, and included unpredictable behavior, \nmedication noncompliance, limited social supports, limited \ncoping skills, no established outpatient treatment, active \nsubstance abuse/intoxication, impulsivity, polarized thinking. \nThese were addressed by arranging outpatient psychiatry \n___, encouraging participation in coping skills groups, \nengaging family by way of family meeting, promoting abstinence \nfrom substances and arranging for outpatient DBT treatment upon \ndischarge. Finally, the patient is being discharged with many \nprotective risk factors: ___ nature, ___ \nviewpoint, reality testing ability, positive therapeutic \nrelationship with outpatient primary care provider, lack of \nsuicidal ideation, and strong social supports. Thus, I feel the \npatient does not meet section 12a criteria for risk of harm to \nself/others.\nOverall, the patient is not at an acutely elevated risk of \n___ nor danger to others due to acutely decompensated \npsychiatric illness. \n \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Citalopram 20 mg PO DAILY \n2. ___ (21) (norethindrone ___ estradiol) ___ \noral DAILY \n\n \nDischarge Medications:\n1. Nicotine Patch 14 mg/day TD DAILY \nRX *nicotine 14 mg/24 hour once a day Disp #*14 Patch \nRefills:*0 \n2. Sertraline 25 mg PO DAILY \nRX *sertraline 25 mg 1 tablet by mouth once a day Disp #*30 \nTablet Refills:*0 \n3. ___ (21) (norethindrone ___ estradiol) ___ \noral DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nBorderline Personality Disorder\n\n \nDischarge Condition:\nMental Status: Improving mood with bright affect, linear thought \nprocess w/o responding to internal stimuli, no delusional \nthought content, denies SI/HI/AVH, improving insight and \njudgment. \n\nLevel of consciousness: Awake and alert\n\nAmbulatory status: Ambulates independently without difficulty.\n\n \nDischarge Instructions:\n-Please follow up with all outpatient appointments as listed - \ntake this discharge paperwork to your appointments.\n-Unless a limited duration is specified in the prescription, \nplease continue all medications as directed until your \nprescriber tells you to stop or change.\n-Please avoid abusing alcohol and any drugs--whether \nprescription drugs or illegal drugs--as this can further worsen \nyour medical and psychiatric illnesses.\n-Please contact your outpatient psychiatrist or other providers \nif you have any concerns.\n-Please call ___ or go to your nearest emergency room if you \nfeel unsafe in any way and are unable to immediately reach your \nhealth care providers.\nIt was a pleasure to have worked with you, and we wish you the \nbest of health.\n \nFollowup Instructions:\n___\n" ]

[ "F603", "F17210", "F1290", "F1690", "F419", "F329", "F1010", "F1410", "F4522", "Y906", "Z9114", "Z915", "Z818" ]

[ "F603: Borderline personality disorder", "F17210: Nicotine dependence, cigarettes, uncomplicated", "F1290: Cannabis use, unspecified, uncomplicated", "F1690: Hallucinogen use, unspecified, uncomplicated", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F1010: Alcohol abuse, uncomplicated", "F1410: Cocaine abuse, uncomplicated", "F4522: Body dysmorphic disorder", "Y906: Blood alcohol level of 120-199 mg/100 ml", "Z9114: Patient's other noncompliance with medication regimen", "Z915: Personal history of self-harm", "Z818: Family history of other mental and behavioral disorders" ]

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

[]

[ " \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:\nHeadache \n \nMajor Surgical or Invasive Procedure:\n___ cerebral angiography \n \nHistory of Present Illness:\n___ F with hx reflux re-presenting ___ to ED with the worst \nheadache of her life on a history of known L MCA aneurysm \ndetected 2 days prior. On ___, patient initially presented with \nsudden onset headache. She was with her father who was getting \nadmitted for a medical issue, when she suddenly developed an \nacute sharp occipital headache associated with nausea. She has \nnever had migraines before and never had headaches like this in \nthe past. Normal CT, but concern for possible reversible \ncerebral vasoconstriction syndrome in setting of beading seen on \nCTA of L MCA (in addition to aneurysmal sac). CTA showed no \nhemorrhage but did show a L MCA aneurysmal sac. LP was deferred. \nMRI w/o contrast was performed and showed subtle hyperintense \nsignal in Right superior frontal sulcus possibly representing \nsubarachnoid hemorrhage; it also showed cortical gyriform \nhyperintensity of Left medial parietal occipital lobe with no \nevidence of hemorrhage on GRE nor restricted diffusion on DWI, \ntherefore likely representing subacute infarct. She was \ndischarged home on ___ after observation with follow-up with \nneurosurgery for the incidental L MCA aneurysm.\n \nSince that time she had continuous dull bioccipital headache \nwithout associated symptoms. Then on day of admission ___ at \n1500 she again developed severe sudden onset bioccipital \nthrobbing headache which progressed to involve her entire head. \nIt is associated w nausea and vomiting but no photophobia or \nphonophobia. At onset she denied neck pain/discomfort, vision \nchanges, weakness, tingling/numbness, speech difficulty, or \nconfusion. On arrival to the ED she was reportedly \nneurologically intact. She had another NCHCT which did not show \nany hypodenstity or hemorrhage. She was again evaluated by \nneurosurgery in the ED who recommended a LP for ruling out SAH. \nCSF with WBC 57, RBC 11,451 in tube 1 and WBC 90, RBC 11,947 in \ntube 4. There was reportedly no xanthochromia. At time of \nneurology evaluation around ___, patient was still having \nnausea and vomiting, but overall reported feeling somewhat \nbetter (headache more dull and less severe). She notes loss of \nright visual field around 6P but otherwise no weakness, tingling \nor numbness. CT/CTA was done which showed a new left \nparietal-occipital intraparenchymal hemorrhage measuring \napproximately 3.8 x 2.7cm with a 1 cm rightward midline shift. \nPatient admitted to neuro ICU for close neurological monitoring \nand blood pressure management. \n\n \nPast Medical History:\nHypothyroidism \nGERD\n \nSocial History:\n___\nFamily History:\nNo neurologic family history\n \nPhysical Exam:\nADMISSION EXAM\n\nVitals: HR 90-70s, BP 150-130/50-60, ___, 98% RA \n \nGeneral: Sitting in chair, comfortable appearing, awake \nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx\nPulmonary: Normal work of breathing\nCardiac: RRR, warm, well-perfused\nAbdomen: Soft, non-distended\nExtremities: No ___ edema, right groin access site with dressing\nin place, oozing small amount of blood, non tender, no hematoma.\n2+ DP and ___ pulses. R arm with swelling at midline site \ncompared to L, mild pain.\nSkin: No rashes or lesions noted, warm and well perfused \n \nNeurologic:\n-Mental Status: Opens her eyes to voice, oriented to self, \n___, ___ and ___. No dysarthria. Follows \nsimple axial and appendicular commands \n\n-Cranial Nerves:\nR pupil 2->1, L pupil 1.5->1, EOMs, right homonymous hemianopia,\nface symmetric at rest, L facial droop\n-Motor: slight pronation on the right with some drift \nRUE: able to lift hold, 4+/5 strength \nLUE: able to lift hold, ___ strength \nRLE: able to lift hold, ___ strength \nLLE: able to lift hold, ___ strength \n\n-Sensory: No deficits \n\n-Reflexes: plantar response was flexor bilaterally\n-Coordination: deferred \n\n-Gait: deferred \n\n++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++\n\nDISCHARGE EXAM\n\nGeneral: Sitting in chair, endorses mild headache, awake \nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx\nPulmonary: Normal work of breathing\nCardiac: RRR, warm, well-perfused\nAbdomen: Soft, non-distended\nExtremities: No ___ edema, swelling in right upper arm improved\nSkin: No rashes or lesions noted, warm and well perfused \n \nNeurologic:\n-Mental Status: awake and alert, attends examiner. \n\n-Cranial Nerves:\nPERRL, right homonymous hemianopia, face symmetric at rest, no\ndysarthria, tongue midline \n\n-Motor: no orbiting, no drift, ___ throughout b/l. \n-Sensory: No deficits \n-Coordination: no overt dysmetria but does undershoot\nbilaterally but corrects \n-Gait: Deferred \n\n \nPertinent Results:\nAdmission Labs \n================\n___ 10:00PM ALT(SGPT)-12 AST(SGOT)-17 ALK PHOS-66 TOT \nBILI-0.6\n___ 10:00PM ALT(SGPT)-12 AST(SGOT)-17 ALK PHOS-66 TOT \nBILI-0.6\n___ 03:30PM BLOOD WBC-8.2 RBC-4.35 Hgb-13.6 Hct-38.8 MCV-89 \nMCH-31.3 MCHC-35.1 RDW-14.6 RDWSD-47.8* Plt ___\n___ 03:30PM BLOOD Neuts-43.3 ___ Monos-9.4 Eos-6.4 \nBaso-0.7 Im ___ AbsNeut-3.53 AbsLymp-3.27 AbsMono-0.77 \nAbsEos-0.52 AbsBaso-0.06\n___ 03:30PM BLOOD ___\n___ 03:30PM BLOOD Plt ___\n___ 03:30PM BLOOD Glucose-110* UreaN-13 Creat-0.8 Na-141 \nK-3.9 Cl-102 HCO3-18* AnGap-21*\n___ 10:00PM BLOOD ALT-12 AST-17 AlkPhos-66 TotBili-0.6\n___ 10:00PM BLOOD ANCA-NEGATIVE B\n___ 04:21AM BLOOD TSH-2.0\n___ 10:00PM BLOOD RheuFac-<10 ___ CRP-3.0\n___ 10:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n___ 04:57PM BLOOD ___ pO2-68* pCO2-21* pH-7.57* \ncalTCO2-20* Base XS-0 Comment-GREEN TOP\n___ 04:57PM BLOOD Lactate-2.2*\n\nDischarge labs \n================\n___ 04:00AM BLOOD WBC-10.2* RBC-3.57* Hgb-10.9* Hct-32.8* \nMCV-92 MCH-30.5 MCHC-33.2 RDW-15.9* RDWSD-53.5* Plt ___\n___ 04:00AM BLOOD Plt ___\n___ 09:52AM BLOOD Na-144\n___ 04:00AM BLOOD CK(CPK)-93\n___ 04:00AM BLOOD CK-MB-<1 cTropnT-<0.01\n___ 04:00AM BLOOD Calcium-9.0 Phos-2.6* Mg-2.0\n___ 09:52AM BLOOD Osmolal-296\n\nMicro\n=====\n___ 3:33 pm BLOOD CULTURE Source: Venipuncture. \n Blood Culture, Routine (Pending): No growth to date ___. \n\nImaging \n========\n___ ___ 3pm\n1. No evidence of acute infarction or intra-axial hemorrhage. \nNo CT correlate for findings seen on recent MRI. \n2. Moderate paranasal sinus disease. \n\n___ CT/CTA 10:30pm\nCT HEAD WITHOUT CONTRAST:\nNew, intraparenchymal hemorrhage within the left \nparietal-occipital region, measuring approximately 3.8 x 2.7 cm. \nThere is an approximately 1 cm rightward shift of normally \nmidline structures, with effacement of the left cerebral \nhemisphere sulci, and mass effect on the left lateral ventricle \nand basilar cisterns. Possible early left uncal herniation. \nSubarachnoid blood is seen within the sulci of the left cerebral \nhemisphere, along with mild subdural blood tracking along the \nfalx. Paranasal sinus disease is redemonstrated.\nCTA HEAD:\nThe approximately 6 mm saccular aneurysm of the distal left M1 \nbifurcation is again seen. Mild focal narrowing of the left \nproximal V4 segment (3:183). Otherwise, no evidence of stenosis, \nocclusion, or aneurysm of the vessels of the circle of ___.\nCTA NECK:\nNo evidence of stenosis or occlusion of the carotid or vertebral \narteries.\nFinal report pending.\n\n___ NCHCT\n1. No significant change in the known, left parieto-occipital \nintraparenchymal hemorrhage, with subsequent mass effect, \nincluding stable rightward shift of normally midline structures, \neffacement of the left lateral ventricle, sulci of the left \ncerebral hemisphere, and basilar cisterns. Stable probable left \nuncal herniation. No evidence of new hemorrhage. \n2. Stable left subdural hematoma, with subdural blood tracking \nalong the falx and tentorium. \n3. Stable subarachnoid blood interdigitating between sulci of \nthe left cerebral hemisphere. \n4. Redemonstrated paranasal sinus disease. \n\n___ MRI\nAgain seen is a large left parietal and occipital all hematoma. \nThe lateral ___ of the hematoma appear to have enlarged \nsince the most recent head CT. There are small peripheral areas \nof enhancement seen on the postcontrast images that were not \ndisplaced on the CTA. These raise a concern of an underlying \nvascular abnormality. In this location, the possibility of a \nmycotic aneurysm should be considered. Alternatively, it is \npossible that the enhancement seen reflects enlarged veins \nassociated with the hematoma itself and peripheral breakdown of \nthe blood-brain barrier due to the hematoma. \nThere is subarachnoid hemorrhage, superficial siderosis, or both \nover the left convexity in the vicinity of the hematoma and in \nthe parasagittal right sulci. Again seen and unchanged is a \nsmall convexity left subdural hematoma, unchanged. Also again \nseen and unchanged is a small amount of subdural hematoma along \nthe falx and along the left tentorium. There is medial \ndisplacement of the left uncus with deformity of the adjacent \ncerebral peduncle. \n\n___ Cerebral Angio:\nFusiform aneurysm of the left MCA bifurcation. \nNo evidence of vascular malformation to explain left occipital \nintraparenchymal hematoma\n\n___: TTE\nIMPRESSION: No 2D echocardiographic evidence for endocarditis. \nNormal biventricular wall\nthicknesses, cavity sizes, and regional/global systolic \nfunction.\n\n \nBrief Hospital Course:\nIn brief, Mr. ___ is a ___ right-handed woman with a \npast medical history of hypothyroidism and GERD who presented \nwith recurrent thunderclap headaches was found to have a new \nleft parietal intracranial hemorrhage and mass-effect on the \nleft ventricle and subarachnoid bleed. She was also noted to \nhave a 6 mm aneurysm of the left M1. Presentation is found to \nbe most consistent with reversible cerebral vasoconstriction \nsyndrome. Reversible cerebral vasoconstriction syndromes (RCVS) \nare a group of conditions characterized by reversible narrowing \nand dilatation of the cerebral arteries. The cause of this \nsyndrome is unknown, though the reversible nature of the \nvasoconstriction suggests an abnormality in the control of \ncerebrovascular tone. RCVS can cause intraparenchymal \nhemorrhages, subarachnoid hemorrhages and cerebral edema. \n\nSeveral other differential diagnoses were ruled out. An MRI \nwith MRV did not show any evidence of venous thrombus. A \ncerebral angiography did not show any vascular spasms or \nvascular malformation. Inflammatory markers were negative \nmaking a vasculitis unlikely. A trans-thoracic echocardiogram \nwas negative for any cardioembolic source or evidence of \nendocarditis.\n\nMs ___ received supportive therapy directed towards managing \nher intracranial pressure, blood pressure and headaches. She was \nstarted on oral calcium channel blockers to treat \nvasoconstriction (nimodipine and amlodipine). She will finish a \n20-day course of nimodipine on ___ and will continue \namlodipine. She was started on a prednisone taper which was \ncompleted on ___. She was started on lisinopril with a goal \nblood pressure in the normotensive range. For symptomatic \ntreatment of headaches and neck pain she received Tylenol, \nlidocaine patches and Flexeril as needed. Zofran was given \nscheduled to help mitigate nausea associated with taking \nnimodipine. \n\n+++++++++++++++++++++++++\n\nTransitional issues\n-Continue nimodipine until ___\n-Continue amlodipine\n-Continue other antihypertensive agents\n-Consider starting a statin if LDL continues to be elevated \n(here LDL was 155)\n-Follow up in our stroke clinic\n-Please call ___ for a Neurosurgery follow-up \nappointment with Dr. ___ in 3 months.\n\n+++++++++++++++++++++++++++\n\nAHA/ASA Core Measures for Intracerebral Hemorrhage \n1. Dysphagia screening before any PO intake? (x) Yes - () No. \nIf no, reason why: \n2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not \n(bleeding risk, hemorrhage, etc.) \n3. Smoking cessation counseling given? () Yes - () No [reason \n(x) non-smoker - () unable to participate] \n4. 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?\n(x) Yes - () No \n5. Assessment for rehabilitation and/or rehab services \nconsidered? (x) Yes - () No. If no, why not? (I.e. patient at \nbaseline functional status) \n\n \nMedications on Admission:\nMedications - Prescription\nLANSOPRAZOLE [PREVACID] - Prevacid 30 mg capsule,delayed \nrelease.\none Capsule(s) by mouth once a day\n \nMedications - OTC\nFAMOTIDINE-CA CARB-MAG HYDROX [PEPCID COMPLETE] - Pepcid \nComplete\n10 mg-800 mg-165 mg chewable tablet. one Tablet(s) by mouth once\na day as needed for cough - (___)\n \nDischarge Medications:\n1. amLODIPine 10 mg PO DAILY \n2. Levothyroxine Sodium 75 mcg PO DAILY \n3. Lidocaine 5% Patch 1 PTCH TD DAILY \n4. Lisinopril 7.5 mg PO DAILY \n5. NiMODipine 60 mg PO Q4H \nLast dose on ___. \n6. Nystatin Oral Suspension 5 mL PO TID:PRN thrush \n7. Ondansetron 4 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nReversible cerebral vasoconstriction syndrome\nIntracranial Hemorrhage\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 You were hospitalized due to symptoms of headaches and \nresulting from an acute brain hemorrhage likely due to a \nsyndrome called reversible cerebral vasoconstriction syndrome. \nReversible cerebral vasoconstriction syndromes (RCVS) are a \ngroup of conditions characterized by reversible narrowing and \ndilatation of the cerebral arteries. The cause of this syndrome \nis unknown, though the reversible nature of the vasoconstriction \nsuggests an abnormality in the control of cerebrovascular tone. \nRCVS can cause brain hemorrhages and cerebral edema. You have \nreceived supportive therapy directed towards managing your \nintracranial pressure, blood pressure and headaches. We have \nstarted you on oral calcium channel blockers to treat \nvasoconstriction. Recurrence of an episode of RCVS is rare. You \nrequire rehabilitation with physical-, occupational and speech \ntherapy to recover from your neurological deficits. \n\nPlease continue taking nimodipine, the last dose is on ___.\nPlease continue taking amlodipine and lisinopril\n\n Please take your other medications as prescribed. \n\n Please follow up with Neurology and your primary care physician \nas listed below. \n If 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 Sincerely, \n Your ___ Neurology Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I67841", "I618", "G936", "I609", "E873", "H53461", "E039", "K219", "R402362", "R402142", "R402252", "I671", "Z87891", "R112" ]

[ "I67841: Reversible cerebrovascular vasoconstriction syndrome", "I618: Other nontraumatic intracerebral hemorrhage", "G936: Cerebral edema", "I609: Nontraumatic subarachnoid hemorrhage, unspecified", "E873: Alkalosis", "H53461: Homonymous bilateral field defects, right side", "E039: Hypothyroidism, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "R402362: Coma scale, best motor response, obeys commands, at arrival to emergency department", "R402142: Coma scale, eyes open, spontaneous, at arrival to emergency department", "R402252: Coma scale, best verbal response, oriented, at arrival to emergency department", "I671: Cerebral aneurysm, nonruptured", "Z87891: Personal history of nicotine dependence", "R112: Nausea with vomiting, unspecified" ]

