Datasets:

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rntc

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mm-icd-visit

like 1

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAbdominal Pain, constipation and inability to tolerate po\nintake\n \nMajor Surgical or Invasive Procedure:\nEGD\nColonoscopy\n\n \nHistory of Present Illness:\n___ y.o. female with hx/o IgA deficiency p/w chronic constipation\nwith ability to pass flatulence. Over the past year, the patient\nhas had progressively worsening constipation, and over the past \n8\ndays has been unable to move her bowels. Was seen here and\nreceived enema and go lytley with resolution. Pt. attempted mag\ncitrate 4 days PTA with two bowel movements of brown stool\nfollowed by clear liquid like water but the feeling of \nincomplete\nevacuation persisted. She was in ___ and returned two weeks\nago. While there she ate foods with gluten but was able to have \na\nnormal bm daily there without the assistance of miralax. Upon\nreturn her constipation returned and despite starting miralax\ntwice daily. She had similar symptoms two months ago which\nrequired ER and UC visits. Her sx resolved with golytely and mag\ncitrate. Prior to the trip to ___ she has been on a low\ngluten diet because this is what she normally per her and her\nmother but she has never seen a nutritionist to be sure she is \non\na gluten free diet. \nWhile in the ER on ___ her KUB demonstrates mild to moderat\nfecal retention in the R colon and majority of the descending\ncolon. Endorses intermittent, diffuse and mild intensity, sharp\nabdominal pain with nausea in all four quadrants along with\nrectal pain. Denies vomiting, fevers/chills, antecedent illness,\nmelena, BRBPR, CP and dyspnea. No mouth sores, rashes, joint\npains or eye symptoms. She is unable to tolerate solid foods\nsecondary to pain and has been on a CLD x 24 hours only drinking\nfluids. Endorses consumption of EtOH on weekends. Able to pass\nflatulence. She had some nausea in the ED but this resolved with\nZofran ODT. No vaginal discharge. No h/o of STDs.\n\nIn ER: (Triage Vitals: 7 |97.5 |52 |118/87 |17 |100% RA \nMeds and IVF Given: \n___ 12:46 IVF NS 1000 mL \n___ 11:31 PO Ondansetron ODT 4 mg \n___ 11:31 PO/NG Lactulose 30 mL \n___ 12:55 PO/NG Senna 8.6 mg \n___ 12:55 PO Acetaminophen 1000 mg \n___ 14:50 PO/NG Polyethylene Glycol 17 g \n___ 14:50 PO Magnesium Citrate 300 mL \n___ 17:01 PO Ondansetron ODT 4 mg \n\n \nPast Medical History:\nThe patient does not smoke cigarettes or\nmarijuana. She will be going to UVM in the fall. She drink ETOH\non weekends. She is not currently sexually active. \n \nSocial History:\n___\nFamily History:\nMother and father are healthy. Maternal\ngrandfather had colorectal cancer in his ___. Paternal great\ngrandfather and grandmother with colorectal cancer. No family \n \nPhysical Exam:\nDischarge Exam:\n\nCONS: NAD, comfortable appearing \nHEENT: ncat anicteric MMM \nNo cervical LAD \nCV: s1s2 rr no m/r/g \nRESP: b/l ae no w/c/r \nGI: +bs, SNTND \nGU: Normal external genitalia\nMSK:no c/c/e 2+pulses \nSKIN: no rash \nNEURO: face symmetric speech fluent \nPSYCH: calm, cooperative \nLAD: No cervical LAD\nPsychiatric [X] WNL\n[X] Appropriate \n \nBrief Hospital Course:\n#Abdominal Pain: Pt was admitted, prep'd, and had EGD / ___ on \n___, which was uneventful. Per pt request, pt was discharged \nhome right after procedure, and no report is available at time \nof discharge. Pt was advised to continue BID miralax and f/u w/ \noutpt GI doctor to discuss the results and next steps.\n\n \nMedications on Admission:\nMiralax BID\n \nDischarge Medications:\n1. Polyethylene Glycol 17 g PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAbdominal 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\nWe admitted you for an EGD and a colonoscopy. Now that they are \ndone, you are fine to go home. You will need to follow up with \nyour outpatient GI doctor for the results and discussion of next \nsteps. \n\nWe wish you the best with your health.\n___ Medicine\n \nFollowup Instructions:\n___\n" ]

[ "R1032", "K5909", "Z800", "R634", "Z681", "D802", "R110" ]

[ "R1032: Left lower quadrant pain", "K5909: Other constipation", "Z800: Family history of malignant neoplasm of digestive organs", "R634: Abnormal weight loss", "Z681: Body mass index [BMI] 19.9 or less, adult", "D802: Selective deficiency of immunoglobulin A [IgA]", "R110: Nausea" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nRash\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with IgG Lambda multiple \nmyeloma on C2D11 of Lenalidomide, Bortezomib and Dexamethasone \n(RVD) who was admitted directly from clinic for diffuse pruritic \nrash, ___, hypotension, and facial edema. The rash began about \n2 days ago, first on her thighs and then spread to her face, \ntrunk, and arms. She reports pruritus but no fevers or chills. \nShe also reports that her face feels swollen. No blistering or \nulceration from the rash. No eye pain or mouth ulcers, no GI or \nGU symptoms presently. She took a couple doses of Mucinex \nrecently for congestion, but aside from her chemotherapy, \notherwise has not started any new medications, OTC drugs or \nherbal meds. She does not remember having any rashes like this \nin the past. Due to the rash, she went to see her doctor in \nclinic, where she was found to have an elevated creatinine of \n1.8 (baseline 0.8). She received 2L NS IVF prior to admission. \n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\n___ Cycle 1 RVD Plan: Lenalidomide 25 mg PO daily on days\n___ of 21-day cycle. Bortezomib IVP 1.3 mg/m2 on days 1, 4, 8,\n11. Dexamethasone 20 mg PO on days 1, 2, 4, 5, 8, 9, 11, 12.\n___ Cycle 2 Day 1 RVD: Lenalidomide 25 mg PO daily on days\n___ of 21-day cycle. Bortezomib IVP 1.3 mg/m2 on days 1, 4, 8,\n11. Dexamethasone 20 mg PO on days 1, 2, 4, 5, 8, 9, 11, 12.\n___ Cycle 2 Day 8 RVD: Bortezomib HELD due to grade 2 \npainful\nneuropathy. Continue lenalidomide and dexamethasone as directed.\n___ Cycle 2 Day 11 RVD: RVD HELD due to grade 3 rash. \nPatient\nadmitted to hospital for hypotension, elevated WBCs, and \nelevated\ncreatinine.\n\nPAST MEDICAL HISTORY:\n-HTN\n-HLD\n-s/p CCY\n-s/p L oopherectomy\n-Sickle trait\n \nSocial History:\n___\nFamily History:\n-Uncle - ___ CA\n-Mother - T2DM, HTN, HLD\n\n \nPhysical Exam:\nON ADMISSION:\n===============\nVS: Tmax 100.4 Tc 99.2 BP 113/58 HR ___ RR 18 SaO2 98% on \nRA\nGEN: NAD\nHEENT: Facial edema, no lip or tongue swelling. Sclera \nanicteric,\nMMM. Tongue with desquamation.\nCards: RRR, nl S1/S2. No murmurs/gallops/rubs. \nPulm: CTAB no crackles or wheezes \nAbd: BS+, soft, nontender, no rebound/guarding\nExtremities: WWP, no edema. DPs, PTs 2+. \nSkin: Morbilliform eruption on the posterior neck, trunk, \nposterior upper extremities, anterior thighs. On the anterior \nthighs are coalescing erythematous plaques with central \nduskiness. BSA > 30%. No mucous membrane involvement. \nNeuro: AOx3, CNII-XII grossly intact. ___ motor strength and \nsensory exam grossly intact. \n\nON DISCHARGE:\n================\nVS: Tc 98.3 BP 120/68 HR 77 RR 16 SaO2 95% on RA\nGEN: NAD\nHEENT: Face less swollen, no lip or tongue swelling.\nSclera anicteric, MMM. \nCards: RRR, nl S1/S2. No murmurs/gallops/rubs. \nPulm: CTAB no crackles or wheezes \nAbd: BS+, soft, nontender, no rebound/guarding\nExtremities: WWP, no edema. DPs, PTs 2+. \nSkin: Faint morbilliform eruption on the posterior neck, trunk, \nupper chest, posterior upper extremities, anterior thighs. On \nthe anterior thighs are regressing coalescing erythematous \nplaques. BSA > 30%. No mucous membrane involvement. Desquamation \non the upper back.\nNeuro: AOx3, CNII-XII grossly intact. ___ motor strength and \nsensory exam grossly intact. \n \nPertinent Results:\nADMISSION LABS:\n=================\n___ 12:15PM WBC-12.1*# RBC-4.31 HGB-12.1 HCT-34.8 MCV-81* \nMCH-28.1 MCHC-34.8 RDW-14.3 RDWSD-41.2\n___ 12:15PM NEUTS-65 BANDS-6* LYMPHS-10* MONOS-5 EOS-12* \nBASOS-2* ___ MYELOS-0 AbsNeut-8.59* AbsLymp-1.21 \nAbsMono-0.61 AbsEos-1.45* AbsBaso-0.24*\n___ 12:15PM HYPOCHROM-NORMAL ANISOCYT-NORMAL \nPOIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL \nPOLYCHROM-NORMAL\n___ 12:15PM PLT SMR-NORMAL PLT COUNT-162\n___ 12:15PM MAGNESIUM-1.9\n___ 12:15PM UREA N-30* CREAT-1.8* SODIUM-138 \nPOTASSIUM-3.5 CHLORIDE-95* TOTAL CO2-30 ANION GAP-17\n___ 04:24PM ___ PTT-25.0 ___\n___ 04:24PM ALBUMIN-3.6 CALCIUM-8.7 PHOSPHATE-4.0 \nMAGNESIUM-1.9\n___ 04:24PM LIPASE-33\n___ 04:24PM ALT(SGPT)-38 AST(SGOT)-13 ALK PHOS-65 TOT \nBILI-0.8\n___ 04:49PM LACTATE-1.9\n\nOTHER STUDIES:\n=================\nCXR ___\nIMPRESSION: No acute cardiopulmonary process.\n\nRenal Ultrasound ___\n1. Left lower pole cystic lesion with an internal solid \ncomponent is concerning for possible renal cell carcinoma.\n2. No hydronephrosis.\nRECOMMENDATION(S): Renal MRI with contrast. MRI Renal with and \nwithout contrast ___\n\nMRI Renal with and without contrast ___:\nPartially hemorrhagic cystic lesion in the lower pole of the \nleft kidney with an enhancing nodule is concerning for a renal \ncell carcinoma. Given the presence of fat within the nodule, it \nmost likely represents a clear cell subtype.\n\nDISCHARGE LABS:\n=================\n___ 03:20PM BLOOD WBC-11.7* RBC-3.73* Hgb-10.5* Hct-30.2* \nMCV-81* MCH-28.2 MCHC-34.8 RDW-14.4 RDWSD-42.1 Plt ___\n___ 03:20PM BLOOD Neuts-80.8* Lymphs-8.1* Monos-8.4 Eos-1.5 \nBaso-0.3 Im ___ AbsNeut-9.43*# AbsLymp-0.94* AbsMono-0.98* \nAbsEos-0.17 AbsBaso-0.03\n___ 03:20PM BLOOD Plt ___\n___ 03:20PM BLOOD ___ PTT-24.8* ___\n___ 03:20PM BLOOD Glucose-204* UreaN-12 Creat-0.7 Na-140 \nK-3.7 Cl-103 HCO3-25 AnGap-16\n___ 03:20PM BLOOD ALT-38 AST-14 LD(LDH)-282* AlkPhos-61 \nTotBili-0.3\n___ 03:20PM BLOOD Albumin-3.5 Calcium-8.5 Phos-2.6* Mg-2.___ with IgG Lambda multiple myeloma on C2D12 of RVD admitted \nwith severe rash, ___, facial edema, and hypotension found to \nhave DRESS/DHS likely secondary to Revlamid, improved with \nsystemic and topical steroids.\n\n# DRESS/DHS:\nPatient presented with a pruritic rash approximately 4 weeks \nafter starting RVD in the setting of fever, ___, facial edema, \nhypotension, and diarrhea, and found to have an elevated WBC \nwith marked eosinophilia (abs eos of of almost 1500). Exam was \nnotable for a morbilliform eruption with areas of central \nduskiness on > 30% BSA, involving primarily her trunk, anterior \nchest, upper arms, and anterior thighs. No mucosal involvement \nto suggest TEN/SJS. Dermatology was consulted and diagnosed the \npatient with DHS (drug hypersensitivity syndrome), also known as \nDRESS (Drug Reaction with Eosinophilia and Systemic Symptoms). \nShe was started on systemic steroids with high-dose prednisone \nas well as topical steroids (clobetasol ointment). Notably, she \nhad received home dexamethasone on ___ and by ___ with mild \nimprovement. Revlimid and Velcade were held and she received \nfamotidine in case of possible angioedema. For pruritus, she was \ntreated with hydroxyzine and sarna with good effect. We \nmonitored her for any evidence of impending airway compromise or \ndevelopment of mucous membrane involvement.\n\n# ___:\nOn admission, Cr elevated at 1.8 (up from baseline 0.8). There \nwas a concern for pre-renal azotemia vs acute interstitial \nnephritis (AIN)/ DRESS given recent drug exposures vs myeloma \nkidney. She was given 2L NS IVF and treated with steroids with \nrapid improvement in her renal function. \n\n#IgG lambda multiple myeloma: \nPrior to admission, patient received RVD C2D12. We continued \nher prophylactic medications while in house, and held her \nlenalidomide and revlamid. Notably, she is on DF/___ Protocol \n___ A Randomized Phase III Study Comparing Conventional Dose \nLenalidomide, Bortezomib and Dexamethasone (RVD) to High-Dose \nTreatment with Peripheral Stem Cell Transplant in the Initial \nManagement of Myeloma in Patients up to ___ Years of Age.\n\n#Left renal mass:\nIncidentally found on renal ultrasound, MRI concerning for renal \ncell carcinoma. Left lower pole cystic lesion appears to contain \nan internal 2.2 cm solid component which appears to demonstrate \ninternal flow and possible echogenic areas which may represent \ncalcification. Patient is scheduled for outpatient PET and CT \nchest on ___. Will follow-up with Dr. ___.\n\n# HTN: Held HCTZ in setting of hypotension, restarted on \ndischarge\n\n# HLD: Continue simvastatin \n\nTransitional issues:\n==============================\n- New medications:\nTriamcinolone 0.1% ointment BID for < 2 weeks\nSarna lotion prn pruritus\nHydroxyzine prn pruritus\n- Will need to discuss alternative myeloma regimen with \noutpatient oncologist \n- Please check CBC with differential, BUN, Cr, and LFTs weekly \nfor 1 month to monitor for rebound\nCODE STATUS: \n- FULL (Confirmed)\nCONTACT INFORMATION:\n- ___ (daughter) Phone: ___ \n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. Dexamethasone 20 mg PO 2X/WEEK (___) \n3. Hydrochlorothiazide 25 mg PO DAILY \n4. Lenalidomide 30 mg PO DAILY \n5. Simvastatin 40 mg PO QPM \n6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n7. Aspirin 81 mg PO DAILY \n8. Omeprazole 20 mg PO DAILY \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q12H \n2. Aspirin 81 mg PO DAILY \n3. Simvastatin 40 mg PO QPM \n4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n5. Omeprazole 20 mg PO DAILY \n6. Hydrochlorothiazide 25 mg PO DAILY \n7. HydrOXYzine 25 mg PO Q6H:PRN itching \nRX *hydroxyzine HCl 25 mg 1 mg by mouth every six (6) hours Disp \n#*28 Tablet Refills:*0\n8. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID Duration: 2 \nWeeks \nRX *triamcinolone acetonide 0.1 % twice a day Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary: \nDRESS (Drug Reaction with Eosinophilia and Systemic Symptoms), \nalso called DHS (drug hypersensitivity syndrome)\nAcute kidney injury \nLeft kidney mass concerning for renal cell carcinoma \n\nSecondary: \nMultiple myeloma\nHypertension\nHyperlipidemia\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 participating in your care while you were at \n___. You were admitted to the hospital for a severe rash and \nfound to have acute kidney injury. You developed a fever and \nhad abnormal lab tests while you were in the hospital and we \nbelieve this was due to your rash. We consulted dermatology to \ncome see you while you were in the hospital and they diagnosed \nyou with a life threatening rash called DRESS (Drug Reaction \nwith Eosinophilia and Systemic Symptoms) due to your treatment \nfor multiple myeloma. You were started on a systemic steroid \ncalled prednisone, a topical steroid ointment called clobetasol, \na soothing emollient called sarna, and an antihistamine called \nhydroxyzine. Your symptoms improved and you felt better.\n\nYou are now medically cleared to be discharged from the \nhospital. Please call your doctor or return to the Emergency \nDepartment for any concerning or worsening symptoms.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed. Please get plenty of rest, \ncontinue to ambulate several times per day, and drink adequate \namounts of fluids. \n\nWe wish you the very best,\n-- Your ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "N179", "C9000", "C642", "G629", "I952", "E860", "I10", "E785", "L270", "T451X5A", "Y92009", "R601", "D573", "Z9181", "R2681" ]

[ "N179: Acute kidney failure, unspecified", "C9000: Multiple myeloma not having achieved remission", "C642: Malignant neoplasm of left kidney, except renal pelvis", "G629: Polyneuropathy, unspecified", "I952: Hypotension due to drugs", "E860: Dehydration", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "L270: Generalized skin eruption due to drugs and medicaments taken internally", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "R601: Generalized edema", "D573: Sickle-cell trait", "Z9181: History of falling", "R2681: Unsteadiness on feet" ]

[ "N179", "I10", "E785" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: UROLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\n left complex renal cyst suspicious for ___\n \nMajor Surgical or Invasive Procedure:\n Robot assisted laparoscopic left partial nephrectomy.\n\n \nHistory of Present Illness:\nShe is a lovely ___ woman who was diagnosed with \nmultiple myeloma earlier this year. She had smoldering \nmonoclonal gammopathy since ___ (IgG lambda). Her studies have \nbeen stable, but earlier this year, she had\nincrease in the free lambda with ___ proteinuria. \nSkeletal survey was done in ___ which was negative, but a \nPET scan was positive as was a bone marrow and she was placed on \na clinical trial.\n\nPreviously she was admitted for hypertension, fever and acute \nkidney injury. A renal ultrasound was performed identifying \nsimple cyst on the right and complex cyst on the left with an \ninternal 2 cm solid component with internal flow. An MRI \nconfirmed the complex nature of the left renal mass it is \nsuspicious for renal cell carcinoma.\n\nShe denies any abdominal pain or flank pain, gross hematuria. \nShe did have an E. coli UTI in ___ of this year without \nobvious\nsymptoms. Her weight has fluctuated. She has occasional night\nsweats.\n\n \nPast Medical History:\nShe has had three vaginal deliveries.\n\nPAST ONCOLOGIC HISTORY:\n___ Cycle 1 RVD Plan: Lenalidomide 25 mg PO daily on days\n___ of 21-day cycle. Bortezomib IVP 1.3 mg/m2 on days 1, 4, 8,\n11. Dexamethasone 20 mg PO on days 1, 2, 4, 5, 8, 9, 11, 12.\n___ Cycle 2 Day 1 RVD: Lenalidomide 25 mg PO daily on days\n___ of 21-day cycle. Bortezomib IVP 1.3 mg/m2 on days 1, 4, 8,\n11. Dexamethasone 20 mg PO on days 1, 2, 4, 5, 8, 9, 11, 12.\n___ Cycle 2 Day 8 RVD: Bortezomib HELD due to grade 2 \npainful\nneuropathy. Continue lenalidomide and dexamethasone as directed.\n___ Cycle 2 Day 11 RVD: RVD HELD due to grade 3 rash. \nPatient\nadmitted to hospital for hypotension, elevated WBCs, and \nelevated\ncreatinine.\n\nPAST MEDICAL HISTORY:\n-HTN\n-HLD\n-s/p CCY\n-s/p L oopherectomy\n-Sickle trait\n\nmonoclonal gammopathy/multiple myeloma\nsickle cell trait\n \nSocial History:\n___\nFamily History:\n-Uncle - ___ CA\n-Mother - T2DM, HTN, HLD\nFamily History: Negative for kidney cancer. \n \nPhysical Exam:\nWdWn, NAD, AVSS\nInteractive, cooperative\nAbdomen soft, appropriately tender along incisions\n___ drain has been removed.\nIncisions otherwise c/d/i\nExtremities w/out edema or pitting and there is no reported calf \npain to deep palpation\n\n \nPertinent Results:\n___ 06:26AM BLOOD WBC-7.7 RBC-3.27* Hgb-9.2* Hct-28.0* \nMCV-86 MCH-28.1 MCHC-32.9 RDW-13.6 RDWSD-42.6 Plt ___\n___ 05:00PM BLOOD WBC-9.6 RBC-3.63* Hgb-10.3* Hct-31.4* \nMCV-87 MCH-28.4 MCHC-32.8 RDW-13.7 RDWSD-43.4 Plt ___\n\n___ 06:26AM BLOOD Glucose-177* UreaN-9 Creat-0.9 Na-139 \nK-3.6 Cl-103 HCO3-29 AnGap-11\n___ 05:00PM BLOOD Glucose-193* UreaN-10 Creat-0.9 Na-136 \nK-3.8 Cl-99 HCO3-25 AnGap-16\n\n___ 08:57AM BLOOD TotProt-4.8*\n\n___ 08:57AM BLOOD PEP-HYPOGAMMAG FreeKap-PND FreeLam-PND \nIgG-389* IgA-53* IgM-35* IFE-PEP PATTER\n\n___ 05:00PM URINE pH-7 Hours-24 Volume-1475 Creat-93 \nTotProt-14 Prot/Cr-0.2\n___ 05:00PM URINE U-PEP-NO PROTEIN IFE-NO MONOCLO\n___ 05:00PM URINE 24Creat-1372 24Prot-207\n \nBrief Hospital Course:\nMs. ___ was admitted to Urology after undergoing robot \nassisted laparoscopic left partial nephrectomy. No concerning \nintraoperative events occurred; please see dictated operative \nnote for details. Ms. ___ received perioperative antibiotic \nprophylaxis and was transferred to the floor from the PACU in \nstable condition. On POD0, pain was well controlled on PCA, \nhydrated for urine output >30cc/hour, and provided with \npneumoboots and incentive spirometry for prophylaxis. On POD1, \nMs. ___ ambulated, restarted on home medications, basic \nmetabolic panel and complete blood count were checked, pain \ncontrol was transitioned from PCA to oral analgesics, diet was \nadvanced to a clears/toast and crackers diet. On POD2, JP and \nurethral Foley catheter were removed without difficulty and diet \nwas advanced as tolerated. The remainder of the hospital course \nwas relatively unremarkable. ___ was discharged in stable \ncondition, eating well, ambulating independently, voiding \nwithout difficulty, and with pain control on oral analgesics. On \nexam, incision was clean, dry, and intact, with no evidence of \nhematoma collection or infection. Ms. ___ was given explicit \ninstructions to follow-up in clinic in approximately four weeks \ntime.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. Aspirin 81 mg PO DAILY \n3. Simvastatin 40 mg PO QPM \n4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n5. Omeprazole 20 mg PO DAILY \n6. Hydrochlorothiazide 25 mg PO DAILY \n7. HydrOXYzine 25 mg PO Q6H:PRN itching \n8. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg ONE capsule(s) by mouth \ntwice a day Disp #*60 Capsule Refills:*0 \n3. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild \nRX *ibuprofen 600 mg ONE tablet(s) by mouth Q8hrs Disp #*30 \nTablet Refills:*0 \n4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ONE tablet(s) by mouth Q4hrs Disp #*30 Tablet \nRefills:*0 \n5. Senna 8.6 mg PO DAILY Duration: 2 Doses \n6. Acyclovir 400 mg PO Q12H \n7. Aspirin 81 mg PO DAILY \n8. Hydrochlorothiazide 25 mg PO DAILY \n9. HydrOXYzine 25 mg PO Q6H:PRN itching \n10. Omeprazole 20 mg PO DAILY \n11. Simvastatin 40 mg PO QPM \n12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n Renal mass.\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\n-Please also refer to the provided “handout” that details \ninstructions and expectations for your post-operative phase as \nmade available by Dr. ___ office.\n\n-Resume your pre-admission/home medications except as noted. \nALWAYS call to inform, review and discuss any medication changes \nand your post-operative course with your primary care doctor.\n\n-___ reduce the strain/pressure on your abdomen and incision \nsites; remember to “log roll” onto your side and then use your \nhands to push yourself upright while taking advantage of the \nmomentum of putting your legs/feet to the ground.\n\n--There may be bandage strips called “steristrips” which have \nbeen applied to reinforce wound closure. Allow these bandage \nstrips to fall off on their own over time but PLEASE REMOVE ANY \nREMAINING GAUZE DRESSINGS WITHIN 2 DAYS OF DISCHARGE. You may \nget the steristrips wet.\n\n-Please AVOID aspirin or aspirin containing products and \nsupplements that may have “blood-thinning” effects (like Fish \nOil, Vitamin E, etc.) unless you have otherwise been advised. \nThis will be noted in your medication reconciliation. \n\n-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken \neven though you may also be taking Tylenol/Acetaminophen. You \nmay alternate these medications for pain control. For pain \ncontrol, try TYLENOL FIRST, then ibuprofen, and then take the \nnarcotic pain medication as prescribed if additional pain relief \nis needed.\n\n-Ibuprofen should always be taken with food. Please discontinue \ntaking and notify your doctor should you develop blood in your \nstool (dark, tarry stools)\n\n-Call your Urologist's office to schedule/confirm your follow-up \nappointment in 4 weeks AND if you have any questions.\n\n-Do not eat constipating foods for ___ weeks, drink plenty of \nfluids to keep hydrated\n\n-No vigorous physical activity or sports for 4 weeks or until \notherwise advised. Light household chores/activity and leisurely \nwalking/activity is OK and should be continued. Do NOT be a \n“couch potato”\n\n-Tylenol should be your first-line pain medication. A narcotic \npain medication has been prescribed for breakthrough pain ___. \nREPLACE the Tylenol with this narcotic pain medication if \nadditional pain control is needed..\n\n-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL \nsources, note that narcotic pain medication also contains \nTylenol\n\n-Do not lift anything heavier than a phone book (10 pounds) or \ndrive until you are seen by your Urologist in follow-up and/or \nas directed in the “handout”\n\n-You may shower normally but do NOT immerse your incisions or \nbathe\n\n-Do not drive or drink alcohol while taking narcotics and do not \noperate dangerous machinery\n\n-Colace has been prescribed to avoid post surgical constipation \nand constipation related to narcotic pain medication. \nDiscontinue if loose stool or diarrhea develops. Colace is a \nstool-softener, NOT a laxative\n\n-If you have fevers > 101.5 F, vomiting, or increased redness, \nswelling, or discharge from your incision, call your doctor or \ngo to the nearest emergency room.\n\n \nFollowup Instructions:\n___\n" ]

[ "C642", "C9000", "I10", "E785", "D573", "G620", "T451X5A", "Y929" ]

[ "C642: Malignant neoplasm of left kidney, except renal pelvis", "C9000: Multiple myeloma not having achieved remission", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "D573: Sickle-cell trait", "G620: Drug-induced polyneuropathy", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y929: Unspecified place or not applicable" ]

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

[]

[ " \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:\nDizziness/Fatigue/Hypotension\n \nMajor Surgical or Invasive Procedure:\n___ Right Internal Jugular Line\n \nHistory of Present Illness:\nMs. ___ is a ___ year old female with h/o HTN, HLD, and MM for \nwhich she was initially enrolled in a clinical trial for chemo \nvs transplant. She initially received chemo but did not do well \nso she is now preparing for transplant. She had chemo on ___ \nand states that since then she has been extremely fatigued with \ndiarrhea ___ daily and lightheadedness. She has been trying to \nkeep up with her PO intake but has not been eating very much \ngiven poor apatite. On ___ she had a fall onto her knee while \ntrying to go up stairs in her home. She denies LOC, head strike \nsyncope or lightheadedness around the fall and says that she was \njust so tired she couldn't keep her gait up. She has been \ncompliant with her medications including her antihypertensives \nand her filgrastim injections. She otherwise denies dark or \nbloody stools, fever or chills, night sweats, SOB, CP, abdominal \npain, nausea, headaches, changes in vision, hearing, smell or \ntaste. \n\nOf note she was treated empirically for UTI with ciprofloxacin \non ___ because of polyuria and foul smelling urine. \n\nIn the ED, initial vitals: T 98.4, HR 107, BP 93/52, RR 18, \nSPO2 99% on RA. \nLabs showed pancytopenia with neutropenia and mild ___ Cr 1.2.\nHer BP decreased to ___ while in the ED and she received 2L \nNS, her BP improved temporarily then dropped again so and IJ was \nplaced and she got an additional 1L NS. She also received \nempiric vanc and zosyn. \nShe was admitted to the ICU with concern for refractory \nhypotension. On transfer, vitals were: T 98.2, HR 70, BP \n97/49, RR 18, SPO2 98% o RA. \n\nOn arrival to the MICU, patient ambulated into her room and \nstates that she is feeling better. \n \nPast Medical History:\nONCOLOGY/TREATMENT HISTORY (PER OMR):\n\n___: Evaluated in the ___ clinic for the first time and PET\nordered for other focal lesions. Repeat labs did not demonstrate\nany anemia, hypercalcemia or elevated creatinine. Repeat K.L\nratio was 0.04 with free Lambda elevated at 315.4 and free \nkappa.\n24 hr urinary collection recommended.\n\n___: PET demonstrated a lytic, destructive lesion in the\nleft eleventh rib with an SUV max of 13.6. A lytic lesion is\nseen in the left scapula as well demonstrating FDG avidity with\nan SUV max of 5.1. In addition to the bony lesions in the chest,\nthere was a focus of FDG avidity, with SUV max of 7.2, along the\nlateral cortex of the\nleft femur. A similar lesion is also seen in the right femur\nwith an SUV max of 3.8. These do not correspond to a definite\nlesion on CT.\n\n___: Repeat serum IFE demonstrated IgG lambda M ptn 0.2 gm.\nK/L ratio was 0.04 and Lambda estimated at 306.1\nBM aspirate performed for study enrollment was inadequate for\nstudy evaluation due to lack of spicules.\n\nUPEP did not show any monoclonal ptn. Urine IFE showed tRACE\nMONOCLONAL FREE (___) LAMBDA DETECTED CONCENTRATION IS\nTOO LOW TO BE SEEN ON PEP FOR QUANTITATION.\n\n24 hour urinary ptn collection demonstrated 140mg ptn only.\n\n___: BM aspirate and biopsy repeated which confirmed ___\nmonoclonal plasma cells. \n\nFinal Diagnosis: Active symptomatic MM based on serum IFE\ndemonstrating IgG Lambda and more than focal lytic lesion on \nPET.\n\n___: Enrolled in clinical trial # ___ \"A Randomized Phase\nIII Study Comparing Conventional Dose Treatment Using a\nCombination of Lenalidomide, Bortezomib and Dexamethasone (RVD)\nto High-Dose Treatment with Peripheral Stem Cell Transplant in\nthe Initial Management of Myeloma in Patients up to ___ Years of\nAge\". \n\n___: C1D1 of RVD started. Tolerated it well without any \nmajor\ncomplications.\n\n___: Improvement in free Lambda burden from 324 to 11.6. M\npin quantity improved from 0.2 gm/dl to undetectable levels. \nC2D1\nof RVD started. C.b rash likely sec to Revlimid, ___ and\nneuropathy requiring inpatient hospitalization. She was found to\nhave a complex cyst concerning for clear cell RCC during the\nhospital course. \n\n___: MRI abdomen confirmed the suspicion of clear cell RCC.\n\n___: Evaluated by Dr ___ agreed with the concern of\nlow grade clear cell RCC and felt pt would be a candidate for\npartial nephrectomy.\n\n___: CT chest did not show any e.o metastasis. \n\n___: After discussion with ___ medical oncology team and Dr\n___ made to complete induction chemo followed by partial\nnephrectomy followed by HDT and autoBMT.\n\n___: Due to a new diagnosis of a second cancer presumed RCC,\npt came off the trial.\n\nTrace M ptn noted after 2 cycles of therapy (<0.06 gm). \n\n___: Started on cycle 3 of RVD off trial although at reduced\ndose of 1 mg/m2 and eventually 0.7 mg/m2 along with Rev at 20mg\nand Dex ___.\n\n___: Disappearance of M ptn after 3 cycles on serum IFE.\nStarted on cycle 4 of RVD. Velcade given at 0.7 mg/m2 on D1 and \n4\nand then discontinued due to persistent neuropathy grade 2 at\nleast. Revlimid continued at 20mg/day.\n\n___: Continued to have no e.o M ptn on serum IFE after 4\ncycles.\n\n___: After extensive discussion within the ___ team and with\nDr ___ made to withhold further therapy for MM given \nthe\nimmunomodulatory effects of Revlimid on RCC and hence pt\nunderwent a robotic assisted laproscopic partial left \nnephrectomy\non ___.\n\nSurgical path c.w pT1a papillary RCC. No e.o high risk features\nseen. Recommended 6 month follow up as tolerated the procedure\nvery well. \n\n___: Seen in clinic for follow up and seemed to be doing \nvery\nwell. Completely recovered from surgery. Resumed treatment with\nRev/Dex at cycle 5 (Rev 20mg/day D1-14 every 21 days and Dex\n___. \n\n___: Started cycle 6 of Rev/Dex, completed on ___.\n\nTentative Transplant Calendar:\n___: admission for chemo pre-collection\n___: start neupogen/cipro\n___: pheresis for collection\n___: admission for auto transplant\n\nPAST MEDICAL HISTORY: \n-HTN \n-HLD \n-s/p CCY \n-s/p L oopherectomy \n-Sickle trait\n \nSocial History:\n___\nFamily History:\nUncle died of colon cancer. Mother is living with hypertension, \ntype 2 diabetes, hypercholesterolemia and glaucoma and father is \ndeceased at age ___ from sickle cell disease. She has three \nhealthy children without medical issues. There is no other \nfamily history of cancer.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION\nVitals: T: afebrile BP: 95/55 P: 77 R: 18 O2: 100% RA \nGENERAL: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP not elevated, no LAD \nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: Warm, well perfused, 2+ pulses, trace edema around the \nankles \nSKIN: no rash or concerning lesions\nNEURO: CN II_XII grossly intact\n\nDISCHARGE EXAM:\nVS: 98.4 92/52 66 17 100RA\nGEN: NAD, ambulatory but seated in bed\nHEENT: AT/NC, MMM, no mucositis, nares nonbloody; EOMI, PERRL\nNECK: no LAD, supple throat\nCV: RRR, no M/R/G\nPULM: CTAB\nABD: S/NT/ND, +BS\nGU: no Foley\nEXT: nontender, nonedematous\nNEURO: A/Ox3; CNII-XII grossly intact\nSKIN: no visible skin changes\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 07:30PM BLOOD WBC-0.4*# RBC-4.51 Hgb-11.9# Hct-35.3 \nMCV-78* MCH-26.4 MCHC-33.7 RDW-16.4* RDWSD-46.3 Plt Ct-96*\n___ 07:30PM BLOOD Neuts-9* Bands-2 ___ Monos-13 \nEos-46* Baso-0 ___ Myelos-0 AbsNeut-0.04* \nAbsLymp-0.12* AbsMono-0.05* AbsEos-0.18 AbsBaso-0.00*\n___ 07:30PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL \nPoiklo-OCCASIONAL Macrocy-NORMAL Microcy-OCCASIONAL \nPolychr-NORMAL Ovalocy-OCCASIONAL Burr-OCCASIONAL Tear \nDr-OCCASIONAL\n___ 07:30PM BLOOD ___ PTT-26.7 ___\n___ 07:30PM BLOOD Glucose-134* UreaN-24* Creat-1.2* Na-138 \nK-4.0 Cl-96 HCO3-25 AnGap-21*\n___ 07:30PM BLOOD ALT-24 AST-25 AlkPhos-67 TotBili-1.5\n___ 07:30PM BLOOD Lipase-31\n___ 07:30PM BLOOD proBNP-92\n___ 07:30PM BLOOD Albumin-3.9 Calcium-8.7 Phos-3.7 Mg-2.1\n\nDISCHARGE LABS\n==============\n___ 08:05AM BLOOD WBC-0.4* RBC-3.47* Hgb-9.2* Hct-27.4* \nMCV-79* MCH-26.5 MCHC-33.6 RDW-15.9* RDWSD-45.7 Plt Ct-39*\n___ 08:05AM BLOOD Neuts-0* Bands-0 ___ Monos-17* \nEos-30* Baso-12* Atyps-1* ___ Myelos-0 AbsNeut-0.00* \nAbsLymp-0.16* AbsMono-0.07* AbsEos-0.12 AbsBaso-0.05\n___ 08:05AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+ \nMacrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+ \nSchisto-OCCASIONAL Tear Dr-OCCASIONAL\n___ 08:05AM BLOOD Plt Smr-VERY LOW Plt Ct-39*\n___ 08:05AM BLOOD Glucose-129* UreaN-9 Creat-0.7 Na-139 \nK-3.5 Cl-107 HCO3-24 AnGap-12\n___ 08:05AM BLOOD Calcium-7.8* Phos-2.1* Mg-1.8\n___ 08:05AM BLOOD Cortsol-17.0\n\nURINALYSIS\n===========\n___ 09:22PM URINE Color-Yellow Appear-Clear Sp ___\n___ 09:22PM URINE Blood-NEG Nitrite-NEG Protein-TR \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG\n___ 09:22PM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-1\n___ 09:22PM URINE CastHy-23*\n\nFLU STUDIES\n===========\n___ 01:30AM OTHER BODY FLUID FluAPCR-NEGATIVE \nFluBPCR-NEGATIVE\n\nMICROBIOLOGY\n============\n___: BLOOD CULTURE X 2: PENDING\n___: URINE CULTURE: PENDING\n \nBrief Hospital Course:\n___ year old woman with past medical history of papillary renal \ncell carcinoma (3.9 cm, T1) status-post left partial nephrectomy \nin ___, sickle cell trait, and IgG lambda multiple myeloma \npreviously randomized to non-transplant arm of study comparing \nconventional dose therapy with RVD to SCT in initial management \nof myeloma, now s/p C6 RVD ___, given cyclophosphamide ___ \nprior to planned stem cell mobilization admitted with fatigue, \ndizziness, loose stools, ___, and borderline hypotension, also \nnoted to be neutropenic.\n\n# Hypotension: Patient presented to ___ with fatigue, \nlightheadedness, weakness, and hypotension with SBP in the ___. \nInfectious workup including UA (negative), urine culture \n(pending), blood cultures x 2 (pending), and CXR (negative) were \nobtained. Given patient's ANC of 30 on admission, patient \ninitially received vancomycin/piperacillin-tazobactam in the \nEmergency Department. This was transitioned to cefepime. Patient \nrequired a total of 5L normal saline. Patient did not require \nany pressors in the intensive care unit and right internal \njugular catheter was removed. On the floor her antihypertensives \nwere held and she remained normotensive. On discharge she was \nwithout antibiotics for 24 hours and had a stable pressure, and \nwas taking PO at her baseline at home.\n\n# Diarrhea: A possible cause of the above hypotension, \nattributable to high dose Cytoxan. The patient was still having \n___ loose BMs at the time of her discharge but will be planned \nreadmission on ___ for apheresis and will re-present if \nher symptoms worsen in the interval.\n\n# Peripheral Eosinophilia: Differential diagnosis included \nmalignant eosinophilia, neupogen effect, drug reaction, adrenal \ninsufficiency. Patient had negative Strongyloides antibodies on \n___. \n\n# IgG lambda multiple myeloma s/p C6 RVD ___: Patient is \npreparing for transplant high dose Cytoxan ___ prior to SC \nmobilization. She was continued on filgrastim at 960 mg daily, \nwith prophylaxis of Bactrim and acyclovir. She was continued on \nB6 and vitamin D. Her cipro prophylaxis was restarted on \ntransfer from the floor, and continued upon discharge.\n\n# Pancytopenia: Thought to be due to high dose Cytoxan. Her \nfilgrastim was continued through the admission, as was her \nBactrim and acyclovir. Plt 58 at time of discharge.\n\n# Hyperkalemia: Thought to be secondary to poor PO intake and \nelevated creatinine. Resolved with IVF.\n\n# Hypertension: Patient has baseline hypertension but presented \nwith hypotension. Continued to hold lisinopril and \nhydrochlorothiazide, which may be restarted upon outpatient \nfollow up in the setting of low-normal BPs.\n\nTRANSITIONAL ISSUES:\n- please evaluate eosinophilia (if true on repeat studies); may \nconsider AM cortisol\n- held lisinopril and HCTZ on discharge, please resume when BP \nroom adequate\n- continue per schedule for stem cell collection and \nauto-transplant\n- Code: full\n- Contact: ___ (NoK) ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 30 mg PO DAILY \n2. Gabapentin 300 mg PO QHS \n3. Simvastatin 40 mg PO QPM \n4. Hydrochlorothiazide 25 mg PO DAILY \n5. Pyridoxine 100 mg PO DAILY \n6. Vitamin D 1000 UNIT PO DAILY \n7. Ciprofloxacin HCl 500 mg PO Q12H \n8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n9. Acyclovir 400 mg PO Q12H \n\n \nDischarge Medications:\n1. Filgrastim 960 mcg SC Q24H \n2. Acyclovir 400 mg PO Q12H \n3. Ciprofloxacin HCl 500 mg PO Q12H \n4. Gabapentin 300 mg PO QHS \n5. Pyridoxine 100 mg PO DAILY \n6. Simvastatin 40 mg PO QPM \n7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n8. Vitamin D 1000 UNIT PO DAILY \n9. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication was \nheld. Do not restart Hydrochlorothiazide until instructed by \nyour oncology team because you have had low BPs.\n10. HELD- Lisinopril 30 mg PO DAILY This medication was held. \nDo not restart Lisinopril until instructed by your oncology team \nbecause you have had low BPs.\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n- hypotension\n- diarrhea\n- neutropenia\n- thrombocytopenia\n- IgG lambda multiple myeloma, C6 RVd ___\n- acute kidney injury\n- eosinophilia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\n\n___ was a pleasure caring for you while you were at ___. You \nwere admitted to the ICU for low blood pressure and mild kidney \ninjury in the setting of eating and drinking less as well as \nmultiple episodes of diarrhea. You were treated with fluids as \nwell a brief course of antibiotics. Once you were feeling better \nyou were transferred to the medical floor. It was thought that \nyour symptoms were a side effect of the chemotherapy you were \ngiven in preparation of your stem cell mobilization. You were \nfeeling better and able to eat and drink more at the time of \nyour discharge, and were sent home with instruction to return on \n___ for your planned admission for line placement and stem \ncell collection.\n\nThank you for allowing us to participate in your care while \nhere.\n\nBest regards,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "I959", "C9000", "N179", "D61818", "D721", "E875", "D696", "I10", "D573", "E785", "R197", "Z85528", "Z9221", "Z8249" ]

[ "I959: Hypotension, unspecified", "C9000: Multiple myeloma not having achieved remission", "N179: Acute kidney failure, unspecified", "D61818: Other pancytopenia", "D721: Eosinophilia", "E875: Hyperkalemia", "D696: Thrombocytopenia, unspecified", "I10: Essential (primary) hypertension", "D573: Sickle-cell trait", "E785: Hyperlipidemia, unspecified", "R197: Diarrhea, unspecified", "Z85528: Personal history of other malignant neoplasm of kidney", "Z9221: Personal history of antineoplastic chemotherapy", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system" ]

[ "N179", "D696", "I10", "E785" ]

[]