[ "E039", "K219", "Z87891" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nAmbien / Isordil / spironolactone / Entresto / lisinopril / \ndigoxin\n \nAttending: ___.\n \nChief Complaint:\nVAD alarm\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a pleasant ___ y/o man with a complex PMH notable \nfor chronic HFrEF ___ NICMP (EF 15% ___ s/p LVAD \nre-placement in ___, s/p CardioMems placement ___, hx of \nDVT on warfarin, HIV on HAART (CD4 1000 in ___ and two \nrecent admission for N/V and lightheadedness attributed to \ndigoxin toxicity, presenting with a VAD alarm of low battery as \nwell as being found with altered mental status.\n\nPer ED dashboard: ___ male hx LVAD, HIV on HART \npresents for alcohol intoxication and LVAD alarm. Per EMS, the \nfamily called ___ because the low battery alarm was beeping. \nPatient endorses EtOH use and denies other drugs. Per EMS, there \nwas some concern with the social situation at home, with \nmultiple\nbatteries noted to be uncharged and overall living quarters in \ndisarray. Patient also reports falling with loss of \nconsciousness sometime in the last day, unable to clarify \nfurther. Denies chest pain, shortness of breath, fever, chills, \nneck pain, abdominal pain, extremity weakness or paresthesia. \nWhen questioned about why the dressing is not applied, the \npatient states that he does not know.\n\nLVAD is completely exposed without a dressing overlying it. \nThere does not appear to be obvious signs of infection. The \npatient's map is 109 by Doppler. LVAD settings are all within \nnormal limits, it is flashing a low battery alarm. There is one \nbattery in place, the second batteries missing. Heart sounds are\nmechanical. Lung sounds are clear bilaterally.\"\n\nIn the ED initial vitals were: 98.1F, BP 92/d, RR 16, SO2 98% RA\nExam notable for: AOx2, +R-sided nystagmus, reluctant to answer \nquestions, otherwise wnl. \nLabs notable for: \n1. CBC: WBC 7.2, Hgb 13.2, Plts 277 \n2. BMP: Na 143, HCO3 21, BUN 9, Cr 1.2, AG 20, CK 259 \n3. LFTs: LDH 312, otherwise wnl \n4. STox: EtOH 345; negative ASA, APAP, and TCAs\n5. Trop: <0.01\n6. proBNP: 551\n7. Lactate: 3.6 \n8. Coags: INR 2.5 \nImages notable for: \n- CXR IMPRESSION: \"An LVAD appears rotated such that portions of \nit are superimposed on the frontal projection, similar to the \nchest radiographs obtained 2 months prior, but different \ncompared to most other chest radiographs. This appearance is of \nuncertain clinical significance.\"\n- NCHCT IMPRESSION: \"No acute findings.\"\n\nEKG: Poor quality, however sinus tachycardia, no obvious ST \nchanges\nPatient was given: IV Vancomycin 1000mg x1 \nVitals on transfer: \n \nOn the floor, Mr. ___ states that he feels \"well\" but a bit \nthirsty. Denies chest discomfort, shortness of breath, \northopnea, abdominal pain, nausea, vomiting, diarrhea, dysuria, \nor BLE edema. Is unsure what happened last night. States that \nhis brother brought him in for a VAD alarm of \"low voltage\" - \ndenies\nany double disconnection events. When asked re: undressed VAD on \narrival, pt states that he does not know how it happened. Denies \nrecent purulence from the VAD site. When asked re: EtOH, pt \nshrugs his shoulders and states that he does not want to talk \nabout it. \n\nREVIEW OF SYSTEMS: \nPositive per HPI. \nCardiac review of systems is notable for absence of chest pain, \ndyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, \nankle edema, palpitations, syncope, or presyncope. \n\n On further review of systems, denies fevers or chills. Denies \nany prior history of stroke, TIA, deep venous thrombosis, \npulmonary embolism, bleeding at the time of surgery, myalgias, \njoint pains, cough, hemoptysis, black stools or red stools. \nDenies exertional buttock or calf pain. All of the other review\nof systems were negative. \n \nPast Medical History:\n1. Cardiac Risk Factors \n - HTN \n - CKD \n\n2. Cardiac History \n -Dilated nonischemic cardiomyopathy most likely due to\nlymphocytic myocarditis \n -S/p HMII LVAD implant ___ and explant ___ due to\ninfection and pump failure (noncompliance per ___ \n -S/p HMIII implant (___) \n -Pulmonary embolism \n\n3. Other PMHx \n -HIV with variable compliance with HAART \n -DVT left basilic/left brachial ___ on warfarin \n -Syphilis (treated per patient) \n -Seizure (?hypoxemic) \n -Hypothyroidism \n -Necrotizing pancreatitis \n -H/o EtOH use disorder \n \n \nSocial History:\n___\nFamily History:\nNo family history of cardiomyopathy \n \n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION: \n===============================\nVS: 98.4, HR 115, MAP 88 \nGENERAL: Well developed, thin young man in NAD. Oriented x3.\nHEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.\nConjunctiva were pink. No pallor or cyanosis of the oral mucosa.\nNo xanthelasma. \nNECK: Supple. JVP of ~10-12 cm. \nCARDIAC: +Vad hum. No thrills or lifts. \nLUNGS: No chest wall deformities or tenderness. Respiration is\nunlabored with no accessory muscle use. No crackles, wheezes or\nrhonchi. \nABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No\nsplenomegaly. \nEXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or\nperipheral edema. +Warm. \nSKIN: No significant skin lesions or rashes.\n\nDISCHARGE PHYSICAL EXAM: \n========================\nVS: 98.2, HR 112, MAP 82\nGENERAL: Well developed, thin young man in NAD. Oriented x3.\nHEENT: Sclera anicteric. PERRL. EOMI. Conjunctiva pink. No \npallor or cyanosis of the oral mucosa. No xanthelasma. \nNECK: Supple. JVP 7cm \nCARDIAC: +Vad hum. No thrills or lifts. \nLUNGS: No chest wall deformities or tenderness. Respiration is \nunlabored with no accessory muscle use. No crackles, wheezes or \nrhonchi. \nABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No \nsplenomegaly. \nEXTREMITIES: Warm, well perfused. No clubbing, cyanosis. Trace \nperipheral edema.\nSKIN: No significant skin lesions or rashes.\n \nPertinent Results:\nADMISSION LABS: \n===============\n___ 06:56AM BLOOD WBC-7.2 RBC-4.39* Hgb-13.2* Hct-40.1 \nMCV-91 MCH-30.1 MCHC-32.9 RDW-15.2 RDWSD-50.8* Plt ___\n___ 06:56AM BLOOD Neuts-62.4 ___ Monos-7.2 Eos-0.0* \nBaso-0.1 Im ___ AbsNeut-4.49 AbsLymp-2.16 AbsMono-0.52 \nAbsEos-0.00* AbsBaso-0.01\n___ 06:56AM BLOOD ___ PTT-43.7* ___\n___ 06:56AM BLOOD Glucose-103* UreaN-9 Creat-1.2 Na-143 \nK-3.9 Cl-102 HCO3-21* AnGap-20*\n___ 06:56AM BLOOD ALT-26 AST-29 LD(LDH)-312* CK(CPK)-259 \nAlkPhos-72 TotBili-0.2\n___ 06:56AM BLOOD Lipase-17\n___ 06:56AM BLOOD cTropnT-<0.01\n___ 06:56AM BLOOD proBNP-551*\n___ 06:56AM BLOOD Albumin-4.8 Calcium-8.7 Phos-4.0 Mg-2.4\n___ 06:56AM BLOOD ASA-NEG ___ Acetmnp-NEG \nTricycl-NEG\n___ 07:13AM BLOOD Lactate-3.6*\n___ 05:11PM BLOOD Lactate-4.6*\n___ 06:53AM BLOOD Lactate-1.8\n\nDISCHARGE LABS: \n===============\n___ 08:02AM BLOOD WBC-5.8 RBC-4.18* Hgb-12.7* Hct-38.8* \nMCV-93 MCH-30.4 MCHC-32.7 RDW-14.7 RDWSD-48.9* Plt ___\n___ 08:02AM BLOOD ___ PTT-36.3 ___\n___ 08:02AM BLOOD Glucose-130* UreaN-10 Creat-1.4* Na-134* \nK-3.6 Cl-94* HCO3-24 AnGap-16\n___ 08:02AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.1\n\nSTUDIES: \n========\nNCHCT (___)\nNo acute findings.\n\nCXR (___)\nSimilar rotated appearance of the LVAD such that portions of it \nare \nsuperimposed, similar to the chest radiographs obtained of ___, but different compared to most other chest \nradiographs. If the LVAD is \nappropriately functioning, this may be positional, but is \notherwise of \nuncertain clinical significance. \n \nBrief Hospital Course:\nTRANSITIONAL ISSUES:\n=====================\n# HFrEF s/p VAD\n[ ] Increased home Amlodipine to 5mg qd. Please monitor MAPs and \ntitrate PRN\n[ ] Discharged on Warfarin 3.5mg qd x2 days (through ___. \nFollowing up in ___ clinic on ___ for further monitoring and \nrepeat INR. \n[ ] Discharged on Doxycycline x7 days total (___) given \nexposed VAD on arrival\n\n# EtOH Use Disorder, relapsed\n[ ] Started on PO Naltrexone 50mg qd. Pt is to follow up with \n___ vs. PCP for initiation of SQ Naltrexone (Vivitrol)\n[ ] Addiction Psychiatry consulted, recommend ___ IOP. Please \nencourage patient to pursue IOP at ___. \n\n# HIV\nFound to have positive viral load on ___ while on HAART. ID \nfollowing, will need further discussions re: ongoing treatment.\n\nBRIEF SUMMARY: \n==============\nMr. ___ is a ___ w niCMP/HFrEF s/p ___ III LVAD and \nCardioMems, HIV (CD4 1000), h/o EtOH use disorder, recent \nhospitalizations for nausea, n/v/lightheadedness secondary to \ndigoxin toxicity, presenting to the ED with altered mental \nstatus, EtOH intoxication, and found to have VAD dressing \nremoved.\n\n# CORONARIES: Unknown\n# PUMP: LVEF 15%\n# RHYTHM: Sinus tachycardia\n\nACTIVE ISSUES: \n============== \n# Heart failure with reduced ejection fraction\n# RV failure\n# Non-ischemic dilated cardiomyopathy\nNon-ischemic dilated cardiomyopathy (EF 15% ___ attributed \nto prior lymphocytic myocarditis. S/p HMIII LVAD ___ as \nbridge to transplant), ___ ICD (___). Currently \nwarm and dry. Presenting in the setting of EtOH intoxication; \nfound to have VAD dressing removed. Pt also noted to have high \nMAPs, likely in the setting of medication non-adherence. He was \ncontinued on his home ASA 81mg. \n- Continue ASA 81mg qd\n- PRELOAD: Continued home torsemide 100 mg PO qAM; Torsemide 60 \nmg PO qPM PRN weight changes\n- AFTERLOAD: Continued Hydralazine 100 mg tid, Captopril 6.25 mg \nq8h, and increased his home Amlodipine to 5mg daily given \npersistently elevated MAPs.\n- NHBK: Continued home eplerenone 50 mg BID. Not on a BB due to \nRV dysfunction.\n- INOTROPE: Continued holding his home digoxin (discontinued \nduring prior admission due to digoxin toxicity)\n- VAD: Received daily dressing changes x3 days (___) without \nevidence of purulence - as such, transitioned back to \n___ dressing changes. He is to follow up in the ___ \nclinic on ___. He otherwise received empiric IV \nVancomycin q8 hours x48 hours given unclear\nduration of time that VAD was exposed, after which he was \ntransitioned to PO doxycycline x7 days (___). Otherwise his \nINR goal was ___ mg and his Warfarin was dosed daily; he is \nbeing discharged on 3.5mg Warfarin on ___ and ___, and is to \nfollow up with the ___ clinic on ___ for an INR check. \n\n# EtOH intoxication\n# H/o EtOH Use Disorder, now relapsed \nPt presented with altered mental status, found to have VAD \ndressing removed and VAD exposed. Serum EtOH 345, thus AMS \nlikely in the setting of EtOH intoxication. Remainder of \nSTox/UTox negative. Of note, has h/o EtOH misuse in the past \nhowever no complicated withdrawals noted in OMR. NCHCT without \nacute findings. Relapsed alcohol use disorder 2 months prior. \nDid not develop withdrawal symptoms while hospitalized. \nAddiction Psychiatry was consulted, who ultimately recommended \nPO Naltrexone while awaiting SQ Vivitrol as an outpatient with \n___ vs. PCP. Patient in agreement with the plan. He was \notherwise started on thiamine and folic acid, and was continued \non his home multivitamin w/ minerals.\n\n# Lactic acidosis - resolved\nPresenting with elevated Lactate to 3.6, which peaked to 4.6 \nbefore self-resolving. Overall suspect a Type B lactic acidosis \nin the setting of EtOH and HIV. \n\nCHRONIC ISSUES: \n================\n# History of PICC associated DVT\n# History of LV thrombus\n# History of RIJ thrombus\nMonitored daily INRs and dosed Warfarin accordingly. As per \nabove, is being discharge on 3.5mg Warfarin for ___ and ___ \nafter which he will follow up with the ___ clinic on ___ for an \nINR check.\n\n# Sinus tachycardia\nChronic and at baseline (110s-120s). Monitored on telemetry.\n\n# HIV: On HAART. As of ___, viral load 2.0, CD4 747, and CD8 \n882. Continued his home Descovy and Dolutegravir. Of note, his \nVL was previously undetectable - ID is following as an \noutpatient.\n\n# Chronic Back/Chest Pain: \nPreviously noted to have L upper back pain since LVAD placement,\nsimilar symptoms with previous LVAD placement, felt to be likely\npostoperative. Continued his home APAP and Gabapentin.\n\n# Gout \nContinued home allopurinol\n\nCORE MEASURES: \n============== \n# CODE STATUS: Full, presumed\n# CONTACT:\nName of health care proxy: ___ \nRelationship: Brother \nPhone number: ___ \nCell phone: ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line \n2. Amoxicillin ___ mg PO ONCE Prior to dental work \n3. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever \n4. Captopril 6.25 mg PO TID \n5. Gabapentin 600 mg PO TID \n6. Allopurinol ___ mg PO DAILY \n7. Prochlorperazine 5 mg PO Q6H:PRN Nausea/Vomiting - Second \nLine \n___ MD to order daily dose PO DAILY16 \n9. amLODIPine 2.5 mg PO DAILY \n10. HydrALAZINE 100 mg PO Q8H \n11. Enoxaparin Sodium 80 mg SC BID PRN instructed by VAD team \nStart: ___, First Dose: Next Routine Administration Time \n12. Ranitidine 150 mg PO BID \n13. Dolutegravir 50 mg PO DAILY \n14. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB \nPO DAILY \n15. Torsemide 100 mg PO QAM \n16. Torsemide 60 mg PO QPM:PRN weight gain \n17. Eplerenone 50 mg PO BID \n18. Multivitamins W/minerals 1 TAB PO DAILY \n19. Potassium Chloride 40 mEq PO BID \n20. Aspirin 81 mg PO DAILY \n21. TraZODone 50 mg PO QHS \n\n \nDischarge Medications:\n1. Doxycycline Hyclate 100 mg PO BID Duration: 5 Days \nRX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day \nDisp #*11 Tablet Refills:*0 \n2. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n3. Naltrexone 50 mg PO DAILY \n4. 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 \n5. amLODIPine 5 mg PO DAILY \nRX *amlodipine 5 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n6. Warfarin 3.5 mg PO ONCE Duration: 1 Dose \n7. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever \n8. Allopurinol ___ mg PO DAILY \n9. Amoxicillin ___ mg PO ONCE Prior to dental work \n10. Aspirin 81 mg PO DAILY \n11. Captopril 6.25 mg PO TID \n12. Dolutegravir 50 mg PO DAILY \n13. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB \nPO DAILY \n14. Enoxaparin Sodium 80 mg SC BID PRN instructed by VAD team \nStart: ___, First Dose: Next Routine Administration Time \n15. Eplerenone 50 mg PO BID \n16. Gabapentin 600 mg PO TID \n17. HydrALAZINE 100 mg PO Q8H \n18. Multivitamins W/minerals 1 TAB PO DAILY \n19. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First \nLine \n20. Potassium Chloride 40 mEq PO BID \nHold for K > \n21. Prochlorperazine 5 mg PO Q6H:PRN Nausea/Vomiting - Second \nLine \n22. Ranitidine 150 mg PO BID \n23. Torsemide 100 mg PO QAM \n24. Torsemide 60 mg PO QPM:PRN weight gain \n25. TraZODone 50 mg PO QHS \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS: \nNonischemic cardiomyopathy/heart failure with reduced ejection \nfraction s/p LVAD and CardioMEMS implantation \n\nSECONDARY DIAGNOSIS: \nAlcohol use disorder, relapsed \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 taking care of you at ___ \n___. \n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n- You were admitted to the hospital because your VAD was \nalarming \n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n- You received antibiotics since your VAD was left undressed \nwhen you first came into the hospital and we wanted to ensure \nthat any possible infection of your VAD's drive-line was \nprevented. \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- Weigh yourself every morning, call your cardiologist Dr. \n___ at ___ if your weight goes up more than \n3 lbs. Please make sure to take your Torsemide 60mg in the \nevening if this occurs. \n- Seek medical attention if you have new or concerning symptoms \nor you develop fever, chills, chest pain, swelling in your legs, \nabdominal distention, or shortness of breath at night. \n- Your discharge weight: 175.71 lbs. You should use this as your \nbaseline after you leave the hospital. \n\nWe wish you the best!\nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I130", "I5020", "Z95811", "E872", "N189", "I428", "F10129", "Z21", "Z86718", "Z7901", "R000", "G8929", "M549", "R079", "M109", "Z86711", "Z95810", "Z9114" ]

[ "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5020: Unspecified systolic (congestive) heart failure", "Z95811: Presence of heart assist device", "E872: Acidosis", "N189: Chronic kidney disease, unspecified", "I428: Other cardiomyopathies", "F10129: Alcohol abuse with intoxication, unspecified", "Z21: Asymptomatic human immunodeficiency virus [HIV] infection status", "Z86718: Personal history of other venous thrombosis and embolism", "Z7901: Long term (current) use of anticoagulants", "R000: Tachycardia, unspecified", "G8929: Other chronic pain", "M549: Dorsalgia, unspecified", "R079: Chest pain, unspecified", "M109: Gout, unspecified", "Z86711: Personal history of pulmonary embolism", "Z95810: Presence of automatic (implantable) cardiac defibrillator", "Z9114: Patient's other noncompliance with medication regimen" ]