[ " \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:\nadmission for HD Cytoxan\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nHPI: Ms. ___ is a ___ year old female with h/o monoclonal \ngammopathy IgG lambda since ___. She has been followed by her \nPCP after initial consultations here in ___ and ___ and her \nmyeloma studies had been stable. In ___, her labs \ndemonstrated increase in free lambda (324, K/L ratio of 0.03, \nIgG Lamda of 0.27gm/dL) as well as UPEP showing ___ \nproteinuria (0.3gm/day). She had not ever had a skeletal survey \nuntil ___ and this was negative for bony lesions. She is now \ns/p C6 of RVD and now presents for HD Cytoxan in preparation for \nstem cell collection. \n\nROS: Overall, patient reports feeling. Baseline neuropathy on \ntoes stable. BLE edema not worse. No recent fevers, chills, \nrigors, sick contacts, URI symptoms, headache, dizziness, chest \npain, SOB, DOE, nausea, vomiting, neck stiffness, diarrhea, \nabdominal pain or cramping, rashes or lesions. Appetite good. \n\nAll other ROS negative.\n \nPast Medical History:\nTREATMENT HISTORY (PER OMR):\n\n___: Evaluated in the ___ clinic for the first time and PET\nordered for other focal lesions. Repeat labs did not demonstrate\nany anemia, hypercalcemia or elevated creatinine. Repeat K.L\nratio was 0.04 with free Lambda elevated at 315.4 and free \nkappa.\n24 hr urinary collection recommended.\n\n___: PET demonstrated a lytic, destructive lesion in the\nleft eleventh rib with an SUV max of 13.6. A lytic lesion is\nseen in the left scapula as well demonstrating FDG avidity with\nan SUV max of 5.1. In addition to the bony lesions in the chest,\nthere was a focus of FDG avidity, with SUV max of 7.2, along the\nlateral cortex of the\nleft femur. A similar lesion is also seen in the right femur\nwith an SUV max of 3.8. These do not correspond to a definite\nlesion on CT.\n\n___: Repeat serum IFE demonstrated IgG lambda M ptn 0.2 gm.\nK/L ratio was 0.04 and Lambda estimated at 306.1\nBM aspirate performed for study enrollment was inadequate for\nstudy evaluation due to lack of spicules.\n\nUPEP did not show any monoclonal ptn. Urine IFE showed tRACE\nMONOCLONAL FREE (___) LAMBDA DETECTED CONCENTRATION IS\nTOO LOW TO BE SEEN ON PEP FOR QUANTITATION.\n\n24 hour urinary ptn collection demonstrated 140mg ptn only.\n\n___: BM aspirate and biopsy repeated which confirmed ___\nmonoclonal plasma cells. \n\nFinal Diagnosis: Active symptomatic MM based on serum IFE\ndemonstrating IgG Lambda and more than focal lytic lesion on \nPET.\n\n___: Enrolled in clinical trial # ___ \"A Randomized Phase\nIII Study Comparing Conventional Dose Treatment Using a\nCombination of Lenalidomide, Bortezomib and Dexamethasone (RVD)\nto High-Dose Treatment with Peripheral Stem Cell Transplant in\nthe Initial Management of Myeloma in Patients up to ___ Years of\nAge\". \n\n___: C1D1 of RVD started. Tolerated it well without any \nmajor\ncomplications.\n\n___: Improvement in free Lambda burden from 324 to 11.6. M\npin quantity improved from 0.2 gm/dl to undetectable levels. \nC2D1\nof RVD started. C.b rash likely sec to Revlimid, ___ and\nneuropathy requiring inpatient hospitalization. She was found to\nhave a complex cyst concerning for clear cell RCC during the\nhospital course. \n\n___: MRI abdomen confirmed the suspicion of clear cell RCC.\n\n___: Evaluated by Dr ___ agreed with the concern of\nlow grade clear cell RCC and felt pt would be a candidate for\npartial nephrectomy.\n\n___: CT chest did not show any e.o metastasis. \n\n___: After discussion with ___ medical oncology team and Dr\n___ made to complete induction chemo followed by partial\nnephrectomy followed by HDT and autoBMT.\n\n___: Due to a new diagnosis of a second cancer presumed RCC,\npt came off the trial.\n\nTrace M ptn noted after 2 cycles of therapy (<0.06 gm). \n\n___: Started on cycle 3 of RVD off trial although at reduced\ndose of 1 mg/m2 and eventually 0.7 mg/m2 along with Rev at 20mg\nand Dex ___.\n\n___: Disappearance of M ptn after 3 cycles on serum IFE.\nStarted on cycle 4 of RVD. Velcade given at 0.7 mg/m2 on D1 and \n4\nand then discontinued due to persistent neuropathy grade 2 at\nleast. Revlimid continued at 20mg/day.\n\n___: Continued to have no e.o M ptn on serum IFE after 4\ncycles.\n\n___: After extensive discussion within the ___ team and with\nDr ___ made to withhold further therapy for MM given \nthe\nimmunomodulatory effects of Revlimid on RCC and hence pt\nunderwent a robotic assisted laproscopic partial left \nnephrectomy\non ___.\n\nSurgical path c.w pT1a papillary RCC. No e.o high risk features\nseen. Recommended 6 month follow up as tolerated the procedure\nvery well. \n\n___: Seen in clinic for follow up and seemed to be doing \nvery\nwell. Completely recovered from surgery. Resumed treatment with\nRev/Dex at cycle 5 (Rev 20mg/day D1-14 every 21 days and Dex\n___. \n\n___: Started cycle 6 of Rev/Dex, completed on ___.\n\nTentative Transplant Calendar:\n___: admission for chemo pre-collection\n___: start neupogen/cipro\n___: pheresis for collection\n___: admission for auto transplant\nPAST MEDICAL HISTORY: \n-HTN \n-HLD \n-s/p CCY \n-s/p L oopherectomy \n-Sickle trait \n \nmonoclonal gammopathy/multiple myeloma \nsickle cell trait \n\n \nSocial History:\n___\nFamily History:\n-Uncle - ___ CA\n-Mother - T2DM, HTN, HLD\nFamily History: Negative for kidney cancer. \n \nPhysical Exam:\nPHYSICAL EXAM:\nGEN: NAD, awake and alert, conversive\nWT: 208.09 lbs\nVS: TC 98.3 PO 104/60 79 21 98%RA \nPain (___): 0 \nHEENT: MMM, no OP lesions, no cervical, supraclavicular, or\naxillary LAD\nCV: Regular, normal S1 and S2 no S3, S4, or murmurs\nPULM: Non-labored. Clear to auscultation bilaterally\nABD: BS+, soft, non-tender, non-distended, no masses, no\nhepatosplenomegaly\nLIMBS: Baseline BLE edema; no inguinal adenopathy\nSKIN: No rashes or skin breakdown\nNEURO: Grossly non-focal, alert and oriented x 3\nACCESS: PIV C/D/I\n\nExam unchanged at discharge\nVS: 97.6 PO 116 / 68 L Lying 68 18 100 RA \nWT: 214.31 lbs\nPIV removed at discharge \n \nPertinent Results:\n___ 03:15AM BLOOD WBC-4.4 RBC-3.63* Hgb-9.5* Hct-29.2* \nMCV-80* MCH-26.2 MCHC-32.5 RDW-17.1* RDWSD-49.7* Plt ___\n___ 10:35AM BLOOD WBC-7.3 RBC-4.13 Hgb-11.1* Hct-33.2* \nMCV-80* MCH-26.9 MCHC-33.4 RDW-17.2* RDWSD-48.4* Plt ___\n___ 03:15AM BLOOD Neuts-80.5* Lymphs-13.4* Monos-4.8* \nEos-0.0* Baso-0.2 Im ___ AbsNeut-3.53 AbsLymp-0.59* \nAbsMono-0.21 AbsEos-0.00* AbsBaso-0.01\n___ 10:35AM BLOOD Neuts-51.1 ___ Monos-17.4* \nEos-3.0 Baso-1.1* Im ___ AbsNeut-3.75 AbsLymp-1.93 \nAbsMono-1.28* AbsEos-0.22 AbsBaso-0.08\n___ 03:15AM BLOOD Plt ___\n___ 10:35AM BLOOD Plt ___\n___ 10:35AM BLOOD ___ PTT-26.2 ___\n___ 03:15AM BLOOD Glucose-220* UreaN-15 Creat-0.8 Na-141 \nK-4.2 Cl-110* HCO3-24 AnGap-11\n___ 05:00PM BLOOD K-3.1*\n___ 10:35AM BLOOD Glucose-146*\n___ 10:35AM BLOOD UreaN-16 Creat-0.9 Na-144 K-2.9* Cl-103 \nHCO3-29 AnGap-15\n___ 03:15AM BLOOD ALT-42* AST-31 LD(LDH)-171 AlkPhos-53 \nTotBili-0.3\n___ 10:35AM BLOOD ALT-28 AST-12 LD(LDH)-193 AlkPhos-62 \nTotBili-0.4 DirBili-<0.2 IndBili-0.4\n___ 03:15AM BLOOD Albumin-3.4* Calcium-8.1* Phos-3.2 Mg-2.0\n___ 10:35AM BLOOD TotProt-6.1* Albumin-4.2 Globuln-1.9* \nCalcium-9.4 Phos-3.7 Mg-2.1\n___ 10:35AM BLOOD PEP-NO SPECIFI ___ FreeLam-12.5 \nFr K/L-0.66 IgG-448* IgA-71 IgM-41\n___ 10:35AM BLOOD STRONGYLOIDES ANTIBODY,IGG-PND\n___ 10:35AM BLOOD HTLV I AND II, WITH REFLEX TO WESTERN \nBLOT-PND\n \nBrief Hospital Course:\nASSESSMENT AND PLAN: A ___ year old female with MM admitted for \nHD Cytoxan\n\n#Multiple Myeloma: Admitted HD Cytoxan without major \ncomplications. UA was negative but did show some glucosuria and \nketones but no frank blood. \n-Transplant calendar as above\n-Outpatient appointment scheduled on ___ with Dr. ___ appointment with Dr. ___ on ___\n-24 hour collection completed prior to discharge, result pending\n-will start ciprofloxacin and neupogen ___, has RX for \noxycodone PRN\n-discussion with patient about holding bactrim ppx for now\n-will likely hold ASA prior to line placement on ___ \n\n#Hyperglycemia: Likely steroid effect, glucose ranged between \n140s-260s during hospital course. Did have mild dizziness with \nelevated BS but resolved prior to d/c. Orthostatic VS were \nstable. Initiated on insulin sliding scale in-house with \nimprovement. Patient has glucometer at home and knows how to use \nit. Advised to check BS pre-meal and if consistently > 200, \nneeds to follow up immediately. As noted above, glucosuria \nlikely a function of her hyperglycemia. Does have ketonuria but \nthis is a common side effect of mesna and she has received this \nmedication as part of her chemotherapy. \n\n#Hypokalemia: (resolved). unclear etiology. ? medication effect \n(HCTZ). Denies nausea, vomiting, diarrhea or decreased appetite. \nK+ normalized prior to d/c\n\n#Neuropathy: Thought to chemotherapy-induced (velcade), continue \nhome Neurontin\n\n#HTN: Stable, continue home regimen of HCTZ and Lisinopril \n\n#Infectious Prophylaxis:\n- PCP: see above\n- HSV/VZV: Acyclovir\n- Bacterial: Ciprofloxacin as above\n\n#Disposition: Discharged ___, follow up on ___.\n\n#Code Status: FULL\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. Simvastatin 40 mg PO QPM \n3. Aspirin 81 mg PO DAILY \n4. Hydrochlorothiazide 25 mg PO DAILY \n5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n6. Gabapentin 600 mg PO QHS \n7. Lisinopril 30 mg PO DAILY \n8. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral \nDAILY \n9. Pyridoxine 100 mg PO DAILY \n10. Dexamethasone 20 mg PO 1X/WEEK (___) \n11. Lenalidomide 20 mg PO DAILY \n12. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \n13. Ondansetron 4 mg PO Q8H:PRN nausea and vomiting \n14. Ciprofloxacin HCl 500 mg PO Q12H \n15. Filgrastim 480 mcg SC Q24H \n\n \nDischarge Medications:\n1. Ciprofloxacin HCl 500 mg PO Q12H \nplease start injections on ___ as discussed with the \ntransplant coordinator \n2. Filgrastim 480 mcg SC Q24H \nplease start injections on ___ as discussed with the \ntransplant coordinator \n3. Ondansetron ___ mg PO Q8H:PRN nausea/vomiting \n4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \n5. Acyclovir 400 mg PO Q12H \n6. Aspirin 81 mg PO DAILY \n___ need to discontinue by next week, please discuss with Dr. \n___ on your appointment on ___ \n7. Gabapentin 600 mg PO QHS \n8. Hydrochlorothiazide 25 mg PO DAILY \n9. Lisinopril 30 mg PO DAILY \n10. Pyridoxine 100 mg PO DAILY \n11. Simvastatin 40 mg PO QPM \n12. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral \nDAILY \n13. HELD- Dexamethasone 20 mg PO 1X/WEEK (___) This medication \nwas held. Do not restart Dexamethasone until ___ discuss with \nyour outpatient provider\n14. HELD- Lenalidomide 20 mg PO DAILY This medication was held. \nDo not restart Lenalidomide until ___ discuss with your \noutpatient provider\n15. HELD- Sulfameth/Trimethoprim SS 1 TAB PO DAILY This \nmedication was held. Do not restart Sulfameth/Trimethoprim SS \nuntil ___ discuss with your outpatient provider\n\n \n___:\nHome\n \nDischarge Diagnosis:\nMultiple Myeloma\nHyperglycemia \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nMrs. ___,\n\n___ were admitted to receive your high dose Cytoxan in \npreparation for the stem cell collection. ___ had mild dizziness \nwhich we think is related your blood sugars being elevated from \nthe steroid used for the anti-nausea regimen. Please check your \nblood sugars at home before ___ eat. If it is consistently over \n200, please contact your outpatient provider right away. The \ntransplant coordinator gave ___ a schedule that lays out your \nappointments and when to take your medications for your stem \ncell collection, please follow this schedule closely. It was a \npleasure taking care of ___. \n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C9001", "D472", "I10", "G620", "R739", "Z006", "D573", "E041", "E7800", "M170", "E876", "R81", "T380X5A", "Y92230", "T451X5A", "Y929", "Z800" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C9001: Multiple myeloma in remission", "D472: Monoclonal gammopathy", "I10: Essential (primary) hypertension", "G620: Drug-induced polyneuropathy", "R739: Hyperglycemia, unspecified", "Z006: Encounter for examination for normal comparison and control in clinical research program", "D573: Sickle-cell trait", "E041: Nontoxic single thyroid nodule", "E7800: Pure hypercholesterolemia, unspecified", "M170: Bilateral primary osteoarthritis of knee", "E876: Hypokalemia", "R81: Glycosuria", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y929: Unspecified place or not applicable", "Z800: Family history of malignant neoplasm of digestive organs" ]

[ "I10", "Y92230", "Y929" ]

[]

[ " \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:\nadmission for autologous transplant\n \nMajor Surgical or Invasive Procedure:\nCVC placement ___\nCVC removal ___ \n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old woman with IgG Lambda Multiple \nMyeloma s/p 4C of RVD then 2C of rev/dex alone secondary to \nneuropathy in CR presenting now for autologous stem cell \ntransplant with mel prep.\n \n\n \nPast Medical History:\nONCOLOGY/TREATMENT HISTORY (PER OMR):\n\n___: Evaluated in the ___ clinic for the first time and PET\nordered for other focal lesions. Repeat labs did not demonstrate\nany anemia, hypercalcemia or elevated creatinine. Repeat K.L\nratio was 0.04 with free Lambda elevated at 315.4 and free \nkappa.\n24 hr urinary collection recommended.\n\n___: PET demonstrated a lytic, destructive lesion in the\nleft eleventh rib with an SUV max of 13.6. A lytic lesion is\nseen in the left scapula as well demonstrating FDG avidity with\nan SUV max of 5.1. In addition to the bony lesions in the chest,\nthere was a focus of FDG avidity, with SUV max of 7.2, along the\nlateral cortex of the\nleft femur. A similar lesion is also seen in the right femur\nwith an SUV max of 3.8. These do not correspond to a definite\nlesion on CT.\n\n___: Repeat serum IFE demonstrated IgG lambda M ptn 0.2 gm.\nK/L ratio was 0.04 and Lambda estimated at 306.1\nBM aspirate performed for study enrollment was inadequate for\nstudy evaluation due to lack of spicules.\n\nUPEP did not show any monoclonal ptn. Urine IFE showed tRACE\nMONOCLONAL FREE (___) LAMBDA DETECTED CONCENTRATION IS\nTOO LOW TO BE SEEN ON PEP FOR QUANTITATION.\n\n24 hour urinary ptn collection demonstrated 140mg ptn only.\n\n___: BM aspirate and biopsy repeated which confirmed ___\nmonoclonal plasma cells. \n\nFinal Diagnosis: Active symptomatic MM based on serum IFE\ndemonstrating IgG Lambda and more than focal lytic lesion on \nPET.\n\n___: Enrolled in clinical trial # ___ \"A Randomized Phase\nIII Study Comparing Conventional Dose Treatment Using a\nCombination of Lenalidomide, Bortezomib and Dexamethasone (RVD)\nto High-Dose Treatment with Peripheral Stem Cell Transplant in\nthe Initial Management of Myeloma in Patients up to ___ Years of\nAge\". \n\n___: C1D1 of RVD started. Tolerated it well without any \nmajor\ncomplications.\n\n___: Improvement in free Lambda burden from 324 to 11.6. M\npin quantity improved from 0.2 gm/dl to undetectable levels. \nC2D1\nof RVD started. C.b rash likely sec to Revlimid, ___ and\nneuropathy requiring inpatient hospitalization. She was found to\nhave a complex cyst concerning for clear cell RCC during the\nhospital course. \n\n___: MRI abdomen confirmed the suspicion of clear cell RCC.\n\n___: Evaluated by Dr ___ agreed with the concern of\nlow grade clear cell RCC and felt pt would be a candidate for\npartial nephrectomy.\n\n___: CT chest did not show any e.o metastasis. \n\n___: After discussion with ___ oncology team and Dr\n___ made to complete induction chemo followed by partial\nnephrectomy followed by HDT and autoBMT.\n\n___: Due to a new diagnosis of a second cancer presumed RCC,\npt came off the trial.\n\nTrace M ptn noted after 2 cycles of therapy (<0.06 gm). \n\n___: Started on cycle 3 of RVD off trial although at reduced\ndose of 1 mg/m2 and eventually 0.7 mg/m2 along with Rev at 20mg\nand Dex ___.\n\n___: Disappearance of M ptn after 3 cycles on serum IFE.\nStarted on cycle 4 of RVD. Velcade given at 0.7 mg/m2 on D1 and \n4\nand then discontinued due to persistent neuropathy grade 2 at\nleast. Revlimid continued at 20mg/day.\n\n___: Continued to have no e.o M ptn on serum IFE after 4\ncycles.\n\n___: After extensive discussion within the ___ team and with\nDr ___ made to withhold further therapy for MM given \nthe\nimmunomodulatory effects of Revlimid on RCC and hence pt\nunderwent a robotic assisted laproscopic partial left \nnephrectomy\non ___.\n\nSurgical path c.w pT1a papillary RCC. No e.o high risk features\nseen. Recommended 6 month follow up as tolerated the procedure\nvery well. \n\n___: Seen in clinic for follow up and seemed to be doing \nvery\nwell. Completely recovered from surgery. Resumed treatment with\nRev/Dex at cycle 5 (Rev 20mg/day D1-14 every 21 days and Dex\n___. \n\n___: Started cycle 6 of Rev/Dex, completed on ___.\n\nTentative Transplant Calendar:\n___: admission for chemo pre-collection\n___: start neupogen/cipro\n___: pheresis for collection\n___: admission for auto transplant\n\nPAST MEDICAL HISTORY: \n-HTN \n-HLD \n-s/p CCY \n-s/p L oopherectomy \n-Sickle trait\n \nSocial History:\n___\nFamily History:\nUncle died of colon cancer. Mother is living with hypertension, \ntype 2 diabetes, hypercholesterolemia and glaucoma and father is \ndeceased at age ___ from sickle cell disease. She has three \nhealthy children without medical issues. There is no other \nfamily history of cancer.\n \nPhysical Exam:\nAdmission Physical Examination:\nVS: T 99.0 HR 88, BP 112/68 RR 18, and SpO2 97% on room air. No\nurine output yet recorded. \nGen: Pleasant ___ woman, well-developed, breathing\ncomfortably, in no acute distress. \nCor: Regular rate and rhythm, S1S2 normal, no murmurs \nPulm: Clear to auscultation bilaterally, no wheeze, rhonci, or\nrales \nAbd: Soft, non-tender, non-distended. Specifically, no right\nupper quadrant or suprapubic tenderness \nExt: Warm, no lower extremity edema\nSkin: No rash. Left CVC site clean, dry, and intact, without\nsurrounding erythema, edema, or tenderness\n\nDischarge Physical Examination: \n\n \nPertinent Results:\nADMISSION LABS:\n\n___ 03:21PM BLOOD WBC-4.7 RBC-3.02* Hgb-8.1* Hct-24.7* \nMCV-82 MCH-26.8 MCHC-32.8 RDW-18.6* RDWSD-51.8* Plt ___\n___ 03:21PM BLOOD Neuts-71.8* Lymphs-14.0* Monos-11.7 \nEos-0.2* Baso-1.5* Im ___ AbsNeut-3.39 AbsLymp-0.66* \nAbsMono-0.55 AbsEos-0.01* AbsBaso-0.07\n___ 03:21PM BLOOD Glucose-174* UreaN-9 Creat-0.8 Na-143 \nK-3.2* Cl-106 HCO3-28 AnGap-12\n___ 03:21PM BLOOD ALT-15 AST-13 LD(LDH)-200 AlkPhos-69 \nTotBili-0.5 DirBili-<0.2 IndBili-0.5\n___ 03:21PM BLOOD TotProt-5.4* Albumin-3.6 Globuln-1.8* \nCalcium-9.1 Phos-3.7 Mg-1.9 UricAcd-5.0\n\nDISCHARGE LABS:\n\n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman with IgG Lambda Multiple \nMyeloma s/p 4C of RVD then 2C of rev/dex alone secondary to \nneuropathy in CR presenting now for autologous stem cell \ntransplant with melphalan prep.\n\nD+15 ___\n\nACTIVE ISSUES:\n\n#Leukocytosis: Noted in the setting of receiving neupogen so \nlikely culprit. Last dose of neupogen given on ___. WBC 20 \nat discharge. Patient has no localizing infectious symptoms \nexcept for diarrhea but this has been improving and most recent \nc-diff is negative. Continue to monitor and trend outpatient \n\n#Febrile Neutrapenia: See prior progress notes for details. No \nsource identified. Was treated with cefepime and vancomycin, \ndiscontinued on ___ and ___ respectively with counts \nrecovery. CXR indicative of small pleural effusion but no sign \nof active pulmonary infection. Blood and urine cultures NTD.\n\n#Nausea/Decreased Appetite/Anorexia: (improving), currently \nwithout vomiting, likely chemotherapy side effect, continue with \nantiemetics outpatient. Encourage drinking > 2L daily. Prior to \ndischarge, able to drink ~ 1.8L on own. Eating fairly\n\n#Diarrhea: (improving), started on ___, likely \nchemotherapy-effect; given concern for infection during \ntransplant, sent c-diff on ___ and ___ which were both \nnegative, continue to monitor outpatient.\n\n#Oral Candidiasis: (resolved). Noted ___ on tongue, initiated \non nystatin suspension, but worsened with c/o heartburn and \nmouth soreness, added fluconazole and protonix on ___ with \nimprovement. Discontinued ___ with count recovery and \nresolution of symptoms\n\n#Pancytopenia: improving, likely secondary to chemotherapy, \nsupport with transfusions per parameters (hgb < 7 and plts < \n10); started GCSF injection on ___ per protocol and \ndiscontinued on ___, last dose was received on ___ as \nabove). Received 1U plts on ___. Did not need more transfusions \nprior to discharge \n\n#Multiple Myeloma: s/p auto transplant, currently D+15. Refer \nabove regarding hospital course. \n\nCHRONIC/RESOLVED ISSUES:\n\n#Neuropathy: stable, off velcade after 4C of salvage \nchemotherapy with improvement, remains on gabapentin qhs. No \nexacerbations while in-house\n\n#Hyperglycemia: (stable), likely secondary to dexamethasone use \nwhile on chemotherapy. Initiated SSI and fingersticks QID but \ndiscontinued ___ since off steroids. \n\n#Hypotension, mild: (resolved), noted SBP in the ___ on ___ ___, \nimproved without intervention. Holding HTN medications for now, \ncontinue to monitor and trend \n\n#HTN: holding HCTZ/Lisinopril since ___ lower pressures. Plan \nto restart outpatient if pressures remain stable\n \n#Coping: SW to follow PRN in-house\n\n#Infectious Prophylaxis:\n- PCP: ___ or with counts recovery\n- HSV/VZV: acyclovir\n\nProphylaxes:\n# Access: CVC removed prior to discharge \n# FEN: low bacteria diet\n# Contact: ___\n# Disposition: Discharged ___. RTC on ___ with Dr. ___\n# Code Status: Full\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q12H \n2. Gabapentin 600 mg PO QHS \n3. Hydrochlorothiazide 25 mg PO DAILY \n4. Lisinopril 30 mg PO DAILY \n5. Ondansetron 8 mg PO Q8H:PRN nausea \n6. Prochlorperazine ___ mg PO Q6H:PRN nausea \n7. Simvastatin 40 mg PO QPM \n8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n9. Aspirin 81 mg PO DAILY \n10. Vitamin D 1000 UNIT PO DAILY \n11. Pyridoxine 100 mg PO DAILY \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q12H \nRX *acyclovir 400 mg 1 tablet(s) by mouth twice a day Disp #*60 \nTablet Refills:*3 \n2. Gabapentin 600 mg PO QHS \nRX *gabapentin 600 mg 1 tablet(s) by mouth @hs Disp #*30 Tablet \nRefills:*0 \n3. Ondansetron 8 mg PO Q8H:PRN nausea \nRX *ondansetron 8 mg 1 tablet(s) by mouth TID prn Disp #*30 \nTablet Refills:*3 \n4. Prochlorperazine ___ mg PO Q6H:PRN nausea \nRX *prochlorperazine maleate 5 mg ___ tablet(s) by mouth every 6 \nhours as needed Disp #*30 Tablet Refills:*3 \n5. Pyridoxine 100 mg PO DAILY \nRX *pyridoxine (vitamin B6) 100 mg 1 tablet(s) by mouth daily \nDisp #*30 Tablet Refills:*3 \n6. Simvastatin 40 mg PO QPM \nRX *simvastatin 40 mg 1 tablet(s) by mouth qPM Disp #*30 Tablet \nRefills:*3 \n7. Vitamin D 1000 UNIT PO DAILY \n8. HELD- Aspirin 81 mg PO DAILY This medication was held. Do \nnot restart Aspirin until outpatient team tells you to do so\n9. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication was \nheld. Do not restart Hydrochlorothiazide until outpatient team \ntells you to do so\n10. HELD- Lisinopril 30 mg PO DAILY This medication was held. \nDo not restart Lisinopril until outpatient team tells you to do \nso\n11. HELD- Sulfameth/Trimethoprim SS 1 TAB PO DAILY This \nmedication was held. Do not restart Sulfameth/Trimethoprim SS \nuntil outpatient team tells you to do so\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nMultiple Myeloma\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 for an autologous stem cell transplant. \n\nYou had a fever and mouth pain while your blood counts were low. \nWe did a work up including blood testing, urine testing, and \nchest x rays which did not find a source of infection. You were \nplaced on antibiotics for your fever spikes and your fevers \nresolved. \n\nYou also developed nausea, diarrhea and loss of appetite while \nyou were admitted. These are common side effects after \ntransplant and your symptoms continue to improve.\n\nYour nausea medications are as follows:\n1 zofran\n2 compazine\n\nYou will continue to take acyclovir to prevent infection. You \nwill start to take Bactrim to prevent a certain type of \npneumonia once your counts have fully recovered. Your outpatient \nprovider ___ tell you when to start this. \n\nPlease take your temperature twice a day, and call us if it goes \nabove 100.4. Please be sure to drink at least 2L (64oz) of \nfluid daily. Call if you are unable to do so, or if you have \nworsening nausea or watery stools.\n\nIt has been a pleasure taking care of you. \n \nFollowup Instructions:\n___\n" ]

[ "C9000", "D61810", "K521", "B370", "I10", "E785", "D573", "Z85528", "T451X5A", "Y92230", "G629", "D72829", "R110", "R739", "T380X5A", "R630", "R6883", "R5081", "E8770", "E861", "R42", "K1230" ]

[ "C9000: Multiple myeloma not having achieved remission", "D61810: Antineoplastic chemotherapy induced pancytopenia", "K521: Toxic gastroenteritis and colitis", "B370: Candidal stomatitis", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "D573: Sickle-cell trait", "Z85528: Personal history of other malignant neoplasm of kidney", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "G629: Polyneuropathy, unspecified", "D72829: Elevated white blood cell count, unspecified", "R110: Nausea", "R739: Hyperglycemia, unspecified", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "R630: Anorexia", "R6883: Chills (without fever)", "R5081: Fever presenting with conditions classified elsewhere", "E8770: Fluid overload, unspecified", "E861: Hypovolemia", "R42: Dizziness and giddiness", "K1230: Oral mucositis (ulcerative), unspecified" ]

[ "I10", "E785", "Y92230" ]

[]

[ " \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:\nL hip pain\n \nMajor Surgical or Invasive Procedure:\nL hip CRPP ___, ___\n \nHistory of Present Illness:\n___ with hx of sleep apnea, frozen shoulder, afib (s/p ablation \n___ years ago and not on anticoagulation) and HLD who is \npresenting with left hip pain after a mechanical fall this \nmorning. She was walking to a bronchoscopy appointment this \nmorning when she tripped on the sidewalk and fell onto her left \nhip. X-rays confirm a mildly impacted left hip FNF. \n \nPast Medical History:\nHYPERLIPIDEMIA \nATRIAL FIBRILLATION \nHEARTBURN \nFROZEN SHOULDER \nSLEEP APNEA \nHYPOTHYROIDISM \n \nSocial History:\ndetermined to be noncontributory \n \nPhysical Exam:\nGen: NAD\n\nLeft lower extremity:\n- dressing c/d/i\n- No deformity, erythema, edema, induration or ecchymosis\n- Soft, non-tender thigh and leg\n- Full, painless AROM/PROM of hip, knee, and ankle\n- ___ fire\n- SILT SPN/DPN/TN/saphenous/sural distributions\n- 1+ ___ pulses, foot warm and well-perfused\n \nPertinent Results:\n___ 07:00AM BLOOD WBC-6.5 RBC-4.43 Hgb-13.1 Hct-40.6 MCV-92 \nMCH-29.6 MCHC-32.3 RDW-13.8 RDWSD-46.5* Plt ___\n___ 11:25AM BLOOD WBC-9.0 RBC-4.76 Hgb-13.7 Hct-42.8 MCV-90 \nMCH-28.8 MCHC-32.0 RDW-13.7 RDWSD-45.3 Plt ___\n \nBrief Hospital Course:\nThe patient presented to the emergency department and was \nevaluated by the orthopedic surgery team. The patient was found \nto have a L femoral neck fx and was admitted to the orthopedic \nsurgery service. The patient was taken to the operating room on \n___ for L hip CRPP, which the patient tolerated well. For \nfull details 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 rehab was appropriate. The \n___ hospital course was otherwise unremarkable.\n\nAt the time of discharge the patient's pain was well controlled \nwith oral medications, incisions were clean/dry/intact, and the \npatient was voiding/moving bowels spontaneously. The patient is \nweight bearing as tolerated in the right extremity, and will be \ndischarged on <<>> for DVT prophylaxis. The patient will follow \nup with Dr. ___ routine. A thorough discussion was had \nwith 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 \nDischarge Medications:\n1. Acetaminophen (Liquid) 650 mg PO Q6H \n2. Docusate Sodium (Liquid) 100 mg PO BID \n3. Enoxaparin Sodium 40 mg SC QHS \nRX *enoxaparin 40 mg/0.4 mL 1 syringe SC every evening Disp #*30 \nSyringe Refills:*0 \n4. OxycoDONE Liquid ___ mg PO Q4H:PRN Pain - Moderate \nRX *oxycodone 5 mg ___ tablets by mouth every three to six hours \nDisp #*20 Tablet Refills:*0 \n5. bisoprolol fumarate 5 mg oral DAILY \n6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n7. Ipratropium Bromide Neb 1 NEB IH TID \n8. Levothyroxine Sodium 50 mcg PO DAILY \n9. Tiotropium Bromide 1 CAP IH DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nL hip CRPP\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:\nDischarge Instructions:\n\nINSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:\n\n- You were in the hospital for orthopedic surgery. It is normal \nto feel tired or \"washed out\" after surgery, and this feeling \nshould improve over the first few days to week. \n- Resume your regular activities as tolerated, but please follow \nyour weight bearing precautions strictly at all times.\n\nACTIVITY AND WEIGHT BEARING:\n- weight bearing as tolerated left 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 lovenox daily for 4 weeks\n\nWOUND CARE:\n- You may shower. No baths or swimming for at least 4 weeks.\n- Any stitches or staples that need to be removed will be taken \nout at your 2-week follow up appointment.\n- Please remain in your dressing and do not change unless it is \nvisibly soaked or falling off.\n- Splint must be left on until follow up appointment unless \notherwise instructed\n- Do NOT get splint wet\n\nDANGER SIGNS:\nPlease call your PCP or surgeon's office and/or return to the \nemergency department if you experience any of the following:\n- Increasing pain that is not controlled with pain medications\n- Increasing redness, swelling, drainage, or other concerning \nchanges in your incision\n- Persistent or increasing numbness, tingling, or loss of \nsensation\n- Fever > 101.4\n- Shaking chills\n- Chest pain\n- Shortness of breath\n- Nausea or vomiting with an inability to keep food, liquid, \nmedications down\n- Any other medical concerns\n\nTHIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB\n\n___ FOLLOW UP: follow up with Dr. ___, NOT PA/NP\nFOLLOW UP:\nPlease follow up with Dr. ___ in the ___ Trauma \nClinic ___ days post-operation for evaluation. Please call \n___ to schedule appointment.\n\nPlease follow up with your primary care doctor regarding this \nadmission within ___ weeks and for and any new \nmedications/refills.\n\nPhysical Therapy:\n- weight bearing as tolerated left lower extremity\nTreatment Frequency:\nAny staples or superficial sutures you have are to remain in \nplace for at least 2 weeks postoperatively. Incision may be \nleft open to air unless actively draining. If draining, you may \napply a gauze dressing secured with paper tape. You may shower \nand allow water to run over the wound, but please refrain from \nbathing for at least 4 weeks postoperatively.\n \nFollowup Instructions:\n___\n" ]

[ "S72092A", "W101XXA", "Y92480", "G4733", "I4891", "E785", "E039", "K648", "Z86010", "Z90710" ]

[ "S72092A: Other fracture of head and neck of left femur, initial encounter for closed fracture", "W101XXA: Fall (on)(from) sidewalk curb, initial encounter", "Y92480: Sidewalk as the place of occurrence of the external cause", "G4733: Obstructive sleep apnea (adult) (pediatric)", "I4891: Unspecified atrial fibrillation", "E785: Hyperlipidemia, unspecified", "E039: Hypothyroidism, unspecified", "K648: Other hemorrhoids", "Z86010: Personal history of colonic polyps", "Z90710: Acquired absence of both cervix and uterus" ]

[ "G4733", "I4891", "E785", "E039" ]

[]

[ " \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:\nLeft groin pain\n \nMajor Surgical or Invasive Procedure:\nLeft inguinal hernia repair\n\n \nHistory of Present Illness:\nPatient is a ___ male with a history of A. fib on \nEliquis\npresenting for severe left groin pain and lump x 2 days. \nPatient\nfirst noticed pain and lump 3 weeks ago, after prolonged\nactivity. He notes that the lump was spontaneously reducible if\nhe sat down. However, ___ morning he observed that the lump\nwas larger than usual and very painful, would not spontaneously\nreduce. The pain was constant, nonradiating, as high as a 7 out\nof 10 in severity. No nausea or vomiting, last BM was ___\nmorning and he has been able to eat and drink. No hematochezia \nor\nBRBPR; he reports dark stools at baseline ___ iron supplements.\nNo dysuria, CP, or difficulty breathing. He last took Eliquis on\n___ morning. \n\nHe initially presented to ___ ED, where he received a CT that\nshowed left inguinal hernia containing nonobstructed sigmoid\ncolon, mild inflammatory change within the hernia sac and a \nsmall\namount of fluid for which early incarceration cannot be ruled\nout. WBC 6.3, H/H 14.5/43.3. Patient was transferred for\nmanagement of incarcerated hernia.\n\nIn the ED, patient received IV morphine 4mg and IV lorazepam \n1mg.\nHe continues to feel significant pain in his left groin,\nespecially with exam manipulation. No additional symptoms.\n \nPast Medical History:\nPast Medical History:\n-Afib \n-Asthma\n-TIA\n-Prostate cancer\n\nPast Surgical History:\n-Laparoscopic appendectomy\n-Radical prostatectomy\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nPhysical Exam:\nVitals: AVSS, see flowsheets\nGEN: A&O, pleasant, conversant\nHEENT: No scleral icterus, mucus membranes moist\nCV: RRR\nPULM: regular respiratory effort\nABD: Soft, nondistended, nontender, no rebound or guarding.\nIncision: Left inguinal hernia incision is clean dry and intact, \nminimal swelling and bruising. Mildly tender on palpation. \nExt: No ___ edema, ___ warm and well perfused\n \nPertinent Results:\n___ 12:09AM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 12:09AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-NEG\n___ 11:45PM GLUCOSE-105* UREA N-11 CREAT-0.8 SODIUM-138 \nPOTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-22 ANION GAP-13\n___ 11:45PM WBC-6.8 RBC-4.43* HGB-14.3 HCT-43.5 MCV-98 \nMCH-32.3* MCHC-32.9 RDW-13.6 RDWSD-49.5*\n___ 11:45PM NEUTS-67.6 LYMPHS-16.9* MONOS-11.7 EOS-3.1 \nBASOS-0.6 IM ___ AbsNeut-4.57 AbsLymp-1.14* AbsMono-0.79 \nAbsEos-0.21 AbsBaso-0.04\n___ 11:45PM ___ PTT-32.4 ___\n___ 11:45PM PLT COUNT-193\n \nBrief Hospital Course:\n___ presented to the ED at ___ on ___ after \nbeing transferred from an OSH where a CT demonstrated a, \nincarcerated left inguinal hernia containing nonobstructed \nsigmoid colon. His eliquis was held for several days to minimize \nthe risk of bleeding. On ___ he went to the OR for open \nrepair of his left ingiunal hernia. He tolerated the procedure \nwell without complications (Please see operative note for \nfurther details). After a brief and uneventful stay in the PACU, \nthe patient was transferred to the floor for further \npost-operative management. \n \n Neuro: Pain was well controlled on oxycodone and Tylenol. \n CV: Vital signs were routinely monitored during the patient's \nlength of stay. His anticoagulation was held for 2 days prior to \nsurgery. He was instructed to resume his home anticoagulation 2 \ndays following surgery.\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. A chest tube was placed at the \ntime of surgery that was removed before discharge.\n GI: The patient was initially kept NPO after the procedure. The \npatient was later advanced to and tolerated a regular diet at \ntime of discharge. \n GU: 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, of which there were none. \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 On ___, the patient was discharged home. At discharge, he \nhad no problems with his breathing, he was tolerating a regular \ndiet, passing flatus, voiding, and ambulating independently. He \nwill follow-up in the clinic in roughly 2 weeks. This \ninformation was communicated to the patient directly prior to \ndischarge. \n \nMedications on Admission:\nMedications:\n-Eliquis 5 mg tablet oral 1 tablet(s) Twice Daily\n-Metoprolol succinate ER 50 mg tablet,extended release 24 hr \noral\n1 tablet extended release 24 hr(s) Twice Daily\n-Diltiazem CD 360 mg capsule,extended release 24 hr oral\n1 capsule,extended release 24hr(s) Once Daily\n-Digox 125 mcg tablet oral 1 tablet(s) MWF am\n-Furosemide 40 mg tablet oral 1 tablet(s) MWF am\n-Advair\n-Iron supplements\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO TID \n2. Digoxin 0.125 mg PO 3X/WEEK (___) \n3. Diltiazem Extended-Release 360 mg PO DAILY \n4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n5. Furosemide 40 mg PO DAILY \n6. Metoprolol Succinate XL 100 mg PO QHS \n7. Metoprolol Succinate XL 50 mg PO QAM \n8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *oxycodone 5 mg 1 tablet(s) by mouth Q4H:PRN Disp #*10 Tablet \nRefills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nLeft inguinal hernia, incarcerated\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 ___ for concerns of an incarcerated left \ninguinal hernia. You have recovered well and are now ready to \ncontinue your recovery at home. \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 do not start your Eliquis (blood thinner) until ___.\n\nPlease resume all other regular home medications, unless \nspecifically advised not to take a particular medication. Also, \nplease take any new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon.\n\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\nIncision Care:\n*Please call your doctor or nurse practitioner if you have \nincreased pain, swelling, redness, or drainage from the incision \nsite.\n*Avoid swimming and baths until your follow-up appointment.\n*You may shower, and wash surgical incisions with a mild soap \nand warm water. Gently pat the area dry.\n*If you have staples, they will be removed at your follow-up \nappointment.\n*If you have steri-strips, they will fall off on their own. \nPlease remove any remaining strips ___ days after surgery.\n\n \nFollowup Instructions:\n___\n" ]

[ "K4030", "I4891", "Z8673", "Z8546" ]

[ "K4030: Unilateral inguinal hernia, with obstruction, without gangrene, not specified as recurrent", "I4891: Unspecified atrial fibrillation", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z8546: Personal history of malignant neoplasm of prostate" ]

[ "I4891", "Z8673" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: PLASTIC\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nL forearm pain s/p MCC\n \nMajor Surgical or Invasive Procedure:\nCompartment release L forearm, I&D of soft tissue wounds, Carpal \ntunnel Release, nailbed repair\n\n \nHistory of Present Illness:\n___ y/o RHD male presents as transfer after MCC. Pt slid on ice\nand the bike landed on top of his L arm. C/o persistent pain \nand\nparesthesias over volar forearm and limited finger motion since\nevent.\n \nPast Medical History:\nNone\n \nSocial History:\nnone recorded\n \nPhysical Exam:\nAFVSS\nNAD\nLUE: in splint, min pain with passive stretch of fingers. \nexpected postop swelling in L forearm but compressible/soft. \nSILT in fingers. cap refill <2 sec in digits, wwp. \n \nBrief Hospital Course:\nThe patient was admitted to the plastic surgery service on \n___ and had a compartment release L forearm, I&D, CTR, \nnailbed repair. The patient tolerated the procedure well.\n.\nNeuro: Post-operatively, the patient received IV dilaudid with \ngood effect and adequate pain control. When tolerating oral \nintake, the patient was transitioned to oral pain medications.\n.\nCV: The patient was stable from a cardiovascular standpoint; \nvital signs were routinely monitored.\n.\nPulmonary: The patient was stable from a pulmonary standpoint; \nvital signs were routinely monitored.\n.\nGI/GU: Post-operatively, the patient was given IV fluids until \ntolerating oral intake. His/Her diet was advanced when \nappropriate, which was tolerated well. Intake and output were \nclosely monitored.\n.\nID: Post-operatively, the patient was started on IV cefazolin, \nthen switched to PO cefadroxil for discharge home. The patient's \ntemperature was closely watched for signs of infection.\n.\nProphylaxis: The patient received subcutaneous heparin during \nthis stay, and was encouraged to get up and ambulate as early as \npossible.\n.\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs, tolerating a regular diet, ambulating, \nvoiding without assistance, and pain was well controlled.\n \nMedications on Admission:\nnone\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H \n2. cefaDROXil 500 mg oral BID Duration: 5 Days \nRX *cefadroxil 500 mg 1 capsule(s) by mouth twice a day Disp \n#*10 Capsule Refills:*0\n3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain not \nrelieved by tylenol \nRX *oxycodone 5 mg 1 tablet(s) by mouth every ___ hours Disp \n#*50 Tablet Refills:*0\n4. Senna 8.6 mg PO BID:PRN constipation>3d \n5. Docusate Sodium 100 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nL forearm compartment syndrome, tuft fractures L ___ and ___ \ndigits\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nFollow-up Instructions:\n___\n" ]

[ "T79A12A", "S62633B", "S62637B", "S51822A", "V284XXA", "Y929" ]

[ "T79A12A: Traumatic compartment syndrome of left upper extremity, initial encounter", "S62633B: Displaced fracture of distal phalanx of left middle finger, initial encounter for open fracture", "S62637B: Displaced fracture of distal phalanx of left little finger, initial encounter for open fracture", "S51822A: Laceration with foreign body of left forearm, initial encounter", "V284XXA: Motorcycle driver injured in noncollision transport accident in traffic accident, initial encounter", "Y929: Unspecified place or not applicable" ]

[ "Y929" ]

[]