[ "I130", "E872", "N189", "Z86718", "Z7901", "G8929", "M109" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \n___\n \nAttending: ___\n \nChief Complaint:\nAltered mental status\n \nMajor Surgical or Invasive Procedure:\n___: Sedated MRI\n___: ___ guided drainage of epidural abscess\n___: TEE\n___: Right PICC placement\n___: TEE\n\n \nHistory of Present Illness:\n___ year old male with history of cirrhosis in setting of \nsarcoidosis (inactive on transplant list, hx of HE and portal \nHTN s/p TIPS), early ___ Disease, and recent admission \nwith GPC bacteremia complicated by discitis/osteomyelitis, \nrespiratory arrest now presenting from rehab with confusion, \nweakness, and falls. \n\nPer the notes, patient had two falls today and was found on his \nhands/knees for both. He has had increased confusion though the \ntimecourse is unknown. He has been compliant with lactulose and \nhaving diarrhea. He has had some left thigh weakness and upper \nthoracic pain over the past ___t ___ today, \nhad noncon head CT which was negative and CXR which showed \n?infiltrate. Transferred here for Hepatology evaluation as he is \nfollowed very closely here. No cough, chills, rhinorrhea, abd \npain, nausea, vomiting, dysuria, frequency, CP, SOB, or leg \nswelling. \n\nOn arrival to the ED, initial vitals were 99.4 93 136/91 18 97% \nRA \nExam was notable for:\n\"jaundiced\ncomfortable, no distress\nno spinal tenderness\nFROM both shoulders\nFROM knees and hips\nabd soft/nt/nd\nlungs CTA\"\n\nLabs significant for elevated LFTs down from prior ALT 7, AST \n61, Alk phos 485 (from 247), Tbili 2.9 (from 4.3). Lipase 64. \nLactate 1.2 \nUA unremarkable\nHepatology was consulted and recommended infectious workup and \nadmit to E-T for further management. Patient had RUQ U/S with \nDoppler which showed main portal vein and TIPS but was limited \nsecondary to poor patient participation. He did not have any \nascites to tap.\n\nLast CRP was 73.2 on ___. Since the patient did not have \ndebridement and has vertebral involvement the course of \ncefazolin was extended for to minimum of 8 weeks with tentative \nend date of ___.\n \nOn the floor, patient is oriented to self and ___ \n___ not oriented to year. Able to answer limited \nquestions with poor attention. Denies headache, chest pain, SOB, \nabdominal pain, dysuria. Does admit to leg cramps. Also with \nlower back pain at times. No fever or chills. Of note, his \nmedication list from rehab facility is missing many medications \nhe was discharged on including lactulose and rifaximin as well \nas gabapentin. He was started on tramadol on ___. \n \nPast Medical History:\n- Sarcoidosis \n- Cirrhosis secondary to sarcoidosis, complicated by varices and \nascites, s/p TIPS on ___, on the transplant list \n- Chronic diarrhea \n- Cutaneous melanoma, resected in ___ \n- Depression, well controlled with sertraline \n- Hyperlipidemia \n- MSSA osteomyelitis and discitis\n \nSocial History:\n___\nFamily History:\nThere is no known family history of liver disease. His brother \nhas rheumatoid arthritis. Otherwise no family history of \nautoimmune disease. \n \nPhysical Exam:\n======================\nADMISSION EXAM: \n======================\nVital Signs: 98.6 PO 128 / 74 80 18 96 RA \nGeneral: Alert, intermittently restless \nHEENT: dry mucus membranes, oropharynx clear, EOMI, PERRL, neck \nsupple\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nLungs: Clear to auscultation bilaterally, decreased breath \nsounds at bases bilaterally\nAbdomen: Soft, non-tender, non-distended, bowel sounds present, \nno rebound or guarding \nBack: no tenderness to palpation, No saddle anesthesia, good \nrectal tone \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nNeuro: CNII-XII intact, ___ strength upper extremities, ___ \nstrength RLE and ___ in LLE. grossly normal sensation\n\n======================\nDISCHARGE EXAM: \n======================\nVital Signs: 98.8 137/73 84 18 98 RA \nGeneral: Lying in bed, AOx3, in no acute distress\nHEENT: Bruise under left eye, anicteric sclerae, MMM\nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nLungs: Clear to auscultation bilaterally\nAbdomen: Soft, non-tender, non-distended, bowel sounds present, \nno rebound or guarding \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nNeuro: AOx3, face symmetric, speech fluent, baseline tremor, \ngait deferred\nACCESS: Right PICC\n\n \nPertinent Results:\n===================\nADMISSION LABS:\n===================\n___ 11:30PM WBC-6.4# RBC-2.99* HGB-8.7* HCT-29.5* MCV-99* \nMCH-29.1 MCHC-29.5* RDW-15.4 RDWSD-55.7*\n___ 11:30PM NEUTS-83.0* LYMPHS-7.0* MONOS-6.4 EOS-2.5 \nBASOS-0.6 IM ___ AbsNeut-5.32 AbsLymp-0.45* AbsMono-0.41 \nAbsEos-0.16 AbsBaso-0.04\n___ 11:30PM PLT COUNT-109*\n___ 11:30PM ALBUMIN-2.4*\n___ 11:30PM LIPASE-64*\n___ 11:30PM ALT(SGPT)-7 AST(SGOT)-61* ALK PHOS-485* TOT \nBILI-2.9*\n___ 11:40PM LACTATE-1.2\n___ 02:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 \nGLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM \n\n\n===================\nPERTINENT RESULTS\n===================\nLABS\n===================\n___ 05:16AM BLOOD CRP-113.5*\n___ 06:10AM BLOOD CRP-44.3*\n___ 06:35AM BLOOD CRP-42.4*\n___ 06:11AM BLOOD CRP-49.6*\n\n===================\nIMAGING\n===================\nRUQ US (___):\n1. Limited exam due to patient cooperation.\n2. The main portal vein and TIPS appear patent, however reliable \nvelocities\ncould not be obtained due to difficulties with positioning from \nAMS.\n3. Cirrhosis and mild ascites.\n===\nCXR (___):\nComparison to ___. Minimal decrease in severity of \nthe pre-existing pulmonary edema. The left PICC line has been \nremoved. Moderate cardiomegaly persists. No pleural effusions. \n No pneumonia.\n===\nMRI Cervical and Thoracic Spine (___):\n1. Nondiagnostic study due to patient motion with only limited \nsequences of the cervical spine obtained. \n2. However, on localizer images of the lumbar spine, there is \napparent \nincreased T2 hyperintense signal of the L3-L4 disc, not seen on \nexamination of ___ on comparable localizer images \nwith possible ventral epidural soft tissue at these levels. \nThis is highly suspicious for discitis osteomyelitis in the \nclinical context and further imaging evaluation when clinically \nfeasible is recommended for confirmation of the finding. \n3. Additional findings described above. \n===\nCT C-Spine, L-Spine, T-Spine ___\n1. There is L3-L4 disc space infection with moderate \nparavertebral edema, left psoas muscle abscesses, and probable \nepidural phlegmon causing moderate to severe central canal \nnarrowing at this level. CT exam may not be sensitive in \ndetecting epidural abscess, and MRI of lumbar spine with and \nwithout gadolinium would be helpful in further evaluation of \nepidural space if\nclinically indicated.\n2. Fragmentation and fracture of L3 vertebral body.\n3. There are multilevel degenerative changes in the lumbar \nspine, as above\n===\nMRI Cervical and Thoracic Spine (___):\n1. Evaluation of the cervical and lumbar spine is limited by \nmotion artifact.\n2. Signal abnormalities in the C4-C5 endplates and in the \nposterior aspect of the C4-C5 disc are unchanged compared to ___, compatible with degenerative changes versus \nsequela of prior infection. Otherwise, no evidence for \ndiscitis/ osteomyelitis in the cervical spine. No evidence for \ncervical epidural or paravertebral collection.\n3. No evidence for diskitis, osteomyelitis,, epidural, or \nparavertebral collection in the thoracic spine.\n4. Compared to ___, there is new \ndiscitis/osteomyelitis at L3-L4. While there is no definite rim \nenhancement of the fluid in the L3-L4 disc, a developing \nintradisc abscess cannot be excluded.\n5. Circumferential epidural phlegmon at L3 and L4 with severe \nthecal sac narrowing and crowding of the intrathecal nerve \nroots.\n6. Small prevertebral phlegmon at L3 and L4.\n7. Extensive edema and contrast enhancement of the left psoas \nfrom L3 through S2 and beyond the inferior margin of the images, \nwith questionable microabscesses from L5 through S2. Less \nextensive edema and contrast enhancement of the right psoas from \nL3 through L5 without evidence for an abscess.\n8. The thecal sac at L4-L5 and L5-S1 is narrowed mainly by \nepidural lipomatosis, but also by degenerative changes.\n9. Interstitial septal thickening in the visualized lung \nparenchyma, suggesting pulmonary edema , as well as small right \nand trace left pleural effusions with bibasilar atelectasis, \nsimilar to the thoracic spine CT from ___.\n===\nCT A/P ___\nIMPRESSION: \n1. Re- demonstrated are findings compatible with \ndiscitis/osteomyelitis with surrounding phlegmon at the L3-4 \nlevel, better evaluated on the prior MRI from ___. \nThere is mild asymmetric enlargement and heterogeneity of the \nleft psoas muscle with tiny areas of phlegmon. No drainable \nfluid collections are seen. \n2. Cirrhotic morphology of the liver with small volume ascites \nand \nsplenomegaly. No focal lesions are seen, however evaluation for \nhepatic \nmasses are limited on single phase examination. Mildly enlarged \ngastrohepatic lymph node is likely reactive to portal \nhypertension. \n3. Stable 6 mm cystic lesion in the body of the pancreas, most \nlikely \nrepresenting a side-branch IPMN. \n===\nCT INTERVENTIONAL ___\n1. Again seen is destructive change and irregularity within the \nL3-L4 disc \nspace, consistent with recent findings from contrast and CT and \nMRI. The site was accessed directly with a 17 gauge needle, \nwith aspiration of cloudy fluid and core biopsy for tissue for \nmicrobiology. \n2. No discrete areas of hyperdensity could be discerned within \nthe left psoas muscle which is diffusely enlarged, consistent \nwith extension of the L3-L4 process into the psoas muscle. \nUsing landmarks and referencing prior CT/MRI images, the left \npsoas muscle is access and 3 separate locations, and no discrete \nfluid could be aspirated. \n===\nTTE ___\n1) Probable vegetation on right coronary cusp of the aortic \nvalve (clips 3, 30, 77). Confidence of the finding is limited \nsince the echo density is not seen in all views, was present on \necho from ___ and does not induce any valvular dysfunction. \nNo specific echocardiographic evidence of abscess seen. Suggest \nTEE to follow up finding as mentioned above likelihood of \nartifact high however with described high pretest probabilty \ncannot rule out endocarditis. \n2) Mild symmetric left ventricular hypertrophy with normal \nbiventricular regional/global systolic function and grade II \ndiastolic dysfunction. \nCompared with the prior study (images reviewed) of ___, \nfindings are similar. \n===\nTEE ___\nThe TEE probe could not be passed into the esophagus due to \nresistance in their upper esophgeal/very posterior pharyngeal \narea. \nRecommend barium swallow to exclude a Zenker's diverticulum. If \nnegative, can re-attempt TEE. \n===\nBarium Esophagram (___): Minimal esophageal dysmotility, \notherwise normal esophagram. No stricture or diverticulum.\n===\nTEE (___): No spontaneous echo contrast or thrombus is seen \nin the body of the left atrium/left atrial appendage or the body \nof the right atrium/right atrial appendage. No atrial septal \ndefect is seen by 2D or color Doppler. Overall left ventricular \nsystolic function is normal (LVEF>55%). There are simple \natheroma in the arch, descending and abdominal aorta. The aortic \nvalve leaflets (3) are mildly thickened. No masses or \nvegetations are seen on the aortic valve. No aortic \nregurgitation is seen. The mitral valve leaflets are \nstructurally normal. No mass or vegetation is seen on the mitral \nvalve. Trivial mitral regurgitation is seen. \nIMPRESSION: No valvular pathology or pathologic flow identified.\n\n================\nMICROBIOLOGY\n================\n___ BLOOD CULTURE Blood Culture, Routine-PENDING \nINPATIENT \n___ BLOOD CULTURE Blood Culture, Routine-PENDING \nINPATIENT \n___ BLOOD CULTURE Blood Culture, Routine-PENDING \nINPATIENT \n___ BLOOD CULTURE Blood Culture, Routine-PENDING \nINPATIENT \n___ ABSCESS GRAM STAIN-FINAL; FLUID \nCULTURE-FINAL; ANAEROBIC CULTURE-FINAL; FUNGAL \nCULTURE-PRELIMINARY INPATIENT \n___ BLOOD CULTURE Blood Culture, Routine-FINAL \nINPATIENT \n___ BLOOD CULTURE Blood Culture, Routine-FINAL \nINPATIENT \n___ BLOOD CULTURE Blood Culture, Routine-FINAL \nINPATIENT \n___ BLOOD CULTURE Blood Culture, Routine-FINAL \nINPATIENT \n___ BLOOD CULTURE Blood Culture, Routine-FINAL \nINPATIENT \n___ BLOOD CULTURE Blood Culture, Routine-FINAL \nINPATIENT \n___ URINE URINE CULTURE-FINAL {YEAST} INPATIENT \n___ BLOOD CULTURE Blood Culture, Routine-FINAL \nEMERGENCY WARD \n\n================\nDISCHARGE LABS\n================\n___ 06:14AM BLOOD WBC-4.0 RBC-2.30* Hgb-6.9* Hct-21.8* \nMCV-95 MCH-30.0 MCHC-31.7* RDW-16.4* RDWSD-55.8* Plt Ct-96*\n___ 06:14AM BLOOD ___ PTT-37.9* ___\n___ 06:14AM BLOOD Glucose-93 UreaN-11 Creat-0.7 Na-139 \nK-3.4 Cl-108 HCO3-21* AnGap-13\n___ 06:14AM BLOOD ALT-16 AST-74* AlkPhos-627* TotBili-2.3*\n___ 06:14AM BLOOD Calcium-7.7* Phos-3.4 Mg-1.9\n___ 06:14AM BLOOD Vanco-20.3*\n \nBrief Hospital Course:\nMr. ___ is a ___ y/o man with history of cirrhosis in setting \nof sarcoidosis (inactive on transplant list, history of HE and \nportal HTN s/p TIPS), early ___ Disease, and recent \nadmission for MSSA bacteremia complicated by \ndiscitis/osteomyelitis treated with cefazolin (intolerant of \nnafcillin due to development of AIN), who presented from rehab \nwith confusion, lethargy, and falls. His mental status improved \ndramatically with frequent lactulose and with withholding opiate \nmedications and tramadol to treat his pain. Given his prior \nhistory of discitis and uptrending CRP, he underwent MRI spine \n(under anesthesia), which demonstrated new \ndiscitis/osteomyelitis at L3-L4 with an epidural phlegmon, as \nwell as a left psoas abscess. He was evaluated by orthopedic \nsurgery who recommended no surgical intervention as he had no \nneurologic deficits. He subsequently underwent ___ guided \ndrainage of the epidural abscess. TTE demonstrated possible \naortic valve vegetation, but ___ did not show any aortic valve \nvegetation. He was initially maintained on cefazolin but \nswitched to vancomycin per ID recommendations (all blood \ncultures were negative), course to be determined by ID as an \noutpatient.\n\n==============\nACTIVE ISSUES\n==============\n# Left psoas abscesses \n# MSSA blood stream infection/discitis/osteomyelitis: The \npatient had a recent admission for MSSA bacteremia complicated \nby discitis/osteomyelitis treated with cefazolin (intolerant of \nnafcillin due to development of AIN). He was initially continued \non cefazolin. Given his prior history of discitis and uptrending \nCRP, he underwent MRI spine (under anesthesia), which \ndemonstrated new discitis/osteomyelitis at L3-L4 with an \nepidural phlegmon, as well as a left psoas abscess. He was \nevaluated by orthopedic surgery who recommended no surgical \nintervention as he had no neurologic deficits. He subsequently \nunderwent ___ guided drainage of the epidural abscess. TTE \ndemonstrated possible aortic valve vegetation, but ___ did not \nshow any aortic valve vegetation. He was initially maintained on \ncefazolin but switched to vancomycin per ID recommendations (all \nblood cultures were negative), course to be determined by ID as \nan outpatient.\n\n# Toxic metabolic encephalopathy: Patient presented with \nsomnolence, worsening of his baseline tremor with choreiform \nmovements, and occasional hallucinations. Of note, he had \npossibly been receiving opiates or tramadol at his \nrehabilitation facility due to worsening pain in his legs. It \nwas unclear if he had been receiving lactulose, although the \npatient's wife reported he had been receiving lactulose. His \nmental status improved dramatically with frequent lactulose, \nwithholding opiate medications and tramadol to treat his pain, \nand treatment of his infection as above.\n\n# Movement disorder: Patient with tremor and choreiform-like \nmovements. Diagnosed with \"early ___ at an outside \nhospital several months ago. Neurology was consulted, and \nconsidered ___ Disease and Stiff Man syndrome, but \nthought that patient's neurologic symptoms (abnormal movements \nand clonus) were likely\nrelated to nerve irritation from infection. The patient should \nfollow up with neurology as an outpatient.\n\n# Cirrhosis: Secondary to hepatic sarcoid. Currently inactive on \ntransplant list. History of hepatic encephalopathy, portal \nhypertension s/p TIPS. He was continued on lactulose and \nrifaximin. \n\n# Leg pain: Patient with bilateral neuropathic leg pain thought \nto be related to his abscesses and osteomyelitis as above. He \nwas started on gabapentin 100 mg TID and capsaicin cream to good \neffect.\n\n================\nCHRONIC ISSUES\n================\n# Anemia: Macrocytotic. No evidence of active bleed. Stable \ninpatient.\n# Thrombocytopenia: Similar to baseline. Likely related to \ncirrhosis.\n# Hyperlipidemia: He was continued on home atorvastatin.\n# Depression: He was continued on home sertraline.\n\n===================\nTRANSITIONAL ISSUES\n===================\n- Vancomycin 750 mg Q12H ongoing for treatment of abscess, \nosteomyelitis, discitis, acute blood stream infection. OPAT will \ndetermine end date as outpatient.\n- The patient should have repeat CT abdomen/pelvis in ___ weeks \nto ensure resolution of infection.\n-- LABS: Patient will need weekly labs drawn beginning on \n___. Please draw: CBC with differential, INR, BMP, LFTs, \nESR, CRP. These labs should be Faxed to 2 numbers: 1) Dr. ___, \n___, FAX: ___ and 2) ___ CLINIC, FAX: \n___ \n- Please also check a vancomycin trough on the evening of ___ \nbefore the evening dose. Please FAX this to ___ CLINIC, \nFAX: ___.\n- Started on 100 mg gabapentin TID and capsaicin ointment as \nneeded for neuropathic thigh pain (felt to be due to abscesses \nand osteomyelitis). Consider increasing gabapentin as tolerated \nif continues to have pain.\n- Please avoid opiate and tramadol as they contributed to the \npatient's delirium.\n- Code Status: Full\n- HCP: Contact info: ___ Relationship: Wife Phone: \n___ \n \n___ on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze \n2. CeFAZolin 2 g IV Q8H \n3. Lidocaine 5% Patch 1 PTCH TD QPM \n4. Poly-Iron (polysaccharide iron complex) 150 mg iron oral BID \n5. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n6. Ascorbic Acid ___ mg PO BID \n\n \nDischarge Medications:\n1. Acetaminophen 500 mg PO Q6H:PRN Pain - Moderate \n2. Capsaicin 0.025% 1 Appl TP TID \n3. Gabapentin 100 mg PO TID \n4. Lactulose 30 mL PO TID \n5. Magnesium Oxide 140 mg PO BID \n6. Rifaximin 550 mg PO BID \n7. Vancomycin 750 mg IV Q 12H \n8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze \n9. Ascorbic Acid ___ mg PO BID \n10. Lidocaine 5% Patch 1 PTCH TD QPM \n11. Poly-Iron (polysaccharide iron complex) 150 mg iron oral \nBID \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis:\n- Osteomyelitis/Discitis\n- Acute blood stream infection\n- Left psoas abscess\n\nSecondary Diagnosis:\n- Toxic metabolic encephalopathy\n- Movement disorder\n- Sarcoidosis\n- Cirrhosis\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt has been a pleasure taking care of you at ___.\n\nWhy was I here?\n- You were admitted to ___ due to confusion, feeling tired and \nfalling in rehab.\n\nWhat was done for me here?\n- You were given lactulose and your pain medications were \nstopped and this improved your mental status.\n- You had an MRI which showed a new location of infection in \nyour spine with an abscess. This was drained by interventional \nradiology.\n- You were seen by infectious disease and given intravenous \nantibiotics (vancomycin).\n\nWhat should I do when I leave the hospital?\n- Continue to take your gabapentin for thigh pain.\n- You will be at rehab to regain strength and to continue your \nIV antibiotics.\n\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "G061", "K6812", "G92", "D696", "R7881", "M4626", "K7469", "G259", "M4646", "D869", "R197", "Z85820", "F329", "E785" ]

[ "G061: Intraspinal abscess and granuloma", "K6812: Psoas muscle abscess", "G92: Toxic encephalopathy", "D696: Thrombocytopenia, unspecified", "R7881: Bacteremia", "M4626: Osteomyelitis of vertebra, lumbar region", "K7469: Other cirrhosis of liver", "G259: Extrapyramidal and movement disorder, unspecified", "M4646: Discitis, unspecified, lumbar region", "D869: Sarcoidosis, unspecified", "R197: Diarrhea, unspecified", "Z85820: Personal history of malignant melanoma of skin", "F329: Major depressive disorder, single episode, unspecified", "E785: Hyperlipidemia, unspecified" ]