[ " \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:\nSeizures \n \nMajor Surgical or Invasive Procedure:\n___: uncomplicated left craniotomy for tumor resection \n\n \nHistory of Present Illness:\n___ year old male presents to ED following acute onset of\nright-sided neck pain that began on ___. He reports that \nit\npersisted through the weekend, and even during a long drive it\nimpaired his range of motion. On ___, the patient\nexperienced an episode of dizziness that was then followed by\nseizure activity witnessed by his wife. He then called ___ and\nwas transferred to a hospital in ___. He underwent a NCHCT and \nMRI\nof the brain that revealed a new brain lesion, and he was\ntransferred to ___ for further evaluation. \n\n \nPast Medical History:\nNo PMHX\n\nAll:\nNKDA\n \nSocial History:\n___\nFamily History:\nFather with stomach cancer \n\n \nPhysical Exam:\nTemp: 97.8 HR: 57 BP: 127/68 RR: 18 O2Sat: 100% RA \n \nGen: WD/WN, comfortable, NAD.\nHEENT: Pupils: PERRL EOMs: Intact\nIncision: c/d/i, no erythema, induration, or swelling\nExtrem: Warm and well-perfused.\nNeuro:\nMental status: Awake and alert, cooperative with exam, normal\naffect.\nOrientation: Oriented to person, place, and date.\nLanguage: Speech fluent with good comprehension 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\nmm bilaterally. \nIII, IV, VI: Extraocular movements intact bilaterally, R \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. \nNormal gait.\n\nSensation: Intact to light touch\n\nCoordination: normal on finger-nose-finger\n\nEXAM ON DISCHARGE: \nXX\n \nPertinent Results:\nPlease refer to OMR\n___ 06:52AM BLOOD Glucose-128* UreaN-15 Creat-0.8 Na-143 \nK-4.3 Cl-103 HCO3-23 AnGap-21*\n___ 06:52AM BLOOD WBC-17.5* RBC-5.41 Hgb-13.1* Hct-40.9 \nMCV-76* MCH-24.2* MCHC-32.0 RDW-14.1 RDWSD-37.5 Plt ___rain lesion\nMr. ___ was admitted to the neurosurgical floor on ___. He \nwas started on Keppra BID which was further increased for c/o \nnumbness and tingling to the right hand. On ___ he underwent a \nleft craniotomy for tumor resection, his intra-operative course \nwas uneventful, please refer to the operative note for further \ndetails. He was admitted to the ___ thereafter, where he \nunderwent q4hr neurologic checks, continued Keppra prophylaxis, \nand began dexamethasone taper; received IV Protonix while on \ndexamethasone. SBP was maintained within target range 100-140 mm \nHg on POD1 with PRN hydralazine and nicardipine gtt; SBP target \nwas liberalized to 160 mm Hg on POD2 and the patient remained \nwithin target range without further intervention thereafter. \nPost-op CT scan revealed pneumocephalus with mass effect on the \nunderlying brain parenchyma with 5 mm of rightward shift; the \npatient was asymptomatic throughout and placed on NRB oxygen \ntherapy to promote resorption.\n and POD1 MRI revealed no residual tumor. Foley was removed on \nPOD1 once the patient was mobilized OOB and target SBP was \nliberalized to 160 mm Hg. Received 24 hours of post-op \nantibiotic prophylaxis. At the time of discharge, the patient \nhad minimal pain controlled without narcotic, was ambulating and \nvoiding independently, did not require supplemental oxygen, and \nhad no evidence of infection at the surgical site. The patient \nwas provided with detailed discharge instructions regarding \nwound care, follow-up, prohibition of driving, and medications, \nincluding dexamethasone with PPI prophylaxis and Keppra \nanti-seizure prophylaxis.\n \nMedications on Admission:\nVicodin prn for neck pain\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q4H:PRN fever or pain \n2. Dexamethasone 2 mg PO Q12H \nTake 4 mg BID x 2 days (4 x, end ___\nTake 3 mg BID x 2 days (4 x, end ___\nTake 2 mg BID \nRX *dexamethasone 2 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*1 \n3. LevETIRAcetam 1000 mg PO BID \nRX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a \nday Disp #*60 Tablet Refills:*3 \n4. Omeprazole 20 mg PO DAILY \nRX *omeprazole 20 mg 1 capsule(s) by mouth Each morning Disp \n#*30 Capsule Refills:*3 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nBrain lesion \nVasogenic edema\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDischarge Instructions\nBrain Tumor\n\nSurgery\n•You underwent surgery to remove a brain lesion from your \nbrain. \n•Frozen preliminary was: glioma\n•Please keep your incision dry until your sutures/staples are \nremoved. \n•You may shower at this time but keep your incision dry.\n•It is best to keep your incision open to air but it is ok to \ncover it when outside.\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 once you are symptom free at rest. \n___ try to do 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 may use Acetaminophen (Tylenol) for minor discomfort if \nyou are not otherwise restricted from taking this medication.\n\nWhat You ___ Experience:\n•You may experience headaches and incisional pain. \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•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•Feeling more tired or restlessness is 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\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•Sudden numbness or weakness in the face, arm, or leg\n•Sudden confusion or trouble speaking or understanding\n•Sudden trouble walking, dizziness, or loss of balance or \ncoordination\n•Sudden severe headaches with no known reason\n\n \nFollowup Instructions:\n___\n" ]

[ "D430", "G936", "R569" ]

[ "D430: Neoplasm of uncertain behavior of brain, supratentorial", "G936: Cerebral edema", "R569: Unspecified convulsions" ]

[]

[]

[ " \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, confusion, visual disturbance\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with history notable for\nHTN, HLD, and ___ transferred from ___ after\npresenting with headaches, visual disturbance, and confusion.\n\nMs. ___ son reports that she first reported a mild \nright\nparietooccipital headache two nights prior to presentation,\naround which time she was noted to be slightly more confused \nthan\nusual, having some inappropriate speech and some difficulty\nfinding her way around her home. By the next day, her symptoms\nhad somewhat progressed, prompting her family to contact her \nPCP,\nwho recommended outpatient imaging. However, yesterday evening,\nMs. ___ was noted to have apparent visual disturbance,\nreporting that she wasn't able to see a donut placed on a plate\nin front of her; she similarly reported difficulty identifying\nobjects in space, though it is not clear to her family whether\nthis was more pronounced on either side. By this morning, her\nconfusion and headaches had continued to progress, prompting\npresentation to ___, where ___ revealed a right\noccipital IPH, resulting in transfer to ___ for further\nevaluation. Ms. ___ family denies a prior history of\nsimilar symptoms. Notably, Ms. ___ has been noted to \nhave\nmemory difficulties more so over the past ___ years, during \nwhich\ntime she has become dependent in her IADLs while remaining\nindependent in her ADLs, allowing her to live with her daughter\nat home.\n \nUnable to directly confirm ROS but family denies recent reports\nof focal weakness, sensory disturbance, dizziness, gait\ndisturbance, bowel or bladder incontinence, fevers, chills, or\nrash. Ms. ___ had briefly reported some abdominal\ndiscomfort in the past few days.\n\n \nPast Medical History:\nHTN\nHLD\nHypothyroidism\nDiverticulitis\nOA\n \nSocial History:\n___\nFamily History:\nNotable for sister with cerebral aneurysm, otherwise negative \nfor\nneurological disorders.\n \nPhysical Exam:\nAdmission physical exam:\n\n Vitals: T: 97.8 HR: 76 BP: 144/102 RR: 21 SpO2: 98% RA\n General: NAD\n HEENT: NCAT, neck supple\n ___: RRR\n Pulmonary: No tachypnea or increased WOB\n Abdomen: Soft, ND\n Extremities: Warm, no edema\n\nNeurologic Examination:\n- Mental status: Awake, alert, not oriented to time or place.\nUnable to provide history. Speech largely fluent in ___ per\nfamily, though with perhaps some comprehension deficit vs. \nmarked\ninattention. Follows, with encouragement, some axial and\nappendicular commands, and perseverates on prior task. No\napparent dysarthria per family. ?Left neglect vs. hemianopia.\n\n- Cranial Nerves: Pupils 3 to 2.5 mm ___, slightly corectopic OS.\nUnable to participate in confrontational visual fields with\nsomewhat inconsistent BTT, but overall attends to examiner in\nright hemifield but not left. Spontaneous EOMI. Subtle L NLFF\nwith reasonably symmetric activation. Hearing intact to\nconversation. Tongue midline.\n\n- Motor: Does not participate in confrontational examination but\nable to provide sustained antigravity effort with all \nextremities\nas well as with intact proximal power in BUE and distal power in\nBLE.\n \n- Reflexes: Limited by impaired relaxation, but 3+ at the\npatellae with crossed adductors.\n\n- Sensory: Response to touch in all extremities.\n\n- Coordination: No dysmetria on reaching for examiner's hand in\nright hemifield bilaterally.\n\n- Gait: Widened base, mildly unsteady.\n\nDischarge physical exam:\n\n___ ___ Temp: 98.0 Axillary BP: 109/63 HR: 94 RR: 18 O2\nsat: 96% O2 delivery: RA \n___ ___ Dyspnea: 0 RASS: 0 Pain Score: ___ \n \n\nGeneral: lying in bed, in NAD\nHEENT - ~1cm x 3cm area of erythema, no fluctuance or induration\nnoted on exam\nExtremities: Warm, no edema\n\nNeurologic Examination:\n- Mental status: awake, pleasant, does not answer questions\nappropriately. Babbles in a mixture of ___ and ___. When \nasked questions, will answer ___ words coherently and then say \nnon-sensical words. Her speech is soft, though no apparent \ndysarthria.\n\n- Cranial Nerves: spontaneous EOMI. Subtle L NLFF.\n\n- Motor: moving all limbs spontaneously to antigravity, does not\nparticipate in confrontational examination. Pushes examiner away \nwith good strength. \n\n- Reflexes: 2+ patellar and 1+ Achilles bilaterally\n\n- Sensory: withdraws to tickle equally in all extremities\n \nPertinent Results:\n___ 06:35AM BLOOD WBC-6.8 RBC-3.62* Hgb-11.1* Hct-35.6 \nMCV-98 MCH-30.7 MCHC-31.2* RDW-12.9 RDWSD-46.1 Plt ___\n___ 06:35AM BLOOD Plt ___\n___ 06:35AM BLOOD Glucose-92 UreaN-28* Creat-0.8 Na-138 \nK-4.2 Cl-102 HCO3-26 AnGap-10\n___ 06:35AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.2\n___ 01:36PM URINE RBC-22* WBC->182* Bacteri-MOD* Yeast-NONE \nEpi-1\n___ 01:36PM URINE Blood-TR* Nitrite-POS* Protein-100* \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG*\n___ 01:36PM URINE Color-Yellow Appear-Cloudy* Sp ___\n\nImaging:\n\nCTA head and neck (___):\nIMPRESSION: \n \n \n1. Evolving intraparenchymal hemorrhage in the right occipital \nlobe, overall \nsimilar in size when compared with the prior study obtained 5 \nhours earlier. \nSimilar mild regional edema and mass effect. No significant \nmidline shift. \n2. No new intracranial hemorrhage or acute large vessel \ninfarct. \n3. Patent circle of ___ without definite evidence of \narteriovenous \nmalformation, aneurysm, high-grade stenosis or occlusion. \n4. Patent bilateral cervical carotid and vertebral arteries \nwithout definite \nevidence of stenosis, occlusion, or dissection. \n5. Chronic lacunar infarcts in the anterior limb of the right \ninternal capsule \nbilateral basal ganglia. \n\nCT head w/o contrast (___):\n \nIMPRESSION: \n \nNo substantial interval change in the right occipital lobe \nintraparenchymal \nhemorrhage compared to study from 12 hours prior. There is no \nsignificant \nmass effect or midline shift. No new intracranial hemorrhage. \n\nUS neck soft tissue:\n \nIMPRESSION: \n \nTargeted exam evaluating a palpable abnormality in the right \nanterolateral \nneck demonstrates no drainable fluid collection. \n\nEKG:\nSinus rhythm with occasional premature ventricular \ndepolarizations\nMinimal voltage criteria for LVH, may be normal variant\nT wave abnormalities\nWhen compared with ECG of ___ 05:41,\npremature ventricular depolarizations are now present\n \nBrief Hospital Course:\n___ w/ hx of HTN, HLD, hypothyroidism, dementia transferred from\n___ after presenting with headaches, visual disturbance,\nand confusion. \n\n#R occipital lobar IPH ___ CAA\nInitial CT head shows R occipital IPH, which was stable on \nrepeat CT head. Given age, dementia, and cortical location, \nlikely etiology is cerebral amyloid angiopathy. Antiplatelets, \nanticoagulants, and NSAIDs were held during hospitalization as \nthese medications increase risk of bleeding. They should \ncontinue to be held as an outpatient as CAA predisposes patient \nto hemorrhage. MRI was not completed as patient could not \ntolerate exam; while GRE sequence on MRI would definitively \ndetermine if patient has amyloid angiopathy, clinical picture \nseemed consistent with amyloid such that information from study \nnot worth harm and distress to patient. She will need a repeat \nMRI prior to stroke follow up, and evaluation for amyloid \nangiopathy can be done at this point. MRI brain with and without \ncontrast (to look for underlying mass lesion, also on \ndifferential) was ordered in OMR for ___ weeks prior to follow \nup in stroke clinic. \n\n#Agitation\nAgitation was a significant issue during hospitalization, \ntreated with PRN medications including Ativan, olanzapine, and \nSeroquel. The most effective PRN was Seroquel at low dose. \nPatient was diagnosed with a UTI which was thought to be \ncontributing to some of this agitation. \n\n#UTI\nPatient was diagnosed with a UTI (UA checked ___ for \nagitation), and was started on Bactrim DS for a 5 day course \n(___). The reflexed urine culture was pending at time of \ndischarge. \n\n#Urinary retention\nPatient also had intermittent urinary retention, for which she \nwas straight-cathed. Intermittently. \n\n#Dysphagia\nSwallow evaluation deemed patient safe for pureed diet with \nnectar thick and thin liquids. Continued outpatient follow up \nfor dietary progression is needed; coordinate this through PCP. \n\n#Hypertension\nHome metoprolol ER 50mg daily was transitioned to 12.5mg Q6H \nwhile inpatient. This can be transitioned to ER on discharge, \nand patient should follow up with PCP for very strict blood \npressure control. In CAA, hypertension predisposes patients to \nintracerebral hemorrhage so strict blood pressure control <130 \nis imperative. \n\nTransitional Issues:\n[] F/U with PCP ___: blood pressure control <130 systolic, \nswallow referral for dietary progression when clinically \nappropriate.\n[] MRI brain with and without contrast 2 weeks prior to stroke \nfollow up appointment ___ ___\n[] Continue to hold antiplatelets, anticoagulants, and NSAIDs\n[] UTI Rx: Bactrim DS ___\n\nPending Results at discharge:\n- Urine culture ___\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Succinate XL 50 mg PO DAILY \n2. Rosuvastatin Calcium 10 mg PO QPM \n3. Levothyroxine Sodium 125 mcg PO DAILY \n4. Omeprazole Dose is Unknown PO DAILY \n5. TraZODone 25 mg PO QHS:PRN Sleep \n6. Aspirin 81 mg PO DAILY \n7. Donepezil 10 mg PO QHS \n\n \nDischarge Medications:\n1. Sulfameth/Trimethoprim DS 1 TAB PO BID until ___\n2. Omeprazole 40 mg PO DAILY \n3. Donepezil 10 mg PO QHS \n4. Levothyroxine Sodium 125 mcg PO DAILY \n5. Metoprolol Succinate XL 50 mg PO DAILY \n6. Rosuvastatin Calcium 10 mg PO QPM \n7. TraZODone 25 mg PO QHS:PRN Sleep \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAcute hemorrhagic stroke\n\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear ___,\n\nYou were hospitalized due to symptoms of headache, visual \ndisturbance, confusion resulting from an ACUTE HEMORRHAGIC \nSTROKE, a condition where a blood vessel breaks and blood pools \nin the brain tissue. The brain is the part of your body that \ncontrols and directs all the other parts of your body, so a \nbleed in the brain can result in a variety of symptoms.\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-dementia\n-old age\n\nWe are changing your medications as follows:\n- START Bactrim 1 double-strength tab for 4 days\n- STOP aspirin\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" ]

[ "E854", "I611", "G936", "F0281", "F05", "I680", "R1310", "R402362", "R402142", "R402242", "H538", "I10", "E7849", "E039", "G309", "Z781", "Z66", "M1990", "R451", "R339", "R2681" ]

[ "E854: Organ-limited amyloidosis", "I611: Nontraumatic intracerebral hemorrhage in hemisphere, cortical", "G936: Cerebral edema", "F0281: Dementia in other diseases classified elsewhere with behavioral disturbance", "F05: Delirium due to known physiological condition", "I680: Cerebral amyloid angiopathy", "R1310: Dysphagia, unspecified", "R402362: Coma scale, best motor response, obeys commands, at arrival to emergency department", "R402142: Coma scale, eyes open, spontaneous, at arrival to emergency department", "R402242: Coma scale, best verbal response, confused conversation, at arrival to emergency department", "H538: Other visual disturbances", "I10: Essential (primary) hypertension", "E7849: Other hyperlipidemia", "E039: Hypothyroidism, unspecified", "G309: Alzheimer's disease, unspecified", "Z781: Physical restraint status", "Z66: Do not resuscitate", "M1990: Unspecified osteoarthritis, unspecified site", "R451: Restlessness and agitation", "R339: Retention of urine, unspecified", "R2681: Unsteadiness on feet" ]

[ "I10", "E039", "Z66" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROSURGERY\n \nAllergies: \nLactose / Codeine / Augmentin / Cipro\n \nAttending: ___.\n \nChief Complaint:\n___ leg pain for ___ years\n \nMajor Surgical or Invasive Procedure:\n___: L4-5 microdiscectomy\n\n \nHistory of Present Illness:\n___ is a ___ year old female who presented to clinic \nwith a ___ year history of ___ leg pain. Imaging demonstrated a \nL4-L5 ___ herniated disc. Patient underwent a spinal cord \nstimulator trial which was successful, but due to the limited \nlong term effects, patient decided to proceed with surgery for \ndiscectomy instead. \n\n \n \nPast Medical History:\n- Low back pain and ___ radicular pain\n- HTN\n- Asthma\n- Migraines\n- Nephrolithiasis\n- Urinary tract infections \n- Urinary incontinence, s/p Tension-free vaginal tape \nsuburethral sling procedure, ___ \n- Sacral Nerve Stimulator ___\n- ___ Breast Cancer s/p lumpectomy x ___, ___ - atypical \nphylloides tumor\n- ___ ACL tear s/p repair ___\n- Catarct\n- Uterine fibroids s/p hysterectomy ___\n- Anxiety\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nON DSICHARGE: \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: ___ ___ Bilat\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\n___\n\n ___ ___\n___ ___\n\n[x]Sensation intact to light touch\n\nWound: \n[x]Surgical dressing with some minimal blood staining \n\n\n \nPertinent Results:\nPlease refer to ___ for pertinent imaging and lab results\n \nBrief Hospital Course:\n___ is a ___ year old female who presented with symptoms \nof ___ leg pain for ___ years with imaging demonstrating \nL4-L5 herniated disc. Patient is admitted for L4-L5 \nmicrodiscectomy. \n\n#L4-L5 herniated disc \nOn ___ Ms. ___ was admitted to ___ Neurosurgery for an \nL4-L5 microdsicectomy. She did well overnight and was ambulating \nwell in the morning. By the afternoon she was voiding without \nissue. The patient's pain was well-controlled. It was determined \nthat she was safe and ready for discharge home with appropriate \nfollow-up. \n \nMedications on Admission:\n- Brimonidine eye drops 0.2% (1 drop into ___ eye BID)\n- Ibuprofen 600mg tablet, 1 tablet PO, with food \n- Dicyclomine 10mg capsule, 1 capsule PO before meals\n- Cyclobenzaprine 5mg tablet, 1 tablet PO at bedtime\n- Zolpidem Tartrate 5mg tablet, 1 tablet PO at bedtime\n- Metoprolol Succinate ER 50mg tablet, 1 tab PO daily\n- Gabapentin 600mg tablet, 1 tab PO BID\n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild \n2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation \n3. Docusate Sodium 100 mg PO BID \n4. Senna 17.2 mg PO QHS \n5. Brimonidine Tartrate 0.15% Ophth. 1 DROP ___ EYE BID \n6. Cyclobenzaprine 5 mg PO Q8H:PRN spasm \nRX *cyclobenzaprine 5 mg 1 tablet(s) by mouth every 8 hours as \nneeded Disp #*21 Tablet Refills:*0 \n7. DICYCLOMine 10 mg PO TID W/MEALS \n8. Gabapentin 600 mg PO BID \n9. Metoprolol Succinate XL 50 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nL4-L5 ___ herniated disc\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nSurgery\n•Your dressing may come off on the second day after surgery. \n•Your incision is closed with dissolvable sutures underneath \nthe skin and steri strips. You do not need suture removal. Do \nnot remove your steri strips, let them fall off. Please keep \nyour incision dry for 72 hours after surgery.\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" ]

[ "M5116", "I10", "J45909", "K219", "K2270", "Z853", "G43909", "K589" ]

[ "M5116: Intervertebral disc disorders with radiculopathy, lumbar region", "I10: Essential (primary) hypertension", "J45909: Unspecified asthma, uncomplicated", "K219: Gastro-esophageal reflux disease without esophagitis", "K2270: Barrett's esophagus without dysplasia", "Z853: Personal history of malignant neoplasm of breast", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "K589: Irritable bowel syndrome without diarrhea" ]

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

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nlower extremity edema, mild ___\ntransferred to ___ for diagnostic work-up of biventricular \nCHF, hypercarbia \n \nMajor Surgical or Invasive Procedure:\nRight heart catheterization ___\n\n \nHistory of Present Illness:\n___ is a ___ year old woman with a history of Pott's \ndisease. Per OSH hospital records, she was admitted to ___ \n___ ___ after presenting with several weeks of \nworsening SOB and DOE walking short distances. On admission she \nwas found to be tachycardic, SPO2 90% on RA at rest, normal BP. \nLabs showed elevated D-dimer, normal CBC, BMP notable for HCO3 \nof 37, NT-pro-BNP 1336. CXR showed patchy right lung opacities, \nsuggestion of mild pulmonary edema, right pleural thickening vs \nloculated fluid with pleural calcifications, moderate \ncardiomegaly. CT chest was negative for PE but was limited by \nmotion artifact. She was admitted with concern for TB \nreactivation vs pneumonia. Exam showed 4+ pitting edema, and she \nwas started on Lasix and antibiotics (ceftriaxone and \nazithromycin, day one ___ BNP was 1336. ECHO showed \npulmonary hypertension, enlarged heart and pulmonary artery, EF \nof ___ and new diastolic dysfunction. \n\nShe was evaluated by cardiology, infectious disease, and \npulmonology, who concluded that she did not have active TB. All \ncultures (Blood, sputum AFB, urine legionella and S. pneumo, \ninfluenza swab, strep throat culture) were negative, and so ID \nrecommended stopping antibiotics. \n\nOn ___, she was found to have persistent hypercapnia and \nhypoxemia on 2L NC, blood gas was ___. Because of \nhypercapnia and elevated HCO3 she was started on acetazolamide \n___. On ___, she was noted to be ambulating and \nindependent, with SOB improved after diuresis. On ___, notes \nindicate she had persistent lower extremity edema, bilaterally \ndecreased breath sounds, satting 94% on 2___, 85% on RA, unable \nto lie flat. Pulmonary consult there recommended right and left \nheart catheterization, and so transfer to ___ was requested. \n\nVitals prior to transfer on ___: 98.7, HR ___, BP 116/68, RR \n___, O2SAT 96% on ___\nHT: 64 inches\nWT: 127 kgs\n\nOn the floor, patient is unable to explain the exact reason for \nwhy she was admitted to ___. She states that she was \nsent in by her PCP. She reports being in her usual state of \nhealth prior to her check-up with PCP. Regarding her SOB, she \nstates that she is not SOB at rest or extremely DOE. She walks \n___ times around the park and states that she will huff and puff \nas any person would after exercise. She denies breathing \ndifficulties out of proportion to the average person. Ankle \nswelling occurs when is sitting at rest for prolonged periods of \ntime (i.e. since being hospitalized at ___ last week)\n\nROS is negative as follows. She denies chest pain, PND, \northopnea, palpitations, fevers, cough, abdominal pain, nausea, \nvomiting, diarrhea, changes in urinary habits, dysuria, \nhematuria, changes in BM, changes in appetite, unintentional \nweight loss. She does not use oxygen at home. \n\n \nPast Medical History:\n-History of Pott's disease s/p T12, L1, and L2 anterior \ncorpectomy, fusion, and instrumentation; \n-TB treated with RIPE and moxifloxacin\n-Obstructive sleep apnea on CPAP\n-Herpes zoster\n \nSocial History:\n___\nFamily History:\nNo known family history of early MI, arrhythmia, \ncardiomyopathies, or sudden cardiac death.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n=======================\nVS: T 98.6 BP 108/77 HR 76 RR 20 O2SAT 94RA WEIGHT: 126 KG \nGENERAL: Well developed, well nourished, in NAD. Oriented x3. \nMood, affect appropriate.\nHEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. \nConjunctiva were pink. No pallor or cyanosis of the oral mucosa. \nNo xanthelasma.\nNECK: Supple. JVP of 8-9 cm.\nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, \nor gallops. No pericardial rubs.\nLUNGS: Breath sounds are distant given body habitus. No chest \nwall deformities or tenderness. Respiration is unlabored with no \naccessory muscle use. No audible crackles, wheezes or rhonchi.\nABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No \nsplenomegaly.\nEXTREMITIES: 2+ pitting edema bilaterally to knees. Warm, well \nperfused. No clubbing, cyanosis.\nSKIN: No significant skin lesions or rashes.\nPULSES: Distal pulses palpable and symmetric.\n\nDISCHARGE PHYSICAL EXAM:\n=========================\nVitals: T 98.1 BP 91-112/59-80, HR 93-112, RR ___ \nAmbulatory O2Sat: 85% -> 96% -> 100% with HR up to 123. Repeat \nambulatory O2 sat: 95% RA, 97-100%RA\nI/O: 24H ___ 8H: ___ \nWeight 114.2 (114.8, 126 kg on admission)\nGENERAL: Well developed, well nourished, in NAD. Oriented x3. \nMood, affect appropriate.\nHEENT: Normocephalic atraumatic. Sclera anicteric. \nNECK: Supple. JVP ~ ___.\nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, \nor gallops. \nLUNGS: Breath sounds are distant given body habitus. Respiration \nis unlabored with no accessory muscle use. CTAB\nABDOMEN: Soft, non-tender, non-distended. BS+\nEXTREMITIES: Warm, well perfused. No clubbing, cyanosis, edema\nSKIN: No significant skin lesions or rashes.\n\n \nPertinent Results:\n___ LABS PRIOR TO ___ TRANSFER:\n==================================\n___:\nTroponin T <0.01\n___\n-WBC 7.8, Hgb 15.1, Plt 230, MCV 84.6\n-INR 1.4, Ptt 28.3\n-D-dimer 0.66 ug/mIFEU (normal less than 0.50)\n\n___:\nTbili 0.8, AST 27, ALT 42, Alk phos 49\nAlbumin 2.7\ntriglyceride 59, cholesterol 124, LDL 83, HDL 29 \n\n___:\n-ABG ___ (on 2L/min per NC)\n\n___:\n-Na 141, K 4.1, cL 97, HCO3 42, BUN 8, creatinine 0.6, calcium \n8.1, magnesium 2.0\n-NTproBNP 330\n-TSH 1.52\n\nBlood culture ___ x2 - preliminary no growth\n\n___ IMAGING:\n=========================\n#CXR patchy right lung infiltrates suggestion of mild pulm \nedema, r pleural thickening vs loculated fluid with pleural \ncalcification. Mod cardiomegaly, spinal fusion hardware\n\n___ CTA negative for pulmonary embolism, “significant streak \nartifact limiting evaluation of succinate mental branches. \nPulmonary opacification is somewhat heterogeneous. There are no \ncentral filling defects. Main pulmonary artery is moderately \nenlarged 3.8 cm in diameter. RA enlarged, subpleural \nconsolidative opacities in the right middle and right lower \nlobes which may represent rounded atelectasis. Significant \npleural thickening and calcification of the right thorax is \nlikely postsurgical. Probable trace right effusion. There is a \n5 mm left upper lobe pulmonary nodule. \n\n___ ECHO Mild MR, Structurally normal MV, Prominent A wave on \nMV Doppler suggests non compliant LV. No AS, No AE, AV is \ntricuspid. Mild TR. PASP est at 37 mmHg. EF ___. LV cavity \nnormal in size, RV cavity mildly enlarged. RV systolic function \nis mildly reduced. Enlarged hypokinetic RV in some views only, \nenlarged RA pulmonary hypertension, enlarged heart and pulmonary \nartery. EF ___, new diastolic dysfunction\n\nADMISSION LABS;\n===================\n\n___ 09:30AM BLOOD WBC-5.0 RBC-5.74*# Hgb-14.1# Hct-48.7*# \nMCV-85 MCH-24.6*# MCHC-29.0*# RDW-18.1* RDWSD-53.0* Plt ___\n___ 06:10AM BLOOD ___ PTT-28.8 ___\n___ 09:30AM BLOOD Glucose-80 UreaN-9 Creat-0.6 Na-144 K-4.6 \nCl-99 HCO3-33* AnGap-17\n___ 09:30AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.2\n___ 09:47AM BLOOD ___ pO2-44* pCO2-87* pH-7.28* \ncalTCO2-43* Base XS-10 Comment-GREEN TOP\n___ 09:47AM BLOOD ___ pO2-44* pCO2-87* pH-7.28* \ncalTCO2-43* Base XS-10 Comment-GREEN TOP\n\nPERTINENT LABS:\n====================\n\n___ 06:10AM BLOOD WBC-5.6 RBC-5.94* Hgb-13.9 Hct-50.4* \nMCV-85 MCH-23.4* MCHC-27.6* RDW-17.3* RDWSD-51.7* Plt ___\n___ 07:40AM BLOOD WBC-4.5 RBC-6.17* Hgb-14.6 Hct-52.0* \nMCV-84 MCH-23.7* MCHC-28.1* RDW-18.4* RDWSD-51.8* Plt ___\n___ 06:30AM BLOOD WBC-6.6 RBC-6.48* Hgb-15.4 Hct-53.9* \nMCV-83 MCH-23.8* MCHC-28.6* RDW-19.1* RDWSD-51.9* Plt ___\n___ 07:40AM BLOOD ___ PTT-28.2 ___\n___ 06:45AM BLOOD ___ PTT-28.2 ___\n___ 06:10AM BLOOD Glucose-86 UreaN-10 Creat-0.6 Na-144 \nK-3.9 Cl-96 HCO3-40* AnGap-12\n___ 08:36AM BLOOD Glucose-101* UreaN-9 Creat-0.5 Na-144 \nK-3.7 Cl-93* HCO3-37* AnGap-18\n___ 07:40AM BLOOD Glucose-72 UreaN-11 Creat-0.5 Na-142 \nK-3.5 Cl-93* HCO3-39* AnGap-14\n___ 06:30AM BLOOD Glucose-82 UreaN-13 Creat-0.6 Na-140 \nK-3.7 Cl-91* HCO3-40* AnGap-13\n___ 06:45AM BLOOD ALT-16 AST-15 LD(LDH)-301* AlkPhos-52 \nTotBili-0.6\n___ 06:45AM BLOOD Albumin-3.2* Calcium-8.6 Phos-4.1 Mg-2.1\n___ 09:30AM BLOOD %HbA1c-6.1* eAG-128*\n___ 01:31PM BLOOD Type-ART Temp-36.7 pO2-60* pCO2-54* \npH-7.49* calTCO2-42* Base XS-15\n___ 11:27AM BLOOD ___ pO2-178* pCO2-57* pH-7.48* \ncalTCO2-44* Base XS-16 Comment-GREEN TOP \n\nDISCHARGE LABS:\n=======================\n\n___ 06:10AM BLOOD WBC-7.3 RBC-6.46* Hgb-15.4 Hct-53.1* \nMCV-82 MCH-23.8* MCHC-29.0* RDW-19.2* RDWSD-51.4* Plt ___\n___ 06:10AM BLOOD Glucose-85 UreaN-13 Creat-0.6 Na-138 \nK-3.8 Cl-90* HCO3-36* AnGap-16\n\nIMAGING:\n=========================\n#CXR ___:\nThere is re- demonstration of right pleural thickening. There \nis a blunting of both costophrenic angles on the frontal \nradiograph, likely reflective of pleural thickening as no \neffusion is seen on the lateral view. There is increased \npulmonary vascular congestion as well as diffuse bilateral \nairspace opacities a thought to reflect pulmonary edema. The \nsize of the cardiomediastinal silhouette is enlarged. \nIncompletely evaluated thoracolumbar spinal hardware. \nIMPRESSION: Pleural thickening bilaterally. Enlargement of \nthe cardiac silhouette as well as diffuse bilateral airspace \nopacities and pulmonary vascular congestion, likely reflective \nof pulmonary edema. \n\n#TRANSTHORACIC ECHOCARDIOGRAM ___:\nThe left atrium is elongated. The right atrium is moderately \ndilated. The estimated right atrial pressure is at least 15 \nmmHg. Left ventricular wall thicknesses are normal. The left \nventricular cavity size is normal. Overall left ventricular \nsystolic function is mildly depressed (LVEF= 45 %) secondary to \nventricular interaction. The right ventricular free wall is \nhypertrophied. The right ventricular cavity is moderately \ndilated with moderate global free wall hypokinesis. [Intrinsic \nright ventricular systolic function is likely more depressed \ngiven the severity of tricuspid regurgitation.] There is \nabnormal septal motion/position consistent with right \nventricular pressure/volume overload. The diameters of aorta at \nthe sinus, ascending and arch levels are normal. The aortic \nvalve leaflets (3) appear structurally normal with good leaflet \nexcursion and no aortic stenosis or aortic regurgitation. The \nmitral valve appears structurally normal with trivial mitral \nregurgitation. Severe [4+] tricuspid regurgitation is seen. \nThere is at least moderate pulmonary artery systolic \nhypertension. [In the setting of at least moderate to severe \ntricuspid regurgitation, the estimated pulmonary artery systolic \npressure may be underestimated due to a very high right atrial \npressure.] There is a trivial/physiologic pericardial effusion. \nThere are no echocardiographic signs of tamponade. There is no \nevidence of pericardial constriction. \n\n Compared with the prior study (images reviewed) of ___, \nsevere tricuspid regurgitation and at least moderate pulmonary \nhypertension are now present, but the technically suboptimal \nnature of both studies precludes definitive comparison. \n\n#RIGHT HEART CATH ___:\nRA: A wave 8; V wave 6; mean 4\nRV: ___\nPA: 41/15; mean 26\nPCWP: A wave 15, V wave 13, mean 10\nCardiac output 6.7; cardiac index: 3\nPulmonary vascular resistance: 2.4 Woods units\nSlightly elevated filling pressures, moderate pulmonary HTN\n\n#ABDOMINAL ULTRASOUND ___:\nLIVER: The hepatic parenchyma appears within normal limits. The \ncontour of the liver is smooth. There is no focal liver mass. \nThe main portal vein is patent with hepatopetal flow. The \nhepatic veins are not dilated. There is no ascites. BILE \nDUCTS: There is no intrahepatic biliary dilation. The CHD \nmeasures 5 mm. GALLBLADDER: Numerous small gravel like stones \nare seen in the gallbladder. There is no gallbladder wall edema \nand no pericholecystic fluid is seen. PANCREAS: The imaged \nportion of the pancreas appears within normal limits, without \nmasses or pancreatic ductal dilation, with portions of the \npancreatic tail obscured by overlying bowel gas. SPLEEN: \nNormal echogenicity, measuring 13.7 cm. KIDNEYS: The right \nkidney measures 10.5 cm. The left kidney measures 10.7 cm. \nNormal cortical echogenicity and corticomedullary \ndifferentiation is seen bilaterally. There is no evidence of \nmasses, stones, or hydronephrosis in the kidneys. \nRETROPERITONEUM: The visualized portions of aorta and IVC are \nwithin normal limits. \n\nIMPRESSION: 1. Cholelithiasis. 2. Mild splenomegaly. \n \nBrief Hospital Course:\n___ y/o F with history of Tuberculosis and Pott's disease, \ninitially presented to ___ with shortness of breath and \ndyspnea on exertion, transferred to ___ for further \nevaluation. Right heart catheterization and ECHO are consistent \nwith right ventricular dysfunction and mild pulmonary \nhypertension (with mildly depressed LVEF 45%) of unclear \netiology. Lab abnormalities are consistent with compensated \n(likely chronic) respiratory acidosis of multifactorial \netiology. \n\n#Right ventricular dysfunction\n#Mild pulmonary hypertension: ECHO with severe tricuspid \nregurgitation though right heart catheterization consistent with \nmild pulmonary hypertension (PA pressure (41/15, mean 26). RA, \nPCWP, CI values are normal). On ECHO, LV systolic function is \nmildly depressed (EF 45%) likely secondary to ventricular \ninteraction from an enlarged RV. Patient without any known \ncardiac history prior to this admission, and no hypertension or \ndiabetes. LFTs are not elevated and her RUQ ultrasound did not \nshow cirrhosis or findings consistent with congestive \nhepatopathy. Etiology of her right ventricular dysfunction \nremains unclear especially in the setting of mild pulmonary \nhypertension and mildly depressed LV function. Patient was \ntreated with IV Lasix 40 mg PRN before being transitioned to \nTorsemide 20 mg po daily on discharge. She will also continue on \nDigoxin 0.125 mg daily in the setting of RV dysfunction. \nAdmission weight was 126 kg. Discharge weight was 114.2 kg. \nDischarge creatinine was 0.6. She will follow with Dr. ___ \n___ further management and workup including cardiac MRI.\n\n#Hypercapneic and hypoxemic respiratory failure: and labs are \nconsistent with likely chronic, well compensated respiratory \nacidosis. Patient did not endorse shortness of breath or dyspnea \non exertion during her entire stay. O2saturation did drop to \nmid-80s while sleeping and occasionally with ambulation, \nrequiring intermittent 2L NC overnight. She was evaluated by \npulmonology. She likely has restrictive lung disease that is \nmultifactorial in etiology secondary to likely undiagnosed \nobesity hypoventilation/OSA versus significant parenchymal and \npleural scarring secondary to her Tuberculosis history. It is \npossible that some component of her right ventricular \ndysfunction is due to chronic hypercapnia/hypoxemia. She will \nneed follow-up with pulmonology and sleep medicine for PFTs and \nsleep study. \n\nTRANSITIONAL ISSUES:\n==========================\n-Discharge weight: 114.2kg (at or slightly above euvolemic \nweight)\n-Discharge creatinine: 0.6\n-Home oxygen: discharged on home oxygen at night and for \nstrenuous exertion since patient was observed to desat on room \nair while sleeping and occasionally (but not always) with \nexertion. Duration of treatment with supplemental oxygen is not \nknown at the time of discharge due to ongoing pulmonary work-up. \n\n- Medications: provided from free care ___ Careplus pharmacy on \ndischarge as patient has Mass Health limited insurance. Will \nneed to either upgrade health insurance or continue to receive \nmedications from CarePlus pharmacy on a monthly basis. \n-Follow-up: cardiac NPs, cardiology (Dr. ___, \npulmonology, sleep medicine. Anticipate cardiac MRI, pulmonary \nfunction testing (for suspected restrictive lung disease), \nlikely sleep study\n-New medications: torsemide, potassium chloride, digoxin\n-Should have electrolytes and renal function checked on initial \npost-discharge follow-up since she is on diuretic therapy and \npotassium supplementation\n \nMedications on Admission:\nNo preadmission medications:\n\n \nDischarge Medications:\n1. Digoxin 0.125 mg PO DAILY \nRX *digoxin 125 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n2. Potassium Chloride 20 mEq PO DAILY \nRX *potassium chloride 20 mEq 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0 \n3. Torsemide 20 mg PO DAILY \nRX *torsemide 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n4.home oxygen\nMass ___ # ___ Dx: ICD ___.___ - restrictive lung \ndisease; Oxygen concentrator (2L/min 8 hrs/day) and portables \n(2L/min, 2hrs/day). For desat to 85% on room air while sleeping \nand ambulating. Length of need ___ yrs, for home use.\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis: Hypercapnea, hypoxemia, right ventricular \ndilatation\nSecondary diagnoses: History of Pott's disease s/p T12, L1, and \nL2 anterior corpectomy, fusion, and instrumentation. \nTuberculosis treated with RIPE and moxifloxacin\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 initially admitted to the hospital at ___ in \n___ after your doctor was concerned about swelling in your \nlegs and some shortness of breath. Testing showed reduced \npumping function of the heart, and decreased ability of the \nlungs to take in oxygen and breathe out carbon dioxide. \nYou were hospitalized at ___ for further diagnostic tests to \nfollow-up on these abnormalities seen at ___. \nAlthough you don't feel short of breath at rest, while walking, \nor while lying in bed, your labs and imaging suggest that the \noxygen in your blood is low. With low blood oxygen and elevated \nblood products (that include carbon dioxide), over time this can \nproduce great harm to your heart and lungs. The right side of \nyour heart does not pump normally and we cannot entirely explain \nits cause at this time. There are a few reasons that this may be \nhappening: 1) scarring in your lungs from being infected with \ntuberculosis in the past, 2) your oxygen level drops while you \nare sleeping (this is worsened with weight gain).\n\nAs we have explained, although you are not experiencing any \nbothersome symptoms, the changes in oxygen in your blood is \naffecting the function of your heart and lungs. It is very \nimportant that you take your medications as prescribed (see \nbelow). Additionally, it is very important to follow closely \nwith the heart and lung doctors ___ below) to work-up \nthe cause of these abnormalities and for long-term management.\n\nWe have started you on a diuretic (Torsemide) to prevent the \naccumulation of fluid in your body. You should take this with a \npotassium tablet everyday. We have also started you on a \nmedication called Digoxin to help the right side of your heart \nto pump better. \n\nAs part of your workup, we will need you to complete two \ndifferent test to start: 1) Cardiac MRI to obtain better images \nof your heart, 2) Pulmonary function tests to assess how your \nlungs are working. You will see a lung doctor (___) \nwho ___ most likely want you to have a \"sleep study\" to monitor \nyour breathing as you sleep.\n\nYou left the hospital with a one-month supply of medications, \nfrom the free-care ___ pharmacy. We recommend you upgrade your \nMass Health insurance to include medication coverage, otherwise \nyou will need to obtain prescriptions from your primary care \ndoctor or heart doctor and pick up the medications at the ___ \n___ pharmacy each month.\n\nWeight control is an important part of your long-term care in \noptimizing your heart function and breathing. Please weigh \nyourself every day and record this value daily. If you have \ngained at least three pounds, please be sure to call your \ndoctor.\n\nIt was a pleasure taking care of you! We wish you the best!\n\nYour ___ Team \n \nFollowup Instructions:\n___\n" ]

[ "I5021", "J9692", "J9691", "I272", "E874", "E662", "Z6842", "J9811", "J984", "Z8611", "M4325", "I361" ]

[ "I5021: Acute systolic (congestive) heart failure", "J9692: Respiratory failure, unspecified with hypercapnia", "J9691: Respiratory failure, unspecified with hypoxia", "I272: Other secondary pulmonary hypertension", "E874: Mixed disorder of acid-base balance", "E662: Morbid (severe) obesity with alveolar hypoventilation", "Z6842: Body mass index [BMI] 45.0-49.9, adult", "J9811: Atelectasis", "J984: Other disorders of lung", "Z8611: Personal history of tuberculosis", "M4325: Fusion of spine, thoracolumbar region", "I361: Nonrheumatic tricuspid (valve) insufficiency" ]