[ "D696", "F329", "E785" ]

[]

[ " \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:\nEGD ___\n\nattach\n \nPertinent Results:\nLABS ON ADMISSION:\n___ 12:00AM BLOOD WBC-6.7 RBC-3.04* Hgb-8.8* Hct-27.8* \nMCV-91 MCH-28.9 MCHC-31.7* RDW-18.8* RDWSD-63.7* Plt Ct-62*\n___ 12:00AM BLOOD Glucose-135* UreaN-11 Creat-1.1 Na-132* \nK-3.8 Cl-95* HCO3-31 AnGap-6*\n___ 12:00AM BLOOD ALT-23 AST-67* LD(LDH)-299* AlkPhos-143* \nTotBili-3.0*\n\nLABS ON DISCHARGE:\n___ 04:49AM BLOOD WBC-4.4 RBC-2.70* Hgb-8.1* Hct-28.1* \nMCV-104* MCH-30.0 MCHC-28.8* RDW-19.9* RDWSD-71.4* Plt Ct-72*\n___ 04:49AM BLOOD Glucose-116* UreaN-7 Creat-0.8 Na-135 \nK-3.7 Cl-104 HCO3-24 AnGap-7*\n___ 04:49AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.0\n\nMICROBIOLOGY RESULTS:\n\n___ 10:54 pm URINE Source: ___. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n ENTEROCOCCUS SP.. >100,000 CFU/mL. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ENTEROCOCCUS SP.\n | \nAMPICILLIN------------ =>32 R\nLINEZOLID------------- 2 S\nNITROFURANTOIN-------- 256 R\nTETRACYCLINE---------- <=1 S\nVANCOMYCIN------------ =>32 R\n\nIMAGING: \n\n___: FINDINGS: \n There is no evidence of fracture, acute \ninfarction,hemorrhage,edema,or mass. \nThere is prominence of the ventricles and sulci suggestive of \ninvolutional \nchanges, greater than expected for age. \n \nThe visualized portion of the paranasal sinuses, mastoid air \ncells, and middle \near cavities are clear. The visualized portion of the orbits \nare normal. \n \nIMPRESSION: \n1. No evidence of acute intracranial abnormality. \n \nCT Abd/Pelvis: \n1. Patent TIPS. \n2. Interval resolution of previously seen portal vein \nthrombosis. There is \nunchanged chronic thrombosis of a segment of the SVC, however \nadditional \ncollateral branches of the SMV which previously contained \nthrombus on CT on ___ are now patent. \n3. Interval resolution of ascites, bowel edema, and mesenteric \nedema. \n4. Cirrhosis with splenomegaly. \n5. No significant change in two liver lesions in segment II and \nVIII which \npreviously demonstrated arterial hyperenhancement but are less \nconspicuous on \ntoday's study. Continued attention on follow-up is recommended. \n\n \n\n \nBrief Hospital Course:\nBRIEF HOSPITAL COURSE:\n======================\nPatient is a ___ male with a history of alcoholic and \nhepatitis C cirrhosis, complicated by history of GI bleeding, \nesophageal varices, hepatic encephalopathy with recent TIPS \nprocedure who was readmitted in the setting of altered mental \nstatus and abdominal pain, as a transfer from ___. \nAt the outside hospital, there was a CT abdomen showing SMV \nthrombus, and as the patient was to be discharged given stable \nstatus, but he started developing abdominal pain and was \ntransferred to ___.\n\nAt ___, ___ was consulted and the pt was found to have on CT \nabdomen a patent TIPS, and SMV thrombus. Initially intervention \nwas planned, however it was later decided that intervention \nwould be deferred given stability of pt. \n\nIn addition, early on in the hospitalization the patient had an \nepisode of melena for which he had EGD performed. There was no \nidentifiable site of bleeding. Post endoscopy, the patient \nbecame increasingly encephalopathic. Noncontrast head CT was \nperformed and was unremarkable, and mental status change was \nlikely attributed to the patient's sedation and acute hepatic \nencephalopathy. The patient's mental status gradually improved \nwith increases in lactulose, and he returned back to his \nbaseline mental status. He was taking appropriate p.o., and \nstooling at his baseline.\n\nTRANSITIONAL ISSUES:\n====================\n#MEDICATION CHANGES:\nHeld medications: Torsemide 20 qd, amiloride 10 bid, potassium \nchloride 20 qd\n\n#OUTPATIENT PROVIDERS:\n[]Patient should continue on lovenox\n[]Patient scheduled for repeat CT abdominal imaging on ___\n[]Patient should have repeat labs drawn within 1 week of \ndischarge including CBC, chem 10, LFTs. Please have patient fax \nresults to liver ___ at ___ Attn: Dr. \n___ ___\n[]The patient's diuretics were held at discharge given stable \nweights and patent TIPS. Please continue to assess volume status \nin the outpatient setting and consider reinitiation of diuretics \nas needed.\n[]Needs repeat EGD in ___ weeks from last to reevaluate \nvarices/ulcer\n\n___:\n[]Please ensure patient has at least ___ bowel movements per \nday. If not, increase lactulose as needed.\n[]Please ensure patient weighs himself each day. Have him call \nthe ___ if his weight goes up by more than 3 lbs in a \nday or above 200 lbs\n\nAdmission weight: 87.9 kg\nDischarge weight: 88.4 kg\n\n#Contact:\n___ Jr (son) ___ \n\nPROBLEM BASED SUMMARY:\n======================\n#Toxic metabolic encephalopathy, improved\n#Acute on chronic hepatic Encephalopathy, improved\nThe patient was admitted with confusion and on clinical exam had \nasterixis consistent with hepatic encephalopathy. The patient \nwas placed on lactulose every 2 hours and his mental status is \nslightly improved. However, during the same time the patient \nstarted to develop melena and had EGD. His mental status acutely \nworsened after EGD, likely in the setting of sedative use. Given \nthat the patient was on Lovenox, and had low platelets, there \nwas initial concern for intracranial hemorrhage. Noncontrast \nhead CT, however, was unremarkable. The patient had no \nlocalizing signs or symptoms of infection, and did not have any \nleukocytosis. At the outside hospital, the patient was noted to \nhave growth of VRE, and was on a brief treatment course which \nwas discontinued. During this hospitalization, the patient \nendorsed no intensive urinary frequency, dysuria, hesitancy, and \nhad no deviations in urine consistency or character. His blood \ncultures no growth. He was maintained on lactulose and \nrifaximin, and was discharged on his home regimen.\n\n#Melena\nPatient has a known history of ulcer on his last EGD, and has \nnoted small varices. Given that he recently had a TIPS, there \nwas less suspicion for a variceal bleed. The patient had repeat \nEGD on ___ without any evidence of gross bleeding. He was \nbriefly placed on octreotide ___, ceftriaxone for SBP \nprophylaxis, all of which was later discontinued. Since that \ntime, the patient was hemodynamically stable, hemoglobin was \nnormal, and he had no further episodes of any bleeding. His CBC \nwas within goal range, he was discharged on p.o. PPI.\n\n#Hypernatremia, improved\nThe patient's sodium on admission was 150, was given IV fluids. \nHis hypernatremia resolved with increasing free water intake.\n\n# Abdominal Pain\n# Left Portal Vein Thrombosis s/p PV recanalization and TIPS on \n___\n# SMV thrombosis\n# Increased TIPS shunt velocities, concerning for stricture\nAt the outside hospital, the patient had developed abdominal \npain and a ruckus there on ___ showed increased shunt \nvelocities with concern for shunt stricture. There is also some \nconcern for SBP but there was no ascites seen on the ultrasound \nor CT there and a point-of-care ultrasound again had shown no \nascites. There were no infectious symptoms, white blood cell \ncount was normal making infection less likely. His hemoglobin \nhad been stable on admission and so there was no clear source of \nulcer causing a bleed. LFTs including T bili were improved from \nthe last admission making cholestatic cause of pain less likely. \nAs noted above, the CT was notable for patent hips with some \ninterval improvement in clot but the presence of the clot still \nraise some suspicion that there could be a mesenteric ischemic \ncomponent of the abdominal pain. Over the course of this \nhospitalization, the patient's abdominal pain resolved and he \nwas back to his baseline. He was continued on Lovenox. ___ \ninitially considered a thrombectomy, pending improvement in \npatient's clinical status, they elected to follow the patient up \nas an outpatient.\n\n# Positive blood culture\n# Positive Urine culture\nUpon review of outside hospital records, the patient was noted \nto have a positive blood culture growing coag negative staph and \nurine culture growing enterococcus ECM from admission to outside \nhospital on ___. The patient was treated with 2 days of \nceftriaxone but this treatment was later discontinued due to low \nconcern for infection. Over this hospitalization course, he had \nno leukocytosis was afebrile, and now had no other symptoms of \nurinary tract infection. He was not placed on any antibiotics \nthis admission.\n\n# Alcoholic and Hep C Cirrhosis\n# Decompensated liver disease \n# History of GI bleed/esophageal varices\n# History of hepatic encephalopathy\n\nOn admission, the patient's meld sodium was 19. He was initially \nvery encephalopathy on admission to his outside hospital, but \nlater improved after aggressive treatment with lactulose and \nrifaximin. His meld was stable over the course of his hospital \nstay. \n- Volume\nThe patient had ascites in the past but no studies were noted on \nthis admission on repeat ultrasound. This is likely in the \nsetting of his TIPS procedure. The patient's torsemide and \namiloride were held given his poor p.o. intake, and then later \nhis episodes of bleeding. Given his tips status, it is possible \nthat the patient may no longer require torsemide and amiloride.\n- Infection\n - No history of SBP. Has abdominal pain here but no ascites on\nimaging and no infectious symptoms making SBP unlikely. \n - No indication currently for SBP prophylaxis\n- Bleeding\n - noted to have small esophageal varices on past admission\nhere with esophageal ulcer s/p banding. Also s/p TIPS last\nadmission.\n - Continued home pantoprazole\n - Had melena with EGD on ___ unrevealing for source of bleed\n- Encephalopathy\n - History of HE and presented with very high ammonia level,\nconfusion and asterixis to OSH. Now improved s/p lactulose and\nrifaximin\n - Continued lactulose and rifaximin titrate to ___ BM daily\n\n#Pre-renal ___, improved\nb/l .8, admission elevation likely in s/o decreased PO intake,\nimproved with albumin.\n-trended Cr\n-avoided nephrotoxic agents \n\n# Hyponatremia, resolved \nSuspect Hypervolemic in setting of cirrhosis. Also suspect\npatient with poor solute intake which could also be \ncontributing.\n- held torsemide, amiloride iso GIB as above\n- Nutrition consult\n- Monitor BMP\n\nCHRONIC ISSUES\n==============\n# Anemia\nLikely secondary to recent GI bleed but has been slowly \nimproving\n- Monitored CBC \n\n# History of alcohol use\n- Continued MV, thiamine, folic acid\n\n# Insomnia\n- Held hydroxyzine due to concerns for sedation\n\n# Vitamin D deficiency\n- Continued home vit D\n\n# Orthostatic hypotension\n- Continued midodrine 5mg TID\n\n# Opiate Dependence\n- Continue home suboxone\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Enoxaparin Sodium 100 mg SC Q12H \n2. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL TID \n3. FoLIC Acid 1 mg PO DAILY \n4. Hydrocortisone Cream 2.5% 1 Appl TP BID \n5. Lactulose 30 mL PO TID \n6. Midodrine 5 mg PO TID \n7. Multivitamins 1 TAB PO DAILY \n8. rifAXIMin 550 mg PO BID \n9. Sarna Lotion 1 Appl TP QID \n10. Thiamine 100 mg PO DAILY \n11. Vitamin D ___ UNIT PO DAILY \n12. Atorvastatin 10 mg PO QPM \n13. HydrOXYzine 50 mg PO QHS \n14. melatonin 5 mg oral QHS \n15. Nicotine Patch 21 mg/day TD DAILY tobacco cessation \n16. aMILoride 10 mg PO BID \n17. Torsemide 20 mg PO DAILY \n18. Potassium Chloride 20 mEq PO DAILY \n19. Pantoprazole 40 mg PO Q24H \n\n \nDischarge Medications:\n1. Atorvastatin 10 mg PO QPM \n2. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL TID \n3. Enoxaparin Sodium 100 mg SC Q12H \n4. FoLIC Acid 1 mg PO DAILY \n5. Hydrocortisone Cream 2.5% 1 Appl TP BID \n6. HydrOXYzine 50 mg PO QHS \n7. Lactulose 30 mL PO TID \n8. melatonin 5 mg oral QHS \n9. Midodrine 5 mg PO TID \n10. Multivitamins 1 TAB PO DAILY \n11. Nicotine Patch 21 mg/day TD DAILY tobacco cessation \n12. Pantoprazole 40 mg PO Q24H \n13. rifAXIMin 550 mg PO BID \n14. Sarna Lotion 1 Appl TP QID \n15. Thiamine 100 mg PO DAILY \n16. Vitamin D ___ UNIT PO DAILY \n17. HELD- aMILoride 10 mg PO BID This medication was held. Do \nnot restart aMILoride until told by a physician\n18. HELD- Potassium Chloride 20 mEq PO DAILY This medication \nwas held. Do not restart Potassium Chloride until told by a \nphysician\n19. HELD- Torsemide 20 mg PO DAILY This medication was held. Do \nnot restart Torsemide until told by a physician\n20.Outpatient Lab Work\nK70.30 Alcoholic cirrhosis of liver without ascites \nZ76.82 Awaiting organ transplant status \nPlease obtain: CBC; Sodium; Potassium; Chloride; Bicarbonate; \nBUN; Creatinine; Alk Phos; ___ (includes INR); ALT; AST; Total \nBili; Albumin. Please fax results to ___ Attn: Dr. \n___\n\n \n___ Disposition:\nHome\n \nDischarge Diagnosis:\n#Hepatic encephalopathy\n#Cirrhosis\n#Melena\n#Opiate dependence\n#Hyponatremia\n#Acute 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:\nDear ___, \n\nYou were admitted to the hospital because you had some confusion \nand abdominal pain.\n\nWHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?\n-You were admitted because you had some confusion. You had some \nscans of your belly which showed that the TIPS procedure that \nyou had was still working. While in the hospital, you briefly \nhad episodes of dark stool to be scoped your intestines, and did \nnot find any sources of any active bleeding. Your mental status \nimproved and you are ready to leave the hospital. \n\nWHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?\n- Take all of your medications as prescribed (listed below)\n- Keep your follow up appointments with your doctors\n- Weigh yourself every morning, before you eat or take your \nmedications. Call your doctor if your weight changes by more \nthan 3 pounds or goes above 200 pounds\n- Please stick to a low salt diet and monitor your fluid intake\n- If you experience any of the danger signs listed below please \ncall your primary care doctor or come to the emergency \ndepartment immediately.\n\nIt was a pleasure participating in your care. I hope that you \nhave a great time with your 4 children and the rest of your \nfamily. We wish you the best!\n- Your ___ Care Team\n\n \nFollowup Instructions:\n___\n" ]

[ "K7290", "G92", "K55069", "C228", "F1120", "I8510", "E870", "N179", "K921", "K766", "E871", "K7030", "Z7682", "B182", "I10", "K219", "D500", "I951", "F17210", "K3189", "T4275XA", "Y92239", "Z7901" ]

[ "K7290: Hepatic failure, unspecified without coma", "G92: Toxic encephalopathy", "K55069: Acute infarction of intestine, part and extent unspecified", "C228: Malignant neoplasm of liver, primary, unspecified as to type", "F1120: Opioid dependence, uncomplicated", "I8510: Secondary esophageal varices without bleeding", "E870: Hyperosmolality and hypernatremia", "N179: Acute kidney failure, unspecified", "K921: Melena", "K766: Portal hypertension", "E871: Hypo-osmolality and hyponatremia", "K7030: Alcoholic cirrhosis of liver without ascites", "Z7682: Awaiting organ transplant status", "B182: Chronic viral hepatitis C", "I10: Essential (primary) hypertension", "K219: Gastro-esophageal reflux disease without esophagitis", "D500: Iron deficiency anemia secondary to blood loss (chronic)", "I951: Orthostatic hypotension", "F17210: Nicotine dependence, cigarettes, uncomplicated", "K3189: Other diseases of stomach and duodenum", "T4275XA: Adverse effect of unspecified antiepileptic and sedative-hypnotic drugs, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "Z7901: Long term (current) use of anticoagulants" ]

[ "N179", "E871", "I10", "K219", "F17210", "Z7901" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nCodeine / Amoxicillin / hayfever / clindamycin\n \nAttending: ___.\n \nChief Complaint:\nright lower quadrant pain\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\nMs. ___ is a ___ female who presents with one\nweek of diarrhea and fevers, and 1 day of RLQ pain, consult to\nevaluate for appendicitis. She reports being in her usual state\nof health until 1 week ago, when she began to experience\ndiarrhea, nausea, anorexia and high-grade fevers (Tmax 102.5 at\nhome), which she attributed to a viral GI illness as she has\nseveral sick contacts. The diarrhea and fevers have\nnear-resolved, but she developed right mid/lower abdominal pain\nyesterday. She describes this as pulsing, sharp and overall\nincreasing in intensity over the course of the day. Lying down\nimproves the pain, while sitting up worsens it. No chills/night\nsweats, no CP/SOB, no dysuria/frequency.\n \nPast Medical History:\nfibroids, anxiety\n\nuterine polyp removal \n \nSocial History:\n___\nFamily History:\nFamily History: Father had appendicitis\n \nPhysical Exam:\nVitals: T98.0, 117/75, P62, RR16, O2 96% on RA\nGEN: A&O, NAD\nCV: RRR, No M/G/R, clear S1&2\nPULM: Clear to auscultation b/l, No W/R/R\nABD: Soft, non-distended, mildly TTP RLQ, no palpable masses\nExt: No ___ edema, ___ warm and well perfused\n \nPertinent Results:\n___ 07:15AM BLOOD WBC-5.6 RBC-3.72* Hgb-11.3 Hct-34.1 \nMCV-92 MCH-30.4 MCHC-33.1 RDW-13.0 RDWSD-43.2 Plt ___\n___ 07:15AM BLOOD Glucose-84 UreaN-5* Creat-0.7 Na-141 \nK-3.5 Cl-106 HCO3-23 AnGap-16\n \nBrief Hospital Course:\nOn ___, ACS was consulted for RLQ pain in the patient who \nalso reported a one\nweek of diarrhea and fevers, and 1 day of RLQ pain, concerning \nfor appendicitis. Pelvic ultrasound showed 3.6cm heterogenous \navascular mass adjacent/inseparable from L ovary w/ trace free \nfluid. Radiology determined the best course of action for the \npatient would be to follow up in 6 weeks with a pelvic \nultrasound. She was started on a 7 day course of Ciprofloxacin \nand Flagyl. \nOn ___ the patient had decreased RLQ pain, with rebound pain \npresent. She was started on a regular diet, switched to all \noral medications, and tolerated both well. She was discharged \nto home to finish the 7 day course of Cipro and Flagyl, and will \nfollow up with a pelvic ultrasound in 6 weeks.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Citalopram 10 mg PO DAILY \n2. Loratadine 10 mg PO DAILY:PRN allergies \n\n \nDischarge Medications:\n1. 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 #*13 Tablet Refills:*0 \n2. MetroNIDAZOLE 500 mg PO Q8H Duration: 7 Days \nRX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) \nhours Disp #*19 Tablet Refills:*0 \n3. Citalopram 10 mg PO DAILY \n4. Loratadine 10 mg PO DAILY:PRN allergies \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nquestionable appendicitis vs. cecal diverticulitis\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nYou have tolerated a regular diet, your pain is well controlled, \nand you are ready to be discharged to home. \n\n**Please follow up in 6 weeks for a pelvic ultrasound. \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.\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\n \nFollowup Instructions:\n___\n" ]

[ "K5732", "F419" ]

[ "K5732: Diverticulitis of large intestine without perforation or abscess without bleeding", "F419: Anxiety disorder, unspecified" ]

[ "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nmorphine / Narcotics / rubber / Dilaudid\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone. Patient left with PICC line and eloped before discharge \npaperwork could be provided.\n\n \nHistory of Present Illness:\nHOSPITALIST INITIAL NOTE\n\nPCP: none\n\nHPI:\nHistory is obtained via ED record and patient though patient \ndoes not provide history due to frustration at \"being told lies \nin ED.\" \"I was promised that I was going to see Dr. ___\n\nMs. ___ is a ___ year old woman with CAH, adrenal \ninsufficiency possible ___ syndrome/stiff person \nsyndrome, GERD, arthritis who presents with several day of L \nbuttock and abdominal pain and no BM for several days. She \nnotes a sharp pain in that area with radiation to her perineum. \nThe pain is burning/sharp. She has developed a rash. She feels \nlike she's constipated. She is nauseated as well. n She feels \ngenerally unwell, \"malaise\" but denies\nfevers, chills, chest pain, dyspnea, V/D, and headaches. She \nreceived her IVIG last month. She used to take rituximab but no \nlonger. She takes chronic steroids and has doubled her dose \ntoday given her symptoms. Case reviewed with ACS and ___.\n\nOn arrival to the floor, she is angry. She states she was lied \nto. She states she was promised a different doctor. \"I don't \ntrust hospitalists.\" She declines exam until \"this mix up is \nfigured out.\" She does not elaborate on further symptoms but \ncontinuously returns to the fact that she was lied to.\n\n10 point review of systems reviewed and otherwise negative \nexcept as listed above\n \nPast Medical History:\n___\narthritis\nadrenal insufficiency\n___ syndrome/stiff person syndrome\nhypogammglobulinemia\nGERD\n\nPast surgical history: \ngenital surgery \nmyomectomy\nhernia surgery - left side\nremoval of mesh - from the hernia\nHill Nissen's procedure\nRemoval of Hill part(took out polypropylene glycol) and redone\nNissen\ncarpal tunnel \nulnar nerve compression\nleft obturator n decomperssion\n\n \nSocial History:\n___\nFamily History:\nNo family history of thyroid or adrenal disease.\n\n \nPhysical Exam:\nADMISSION EXAM\nVS: 98.4 PO 103 / 65 78 18 99 RA \nGEN: thin, tan, hirsuit, lying in bed in NAD\nHEENT: declines formal exam\nNECK: declines formal exam\nCV: declines formal exam\nLUNG: declines formal exam\nGI: declines formal exam\nEXT: declines formal exam\nSKIN: declines formal exam\nNEURO: awake and alert. Answers questions appropriately \nPSYCH: tangential, redirectible. makes good eye contact\n\nDISCHARGE EXAM\n98.6 PO 152 / 81 74 18 98 RA \nGEN: thin, tan, hirsuit, lying in bed, researching on computer, \ntells me to leave the room\nHEENT: declines formal exam\nNECK: declines formal exam\nCV: declines formal exam\nLUNG: declines formal exam\nGI: declines formal exam\nEXT: declines formal exam\nSKIN: declines formal exam\nNEURO: awake and alert. \nPSYCH: agitated, tangential\n \nPertinent Results:\nADMISSION LABS\n\n___ 10:00PM BLOOD WBC-5.6 RBC-4.35 Hgb-13.3 Hct-39.5 MCV-91 \nMCH-30.6 MCHC-33.7 RDW-13.3 RDWSD-43.9 Plt ___\n___ 10:00PM BLOOD Neuts-71.2* ___ Monos-6.1 Eos-1.3 \nBaso-0.4 Im ___ AbsNeut-3.97 AbsLymp-1.15* AbsMono-0.34 \nAbsEos-0.07 AbsBaso-0.02\n___ 10:00PM BLOOD Glucose-88 UreaN-11 Creat-0.5 Na-139 \nK-4.2 Cl-102 HCO3-24 AnGap-13\n___ 10:00PM BLOOD ALT-12 AST-13 AlkPhos-74 TotBili-0.3\n___ 10:00PM BLOOD Lipase-23\n___ 10:00PM BLOOD Albumin-3.9\n___ 10:22PM BLOOD Lactate-1.5\n\n___ \nCT abd/pel w/ contrast\nIMPRESSION: \n1. No bowel obstruction. \n2. Interval increased in size of a fluid collection in the left \nhemipelvis/adnexa abutting the bladder and the rectum when \ncompared to ___, now measuring 5.4 x 3.3 cm, previously 4.1 x 2.2 \ncm. Please \ncorrelate clinically for symptoms of infection. Differential \nconsiderations \nfor this fluid collection include duplication cyst or adnexal \ncyst. If \nclinically relevant, this can be further assessed with pelvic \nultrasound or MRI\n\n___ \nMRI pelvis w/ contrast\nIMPRESSION:\n1. Within the limits of MRI assessment, there is no evidence of \nnerve\ncompression. Specifically, the lumbosacral nerve roots \ndemonstrate normal\nsize and are not edematous.\n2. Loculation of retained fluid within the vaginal canal has \nresolved since\nthe prior study. Minimal pelvic free fluid is within \nphysiologic limits.\n3. Three uterine fibroids measuring up to 2.5 cm.\n4. Low position of the anorectal junction at rest, suggests \nresting pelvic\nfloor dysfunction.\n\n___\nKUB\nIMPRESSION: \nLarge fecal load. No radiographic evidence of bowel obstruction. \n\n\n___\nTerminal ileum biopsy\nFocal mild active enteritis with reactive change. No granuloma \nseen.\n\n___\nKUB\nIMPRESSION: \nNo formed stool is seen within the large bowel. Unremarkable, \nnonobstructive bowel gas pattern. \n\nColonoscopy ___ \nInternal hemorrhoids, diverticulosis of the sigmoid colon, and \nerythema in the terminal ileum, which was biopsied. Stool in the \nascending colon and cecum. Otherwise normal retroflexion and \ncolonoscopy to cecum and terminal ileum. \n\nDischarge labs\n\n___ 05:51AM BLOOD WBC-6.9 RBC-3.63* Hgb-11.5 Hct-34.7 \nMCV-96 MCH-31.7 MCHC-33.1 RDW-14.8 RDWSD-49.5* Plt ___\n___ 05:51AM BLOOD Glucose-109* UreaN-11 Creat-0.5 Na-142 \nK-4.0 Cl-105 HCO3-26 AnGap-11\n___ 05:51AM BLOOD Calcium-8.3* Phos-3.9 Mg-2.2\n \nBrief Hospital Course:\nMs. ___ is a ___ year-old woman with a history of \ncongenital adrenal hypoplasia and adrenal insufficiency on \nchronic steroids who presented with malaise and pelvic fullness, \nand was admitted with findings of a pelvic fluid collection. She \nwas noted to have a urinary tract infection, as well as pustular \nlesions in a dermatomal distribution. A swab of these lesions \nwas nondiagnostic, and her HSV1 IgG was elevated. She was \ninitially started on IV acyclovir and IV ceftriaxone; this were \nnarrowed to PO valacyclovir and PO cefpodoxime. Her case was \ndiscussed with the interventional radiology team who felt that \nthe fluid collection was her uterus, and that it was unlikely to \nbe contributing to her symptoms. Her case was also discussed \nwith gynecology, though the patient refused to be evaluated by a \nresident. Therefore, she was set up with outpatient \nurogynecology follow up. Her course was also complicated by a \nmild ___ likely due to acyclovir, but this resolved after her \ntransition to valacyclovir.\n\nDuring the hospitalization, the patient demonstrated multiple \nepisodes of inappropriate and maladaptive behavior -- she \nrefused to allow herself to be examined by residents, she was \nverbally abusive to staff members, fired providers, and she \nexpressed considerable dissatisfaction with her care. A safety \nalert and event note have been left in the chart for future \nproviders, and she should be placed on a behavior contract for \nfuture admissions. While her pelvic pain was still present, her \nUTI and zoster were appropriately treated. At this point, she \nwas medially stable for discharge with outpatient follow up.\n\nDespite this, the patient declined discharge until her pain and \nconstipation were addressed, despite conflict at each aspect of \ncare. The case was reviewed further with GI who recommended \noutpatient anorectal manometry. Ultimately after discussion with \nthe patient, we pursued specifically protocoled MRI of the \npelvic, which did not show clear nerve compression. MRI noted \nresolution of the fluid collection, but with low lying rectum \nsuspicious for pelvic floor dysfunction. \n\nHospitalization was prolonged by significant constipation, pt \nwas treated with aggressive po and pr bowel regimen. She was \nanxious to be seen by GI to better understand the etiology was \ntaken for colonoscopy, which showed known internal hemorrhoids \nand diverticulosis but no mass. KUB after the colonoscopy showed \nno formed stool in the bowels. The GI team provided \nrecommendations for a bowel regimen going forward as an \noutpatient to prevent further recurrences of severe\nconstipation. During this time, she was also seen by the \nendocrinology team, who had no acute concerns from an endocrine \nperspective. She was again cleared for discharge.\n\nHowever, then the patient reported whole body burning pain. She \nsaid gabapentin was ineffective. She wanted to see rheumatology \nas an inpatient because she believed it was a flare of her \nSjogren's and required rituximab and IVIG. She did not allow \nproviders to obtain records of her diagnosis of Sjogren's and \nprior treatments, saying that \"we should think from scratch.\" \nShe continued to display rude and disrespectful behavior to \nstaff and providers. She was extremely angry when told that \nrheumatology could see her as an outpatient but that they did \nnot think that her symptoms were suggestive of the need for an \ninpatient consult given that she we did not have (and she would \nnot allow access to) documentation verifying a diagnosis of \nSjogren's and that workup would happen as an outpatient. She \nalso did not allow discussion of any treatment of her \nneuropathic pain that did not include rituximab and more IVIG, \nwhich her primary team and rheumatology both agreed were not \nindicated. She again refused discharge, despite explanations \nthat she had specialty appointments as an outpatient specialty \nappointments (including dermatology, rheumatology, \nuro-gynecology). \n\nSubsequently, she tried to leave and adamantly refused to take \nout her PICC line and said she was going to another hospital. \nCase management contacted the IV ___ home nursing service to \nsee if they would take care of her PICC line at home. The \ncompany stated that they would not take care of the line as it \nisn't indicated to have a PICC line for monthly infusions. \nPatient relations, legal, social work and nursing, physician and \ncase management supervisors were involved in trying to arrange a \nsafe\ndischarge plan for this patient. \n\nUnfortunately she remained insistent on leaving with her PICC. \nAs documented in an event note by Dr. ___, she was able \nto display capacity to understand the risks involved of leaving \nwith a PICC. It was explained to her that we do not recommend \nthat she leave with a PICC line because it is unsafe. It was \nexplained to her that the risks include severe infection, severe \nbloodstream infection, blood clot, bleeding, and, if there are \nsevere complications, death. We told her that\nwe recommended that she remove the PICC. She was able to say \nthat she knows that there is a risk of severe infection, blood \nclot, bleeding, and even death. She reiterated that she plans to \ngo to another hospital and will have care of the ___ there. \nDocumentation regarding ___ care was provided to her. She has \nno\nknown history of IV drug use. She denied suicidal ideation and \nhomicidal ideation. \n\nWhile she was medically cleared for discharge, her discharge was \nagainst medical advice from the perspective that she understood \nthat we did not recommend leaving with a PICC line. She eloped \nbefore taking any discharge paperwork or prescriptions.\n\nAgain briefly summarized, her medical problems were as follows:\n\n1. Zoster\n- Completed course of Valtrex\n\n2. UTI.\n-Completed course of Cefpodoxime\n\n3. Pelvic pain: Recommended follow up with Dr. ___\n\n4. ___. Resolved.\n\n5. Behavioral problems. Should be placed on behavior contract on \nfuture admissions.\n\n6. CAD. Home fludrocortisone and hydrocortisone.\n\n7. Constipation. Resolved. \n\nShe also received IVIG per usual schedule while she was here.\n \nMedications on Admission:\nFludricortisone 0.1mg daily\nHydrocortisone 15mg qAM, 10mg qPM\n \nDischarge Medications:\nThe patient eloped before she could receive any prescriptions.\n\n1. Cefpodoxime Proxetil 200 mg PO/NG Q12H \nRX *cefpodoxime 200 mg 1 tablet(s) by mouth Twice daily Disp \n#*10 Tablet Refills:*0 \n2. ValACYclovir 1000 mg PO Q8H \nRX *valacyclovir 1,000 mg 1 tablet(s) by mouth Every eight hours \nDisp #*15 Tablet Refills:*0 \n3. Fludrocortisone Acetate 0.1 mg PO DAILY \n4. Hydrocortisone 15 mg PO QAM \n5. Hydrocortisone 10 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPatient left with PICC line and eloped before discharge \npaperwork could be provided.\n\nBacterial UTI\nHerpes/zoster infection\nPelvic fluid collection, resolved\nCongenital adrenal hyperplasia\nAdrenal insufficiency\n\n \nDischarge Condition:\nPatient left with PICC line and eloped before discharge \npaperwork could be provided.\n\n \nDischarge Instructions:\nPatient left with PICC line and eloped before discharge \npaperwork could be provided.\n \nFollowup Instructions:\n___\n" ]

[ "B029", "N179", "D801", "E250", "E2740", "G2582", "Q796", "R188", "G629", "N3090", "K219", "I2510", "K5900", "E668", "Z6827", "B9620", "K648", "F918", "E860", "R1032", "K5730", "T375X5A", "Y92239" ]

[ "B029: Zoster without complications", "N179: Acute kidney failure, unspecified", "D801: Nonfamilial hypogammaglobulinemia", "E250: Congenital adrenogenital disorders associated with enzyme deficiency", "E2740: Unspecified adrenocortical insufficiency", "G2582: Stiff-man syndrome", "Q796: Ehlers-Danlos syndromes", "R188: Other ascites", "G629: Polyneuropathy, unspecified", "N3090: Cystitis, unspecified without hematuria", "K219: Gastro-esophageal reflux disease without esophagitis", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "K5900: Constipation, unspecified", "E668: Other obesity", "Z6827: Body mass index [BMI] 27.0-27.9, adult", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "K648: Other hemorrhoids", "F918: Other conduct disorders", "E860: Dehydration", "R1032: Left lower quadrant pain", "K5730: Diverticulosis of large intestine without perforation or abscess without bleeding", "T375X5A: Adverse effect of antiviral drugs, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause" ]

[ "N179", "K219", "I2510", "K5900" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \ngeneral anesthesia\n \nAttending: ___.\n \nChief Complaint:\nRLQ abdominal pain\n \nMajor Surgical or Invasive Procedure:\n1. laparoscopic appendectomy \n\n \nHistory of Present Illness:\nMr. ___ is a ___ yo male, previously healthy, who presents with \n2 days of right lower quadrant abdominal pain and nausea. His \nappetite has been poor. Patient denies fevers, chills, diarrhea, \nand vomiting. He states his pain has been stable and maybe \nslightly improved. He has not had pain like this before. \n \nPast Medical History:\nPMH: None\n\nPSH: left ear surgery\n \nSocial History:\n___\nFamily History:\nNoncontributory\n \nPhysical Exam:\nAfebrile, hemodynamically stable\nGEN: A&O, NAD \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, appropriately tender near incisions, no \nrebound or guarding, normoactive bowel sounds, no palpable \nmasses. Port sites c/d/i. \nDRE: normal tone, no gross or occult blood \nExt: No ___ edema, ___ warm and well perfused \n \nPertinent Results:\n___ 12:13PM BLOOD WBC-8.6 RBC-5.06 Hgb-14.7 Hct-43.8 MCV-87 \nMCH-29.1 MCHC-33.6 RDW-12.8 RDWSD-40.1 Plt ___\n___ 12:13PM BLOOD Neuts-64.8 ___ Monos-10.7 \nEos-0.5* Baso-0.2 Im ___ AbsNeut-5.56 AbsLymp-2.02 \nAbsMono-0.92* AbsEos-0.04 AbsBaso-0.02\n___ 12:13PM BLOOD Glucose-84 UreaN-16 Creat-1.1 Na-139 \nK-4.1 Cl-102 HCO___ AnGap-1\n\nCT ___:\nIMPRESSION: Acute appendicitis with reactive wall thickening at \nthe base of the cecum. No perforation or abscess.\n \nBrief Hospital Course:\nThe patient was admitted to the General Surgical Service on ___ \nfor evaluation and treatment of abdominal pain. Admission \nabdominal/pelvic CT revealed acute appendicitis. The patient \nunderwent laparoscopic appendectomy, which went well without \ncomplication (reader referred to the Operative Note for \ndetails). After a brief, uneventful stay in the PACU, the \npatient arrived on the floor tolerating clears, on IV fluids, \nand with adequate pain control. The patient was hemodynamically \nstable.\n\nWhen tolerating a diet, the patient was converted to oral pain \nmedication with continued good effect. Diet was progressively \nadvanced as tolerated to a regular diet with good tolerability. \nThe patient voided without problem. During this hospitalization, \nthe patient ambulated early and frequently, was adherent with \nrespiratory toilet and incentive spirometry, and actively \nparticipated in the plan of care. The patient received \nsubcutaneous heparin and venodyne boots were used during this \nstay.\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:\nNone\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild \n2. Docusate Sodium 100 mg PO BID:PRN constipation \n3. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain - \nModerate \n4. Senna 8.6 mg PO BID:PRN constipation \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n1. acute appendicitis\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 acute appendicitis and \nunderwent laparoscopic appendectomy. You did well \npost-operatively and are being discharged home in stable \ncondition on post-operative day 1. Please follow the following \ndirections:\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.\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 \nFollowup Instructions:\n___\n" ]

[ "K3580", "K660", "Z006" ]