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[ " \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:\nright MCA syndrome \n \nMajor Surgical or Invasive Procedure:\nPEG ___ \n \nHistory of Present Illness:\nThe patient is a ___ woman with a past medical history \nof\nmitral valve prolapse with mitral regurgitation status post\nMVR on ___ with a size ___ ___ Mosaic tissue valve,\nAortic regurgitation, A. fib not on Coumadin and hypertension \nwho\npresents as an outside hospital transfer for further management\nof stroke. Briefly per daughter patient was in her usual state\nof health until 10 AM this morning. Daughter went to work and\nwhen she came back at 4 ___ she found her mother on the floor \nwith\nleft-sided weakness left-sided and slurred speech. Patient was\nbrought to outside hospital where imaging showed right MCA\ninfarct with thrombus. She was outside the window for TPA and\nnot a candidate for endovascular intervention. Patient was\nsupposed to go to ICU at ___ but no ICU bed was \navailable\nand decision was made to transfer the patient to ___ for further care. \n\nUpon arrival to ___ ED patient's vitals were notable for blood\npressure of 138/90 satting 97% on room air, heart rate 104. \n\nOn neuro ROS unable to obtain .\n\non general review of systems unable to obtain\n\n \nPast Medical History:\nHypertension\nA. fib\nAORTIC REGURGITATION \nCARDIAC VALVE REPLACEMENT (MECHANICAL) \n \nSocial History:\n___\nFamily History:\nNo family history of neurological disease\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n**********\nPhysical Exam:\nVitals: T: 97.7 P: 104 r: 18 BP: 138/90 SaO2: 97% room air\nGeneral: Eyes closed but easily arousable to verbal stimuli\ncooperative\nHEENT: MMM, no lesions noted in oropharynx\nNeck: Supple\nPulmonary: CTAB, no increased work of breathing\nCardiac: Irregularly irregular\nAbdomen: soft, NT/ND\nExtremities: No C/C/E bilaterally\nSkin: no rashes or lesions noted.\n\nNeurologic:\n\n-Mental Status: Alert, oriented x 3. Language is fluent with\nintact repetition and comprehension. There were no paraphasic\nerrors. Pt was able to name both high and low frequency objects.\nSpeech was not dysarthric. There was evidence of left-sided\nneglect.\n\n-Cranial Nerves:\nI: Olfaction not tested.\nII: PERRL 3 to 2mm and brisk. VFF to confrontation.\nV: Facial sensation intact to light touch.\nVII: Left facial droop\nIX, X: Palate elevates symmetrically.\nXII: Tongue protrudes in midline.\n\n- Motor \nRight upper and right lower extremity antigravity, left upper \nand\nleft lower extremity unable to move. \n\n-DTRs: \n2+ throughout \n\n-Sensory: Deficits to light touch and pinprick in the left upper\nand left lower extremity\n\n-Coordination: Unable to assess\n\n-Gait: Deferred\nDISCHARGE PHYSICAL EXAM:\nTm 98.3F/Tc 98.1F, BP 111-142/80-98, HR 88-114, RR ___, RA 94 \nRA \n\nGen: awake, alert, comfortable, in no acute distress\nHEENT: normocephalic atraumatic, no oropharyngeal lesions \nCV: warm, well perfused, irregularly irregular on telemetry \nPulm: breathing non labored on room air\nExtremities: no cyanosis/clubbing or edema\n\nNeurologic:\n-MS: Alert, alert interactive. Eyes open to verbal stimuli. \nOriented to self, hospital and situation. Not consistently \noriented to date. Attends to examiner well. Left sided \nhemineglect, but able to attend to left side when redirected. \nAble to relate some recent history. Oriented to self, hospital \nand year. follows simple commands. \n-CN: Eyelid apraxia. R eye ptosis, R eye is hypotropic and \nexotropic, L facial\ndroop, palate elevates symmetrically, tongue midline\n-Motor: Normal bulk, left side is flaccid. LUE ___, LLE moves\nspontaneously in plane of bed, some antigravity movement of L \nhip\nflexors, difficult to assess secondary to motor impersistence. \nNo\ntremor or asterixis. \n- Sensory: decreased light touch of the left arm and leg;\nextinguishes to DSS with left stimulation at the left arm and\nleg. \n- Reflexes: right toe downgoing, left toe upgoing\n- Coord: intact R FNF, unable to perform coordination testing on\nthe left\n-Gait: deferred due to left hemiplegia \n\n \nPertinent Results:\nLABORATORY STUDIES\n\n___ 06:40AM BLOOD WBC-5.0 RBC-3.86* Hgb-11.9 Hct-36.7 \nMCV-95 MCH-30.8 MCHC-32.4 RDW-14.1 RDWSD-48.6* Plt ___\n___ 06:40AM BLOOD Glucose-116* UreaN-22* Creat-0.6 Na-147* \nK-3.8 Cl-110* HCO3-26 AnGap-15\n___ 09:25AM BLOOD ALT-20 AST-24 CK(CPK)-347* AlkPhos-49 \nTotBili-0.7\n___ 12:40AM BLOOD Lipase-75*\n___ 06:40AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.1\n___ 12:40AM BLOOD %HbA1c-5.6 eAG-114\n___ 12:40AM BLOOD Triglyc-90 HDL-64 CHOL/HD-2.9 LDLcalc-101\n___ 12:40AM BLOOD TSH-1.9\n\n**************\n\nIMAGING STUDIES\n\n___ Bilateral ___ venous Doppler: \nNo evidence of deep venous thrombosis in the right or left lower \nextremity \nveins. \n \n___ CXR\nImproved positioning of enteric tube, its tip projecting in the \npresumed \nlocation of the gastric lumen. Right middle lobe consolidation, \nlikely \naspiration related. \n\n___ CT head w/o contrast\nExtensive edema along the right frontoparietal lobes secondary \nto known left frontal lobe infarction, increased from prior \nexaminations with minimally progressed right lateral ventricle \neffacement without midline shift or ventriculomegaly. No \nevidence of hemorrhage or new area of infarction.\n\n___ MRI head w/o contrast; MRA head w/o contrast; MRA neck w/ \nand w/o contrast\n1. Acute large right MCA territory infarct. No evidence of \nhemorrhagic \nconversion. Mild effacement of the body of the right lateral \nventricle. No shift of midline structures or cisternal \ncompression. \n2. Small acute infarcts in the left frontal white matter and \nleft anterior \ninsular cortex. \n3. Motion limited brain MRA demonstrates occlusion of the right \ninternal \ncarotid artery terminus, occlusion of the right middle cerebral \nartery without evidence for distal reconstitution, and occlusion \nof the proximal A1 segment of the right anterior cerebral artery \nwith diminished flow in the remaining right A1 segment and in \nthe right A2 segment compared to the left. \n4. Diminished flow in proximal P2 segments of bilateral \nposterior cerebral \narteries may be due to atherosclerosis or motion artifact. \n5. Bulbous appearance of distal left anterior cerebral artery \nmay be secondary to motion artifact, but evaluation for an \naneurysm is limited. \n6. The aortic arch, proximal common carotid arteries, and V1 \nsegments of the vertebral arteries are not adequately assessed \non the neck MRA. No evidence for internal carotid stenosis by \nNASCET criteria. \n \n \nTTE ___: Atrial fibrillation. Low normal global biventricular\nsystolic function. Well seated mitral valve bioprosthesis with\nhigh normal gradients with HR 85-95/min. At least moderate\ntricuspid regurgitation with moderate pulmonary hypertension. No\nLV mass/thrombus visualized. Left atrial appendage thrombus as\nwell as small mitral valve leaflet thrombi would be better\nexcluded with TEE if there is a high cinical suspicion and/or\nthis would change management. \n\n \n\n \nBrief Hospital Course:\nSUMMARY: \nMs. ___ is a ___ woman with a past medical \nhistory of mitral valve prolapse with mitral regurgitation \nstatus post MVR on ___ (size ___ ___\nMosaic tissue valve), aortic regurgitation, atrial fibrillation \nnot on anticoagulation and hypertension who presented as an \noutside hospital transfer for further management of right MCA \ninfarct with distal right MCA thrombosis. Examination notable \nfor significant inattention, dense left sided neglect, right eye\nptosis with exo- and hypotropia, and left upper>lower plegia.\n\nEtiology for infarction is likely cardioembolic in the setting \nof atrial fibrillation not on anticoagulation. Given the large \narea of infarction, we will defer anticoagulation for another \nfew days given significant risk of hemorrhagic conversion. \n\n**************\nHOSPITAL COURSE BY PROBLEM:\n#R MCA Ischemic Infarction: Initial examination was notable for \na R MCA syndrome with significant inattention, dense left sided \nneglect, right eye ptosis with exo- and hypotropia, and left \nupper>lower left hemiplegia. The etiology for infarction was \nlikely cardioembolic, in the setting of presenting with atrial \nfibrillation not on anticoagulation (please see details below \nregarding atrial fibrillation). Her MRI head w/o contrast with \nMRA Head/Neck confirmed the clinical suspicion of large right \nMCA territory infarction with occlusion of the right internal \ncarotid artery terminus, occlusion of the right middle cerebral \nartery without evidence for distal reconstitution, and occlusion \nof the proximal A1 segment of the right anterior cerebral \nartery. Given the large area of infarction, anticoagulation was \ndeferred until 5 days post infarction to minimize risk of \nhemorrhagic conversion. In the interim, she was continued on \naspirin 81mg daily. \n\nStroke risk factors were otherwise notable for hemoglobin A1c \n5.6, LDL 101, TSH 1.9. She was started on atorvastatin 40mg \ndaily for hypercholesterolemia. During the hospitalization, \neuglycemia was maintained; blood pressures allowed to \nautoregulate with goal SBP<180. She was evaluated by ___ and \nrecommended for rehab placement. \n\nOn ___, patient was started on anticoagulation for Afib with \nEliquis (apixaban). Decision was made to start Eliquis given her \nlikely inconsistent to poor oral intake given dysphagia s/p \nstroke, ease of convenience per patient preference. \n\n#Right middle lobe aspiration pneumonia: Early in the hospital \ncourse, on ___ patient was noted to have a witnessed aspiration \nevent. On morning assessment, she was noted to have witnessed \nchoking vs gagging, with visible reflux of tube feeds into the \npump. Tube feeds were stopped temporarily without improvement. \nNG tube was subsequently removed. She was initially hypoxic to \nlow ___ on room air, stable on 2L NC. Follow up chest xray \nrevealed a large right middle lobe infiltrate concerning for \npneumonia. Given the constellation of new oxygen requirement, \ninfiltrate on CXR and witnessed aspiration event she was started \non Unasyn 3g IV q6h for aspiration pneumonia, with plans to \ncomplete a 7 day course (___). Oxygen was weaned to room \nair. She received albuterol nebs for wheezing with improvement. \n\n\n#Atrial fibrillation, new onset: Patient has a history of mitral \nvalve prolapse and regurgitation status post mitral valve \nreplacement in ___. Initially, there was question of whether \nshe had prior history of atrial fibrillation, but after \ndiscussion with the patient's primary cardiologist Dr. \n___ on ___, he confirmed that there was no known history \nof prior history of Atrial fibrillation. She initially had \nelevated heart rates, being in rapid ventricular response, \neventually controlled with IV Lopressor pushes and PO Lopressor. \nHer heart rate was controlled after uptitration to metoprolol \n100mg TID. Goal HR moving forward would be HR 110. To look into \nalternative etiologies for atrial fibrillation, cardiac enzymes \nwere cycled and remained negative; thyroid function studies were \nnegative; electrolytes were unremarkable. \n[ ] PLEASE NOTE: HR tended to run HR ___, often when \nelevated it was due to pain or discomfort, can uptitrate \nmetoprolol tartrate as needed. Currently at 100mg TID. Can \nuptitrate to max total daily dose of 400mg daily. \n\n#Urinary Tract Infection: on presentation, patient was noted to \nbe somnolent and confused. Infectious workup was undertaken \nwhich revealed a grossly positive urinalysis. She was started on \nCeftriaxone 1g q24h to complete a 3 day course for UTI \n(___) given pyuria and altered mental status. \n\n#Dysphagia status post stroke: Patient failed her bedside speech \nswallow and was not determined to be safe for PO intake after \nevaluations by speech and swallow. She was started on tube feeds \nvia NG tube, without significant improvement after a few days. \nSubsequently after discussion with family and patient, decision \nwas made to undergo PEG placement. Patient underwent PEG \nplacement on ___ and tolerated it well, being resumed on \ntube feeds and nutrition within the next ___ hours. \n\n#Diarrhea: Patient was noted to have diarrhea during hospital \ncourse that was watery and loose. She was well appearing \nclinically during this time, and did not have any abdominal \npain. C Diff assay was checked on ___ and was negative. Etiology \nwas thought to be antibiotic related or related to tube feeds. \nBanana flakes were added to tube feeds, and nutrition did not \nrecommend any changes to tube feeding regimen. The patient's \nantibiotic course for pneumonia was to be completed on ___. \n\n#History of hypothyroidism: Patient was continued on home \nlevothyroxine 50 daily.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Amoxicillin ___ mg PO PREOP prior to dental visit \n2. Levothyroxine Sodium 50 mcg PO DAILY \n3. Lisinopril 40 mg PO DAILY \n4. Metoprolol Tartrate 50 mg PO BID \n5. Ascorbic Acid ___ mg PO DAILY \n6. Aspirin 81 mg PO DAILY \n7. flaxseed oil 1,000 mg oral every other day \n8. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN \nDiscomfort in abdomen, burping \n3. Ampicillin-Sulbactam 3 g IV Q6H \ncontinue through ___ \n4. Apixaban 5 mg PO BID \n5. Atorvastatin 40 mg PO QPM \n6. Docusate Sodium 100 mg PO BID \n7. Senna 8.6 mg PO BID:PRN Constipation \n8. Metoprolol Tartrate 100 mg PO Q6H \n9. Amoxicillin ___ mg PO PREOP prior to dental visit \n10. Ascorbic Acid ___ mg PO DAILY \n11. flaxseed oil 1,000 mg oral every other day \n12. Levothyroxine Sodium 50 mcg PO DAILY \n13. Lisinopril 40 mg PO DAILY \n14. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___ \n___)\n \nDischarge Diagnosis:\nRight middle cerebral artery ischemic stroke \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 \nDischarge Instructions:\nDear Ms. ___,\nYou were hospitalized due to symptoms of left sided weakness and \ndifficulty speaking resulting from an ACUTE ISCHEMIC STROKE, a \ncondition where a blood vessel providing oxygen and nutrients to \nthe brain is blocked by a clot. The brain is the part of your \nbody that controls and directs all the other parts of your body, \nso damage to the brain from being deprived of its blood supply \ncan result in a variety of symptoms.\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-high blood pressure\n-atrial fibrillation\n-history of heart valve disease (mitral valve replacement) \n\nWe are changing your medications as follows:\n-started apixaban (eliquis) for anticoagulation due to atrial \nfibrillation \n-increased metoprolol (Lopressor) to control your heart rate \n-started atorvastatin to treat high cholesterol \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", "J690", "G8194", "I4891", "R1310", "R414", "N390", "I10", "R4781", "E785", "H5021", "Z953", "I351", "Z7901", "R0902", "E039", "R197", "R29810" ]

[ "I63411: Cerebral infarction due to embolism of right middle cerebral artery", "J690: Pneumonitis due to inhalation of food and vomit", "G8194: Hemiplegia, unspecified affecting left nondominant side", "I4891: Unspecified atrial fibrillation", "R1310: Dysphagia, unspecified", "R414: Neurologic neglect syndrome", "N390: Urinary tract infection, site not specified", "I10: Essential (primary) hypertension", "R4781: Slurred speech", "E785: Hyperlipidemia, unspecified", "H5021: Vertical strabismus, right eye", "Z953: Presence of xenogenic heart valve", "I351: Nonrheumatic aortic (valve) insufficiency", "Z7901: Long term (current) use of anticoagulants", "R0902: Hypoxemia", "E039: Hypothyroidism, unspecified", "R197: Diarrhea, unspecified", "R29810: Facial weakness" ]

[ "I4891", "N390", "I10", "E785", "Z7901", "E039" ]

[]

[ " \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:\nCC: fever and abdominal pain\n\n \nMajor Surgical or Invasive Procedure:\nNone \n\n \nHistory of Present Illness:\nHPI(4): Ms. ___ is a ___ female with the past medical \nhistory\nnoted below including history of cholangitis s/p\nhepaticojejunostomy who presents with fevers and abdominal pain. \n\n\nPatient notes 1 day history of subjective fever, chills, \nheadache\n(6 out of 10 pressure-like pain in the frontal aspect\nbilaterally), myalgias, associated with abdominal pain worse \nwith\nleaning forward and eating and better with Tylenol and laying\ndown. Patient was given a prescription for Tylenol as well as\namoxicillin this morning by her primary care physician in \n___.\nPatient denies chest pain, shortness of breath, urinary \nsymptoms,\nnew onset numbness tingling. She further denies dysuria, urinary\nfrequency, diarrhea, constipation, nausea, vomiting or\npalpitations. \n\nIn the ED: Tmax 100.2, P 80-90, BP 120-150/80's, 99% on RA. \nExam: anicteric, Normal S1-S2, regular rate and rhythm, no\nmurmurs/gallops, ___ systolic murmur best heard at L ICS, 2+\nperipheral pulses bilaterally, lungs CTAB, abdomen soft, + ttp \nin\nRUQ. Labs: CBC at baseline, chem panel notable for anion gap of\n16, transaminitis with AST 49, ALT 100, ALP 168, Tbili 0.5,\nlipase 23, albumin 4.4. UA with trace ketones. RUQ ultrasound \nwas\nconcerning for recurrent pyogenic cholangitis. GI was called and\ndecision made to admit patient and keep NPO for possible ERCP.\nShe received 4.5mg IV zosyn in the ED as well as 1g Tylenol and\nstarted on IVF (NS at 150 cc/hr). \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- s/p Roux-en-Y (hepaticojejunostomy)...unclear indication, but \napparent from MRCP\n- s/p open cholecystectomy in ___ ___ years ago\n- HTN\n- endometrial hyperplasia\n- s/p TAH/BSO ___\n \nSocial History:\n___\nFamily History:\nNo known GI cancers\n \nPhysical Exam:\nGen: Lying in bed in no apparent distress\nVitals: 98.1PO BP 118 / 78, HR 76, RR 16, O2Sat 100 Ra \nHEENT: Anicteric, eyes conjugate, MMM, no JVD\nCardiovascular: RRR no MRG, nl. S1 and S2\nPulmonary: Lung fields clear to auscultation throughout\nGastroinestinal: Soft, non-tender, non-distended, bowel sounds\npresent, no HSM\nMSK: No edema\nSkin: No rashes or ulcerations evident\nNeurological: Alert, interactive, speech fluent, face symmetric,\nmoving all extremities\nPsychiatric: pleasant, appropriate affect\n\n \nPertinent Results:\n___ 09:47AM NEUTS-78.2* LYMPHS-13.1* MONOS-8.3 EOS-0.0* \nBASOS-0.2 IM ___ AbsNeut-3.93 AbsLymp-0.66* AbsMono-0.42 \nAbsEos-0.00* AbsBaso-0.01\n___ 09:47AM ALT(SGPT)-112*\n___ 10:43AM URINE AMORPH-RARE*\n___ 08:40PM PLT COUNT-189\n___ 08:40PM NEUTS-70.2 LYMPHS-16.9* MONOS-12.2 EOS-0.0* \nBASOS-0.2 IM ___ AbsNeut-2.98 AbsLymp-0.72* AbsMono-0.52 \nAbsEos-0.00* AbsBaso-0.01\n___ 08:40PM WBC-4.3 RBC-5.97* HGB-12.5 HCT-41.0 MCV-69* \nMCH-20.9* MCHC-30.5* RDW-14.6 RDWSD-35.3\n___ 08:40PM LIPASE-23\n___ 08:40PM ALT(SGPT)-100* AST(SGOT)-49* ALK PHOS-168* \nTOT BILI-0.5\n___ 08:47PM LACTATE-1.8\n\n \nINDICATION: ___ female with the past medical history including \nhistory of \ncholangitis s/p hepaticojejunostomy who presents with fevers and \nabdominal \npain, ERCP concerned about anatomy. Assess for cholangitis. \n \nTECHNIQUE: T1- and T2-weighted multiplanar images of the \nabdomen were \nacquired in a 1.5 T magnet. \nIntravenous contrast: 6 mL Gadavist. \nOral contrast: 1 cc of Gadavist mixed with 50 cc of water was \nadministered \nfor oral contrast. \n \nCOMPARISON: MR abdomen ___ \nMRCP ___ \n \nFINDINGS: \n \nLower Thorax: Limited evaluation of the lung bases are clear. \nNo pleural \neffusion. No pericardial effusion \n \nLiver: There is persistent atrophy of the left hepatic lobe with \ncaudate lobe \nhypertrophy. No hepatic steatosis. Few scattered arterially \nhyperenhancing \nfoci do not persist on additional sequences and are consistent \nwith transient \nhepatic intensity differences (1300:31). Largest is band shaped \nin \nconfiguration within segment 4A/4B (13:71). There is a new 2.7 \nx 1.3 cm \nsegment VII peripherally located lesion with subtle ill-defined \nT2 \nhyperintensity and a rounded 0.5 cm T2 hyperintense nonenhancing \ncomponent \ncentrally which demonstrates restricted diffusion, consistent \nwith a hepatic \nabscess and reactive hyperemia (1300:69). No drainable \ncollection. \n \nBiliary: Status post cholecystectomy and hepaticojejunostomy. \nAgain seen is \nmoderate irregular central and left intrahepatic biliary duct \ndilatation with \npersistent narrowing at the hepaticojejunostomy anastomosis, \nunchanged in \nconfiguration dating back to ___ (600:1). Largest \ncaliber measures 0.5 \ncm within the left intrahepatic biliary ducts (previously 0.5 \ncm) (04:10). No \ncholedocholithiasis. Mild enhancement with wall thickening and \nrestricted \ndiffusion of the right anterior segmental bile ducts is \nconsistent with \ncholangitis. \n \nPancreas: The pancreas is atrophic but normal in signal \nintensity. 0.4 cm \npancreatic head cystic lesion is unchanged since ___ and \nstatistically \nlikely to represent a side branch IPMN (05:38). No worrisome \nlesion. No \ndilatation of main pancreatic duct. \n \nSpleen: The spleen is normal in size. Splenosis in the left \nupper quadrant \nagain noted. \n \nAdrenal Glands: The adrenal glands are normal in size and shape. \n\n \nKidneys: Subcentimeter right renal cysts are noted. The kidneys \nare otherwise \nunremarkable. No hydronephrosis. No perinephric fat stranding. \n\n \nGastrointestinal Tract: Unremarkable. No obstruction. No \nascites. \n \nLymph Nodes: No retroperitoneal or mesenteric lymph node \nenlargement. \n \nVasculature: No abdominal aortic aneurysm. Marked narrowing at \nthe celiac \naxis origin, without poststenotic dilatation, may be related to \nmedian arcuate \nligament effect. Celiac axis, SMA, bilateral renal arteries are \notherwise \npatent. Again seen is the right hepatic artery arising from the \nSMA and left \nhepatic artery arising left gastric artery. Hepatic veins main \nportal vein, \nsplenic vein, and proximal SMV are patent. \n \nOsseous and Soft Tissue Structures: 3.3 x 1.2 cm left paraspinal \nmuscle lipoma \nis stable (05:18). Osseous structures and soft tissues \notherwise \nunremarkable. Note is made of a osseous hemangioma in the L1 \nvertebral body. \n \nIMPRESSION: \n \n1. Active segmental cholangitis of the anterior right biliary \nducts. 0.5 cm \nsegment VII hepatic microabscess with peripheral hyperemia. No \ndrainable \ncollection. \n2. Moderate central and intrahepatic biliary duct dilatation \nwith narrowing \nat hepaticojejunostomy, unchanged in configuration since ___. \n3. Unchanged 0.4 cm pancreatic head cystic lesion, likely to \nrepresent a side \nbranch IPMN. \n \n\n \nBrief Hospital Course:\nMs. ___ is a ___ woman s/p ccy and hepaticojejunostomy with\nrecurrent episodes of cholangitis presents again with fevers and\nabdominal pain c/w cholangitis now stable on antibiotics. \n\nACUTE/ACTIVE PROBLEMS:\n#Fever\n#Abdominal pain\n#Chronic cholangitis: Patient has a complicated GI history\nincluding h/o cholelithiasis and pyogenic cholangitis requiring\nsurgical drainage. She underwent Roux-en-Y hepaticojejunostomy \nin\n___ followed by an open cholecystectomy. She was admitted here\nin ___ and underwent extensive workup including MRCP and CT\nabdomen with workup consistent with chronic cholangitis and\nsuggestive of IPMN as well possible stricture. Unfortunately\ngiven her anatomy ERCP was not successful at that time. ERCP \nteam\nwas again consulted and recommended repeat MRCP which again \nshows\ncholangitis. Will need two weeks of antibiotics and was \ndischarged on cipro and flagyl. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Losartan Potassium 100 mg PO DAILY \n2. Felodipine 10 mg PO DAILY \n\n \nDischarge Medications:\n1. Ciprofloxacin HCl 750 mg PO Q12H \nRX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth twice a day \nDisp #*28 Tablet Refills:*0 \n2. MetroNIDAZOLE 500 mg PO Q8H \nRX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8) \nhours Disp #*42 Tablet Refills:*0 \n3. Ondansetron ODT 4 mg PO Q8H:PRN nausea \nRX *ondansetron 4 mg 1 tablet(s) by mouth twice a day Disp #*10 \nTablet Refills:*0 \n4. Felodipine 10 mg PO DAILY \n5. Losartan Potassium 100 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nCholangitis \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nMental Status: Confused - sometimes.\nMental Status: Confused - always.\n\n \nDischarge Instructions:\nDear ___,\n\nYou were admitted after you began to have abdominal Pain at \nhome. You had an MRI of your liver which showed infection of \nyour bile ducts. The gastroenterology team was consulted and \ngiven your usual anatomy felt that a repeat ERCP would not be \nsuccessful. You were treated with IV antibiotics and improved. \nYou will be discharged on two antibiotics and will need to \ncomplete two full weeks. You were also given a medication for \nnausea. It was a pleasure caring for you. \n\n \nFollowup Instructions:\n___\n" ]