[ "K3580: Unspecified acute appendicitis", "K660: Peritoneal adhesions (postprocedural) (postinfection)", "Z006: Encounter for examination for normal comparison and control in clinical research program" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \npeginterferon alfa-2a / propranolol / nadolol\n \nAttending: ___.\n \nChief Complaint:\ns/p TACE\n \nMajor Surgical or Invasive Procedure:\nTACE ___\n \nHistory of Present Illness:\n___ year old man with segment VII OPTN 5B lesion consistent with\nHCC, now s/p right common femoral artery approach trans-arterial\nchemoembolization of a segment VII lesion with doxorubicin mixed\nwith lipiodol. Rt femoral access, hemostasis at Noon on ___ per\n___ notes. \n\nPer report had small hematoma ,pressure held, hematoma\nmarked. On arrival to the floor patient feels well. No\ncomplaints. No shortness of breath ,confusion, chest pain, groin\npain, numbness or tingling in lower extremities. \n\nROS otherwise negative\n \nPast Medical History:\n1. HCV, treated with Sovaldi and ribavirin, completed ___,\ncomplicated by cirrhosis and portal hypertension.\n2. History of acute hepatitis A virus.\n3. History of upper GI bleed.\n4. Polymyalgia rheumatica.\n5. Hiatal hernia.\n6. Severe aortic stenosis.\n7. Diverticulosis.\n8. History of pneumonia.\n\n \nSocial History:\n___\nFamily History:\nThe patient's father died at ___ years with\nesophageal cancer. His mother died at ___ years with\ntobacco-associated lung cancer. A brother is treated for \nchronic\nleukemia. He has seven siblings, one died of lung cancer at ___\nyears, another died with complications of asthma at ___ years, a\nsister is treated for diabetes mellitus, another for asthma and\nanother for aortic stenosis.\n\n \nPhysical Exam:\nDISCHARGE PHYSICAL EXAM\nVS: 98.8 110 / 60 66 18 93 RA \nGEN: No acute distress, comfortable appearing\nHEENT: NCAT, anicteric sclera, no conjunctival pallor\nCV: Normal S1, S2, no murmurs\nRESP: Good air entry, no rales or wheezes\nGI: Normal bowel sounds, soft, non-tender, non-distended, no\nrebound/guarding; \nMSK: No edema. Intact pulses. \nDERM: No rash.\nNEURO: Face symmetric, speech fluent, non-focal \nPSYCH: Calm, cooperative \n \nPertinent Results:\n==========================================\n\nADMISSION LABS\n___ 07:53AM BLOOD AFP-2.6\n___ 07:53AM BLOOD ALT-14 AST-28 AlkPhos-55 TotBili-1.8*\n\nDISCHARGE LABS\n___ 07:15AM BLOOD WBC-6.6 RBC-3.22* Hgb-10.8* Hct-32.0* \nMCV-99* MCH-33.5* MCHC-33.8 RDW-13.4 RDWSD-49.4* Plt Ct-51*\n___ 07:15AM BLOOD ___ PTT-30.5 ___\n___ 07:15AM BLOOD Glucose-101* UreaN-14 Creat-1.1 Na-138 \nK-3.4 Cl-103 HCO3-24 AnGap-14\n___ 07:15AM BLOOD ALT-317* AST-528* AlkPhos-50 TotBili-2.1*\n___ 07:15AM BLOOD Albumin-3.1*\n\n==========================================\n\n___ TACE\nSuccessful right common femoral artery approach trans-arterial \nchemoembolization of a segment VII lesion. \n \nRECOMMENDATION(S): 1. The patient will be observed following \nthe procedure. \nA noncontrast abdominal CT should be obtained on ___ to \nassess for \nlipiodol deposition following TACE. \n2. The patient developed a small right groin hematoma following \nthe \nprocedure. The skin was marked to delineate the size of the \nhematoma, which \nshould be serially assessed for change in size. \n3. The patient will follow up in the outpatient ___ \n___ \n___ in 1 week following the procedure. \n\n___ CT ABDOMEN/PELVIS\n1. Post-TACE Lipiodol deposition in hepatic segment VII and VI \nsurrounding the HCC. No extrahepatic Lipiodol noted. \n2. Sequela of portal hypertension including splenomegaly and a \nrecannulized umbilical vein. \n\n \nBrief Hospital Course:\n___ year old man with segment VII OPTN 5B lesion consistent with\nHCC, now s/p right common femoral artery approach trans-arterial\nchemoembolization of a segment VII lesion with doxorubicin mixed\nwith lipiodol. \n\n# Hepatocellular carcinoma s/p TACE\nAdmitted for post-TACE monitoring. R femoral access with small \nhematoma treated with pressure and stable without bruit. LFTs \nwere elevated, which is expected post-TACE. Non-con CT with \nexpected appearance post-TACE. Tolerated a regular diet, pain \ncontrolled with oral regimen, and cleared for discharge by ___. \n- He has follow up with ___ on ___, and planned radiofrequency \nablation to be arranged by ___\n\n# Severe aortic stenosis: Gentle IV fluids post-TACE with no \nevidence of heart failure, chest pain.\n\n# GERD: Continued home omeprazole \n\n# Portal hypertension, thrombocytopenia: Known liver disease, \nfollowed by Dr. ___.\n\n> 30 minutes on discharge activities\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Omeprazole 20 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Ondansetron 4 mg PO Q8H:PRN nausea \nRX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours \nDisp #*15 Tablet Refills:*0 \n3. 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#*15 Tablet Refills:*0 \n4. Omeprazole 20 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nHepatocellular carcinoma s/p TACE\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 monitoring after your TACE procedure.\nYou will follow up with interventional radiology as scheduled \nbelow. They will arrange for you to have radiofrequency \nablation and will give you further details during your follow up \nappointment.\n\nAvoid heavy physical exertion until you follow up with \ninterventional radiology.\n\nPlease note that you have low platelets and a condition called \nportal hypertension. This means that you are at increased risk \nof bleeding and complications of liver disease. Please ensure \nthat you are evaluated and treated by a liver specialist.\n \nFollowup Instructions:\n___\n" ]

[ "C220", "K766", "D696", "I350", "Z87891", "K219" ]

[ "C220: Liver cell carcinoma", "K766: Portal hypertension", "D696: Thrombocytopenia, unspecified", "I350: Nonrheumatic aortic (valve) stenosis", "Z87891: Personal history of nicotine dependence", "K219: Gastro-esophageal reflux disease without esophagitis" ]

[ "D696", "Z87891", "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:\nRigors, hypotension\n \nMajor Surgical or Invasive Procedure:\nPercutaneous biliary duct drain exchange and indwelling drain \nplacement \n\n \nHistory of Present Illness:\nMs. ___ is an ___ with PMH of dementia, h/o breast cancer\nand gallstone pancreatitis s/p subtotal CCY c/b bile leak s/p\nfailed ERCP ___ duodenal stricture s/p PTBD and cholangioplasty\nx5 who presents after most recent cholangiogram with hypotension\nand AMS. \n\nPatient underwent laparoscopic subtotal cholecystectomy for\ngallstone pancreatitis in ___. This was complicated by\nsuspected bile leak. ERCP was attempted, but unsuccessful due to\nduodenal stricture. ERCP was again attempted at ___ after\nballoon dilation, but this was also unsuccessful. She was\nreferred to ___, who placed PTBD ___. She has subsequently \nhad\nmultiple repeat cholangiograms with cholangioplasty, increasing\nupsized PTBD to ___. Of note, brushings taken of CBD (given\nrecurrent stricturing) has been negative. She underwent repeat\ncholangiogram ___, found to have no evidence of bile leak, and\nimproved antegrade flow through CBD. PTBD was exchanged with \n___\nexternal anchor drain.\n\nPost procedure, patient noted rigors and nausea when attempted \nto\nleave. She was treated with meperidine and ondansetron. Her\nnausea improved, but she developed rigors again, treated with\nadditional dose of meperidine. She reported feeling better, but\nwas unsteady on her feet when trying to get up, SBP ___ at that\ntime. She was treated with CTX IV 1g, in case of potential\nbacterial translocation. He BP stabilized and she was admitted \nto\nthe floor for monitoring. \n\nPer her son and per the interventional radiology team, patient\nhas been declining over the past few weeks/months. She did not\nappear at her baseline this evening - less interactive, etc. \n\nTransfer VS were: 98.2 96/60 71 16 98 Ra \n\nOn arrival to the floor, further history unable to obtain as\npatient does not respond to my questions. She shakes her head no\nwhen asked if pain. Per daughter, patient has been declining\nsince CCY, with worsening functional status. She is\nintermittently confused, but most often knows where she is and\nknows date. \n \nPast Medical History:\ndementia, breast CA\n \nSocial History:\n___\nFamily History:\ngallbladder disease, CKD\n \nPhysical Exam:\nADMISSION EXAM:\n===============\nVS: 98.1 90/50 60 16 99 Ra \nGENERAL: NAD\nHEENT: MMM\nNECK: no JVD\nHEART: RRR, nl S1 S2, no murmurs, gallops, or rubs\nLUNGS: CTAB, no wheezes, rales, rhonchi\nABDOMEN: soft, not appreciably tender, ND, NABS, drain in places\nwith dressing C/D/I, draining scant bilious fluid. \nEXTREMITIES: no edema\nPULSES: 2+ DP pulses bilaterally\nSKIN: WWP, no rashes \nNEURO: does not respond to questions on initial exam, shakes \nhead\nyes or no to questions about pain, withdraws to pain on all\nextremities. On repeat interview, wakes up with nail-bed\npressure, requesting exam to stop, moving all extremities\nspontaneously. Pupils miotic but reactive.\n\nDISCHARGE EXAM:\n================\nVS: ___ 0743 Temp: 98.7 PO BP: 126/57 L Sitting HR: 57 O2\nsat: 96% O2 delivery: Ra \nGENERAL: NAD\nHEART: RRR, nl S1 S2, no murmurs, gallops, or rubs\nLUNGS: CTAB, no wheezes, rales, rhonchi\nABDOMEN: soft, not appreciably tender, ND, NABS, drain in places\nwith dressing C/D/I, draining scant bilious fluid. \nEXTREMITIES: no edema\nNEURO: Alert and oriented x 3. CN intact, strength and sensation\nintact in ___ upper and lower extremities.\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 11:23PM BLOOD WBC-5.7 RBC-3.11* Hgb-9.1* Hct-27.7* \nMCV-89 MCH-29.3 MCHC-32.9 RDW-13.5 RDWSD-43.7 Plt Ct-90*\n___ 11:23PM BLOOD Neuts-89.9* Lymphs-5.5* Monos-3.9* \nEos-0.0* Baso-0.2 NRBC-0.4* Im ___ AbsNeut-5.11 \nAbsLymp-0.31* AbsMono-0.22 AbsEos-0.00* AbsBaso-0.01\n___ 11:23PM BLOOD ___ PTT-25.7 ___\n___ 11:23PM BLOOD Glucose-252* UreaN-18 Creat-1.0 Na-142 \nK-3.8 Cl-108 HCO3-21* AnGap-13\n___ 12:00PM BLOOD AlkPhos-79 TotBili-1.5\n___ 11:23PM BLOOD Calcium-10.1 Phos-1.3* Mg-1.3*\n___ 04:50AM BLOOD calTIBC-195* Hapto-<10* Ferritn-195* \nTRF-150*\n___ 11:48PM BLOOD Lactate-4.1*\n\nDISCHARGE LABS:\n===============\n___ 04:45AM BLOOD WBC-4.8 RBC-2.97* Hgb-8.8* Hct-26.4* \nMCV-89 MCH-29.6 MCHC-33.3 RDW-13.8 RDWSD-44.7 Plt Ct-82*\n___ 04:50AM BLOOD Glucose-118* UreaN-17 Creat-0.9 Na-140 \nK-3.8 Cl-107 HCO3-23 AnGap-10\n___ 04:45AM BLOOD ALT-13 AST-25 AlkPhos-64 TotBili-0.9\n___ 04:50AM BLOOD Calcium-9.5 Phos-3.2 Mg-2.2 Iron-11*\n___ 09:46AM BLOOD Lactate-2.0\n\nIMAGING:\n========\n___ (PORTABLE AP)\nThe NG tube has been removed. There is gaseous distension of \nthe stomach. \nPatchy parenchymal opacity in the right lung base most likely \nrepresents\nsubsegmental atelectasis. Lungs are low volume. \nCardiomediastinal silhouette\nis stable. There is no pleural effusion. No pneumothorax is \nseen. Surgical\nclips are seen in the left lower paraspinal region.\n\n___ CATH CHECK/REPO\n1. Right ___ Fr percutaneous transhepatic biliary drainage \ncatheters.\n2. Cholangiogram showing improved antegrade flow through common \nbile duct\nstricture. No persistent biliary leak identified from the \nremnant\ngallbladder.\n3. Successful exchange of 12 percutaneous transhepatic biliary \ndrainage\ncatheters with new 12 ___ external anchor drain.\n \nBrief Hospital Course:\n___ with PMH of dementia, h/o breast cancer and gallstone \npancreatitis s/p subtotal CCY c/b bile leak s/p failed ERCP ___ \nduodenal stricture s/p PTBD and cholangioplasty x5 who presents \nafter most recent cholangiogram with post procedural hypotension \nand AMS.\n\n# HYPOTENSION/RIGORS: The patient had rigors and hypotension \nafter her ___ procedure on the day of admission. Her labs were \nconcerning for a lactate of 4.1. Her presentation most \nconcerning for infection initially with the most likely source \nbeing intra-abdominal/biliary. Given this, she was started on \nCeftriaxone and Flagyl overnight. By the morning on the day \nafter admission, the patient was afebrile, and her lactate had \ndowntrended to 2.0. Her blood pressure had normalized and she \nremained afebrile. Antibiotics were discontinued, and her rigors \nwere thought to be secondary to transient bactermia vs. contrast \ninduced cholangitis like physiology. Her drain remained \nfunctioning well, blood cultures, urine cultures and a CXR were \nall negative for a source of infection. After 24 hours off of \nantibiotics, she remained afebrile and was discharged home. She \nhas scheduled follow up with ___ for possible drain removal.\n\n# ALTERED MENTAL STATUS: \n# DEMENTIA: The patient has a history of dementia of unknown \netiology. On admission, she was more lethargic and confused than \nher baseline per discussion with the patient's family. With \nresolution of her hypotension and rigors, her mental status \nimproved and she was alert and oriented x 3, though remained \nintermittently confused throughout the day, still slightly worse \nthan baseline per her family. \n\n# SUBTOTAL CCY C/B BILE LEAK AND STRICTURE S/P PTBD X5\nPer ___, discharged with drain to bag for now. Will f/u in 1 week \nfor capping trial. \n\n# ANEMIA: \nHgb 11 from baseline 9s. ___ be due to operative losses. Given \nthrombocytopenia, potential also for hemolysis, though hemolysis \nlabs were negative. Would get CBC at first follow up.\n\nTRANSITIONAL ISSUES:\n====================\n[] Discharge Hgb 8.8, PLT 82: Please get repeat CBC on first \nfollow up\n[] ___ appointment for ___ for follow up cholagiogram and \ncapping trial\n[] Some concern about patient's ability to function well at \nhome: Please ensure able to perform ADLs safely \n\n#CODE: Full (presumed)\n#CONTACT: ___, daughter ___\n\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Ondansetron 4 mg PO TID:PRN nausea \nTake before meals as needed for nausea \nRX *ondansetron HCl [Zofran] 4 mg 1 tablet(s) by mouth three \ntimes a day Disp #*30 Tablet Refills:*0 \n2. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nCommon bile duct stricture\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the hospital because:\n- You developed some fevers and chills after your procedure\n\nWhile you were here:\n- You received antibiotics through your veins because there was \na concern that you had an infection\n- You did not have any more fevers or chills\n- You were monitored overnight to ensure that you did not show \nany other signs of infection\n- When you did not have a fever for 24 hours, you were \ndischarged home\n\nWhen you leave:\n- Please take all of your medications as prescribed\n- Please attend all of your follow up appointments as scheduled\n\nIt was a pleasure to care for you during your hospitalization!\n\nYour ___ care team\n \nFollowup Instructions:\n___\n" ]

[ "R7881", "K831", "K830", "I959", "R4182", "F0390", "D649", "D696", "E8342", "E8339", "Z853", "T508X5A", "Y92234" ]

[ "R7881: Bacteremia", "K831: Obstruction of bile duct", "K830: Cholangitis", "I959: Hypotension, unspecified", "R4182: Altered mental status, unspecified", "F0390: Unspecified dementia without behavioral disturbance", "D649: Anemia, unspecified", "D696: Thrombocytopenia, unspecified", "E8342: Hypomagnesemia", "E8339: Other disorders of phosphorus metabolism", "Z853: Personal history of malignant neoplasm of breast", "T508X5A: Adverse effect of diagnostic agents, initial encounter", "Y92234: Operating room of hospital as the place of occurrence of the external cause" ]

[ "D649", "D696" ]

[]

[ " \nName: ___ ___ 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:\nNausea/Vomiting, poor PO intolerance\n \nMajor Surgical or Invasive Procedure:\nWithdrawal of 2.5cc NS from lap band under fluoroscopy\n\n \nHistory of Present Illness:\nMs. ___ is an ___ year old female s/p laparoscopic adjustable \ngastric band and device placement in ___ in ___, ___ who \npresents to the ED with 1 week of poor PO tolerance associated \nwith spasms in her abdomen, nausea and\nvomiting. She reports a 70 lb weight loss since surgery with a \nfew band adjustments. Her pre-surgery BMI was 51.2, wt 327 lb, \nand her current BMI is 42.0, wt 268 lb. She had similar \nepisodes in the past when her gastric band was too tight and her \nsymptoms resolved with loosening of the lap band. In ___, \nshe experienced over fill with severe symptoms requiring \nhospitalization. Her last fill was reportedly in ___ and \nlater she found the band to be too restricted with significant \nweight loss in a short period of time requiring band deflation \nin ___. She attributes her symptoms to increased anxiety \nand stress at school and also reports that she experiences \nincreased restriction while flying. She was able to tolerate \nthin soups until a week ago but had difficulty with solid food \ncausing her to have multiple episodes of regurgitation. Her \nsymptoms progressively worsened with both solid and liquid \nintake and for the past two days she feels overly restricted \nwith associated gastric reflux and wishes to have band-fill \ndecreased to improve PO tolerance. She denies dysphagia, \nodynophagia, aspiration, night time cough, change in bowel \nhabits or bowel movements, melena, hematochezia, hematemesis, \nfevers/chills, chest pain, dypnea, GU symptoms\n \nPast Medical History:\nMorbid obesity\nArthritis\n\nPast Surgical History: \nLaparoscopic adjustable gastric banding in ___\nKnee miniscectomy - ___\nAdenoidectomy \n \nSocial History:\n___\nFamily History:\nLymphoma, leukemia, heart disease\n \nPhysical Exam:\nVITAL SIGNS: 98.3 126/64 89 18 100% RA\n\nGENERAL: AAOx3 NAD\nHEENT: NCAT, EOMI, PERRLA, No scleral icterus, mucosa moist, no \nLAD\nCARDIOVASCULAR: R/R/R, S1/S2, NO M/R/G\nCAROTIDS: 2+, No bruits or JVD\nPULMONARY: CTA ___, No crackles or rhonchi\nGASTROINTESTINAL: S/NT/ND. No guarding, rebound, or frank \nperitonitis. +BSx4. Lap band port palpable below left costal \nmargin. \nINCISION/WOUNDS: well healed. No hernia. \nEXT/MS/SKIN: No C/C/E; Feet warm. Good perfusion\nNEUROLOGICAL: Reflexes, strength, and sensation grossly intact\nCNII-XII: WNL\n \nPertinent Results:\n___ 05:30PM PLT COUNT-267\n___ 05:30PM NEUTS-59.6 ___ MONOS-6.3 EOS-3.1 \nBASOS-0.8 IM ___ AbsNeut-5.17 AbsLymp-2.60 AbsMono-0.55 \nAbsEos-0.27 AbsBaso-0.07\n___ 05:30PM WBC-8.7 RBC-4.71 HGB-12.8 HCT-39.0 MCV-83 \nMCH-27.2 MCHC-32.8 RDW-12.7 RDWSD-37.9\n___ 05:30PM 25OH VitD-36\n___ 05:30PM calTIBC-306 VIT B12-650 FOLATE-15.0 \nFERRITIN-109 TRF-235\n___ 05:30PM CALCIUM-9.9 PHOSPHATE-4.3 MAGNESIUM-2.0 \nIRON-66\n___ 05:30PM estGFR-Using this\n___ 05:30PM GLUCOSE-81 UREA N-10 CREAT-0.6 SODIUM-141 \nPOTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-22 ANION GAP-19\n___ 10:00PM URINE MUCOUS-OCC\n___ 10:00PM URINE RBC-3* WBC-1 BACTERIA-NONE YEAST-NONE \nEPI-1\n___ 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR \nGLUCOSE-NEG KETONE-80 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 \nLEUK-NEG\n___ 10:00PM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 10:00PM URINE GR HOLD-HOLD\n___ 10:00PM URINE UCG-NEGATIVE\n___ 10:00PM URINE HOURS-RANDOM\n___ 10:00PM URINE HOURS-RANDOM\n \nBrief Hospital Course:\n___ s/p lap band ___ p/w N/V, po intolerance. She has noted to \nhave vh/o of similar symptoms relieved by band adjustment. We \ninitally attempted aspiration at the bedside, however was unable \nto access the port. We therefore consulted ___ for assistance. \nUnder sterile technique and imaging, 2.5cc was withdrawn from \nthe patient's band. Patient tolerated this procedure without \nissue. Subsequent swallow study with contrast demonstrates no \nobstruction, and no delay emptying. Furthermore, position of \nband and port was appropriate. With relief of symptoms, patient \nwas deemed appropriate for discharge and instructed to follow up \nwith her regular bariatric surgeon. She was hemodynamically \nstable and afebrile throughout hospitalization. \n \nMedications on Admission:\nNexplanon implant in left arm\nNaproxen prn\n \nDischarge Medications:\nNexplanon implant in left arm\nNaproxen prn\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nNausea\nVomiting \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 It was a pleasure taking care of you here at ___ \n___. You were admitted to our hospital for \nnausea and vomiting. We were able to withdraw 2.5cc from your \nadjustable gastric band. You were able to demonstrate adequate \nswallowing potential and are now ready to be discharged home. \nPlease continue your diet as previously instructed by your \nbariatric surgeon. \n\nYour ___ surgery team\n \nFollowup Instructions:\n___\n" ]

[ "K9509", "E669", "Z6834", "M1990", "R112", "Y732", "Y929" ]

[ "K9509: Other complications of gastric band procedure", "E669: Obesity, unspecified", "Z6834: Body mass index [BMI] 34.0-34.9, adult", "M1990: Unspecified osteoarthritis, unspecified site", "R112: Nausea with vomiting, unspecified", "Y732: Prosthetic and other implants, materials and accessory gastroenterology and urology devices associated with adverse incidents", "Y929: Unspecified place or not applicable" ]

[ "E669", "Y929" ]

[]

[ " \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:\nRight-sided weakness and dysarthria\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ RHM with history of prior stroke (R \nfrontal\nnoted on CT), HTN, enlarged prostate, who presents with weakness\nand dysarthria.\n\nHe was in USOH around 3pm, seen by his wife when she left their\nhome for an appointment. Between ___ he called her\ncellphone because he had fallen and could not get up. She\nreturned home and found him on the ground, and recognized that \nhe\nwas having a stroke. She noted R facial droop, dysarthria, R arm\nweakness. Presumably he also had R leg weakness as he could not\nget up, though that was not specifcally noted. He was taken to\nOSH where NIHSS was 18 with scores for weakness, neglect,\ndysarthria, and sensory loss. Initial plan was to give tPA,\nhowever hematuria was noted when foley was placed and tPA was\nthen contraindicated. He also had an episode of hypotension to\nSBP ___ in the ED, which improved with IVF bolus, and no \npressors\nwere needed. He was transferred to BI ED for consideration of\nthrombectomy. En route, his symptoms significantly improved, \nwith\nNIHSS 6 en route.\n\nIn the BI ED, NIHSS was 2 on arrival. His BPs were stable SBP\n>140s. He was noted to have Afib with RVR, and was given \ndiltizem\nwith good effect (HR to 100s) without significant drop in blood\npressure. He was noted to have ongoing hematuria.\n\nHis last stroke was reported to be ___ years ago. He had \nsymptoms\nof hemiparesis and facial droop and dysarthria (patient does not\nknow which side; his wife initially says R, then says L later).\nApparently his weakness resolved by the following day with \nslight\nremaining facial droop that subsequently fully recovered. \n\n On general review of systems, the pt denies recent fever or\nchills. No night sweats or recent weight loss or gain. Denies\ncough, shortness of breath. Denies chest pain or tightness,\npalpitations. Denies nausea, vomiting, diarrhea, constipation \nor\nabdominal pain. No recent change in bowel or bladder habits. \nNo\ndysuria. Denies arthralgias or myalgias. Denies rash. He had\nprior hematuria several years ago after prostate biopsy, but not\nrecently.\n \nPast Medical History:\nHypertension\nProstate enlargement\nDiabetes - diet controlled\nHyperlipidemia\nStroke around ___ - likely R frontal per today's CT\n \nSocial History:\n___\nFamily History:\nNo history of early strokes, no clotting or bleeding\ndisorder.s\n \nPhysical Exam:\nAdmission Physical Exam:\n========================\nVitals: T: 97.3 P: 92-107 R: ___ BP: 150/82 SaO2: 95% 6L-->\n93% RA\nGeneral: Awake, cooperative, NAD.\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in \noropharynx\nNeck: Supple, No nuchal rigidity\nPulmonary: Normal work of breathing\nCardiac: Afib w/ RVR, warm, well-perfused\nAbdomen: soft, non-distended\nGU: foley in place with dark pink urine.\nExtremities: No ___ edema.\nSkin: no rashes or lesions noted.\n \nNeurologic: \n-Mental Status: Alert, oriented, attentive. Language is fluent \nwith intact repetition and comprehension. Normal prosody. \nParaphasic errors - initially says \"hand\" and self-corrects to \n\"glove\" on naming card, says \"hard\" instead of \"heard\" with \nreading sentence. Pt. was able to name both high and low \nfrequency objects. Able to read without difficulty. Speech was \nmoderately dysarthric. Able to follow both midline and \nappendicular commands. There was no evidence of apraxia or \nneglect. \n\nCN \nII,III: VFF to confrontation, pupils 2mm->1mm bilaterally\nIII,IV,VI: EOMI, no ptosis. No nystagmus\nV: sensation intact V1-V3 to LT \nVII: R facial droop, R lower face weak with activation\nVIII: hears finger rub bilaterally \nIX,X: palate elevates symmetrically, uvula midline \nXI: SCM/trapezeii ___ bilaterally \nXII: tongue protrudes midline, no dysarthria \n\nMotor: Normal bulk and tone, no rigidity; No pronator drift. \n Delt Bi Tri WE FE Grip IO \n C5 C6 C7 C6 C7 C8/T1 T1 \n L 5 ___ 5 5 5\n R 5 ___ 5 5 5\n \n IP Quad ___ PF \n L2 L3 L4-S1 L4 L5 S1/S2 \n L 5 5 5 ___ \n R 5 5 5 ___\n\nReflex: No clonus \n Pat An Plantar \n L4 S1 CST \n L 2 0 2 mute \n R 2 0 2 extensor\n\n-Sensory: No deficits to light touch. No extinction to DSS. \n \n-Coordination: + intention tremor. No dysmetria on FNF \nbilaterally. \n\n-Gait: deferred\n\nDischarge Exam:\n===============\nTmax: 37.1 °C (98.7 °F)\nTcurrent: 36.9 °C (98.4 °F)\nHR: 87 (0 - 132) bpm\nBP: 107/55(68) {107/55(68) - 149/107(119)} mmHg\nRR: 20 (20 - 20) insp/min\nSpO2: 95% \nHeart rhythm: AF (Atrial Fibrillation)\n\nGeneral: Pleasant elderly man, sitting comfortably up in chair\nHEENT: Normocephalic, neck supple, a-traumatic \nCV: Rapid, irregular rate \nLungs: diminished at the bases \nAbdomen: soft, obese non-tender \nGU: Deferred\nExt: warm, well perfused \nSkin: dry and intact\n\nNeurologic: \n-MS: Awake, alert, oriented to self, ___, date. Naming intact.\nRepetition intact. Follows midline and appendicular commands. No\nevidence of neglect. \n-CN: PERRL 4-2mm b/l brisk. EOMI no nystagmus. VFF to number\ncounting. Sensation equal ___ in V1, V2, V3. Right NLFF with\nsymmetric activation. Tongue midline. ___ trapezius b/l. \n-Motor: Very subtle left sided pronation. Full strength\nthroughout.\n-Sensory: Intact to light touch b/l throughout.\n-Reflexes: Deferred \n-Coordination: Intention tremor. Intact FNF b/l. \n-Gait: deferred\n\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 06:27PM BLOOD WBC: 19.0* RBC: 5.41 Hgb: 15.6 Hct: 48.5\nMCV: 90 MCH: 28.8 MCHC: 32.2 RDW: 13.2 RDWSD: 43.___ \n___ 06:48PM BLOOD ___: 12.0 PTT: 26.9 ___: 1.1 \n___ 06:27PM BLOOD Glucose: 82 UreaN: 10 Creat: 0.5 Na: 143\nK: 2.5* Cl: 117* HCO3: 14* AnGap: 12 \n___ 06:27PM BLOOD ALT: 20 AST: 12 AlkPhos: 48 TotBili: 0.2 \n___ 06:27PM BLOOD Albumin: 2.5* Calcium: 5.5* Phos: 1.0* \nMg:\n1.0* Cholest: 103 \n___ 06:27PM BLOOD Cholest: 103 Triglyc: 89 HDL: 34* \nCHOL/HD:\n3.0 LDLcalc: 51 \n___ 07:21PM BLOOD %HbA1c: 5.7 eAG: 117 \n___ 06:27PM BLOOD TSH: 0.73 \n___ 06:27PM BLOOD ASA: NEG Ethanol: NEG Acetmnp: NEG\nTricycl: NEG \n___ 06:35PM BLOOD Glucose: 88 Creat: 0.6 Na: 141 K: 2.4* \nCl:\n116* calHCO3: 16* \n\nEKG:\nAtrial fibrillation\n \nIMAGING:\n========\nCXR: Opacity in the right upper lung and left lower lung, \nconcerning for pneumonia.\n\nNon-Contrast CT of Head:\nHead CT: \nThe study is significantly limited by motion. Within this \nlimitation, there is a focal hypodensity within the right \nfrontal lobe (02:22),\nwhich is not definitively apparent on the CTA portion, likely \nreflecting\nartifact. Otherwise, no definite evidence of acute intracranial\nabnormality. \n \nHead CTA: \nNo evidence of high-grade stenosis, occlusion, or aneurysm of \nthe\nvessels of \nthe circle of ___. \n \nNeck CTA: \nAberrant right subclavian artery. The right vertebral artery is\ndiminutive. Otherwise, no evidence of high-grade stenosis or \nocclusion of the carotid or vertebral arteries. \n \nCT perfusion: \nThe perfusion study is limited by patient motion. CBF less than\n30% volume 0 cc. Tmax greater than 6 seconds volume 26 cc. \nMismatch volume 26 cc. \n\nMRI Brain ___ IMPRESSION:\n \n1. Subacute infarction involving the left putamen and body of \nthe left caudate without evidence of hemorrhagic transformation.\n2. Nonspecific white matter changes in the cerebral hemispheres \nbilaterally and in the pons likely reflect a sequela of chronic \nmicroangiopathic changes.\n3. Known left MCA cut off is better identified on the recent \nCTA.\n\nTTE ___ \nThe left atrial volume index is normal. There is normal left \nventricular wall thickness with a normal cavity size. There is \nnormal regional and global left ventricular systolic function. \nThe visually estimated left ventricular ejection fraction is \n55-60%. There is no resting left ventricular outflow tract \ngradient. Mildly dilated right ventricular cavity with mild \nglobal free wall hypokinesis. The aortic sinus diameter is \nnormal for gender with mildly dilated ascending aorta. The \naortic arch diameter is normal with a normal descending aorta \ndiameter. The aortic valve leaflets (3) appear structurally \nnormal. There is no aortic valve stenosis. There is no aortic \nregurgitation. The mitral valve leaflets appear structurally \nnormal with no mitral valve prolapse. There is trivial mitral \nregurgitation. The pulmonic valve leaflets are normal. The \ntricuspid valve leaflets appear structurally normal. There is \nphysiologic tricuspid regurgitation. The estimated pulmonary \nartery systolic pressure is normal. There is no pericardial \neffusion.\n\nIMPRESSION: 1) Normal left ventricular wall thickness and \nbiventricular cavity sizes and regional/global systolic \nfunction. 2) Mild RV dilation with mild global RV systolic \nhypokinesis.\n\n \nBrief Hospital Course:\nPATIENT SUMMARY:\n================\nMr. ___ is a ___ year old man with history of prior stroke \n(right frontal noted on CT) and HTN who presented to another \nhospital with right sided weakness and facial droop with initial \nNIHSS 18. When he was transferred to ___, his NIHSS improved \nto 2 without any intervention. He was not a candidate for tPA \ndue to gross hematuria upon placement of a Foley catheter and \nthere was no LVO for thrombectomy. \n\nACTIVE ISSUES:\n==============\n# Atrial Fibrillation with Rapid Ventricular Response\nHe was initially admitted to NeuroICU and then transferred to \nNeurology Step Down Unit where he was found to have new atrial \nfibrillation, with rapid ventricular response. He was started on \nMetoprolol which was gradually up-titrated to 100 mg BID for \nrate control. He was also started on diltiazem which was also \nup-titrated to 120 mg of extended release daily. \n\n# Left MCA Strokes\nOn MRI, he was found to have left MCA territory infarcts, likely \nrelated to his atrial fibrillation. He was started on apixaban \n5mg BID for prophylaxis in setting of atrial fibrillation prior \nto discharge. Neurological exam at time of discharge notable for \nright nasolabial fold flattening but overall preserved strength. \n\n\n# Urinary Retention\n# Hematuria\nDue to ongoing hematuria with Foley placement, Urology was \nconsulted who recommended discharge with Foley and place and \nfollow up with urology in the outpatient setting. \n\n# Community Acquired Pneumonia\nOn Chest X-ray, there was concern for bilateral opacities and \npatient was started on antibiotic treatment with ceftriaxone and \nazithromycin. He completed a ___nd was discharged \nwithout any respiratory complaints. \n\nTRANSITIONAL ISSUES:\n====================\n# Patient had O2 desaturations at night. Consider workup for OSA \nas outpatient.\n\n# Patient started on metoprolol succinate 100 mg BID and \ndiltiazem 120 mg daily for rate control. Consider uptitrating \nfurther as outpatient.\n\n# Follow up with urology for management of urinary \nretention/enlarged prostate.\n\n# Follow with Dr. ___ in Stroke ___.\n\n# Follow up with PCP; of note, it may be beneficial for him to \nsee a cardiologist for management of his newfound atrial \nfibrillation.\n\nAHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic \nAttack \n=\n=\n=\n=\n=\n=\n=\n================================================================\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 = 51) - () 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: () \nAntiplatelet - (x) 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. Pravastatin 10 mg PO QPM \n2. Finasteride 5 mg PO DAILY \n3. Lisinopril 40 mg PO DAILY \n4. Felodipine 10 mg PO DAILY \n5. Oxybutynin XL (*NF*) 10 mh PO DAILY \n6. MetFORMIN (Glucophage) 500 mg PO BID \n7. Metoprolol Tartrate 50 mg PO BID \n8. Aspirin 81 mg PO DAILY \n\n \nDischarge Medications:\n1. Apixaban 5 mg PO BID \nRX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*2 \n2. Diltiazem Extended-Release 120 mg PO DAILY \nRX *diltiazem HCl 120 mg 1 capsule(s) by mouth once a day Disp \n#*30 Capsule Refills:*3 \n3. Metoprolol Succinate XL 100 mg PO BID \nRX *metoprolol succinate 100 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*3 \n4. Tamsulosin 0.4 mg PO QHS \nRX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30 \nCapsule Refills:*2\nRX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30 \nCapsule Refills:*3 \n5. Felodipine 10 mg PO DAILY \n6. Finasteride 5 mg PO DAILY \n7. Lisinopril 40 mg PO DAILY \n8. MetFORMIN (Glucophage) 500 mg PO BID \n9. Oxybutynin XL (*NF*) 10 mh PO DAILY \n10. Pravastatin 10 mg PO QPM \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAcute ischemic stroke\nAtrial fibrillation with rapid ventricular response\nUrinary retention\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\n You were hospitalized due to symptoms of weakness resulting \nfrom an ACUTE ISCHEMIC STROKE, a condition where a blood vessel \nproviding oxygen and nutrients to the brain is blocked by a \nclot. The brain is the part of your body that controls and \ndirects all the other parts of your body, so damage to the brain \nfrom being deprived of its blood supply can result in a variety \nof symptoms. \n \n Stroke 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. \n \n Your risk factors are: \n High blood pressure\n Atrial fibrillation (abnormal heart rhythm)\n Prior stroke \n\n We are changing your medications as follows: \n \n Please start Apixiban (Eliquis) 5mg twice daily \n Please change your Metoprolol to 100 mg twice per day\n Please start taking Tamsulosin 0.4mg at bedtime for prostate \nissues \n Please take your other medications as prescribed. \n \n Please follow up with Neurology and your primary care physician \nas listed below. \n If 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" ]

[ "I63412", "J189", "G8191", "Z23", "R29702", "I10", "E785", "Z8673", "I480", "E119", "Z7984", "R29810", "Y846", "Y92239", "R471", "R310", "R000", "N401", "R338" ]

[ "I63412: Cerebral infarction due to embolism of left middle cerebral artery", "J189: Pneumonia, unspecified organism", "G8191: Hemiplegia, unspecified affecting right dominant side", "Z23: Encounter for immunization", "R29702: NIHSS score 2", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "I480: Paroxysmal atrial fibrillation", "E119: Type 2 diabetes mellitus without complications", "Z7984: Long term (current) use of oral hypoglycemic drugs", "R29810: Facial weakness", "Y846: Urinary catheterization 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", "R471: Dysarthria and anarthria", "R310: Gross hematuria", "R000: Tachycardia, unspecified", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "R338: Other retention of urine" ]

[ "I10", "E785", "Z8673", "I480", "E119" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: CARDIOTHORACIC\n \nAllergies: \nPercocet\n \nAttending: ___.\n \nChief Complaint:\nLeft lower lobe lung nodule\n \nMajor Surgical or Invasive Procedure:\n___\nVideoassisted thoracoscopic surgery, left lower lobe wedge \nresection\n\n \nBrief Hospital Course:\nMs. ___ was admitted to the hospital and taken to the \nOperating Room where she underwent a left lower lobe wedge \nresction. She tolerated the procedure well and returned to the \nPACU in stable condition. She maintained stable hemodynamics and \nher main was minimal. Her chest tube drained a moderate amount \nof thin bloody fluid and had an intermittent air leak.\n\nFollowing transfer to the Surgical floor she progressed well. \nShe had a persistent air leak on POD 1. Her diet was advanced to \na regular diet. repeat imaging showed a stable left apical \npneumothorax. Her pain was well controlled with tramadol and \nacetaminophen. On POD 2, the air leak appeared to resolve. Her \nchest tube was removed and a follow up chest x ray revealed a \nsmaller left sided apical pneumothorax. The decision was made to \ndischarge the patient.\n\nHer pain remained manageable with scheduled Tylenol. She was up \nand walking independently. After an uneventful recovery she was \ndischarged to home on ___. Follow up with Dr. ___ \nwas scheduled in clinic in 2 weeks. \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. LORazepam 0.5 mg PO QHS:PRN insomnia \n2. levonorgestrel 20 mcg/24 hr ___ years) injection ___ yrs \n3. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \nDo not take more the 4000mg in one day \nRX *acetaminophen 650 mg 1 tablet(s) by mouth every 8 hours as \nneeded Disp #*30 Tablet Refills:*0 \n2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild \nAlternate with acetaminophen \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every 8 hours as \nneeded Disp #*30 Tablet Refills:*0 \n3. levonorgestrel 20 mcg/24 hr ___ years) injection ___ yrs \n4. LORazepam 0.5 mg PO QHS:PRN insomnia \n5. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nLeft lung nodule\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 were admitted to the hospital for lung surgery and you've \nrecovered well. You are now ready for discharge. \n\n* Continue to use your incentive spirometer 10 times an hour \nwhile awake.\n\n* Check your incisions daily and report any increased redness or \ndrainage. Cover the area with a gauze pad if it is draining.\n\n* Your chest tube dressing may be removed in 48 hours. If it \nstarts to drain, cover it with a clean dry dressing and change \nit as needed to keep site clean and dry.\n\n * You may need pain medication once you are home but you can \nwean it over the next week as the discomfort resolves. Make \nsure that you have regular bowel movements while on narcotic \npain medications as they are constipating which can cause more \nproblems. Use a stool softener or gentle laxative to stay \nregular.\n\n* No driving while taking narcotic pain medication.\n\n* Take Tylenol for pain. \n\n* Continue to stay well hydrated and eat well to heal your \nincisions\n\n* Shower daily. Wash incision with mild soap & water, rinse, pat \ndry\n * No tub bathing, swimming or hot tubs until incision healed\n * No lotions or creams to incision site\n\n* Walk ___ times a day and gradually increase your activity as \nyou can tolerate.\n\nCall Dr. ___ ___ ___ if you experience:\n -Fevers > 101 or chills\n -Increased shortness of breath, chest pain or any other \nsymptoms that concern you.\n\n \n\n** If pathology specimens were sent at the time of surgery, the \nreports will be reviewed with you in detail at your follow up \nappointment. This will give both you and your doctor time to \nunderstand the pathology, its implications and discuss options \ngoing forward.**\n\n \n\n \n \nFollowup Instructions:\n___\n" ]

[ "Q859" ]

[ "Q859: Phakomatosis, unspecified" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nReglan / Methotrexate / Dronabinol / chlorhexidine / vancomycin \n/ levofloxacin / Betadine / Feraheme / cefepime / adhesives / \nGammagard S/D\n \nAttending: ___.\n \nChief Complaint:\n Abdominal pain/distension\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with complex PMH including eosinophilic GI disease,\ngastroparesis, TPN dependent c/b multiple line infections, POTS,\nadrenal insufficiency, and hypogammaglobulinemia with recurrent\ninfections on IVIG presents to the emergency department with c/o\nabdominal pain and distention. \n\nOf note, patient was recently admitted ___ for fevers and\nfound to have pseudomonas oryzihabitans bacteremia treated with\npip/tazo. She was also admitted ___ for abdominal pain and\nN/V and treated symptomatically for an ileus. She was discharged\nand has been doing well until today. This morning she went to\n___ ED to have stitches placed in her left thumb and was\npain-free at that time. Around 1630-1645 she developed sudden\nonset abdominal pain and distention. The pain is mostly located\nin the periumbilical area, throbbing, is constant but fluctuates\nin intensity, exacerbated with movement, with no alleviating\nfactors. She notes a chronic low-grade fever and chronic nausea\nbut the nausea does appear worse. She denies any chest pain or\ndifficulty breathing. Last bowel movement was 2 days ago and was\nnormal for her. She denies any melena or BRBPR. Unsure if she is\nstill passing gas. She states that this pain is different from\nher pancreatitis pain.\n\nIn the ED, initial VS were: 98.3 BP 154/131 RR 16 SpO2 100% RA \nHR\n128\n\nExam notable for:\nUncomfortable, non-toxic\nTachycardic, no appreciable murmur\nCTA bilaterally, no wheezing or crackles\nAbdomen distended, J-tube in LUQ is clean/dry/intact with no\nsurrounding erythema, abdomen is distended with diffuse\ntenderness most pronounced in RUQ, hepatomegaly, decreased bowel\nsounds\nSkin is warm and dry\n\nLabs showed:\nWBC 4.6 Hgb 8.2 Plt 174\n136 | 100 | 11\n---------------\n4.3 | 25 | 0.7\nCa 9.3 Mg 1.9 P 4.0\nALT 29 AST 34 AP 100 Tbili 0.2 Alb 4.2\nINR 1.0\nuCG negative\nLactate 0.7\n\nImaging showed:\nCXR: No evidence for acute cardiopulmonary disease. Central\nvenous catheter terminating at the cavoatrial junction. \n\nAXR: Finding suggest pneumatosis along the ascending colon. CT\nshould be considered to evaluate further if clinically\nappropriate in addition to correlation with clinical findings. \n\nSurgery was consulted, with recommendation for CT A/P, noting\nthat ischemic bowel cannot be ruled out by physical exam and if\nthere is ongoing concern radiographically for pneumatosis a CT\nwith contrast would be recommended.\n\nUnfortunately CT A/P with contrast was unable to be performed \ndue\nto lack of access despite multiple attempts so CT was deferred\nuntil patient is on the floor. \n\nPatient received: \nHydromorphone 1 mg IV x2\nDiphenhydramine 50 mg x 2\nNS @ 100 mL/hr\n\nTransfer VS were:\n\nREVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as\nper HPI\n\n \nPast Medical History:\n- Eosinophilic GI disease involving esophagus, stomach and small \n\nintestine \n- TPN dependent (cycles over 12 hours at night) \n- Previously had been doing: G tube for meds and venting, J tube \n\nfor trickle feeds (___) but this is variable. \n- POTS with concomitant workup for dysautonomia and Ehlers \nDanlos\n- Adrenal insufficiency \n- ___: Line-associated Enterobacter absuriae and C. \nparapsilosus bacteremia treated with line exchange and 14 days \nof cefepime and IV fluconazole \n- ___: Line infection although blood cultures negative, \n\ntreated with IV daptomycin. \n- ___: Line-associated DVT, started on lovenox \n- ___: GNR bacteremia and candidal fungemia, ~month-long \nhospitalization \n- ___: enterobacter and klebsiella bacteremia\n- Severe gastroparesis \n- Hypogammaglobulinemia with recurrent infections currently on\nmonthly IVIg\n- Recurrent fevers with largely negative infectious workup\nrecently\n \nSocial History:\n___\nFamily History:\nShe has an identical twin who has some symptoms of POTS and\nquestion eosinophilic esophagitis and joint pain. She has a\nmaternal cousin with ___ disease. Father has hypertension \nand\na colon tumor and Parkinsonian smyptoms. Her maternal uncle died\nof pancreatic cancer. Mother had a ___ tear.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVS: ___ 0537 Temp: 98.9 PO BP: 134/78 HR: 130 RR: 18 O2 \nsat:\n94% O2 delivery: ra Dyspnea: 0 RASS: +2 Pain Score: ___ \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, distended, tender in all quadrants \nparticularly\nRUQ, no rebound/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\nTemp: 97.3 PO BP: 107/69 L Lying HR: 97 RR: 18 O2\nsat: 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. \nCHEST: R tunneled line c/d/i\nPULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles\nGI: abdomen distended, improved from admission. Erythematous\npapule w/o drainage improved bordering GJ tube site. \nEXTREMITIES: no cyanosis, clubbing, or edema. thumb laceration\nc/d/i, healing. \nNEURO: Alert, moving all 4 extremities with purpose, face\nsymmetric\nDERM: warm and well perfused, no excoriations or lesions.\nErythema along nasal bridge and below eyes, NOW RESOLVED\n\n \nPertinent Results:\nADMISSION/PERTINENT LABS\n___ 10:28PM BLOOD WBC-4.6 RBC-3.81* Hgb-8.2* Hct-26.6* \nMCV-70* MCH-21.5* MCHC-30.8* RDW-17.3* RDWSD-43.5 Plt ___\n___ 10:28PM BLOOD ___ PTT-73.8* ___\n___ 10:28PM BLOOD Glucose-76 UreaN-11 Creat-0.7 Na-136 \nK-4.3 Cl-100 HCO3-25 AnGap-11\n___ 10:28PM BLOOD ALT-29 AST-34 AlkPhos-100 TotBili-0.2\n___ 10:28PM BLOOD Albumin-4.2 Calcium-9.3 Phos-4.0 Mg-1.9\n___ 10:25PM BLOOD Lactate-0.7\n___ 05:53AM BLOOD WBC-2.6* RBC-3.05* Hgb-6.6* Hct-22.2* \nMCV-73* MCH-21.6* MCHC-29.7* RDW-17.2* RDWSD-45.0 Plt ___\n___ 05:53AM BLOOD calTIBC-391 ___ Ferritn-7.5* \nTRF-301\n\nDISCHARGE LABS:\n___ 04:15AM BLOOD WBC-3.3* RBC-3.71* Hgb-8.3* Hct-27.1* \nMCV-73* MCH-22.4* MCHC-30.6* RDW-18.1* RDWSD-47.2* Plt ___\n___ 04:15AM BLOOD Glucose-71 UreaN-13 Creat-0.5 Na-139 \nK-4.7 Cl-103 HCO3-27 AnGap-9*\n\n **FINAL REPORT ___\n\n Blood Culture, Routine (Final ___: \n ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES. \n HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml \nof\n gentamicin. Screen predicts possible synergy with \nselected\n penicillins or vancomycin. Consult ID for details. \n HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to \n1000mcg/ml of\n streptomycin. Screen predicts possible synergy with \nselected\n penicillins or vancomycin. Consult ID for details.. \n Daptomycin MIC OF 2 MCG/ML test result performed by \nEtest. \n STAPHYLOCOCCUS, COAGULASE NEGATIVE. \n Isolated from only one set in the previous five days. \n SENSITIVITIES REQUESTED BY ___ ___ ON \n___. \n FINAL SENSITIVITIES. \n Staphylococcus species may develop resistance during \nprolonged\n therapy with quinolones. Therefore, isolates that are \ninitially\n susceptible may become resistant within three to four \ndays after\n initiation of therapy. Testing of repeat isolates may \nbe\n warranted. \n Oxacillin RESISTANT Staphylococci MUST be reported as \nalso\n RESISTANT to other penicillins, cephalosporins, \ncarbacephems,\n carbapenems, and beta-lactamase inhibitor combinations. \n\n RIFAMPIN should not be used alone for therapy. \n COAG NEG STAPH does NOT require contact precautions, \nregardless of\n resistance. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ENTEROCOCCUS FAECALIS\n | STAPHYLOCOCCUS, \nCOAGULASE NEGATIVE\n | | \nAMPICILLIN------------ <=2 S\nCLINDAMYCIN----------- <=0.25 S\nERYTHROMYCIN---------- <=0.25 S\nGENTAMICIN------------ <=0.5 S\nLEVOFLOXACIN---------- <=0.12 S\nOXACILLIN------------- =>4 R\nPENICILLIN G---------- 2 S\nRIFAMPIN-------------- <=0.5 S\nVANCOMYCIN------------ 1 S 2 S\n\nIMAGING\n___ CT A/P\n1. Dilatation of the duodenum and proximal jejunum, with abrupt \ntransition \npoint in the left mid abdomen, just before the entry point of \nthe jejunostomy \ntube, concerning for small bowel obstruction. \n2. No fluid collection or pneumoperitoneum. \n3. Splenomegaly. \n\n___ CXR\nNo pneumonia or acute cardiopulmonary process.\n\n \nBrief Hospital Course:\n___ with complex PMH including eosinophilic GI disease, \ngastroparesis, TPN dependent c/b multiple line infections, POTS, \nadrenal insufficiency, and hypogammaglobulinemia with recurrent \ninfections on IVIG presents to the emergency department with c/o \nabdominal pain and distention found to have enterococcus \nbacteremia\n\n# Abdominal pain\nAbdominal XR in ED was read as concering for pneumatosis \nintestinalis although repeat KUB resolution of air lucencies. \nLabs reassuring including normal lactate. Suspect her pain \nlikely multifactorial from refractory gastroparesis, \neosinophilic GI disease, and superimposed dysmotility from \nopioid use. Enterococcus bacteremia\nlikely contributing as well. Recommended tapering opioids as \ninpatient, but patient preferred to do this as outpatient. Pain \nwas controlled with home methadone (___) and dilaudid 1.5mg \nIV q4h PRN.\n\n#Enterococcal bacteremia\nAdmission bcx grew enterococcus likely ___ gut translocation in \nthe setting of known GI disease. ID involved and recommended 2 \nweek course of daptomycin (___). Did not get additional \nabdominal imaging given clinical stability and patient would \nneed femoral line to receive IV contrast given poor access. \nUnable to remove tunneled line given difficult access. PEVA team \ninvolved and recommended daptomycin locks as well. Pt continued \non ethanol dwells. Had intermittent low grade fever at baseline \nand had fever of 100.7 on ___, afebrile since then with \nnegative culture result. \n\n#Pancytopenia\n#Iron deficiency anemia\nHx of multiple transfusions. Hgb 6.6 on ___, but pt \nasymptomatic. No signs of occult GI bleed. Likely ___ marrow \nsuppression iso infection. Iron studies consistent with iron \ndeficiency anemia. Offered to start liquid iron as inpatient, \nbut patient wanted to defer to outpatient as started on prazosin\n\n# PTSD\n# Possible Opiate Use Disorder: \nShe admits she has had negative experiences w/ healthcare \nsystem, and has been labeled with PTSD\nby outpt psychiatrist. Seen by psychiatry who recommended \nstarting prazosin 1mg and uptitrating as outpatient.\n\n# Facial rash\nHas had intermittent facial rash of unclear etiology. Seen by \nderm, who suspects ___ contact/irritant dermatitis. Rash \nresolved inpatient. Patient will have dermatology followup as \noutpatient\n\n# Thumb laceration: \nOccurred in setting of cut from apple core tool s/p suturing in \n___ ED. Patient received tdap in ___. No sign of infection. \nShe was given mupirocin ointment. Wound well healed on \ndischarge.\n\n# Adrenal insufficiency: \nContinue home Hydrocortisone 2.5 mg QPM, 5 mg QAM. Seen by \noutpatient endocrinologist who recommended downtitrating \nhydrocort as outpatient. \n\n# POTS disease\n# Gastroparesis \n# Autonomic neuropathy\n S/p J-tube and currently TPN dependent. Her J-tube is changed \nevery three months. She had a gastric pacemaker placed in ___. Patient appears to have baseline tachycardia in setting of \nPOTS. Continued home pyridostigmine 60 mg TID and home benadryl \nIV 50mg q4h PRN nausea, \n\n# Eosinophilic enteropathy\n# TPN dependence\nContinued home TPN and lansoprazole 30 mg BID\n\n#Hypogammaglobulinemia\nReceives IVIG as outpatient. Last infusion on ___\n\nTRANSITIONAL ISSUES\n[]Pt with iron deficiency anemia. Did not tolerate IV iron \ninfusion in past. Recommend trialing liquid ferrous sulfate as \noutpatient\n[]Continue to encourage tapering of opioids as outpatient. \nRecommend that pt keeps a log of her use\n[]Will continue IV daptomycin with daptomycin locks to complete \n2 week course for enterococcus bacteremia (___). Will \ncontinue to use ethanol dwells after IV abx\n[]Continue prazosin 1mg as outpatient. Titrate upwards for \neffect for PTSD nightmare, caution with orthostasis given \npatient's known history of POTS. \n[] Consider future medication trials (eg SSRI, SNRI, TCA, or \nmirtazapine) for depression/anxiety/PTSD/intrusive thoughts. Can \nbe referred to ___ psychiatry: ___ \n[]Per endocrinology, recommend patient decrease hydrocortisone \nto 2.5mg BID\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. DiphenhydrAMINE 50 mg IV Q4H:PRN pruritis \n2. Fexofenadine 180 mg PO BID \n3. Fluocinonide 0.05% Ointment 1 Appl TP BID \n4. Hydrocortisone 2.5 mg PO QPM \n5. Hydrocortisone 5 mg PO QAM \n6. Hydromorphone (Oral Solution) 1 mg/1 mL ___ mg PO Q4H:PRN \npain \n7. Lansoprazole Oral Disintegrating Tab 30 mg PO BID \n8. Lidocaine 5% Patch 2 PTCH TD QAM \n9. Mupirocin Ointment 2% 1 Appl TP BID \n10. Promethazine 25 mg IV Q6H:PRN nausea \n11. Pyridostigmine Bromide Syrup 60 mg PO TID \n12. Sarna Lotion 1 Appl TP QID:PRN pruritis \n13. Vitamin D 8000 UNIT PO DAILY \n14. Methadone (Oral Solution) 2 mg/1 mL 10 mg PO QHS \n15. Methadone (Oral Solution) 2 mg/1 mL 5 mg PO QAM \n16. Methadone (Oral Solution) 2 mg/1 mL 5 mg PO Q1400 \n17. Bystolic (nebivolol) 15 mg oral BID \n18. ___ (hydrocorTISone) 2.5 % topical DAILY:PRN \n19. Ethanol 70% Catheter DWELL (Tunneled Access Line) 2 mL DWELL \nDAILY \n\n \nDischarge Medications:\n1. Bacitracin Ointment 1 Appl TP ASDIR \n2. Daptomycin-Heparin Lock ___AILY R tunneled line \nDaptomycin 2mg/mL\n+ Heparin 100 Units/mL \n3. Daptomycin-Heparin Lock ___AILY \nDaptomycin 2mg/mL\n+ Heparin 100 Units/mL \n4. Daptomycin 350 mg IV Q24H \nend date ___ \nRX *daptomycin 350 mg 350 mg IV daily Disp #*3 Vial Refills:*0 \n5. Prazosin 1 mg PO QHS \nRX *prazosin 1 mg 1 capsule(s) by mouth at bedtime Disp #*30 \nCapsule Refills:*0 \n6. ___ (hydrocorTISone) 2.5 % topical DAILY:PRN \n7. Bystolic (nebivolol) 15 mg oral BID \n8. DiphenhydrAMINE 50 mg IV Q4H:PRN pruritis \n9. Ethanol 70% Catheter DWELL (Tunneled Access Line) 2 mL DWELL \nDAILY \n10. Fexofenadine 180 mg PO BID \n11. Fluocinonide 0.05% Ointment 1 Appl TP BID \n12. Hydrocortisone 2.5 mg PO QPM \n13. Hydrocortisone 5 mg PO QAM \n14. Hydromorphone (Oral Solution) 1 mg/1 mL ___ mg PO Q4H:PRN \npain \n15. Lansoprazole Oral Disintegrating Tab 30 mg PO BID \n16. Lidocaine 5% Patch 2 PTCH TD QAM \n17. Methadone (Oral Solution) 2 mg/1 mL 10 mg PO QHS \n18. Methadone (Oral Solution) 2 mg/1 mL 5 mg PO QAM \nConsider prescribing naloxone at discharge \n19. Methadone (Oral Solution) 2 mg/1 mL 5 mg PO Q1400 \nConsider prescribing naloxone at discharge \n20. Mupirocin Ointment 2% 1 Appl TP BID \n21. Promethazine 25 mg IV Q6H:PRN nausea \n22. Pyridostigmine Bromide Syrup 60 mg PO TID \n23. Sarna Lotion 1 Appl TP QID:PRN pruritis \n24. Vitamin D 8000 UNIT PO DAILY \n25.Daptomycin-Heparin Lock\nDaptomycin-Heparin Lock ___AILY R tunneled line \nDaptomycin 2mg/mL + Heparin 100 Units/mL\nFOR USE AFTER ETHANOL LOCK FINISHED, when line not in use. \nAspirate back before line use. Please use dwells in both lumen. \nShould be used until ___.\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY:\nBloodstream infection secondary to enterococcus\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 care of you.\n\nWhy you were admitted?\n- You were admitted because you were having abdominal pain. \n\nWhat we did for you in the hospital?\n- You were found to have an enterococcus bloodstream infection.\n- You were treated with antibiotics.\n- Your abdominal pain improved\n- You were given a unit if blood\n\nWhat should you do when you leave the hospital?\n- Please continue taking daptomycin to complete 14 day course \n(last day ___\n- Please maintain a log of your use of dilaudid.\n- Your endocrinologist recommended going down on your \nhydrocortisone to 2.5mg twice a day when you are feeling better.\n- Please attend your follow up appointments.\n\nWe wish you the best,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "K3184", "R7881", "D801", "Q796", "E872", "E2749", "D61818", "B952", "K5281", "K200", "I10", "D509", "Z934", "Z79899", "G909", "I498", "L2489", "K30", "Z931", "F4310", "F329", "F419" ]

[ "K3184: Gastroparesis", "R7881: Bacteremia", "D801: Nonfamilial hypogammaglobulinemia", "Q796: Ehlers-Danlos syndromes", "E872: Acidosis", "E2749: Other adrenocortical insufficiency", "D61818: Other pancytopenia", "B952: Enterococcus as the cause of diseases classified elsewhere", "K5281: Eosinophilic gastritis or gastroenteritis", "K200: Eosinophilic esophagitis", "I10: Essential (primary) hypertension", "D509: Iron deficiency anemia, unspecified", "Z934: Other artificial openings of gastrointestinal tract status", "Z79899: Other long term (current) drug therapy", "G909: Disorder of the autonomic nervous system, unspecified", "I498: Other specified cardiac arrhythmias", "L2489: Irritant contact dermatitis due to other agents", "K30: Functional dyspepsia", "Z931: Gastrostomy status", "F4310: Post-traumatic stress disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified" ]

[ "E872", "I10", "D509", "F329", "F419" ]

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