[ "K830", "I10", "D508", "Z90710" ]

[ "K830: Cholangitis", "I10: Essential (primary) hypertension", "D508: Other iron deficiency anemias", "Z90710: Acquired absence of both cervix and uterus" ]

[ "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nHeadache\n \nMajor Surgical or Invasive Procedure:\nLP\n\n \nHistory of Present Illness:\n___ found seated in his apartment with his mother. ___ stated \nthat he had awoke around 0700 that morning with a \"splitting \nheadache\" located behind his eyes. He had begun to vomit about \n20 minutes later and had vomited 5 or 6 times prior to EMS \narrival. ___ stated that he had had a single beer the previous \nevening and admitted to smoking marijuana occasionally but \ndenied excessive drug and ETOH use recently. ___ denied fever and \nchill and had no signs of either. Prior to this he had stomach \ncramps the day prior. No recent foreign travel. No sick contacts\nIn ER: (Triage Vitals:3 97.3 72 117/72 18 100% RA ) \nMeds Given: \n___ 10:45 IVF 1000 mL NS 1000 mL \n___ 10:45 IV Metoclopramide 10 mg \n___ 11:13 IV Ondansetron 4 mg \n___ 12:43 IV Ketorolac 30 mg \n___ 12:43 IV DiphenhydrAMINE 25 mg \n___ 14:00 IV Lorazepam 1 mg \n___ 17:20 IVF 1000 mL NS 1000 mL \n___ 17:20 IV Morphine Sulfate 5 mg \n___ 19:32 IV Lorazepam 1 mg \n___ 22:43 IV Acyclovir 600 mg \nFluids given: as above\nRadiology Studies:CT abdomen- borderline splenomegaly and \nnumerous scattered mesenteric lymph nodes\nconsults called: None\n.\nPAIN SCALE: ___ location:\n\n.REVIEW OF SYSTEMS:\nCONSTITUTIONAL: As per HPI\nHEENT: [X] All normal\nRESPIRATORY: [X] All normal\nCARDIAC: [X] All normal\nGI: As per HPI\nGU: [X] All normal\nSKIN: [X] All normal\nMUSCULOSKELETAL: [X] All normal\nNEURO: [X] All normal\nENDOCRINE: [X] All normal\nHEME/LYMPH: [X] All normal\nPSYCH: [X] All normal\nAll other systems negative except as noted above\n\n \nPast Medical History:\nPMH of anxiety, on celexa \n\n \nSocial History:\n___\nFamily History:\nHis father just had an MI at age ___. \n \nPhysical Exam:\nAdmission Exam:\nVitals: T 97.8 P 83 BP 113/66 RR 18 SaO2 100% on RA\nGEN: NAD, comfortable appearing \nHEENT: ncat anicteric MMM, PERRL\nNECK: supple\nCV: s1s2 rr no m/r/g \nRESP: b/l ae no w/c/r \nABD: +bs, soft, NT, ND, no guarding or rebound \nback: tender at site of LP puncture. LP puncture site c/d/i\nEXTR:no c/c/e 2+pulses \nDERM: no rash \nNEURO: face symmetric speech fluent \nPSYCH: calm, cooperative \n\nDischarge Exam:\nVital Signs: 97.2 ___ 16 100%RA\nGEN: Alert, NAD\nHEENT: NC/AT\nCV: RRR, no m/r/g\nPULM: CTA B \nGI: S/ND, BS present, mild epigrastric TTP without rebound or \nguarding\nNEURO: Alert, Nonfocal\n\n \nPertinent Results:\nAdmission Labs:\n___ 10:40AM BLOOD WBC-13.5* RBC-5.09 Hgb-15.2 Hct-43.8 \nMCV-86 MCH-29.9 MCHC-34.7 RDW-12.4 RDWSD-38.9 Plt ___\n___ 10:40AM BLOOD Neuts-69 Bands-0 ___ Monos-4* Eos-3 \nBaso-0 Atyps-1* ___ Myelos-0 AbsNeut-9.32* AbsLymp-3.24 \nAbsMono-0.54 AbsEos-0.41 AbsBaso-0.00*\n___ 10:40AM BLOOD Glucose-134* UreaN-16 Creat-0.9 Na-141 \nK-4.0 Cl-104 HCO3-20* AnGap-21*\n___ 10:40AM BLOOD ALT-28 AST-31 AlkPhos-62 TotBili-0.6\n___ 10:40AM BLOOD Albumin-4.6\n___ 11:04AM BLOOD Lactate-3.1*\n\nDischarge Labs:\n___ 11:00AM BLOOD WBC-6.8 RBC-4.57* Hgb-13.6* Hct-41.0 \nMCV-90 MCH-29.8 MCHC-33.2 RDW-12.9 RDWSD-42.5 Plt ___\n___ 11:00AM BLOOD Glucose-88 UreaN-11 Creat-0.8 Na-143 \nK-4.0 Cl-106 HCO3-30 AnGap-11\n___ 11:00AM BLOOD Calcium-9.4 Phos-2.9 Mg-2.0\n\n___ 02:50PM BLOOD HIV Ab-Negative\n___ 10:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n\n___ 12:40PM URINE Color-Yellow Appear-Clear Sp ___\n___ 12:40PM URINE Blood-NEG Nitrite-NEG Protein-TR \nGlucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG\n___ 12:40PM URINE RBC-5* WBC-1 Bacteri-FEW Yeast-NONE Epi-0\n\n============================================\n\nCSF Studies:\n\n___ 08:00PM CEREBROSPINAL FLUID (CSF) WBC-225 RBC-6* \nPolys-0 ___ ___ 08:00PM CEREBROSPINAL FLUID (CSF) WBC-123 RBC-79* \nPolys-0 ___ ___ 08:00PM CEREBROSPINAL FLUID (CSF) TotProt-107* \nGlucose-67\n\n___ 8:00 pm CSF;SPINAL FLUID #3. \nGRAM 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.. \nFLUID CULTURE (Preliminary): NO GROWTH. \n\nHerpes Simplex Virus PCR\n HSV 1, PCR Negative \n HSV 2, PCR Negative \n\n============================================\nImaging:\n\nCT Head -\nFINDINGS: There is no intra-axial or extra-axial hemorrhage, \nedema, shift of normally midline structures, or evidence of \nacute major vascular territorial infarction. Ventricles and \nsulci are normal in overall size and configuration. Mild mucosal \nthickening is seen within the ethmoid air cells. Mastoid air \ncells and middle ear cavities are well aerated. The bony \ncalvarium is intact. \nIMPRESSION: No acute intracranial process. \n\nCT A/P - \nIMPRESSION: \n1. No definite acute abnormality in the abdomen or pelvis. The \nappendix is normal. \n2. Borderline size of the spleen at 13 cm and numerous scattered \nnonspecific mesenteric lymph nodes, prominent in number, but not \npathologically enlarged by CT size criteria. While these \nfindings are nonspecific an underlying viral infection could be \nconsidered. \n\n \nBrief Hospital Course:\n___ year old male with PMH of anxiety who presented with severe \nheadache, as well as nausea / vomiting. Evaluation in the ED was \nconsistent with viral meningitis. He was placed on IV acyclovir \nuntil CSF HSV PCR returned negative. Symptoms resolved quickly \nduring ___ hospital course, and headache was resolved by \nthe time of discharge. CSF cx remained with NGTD at the time of \ndischarge; final results will need to be followed up.\n\nOf note, CT A/P in the ED did show \"borderline size of the \nspleen at 13 cm and numerous scattered nonspecific mesenteric \nlymph nodes.\" HIV was checked and was negative. CT findings were \nfelt to likely be related to underlying viral process; however, \nthis should be followed up in the outpatient setting.\n\nPt did report some mild intermittent epigastric discomfort \nduring admission. This was felt to likely be related to mild \ngastritis / esophagitis from episodes of vomiting prior to \nadmission. This should be followed up.\n\nTRANSITIONAL ISSUES:\n- f/u CT findings as above\n- final CSF cx results will need to be followed up to ensure \nnegative\n \nMedications on Admission:\nCelexa 20 mg daily\n \nDischarge Medications:\n1. Citalopram 20 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nViral Meningitis\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 viral meningitis. You were treated with \nIV antiviral medications for possible HSV meningitis until this \ntest returned negative. Your symptoms are now much improved, and \nyou are being discharged home. You should follow up with your \nPCP as directed.\n\nWe will follow up with you re: your final viral and CSF culture \nresults.\n\nIt was a pleasure taking part in your medical care.\n \nFollowup Instructions:\n___\n" ]

[ "A879", "F419", "R1013" ]

[ "A879: Viral meningitis, unspecified", "F419: Anxiety disorder, unspecified", "R1013: Epigastric pain" ]

[ "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nsymptomatic fibroid uterus \n \nMajor Surgical or Invasive Procedure:\nexploratory laparotomy, myomectomy \n \nPhysical Exam:\nDischarge physical exam\nVitals: stable and within normal limits\nGen: no acute distress; alert and oriented to person, place, and \ndate\nCV: regular rate and rhythm; no murmurs, rubs, or gallops\nResp: no acute respiratory distress, clear to auscultation \nbilaterally\nAbd: soft, appropriately tender, no rebound/guarding; incision \nclean, dry, intact\nExt: no tenderness to palpation\n \nPertinent Results:\nLabs on Admission:\n\n___ 11:40AM BLOOD WBC-6.6 RBC-4.21 Hgb-11.2 Hct-35.9 MCV-85 \nMCH-26.6 MCHC-31.2* RDW-16.5* RDWSD-51.8* Plt ___\n\nRelevant Labs:\n\n___ 07:24AM BLOOD WBC-19.2* RBC-3.64* Hgb-9.8* Hct-30.9* \nMCV-85 MCH-26.9 MCHC-31.7* RDW-16.8* RDWSD-53.1* Plt ___\n \nBrief Hospital Course:\nOn ___, Ms. ___ was admitted to the gynecology service after \nundergoing an exploratory laparotomy and myomectomy. Please see \nthe operative report for full details. Her ___ course \nwas uncomplicated. Immediately post-op, her pain was controlled \nwith IV Dilaudid and IV Toradol.\n\nOn ___ day 1, her urine output was adequate, so her \nfoley was removed, and she voided spontaneously. Her diet was \nadvanced without difficulty, and she was transitioned to PO \noxycodone, ibuprofen, and Tylenol.\n\nBy ___ day 2, 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:\nActive Medication list as of ___:\n \nMedications - Prescription\nCLOMIPRAMINE - clomipramine 50 mg capsule. 1 capsule(s) by mouth\ndaily Day ___\nDESOGESTREL-ETHINYL ESTRADIOL [APRI] - Apri 0.15 mg-0.03 mg\ntablet. 1 tablet(s) by mouth Daily\nERYTHROMYCIN - erythromycin 5 mg/gram (0.5 %) eye ointment. \napply\nthin strip eyes up to 4 times daily apply up to 4 times daily\nuntil symptoms resolve\nFLUTICASONE - fluticasone 50 mcg/actuation nasal\nspray,suspension. 1 spray nasal daily use while your seasonal\nallergies are active\nIPRATROPIUM BROMIDE - ipratropium bromide 42 mcg (0.06 %) nasal\nspray. 1 spray NASAL ___ times per day use for ___ days\nMUPIROCIN [BACTROBAN] - Bactroban 2 % topical ointment. apply to\naffected area twice daily\n \nMedications - OTC\nBIOTIN-KERATIN [BIOTIN PLUS KERATIN] - Biotin Plus Keratin \n10,000\nmcg-100 mg tablet. tablet(s) by mouth - (OTC)\n\n \nDischarge Medications:\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever \ndo not exceed 4000mg in 24 hours \nRX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) \nhours Disp #*50 Tablet Refills:*1 \n2. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First \nLine \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*1 \n3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours \nDisp #*50 Tablet Refills:*1 \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\ndo not drink or drive while taking this medication \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*30 Tablet Refills:*0 \n5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third \nLine \nRX *polyethylene glycol 3350 17 gram 1 packet(s) by mouth once a \nday Disp #*30 Packet Refills:*1 \n6. Simethicone 40-80 mg PO QID:PRN gas pains \nRX *simethicone 80 mg 1 tablet(s) by mouth every eight (8) hours \nDisp #*30 Tablet Refills:*1 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nsymptomatic uterine fibroids\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the gynecology service after your \nprocedure. You have recovered well and the team believes you are \nready to be discharged home. Please call Dr. ___ office with \nany questions or concerns. Please follow the instructions below.\n\nGeneral instructions:\n* Take your medications as prescribed.\n* Do not drive while taking opioids (e.g. oxycodone, \nhydromorphone)\n* Take a stool softener such as colace while taking opioids to \nprevent constipation.\n* Do not combine opioid and sedative medications or alcohol.\n* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.\n* No strenuous activity until your post-op appointment.\n* Nothing in the vagina (no tampons, no douching, no sex) for 6 \nweeks.\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* Leave the steri-strips in place. They will fall off on their \nown. If they have not fallen off by 7 days post-op, you may \nremove them.\n* If you have staples, they will be removed at your follow-up \nvisit.\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\nConstipation:\n* Drink ___ liters of water every day.\n* Incorporate 20 to 35 grams of fiber into your daily diet to \nmaintain normal bowel function. Examples of high fiber foods \ninclude:\nWhole grain breads, Bran cereal, Prune juice, Fresh fruits and \nvegetables, Dried fruits such as dried apricots and prunes, \nLegumes, Nuts/seeds. \n* Take Colace stool softener ___ times daily.\n* Use Dulcolax suppository daily as needed.\n* Take Miralax laxative powder daily as needed. \n* Stop constipation medications if you are having loose stools \nor diarrhea.\n\nTo reach medical records to get the records from this \nhospitalization sent to your doctor at home, call ___.\n \nFollowup Instructions:\n___\n" ]

[ "D251", "D252" ]

[ "D251: Intramural leiomyoma of uterus", "D252: Subserosal leiomyoma of uterus" ]

[]

[]

[ " \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:\nChest pain \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ patient with PMH of HTN, CAD s/p 2 stent placed ___ at \n___ in ___ and ___ at ___), bipolar \ndisease, and deafness presents with chest pain, lightheadedness \nand testicular pain. The patient is ASL speaking and an \ninterpreter was used. The patient has a past medical history \nnotable for hypertension, hyperlipidemia, diabetes and MI status \npost stenting x2 this past ___. He is currently on aspirin \nand Plavix and has been taking his medications regularly. He \nadditionally had testicular surgery approximately one year ago \nwhere he had a single orchectomy. He has been having \nintermittent testicular pain since the surgery, however, this \npain has recently worsened over the past few days. His chest \npain has also been present for approximately 2 days and is \nintermittent in nature. It feels similar to his prior MI. It is \nassociated with dyspnea/lightheadedness on exertion and improves \nslightly at rest. His stenting was performed at a hospital in \n___.\n \n \nIn the ED, initial vitals were temp. 96.7, HR 88, BP 114/68, RR \n16, 100% RA. Labs in the ED notable for WBC 5.8, Hg 11.2, Hct \n34.2, platelets 237. Na 139, K 3.7, Cl 103, Bicarb 24, BUN 17, \nCr 1.0, glucose of 321. Trop X 1 negative. CK 140 and MB 3. \nTesticular ultrasound without evidence of torsion. CXR showed \ntop-normal cardiac silhouette size. No pulmonary edema. \n\nEKG showed sinus rhythm. Possible anteroseptal infarct and \ninferior/lateral non-specific ST-T wave changes. Vent. rate 61 \nPR: 150 QRS: 114 ms QTc: 450.\n \nPatient was given 243 mg of aspirin, 1 tab \noxycodone-acetaminophen, atorvastatin 80ng, 4000 units of \nheparin IV, and nitro gtt, and 5 mg of morphine. Was having pain \ndespite having increased nitro gtt and getting multiple doses of \nmorphine. The patient was evaluated by Cardiology fellow who \nperformed bedside echo without evidence of pericardial effusion \nwith normal appearing LV function. Noted reproducible tenderness \nof chest wall on exam with minimal palpation. \nRecommended discontinuation of heparin drip and nitro gtt.\n\nOn arrival to the floor patient continues to have chest pain \nthat is associated with constant anxiety and anger. He notes \nthat the pain started 3 weeks ago. He is upset about having to \nlive in a shelter and has family stressors. He has a hx. of \nbipolar disease and has trouble sleeping. He has had a hx. of \nmanic episodes in past. Fiance endorses that when the patient \ngets frustrated hits himself in left pectoral area. Does not \nwant to hurt himself or anyone else. Does Patient also complains \nof abdominal pain, dysuria, and nausea. He has also been having \na one week history of scrotal pain associated with dysuria. He \nnotes he takes his Plavix and aspirin most days though has \nmissed a few doses of Plavix in the last month. \n\nHe does note an episode of diarrhea or possible just loose \nstools earlier today after not having a BM for 3 days. Was \nassociated with abdominal cramping. \n\nOn review of systems, he denies any prior history of stroke, \nTIA, deep venous thrombosis, pulmonary embolism, bleeding at the \ntime of surgery, myalgias, joint pains, cough, hemoptysis, black \nstools or red stools. He denies recent fevers, chills or rigors. \nHe denies exertional buttock or calf pain. \n \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 \nPast Medical History:\n1. CARDIAC RISK FACTORS: \n- Hypertension \n- Hyperlipidemia \n- Diabetes \n2. CARDIAC HISTORY: \n- CABG/PCI: Stent x2 this summer at ___ on ASA/Plavix. \n- PUMP FUNCTION: unknown \n- PACING/ICD: none \n3. OTHER PAST MEDICAL HISTORY: Bipolar Affective Disorder, DM2, \nHTN, Hx. of orchiectomy. \n\n \nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death; otherwise non-contributory. \n \n\n \nPhysical Exam:\nPHYSICAL EXAM ON ADMISSION\n====================================\nVitals: T: 98.2 F HR: 62 BP 120/64 RR: 18 SaO2: 97% RA \nGeneral: Anxious, cooperative. AOx3. \nHEENT: MMM, PERRL, No JVP\nNeck: No JVP\nCV: RRR and No MRG\nChest: Very tender to mild palpation. No crepitus \nLungs: Clear to auscultation \nAbdomen: Soft, non-distended, no masses. Tenderness to \npalpation in all quadrants. \nGU: Tenderness to palpation of scrotum. No erythema, swelling, \nor warmth. Right upper thigh outgrowth that is consistent with a \nwart. \nExtr: +2 ___. No edema. \nNeuro: No gross deficits. \nSkin: Scabs and hyperpigmented spots throughout lower legs. \nCondyloma like lesion on right upper thigh. \n\nPHYSICAL EXAM ON DISCHARGE\n=====================================\nVitals: T: 98.4 F HR: 54 BP 112/51 RR: 16 SaO2: 99% RA \nGeneral: Anxious, cooperative. AOx3. \nHEENT: MMM, PERRL, No JVP\nNeck: No JVP\nCV: RRR and No MRG\nChest: Less distend to palpation. No hematomas. \nLungs: Clear to auscultation \nAbdomen: Soft, non-distended, no masses. No tenderness in \nquadrants. \nGU: Tenderness to palpation of scrotum. No erythema, swelling, \nor warmth. Right upper thigh outgrowth that is consistent with a \nwart. \nExtr: +2 ___. No edema. \nNeuro: No gross deficits. \nSkin: Scabs and hyperpigmented spots throughout lower legs. \nCondyloma like lesion on right upper thigh. \n \nPertinent Results:\nLABS ON ADMISSION\n====================================\n___ 09:30AM WBC-5.8 RBC-3.95* HGB-11.2* HCT-34.2* MCV-87 \nMCH-28.4 MCHC-32.7 RDW-12.3 RDWSD-39.1\n___ 09:30AM NEUTS-56.3 ___ MONOS-8.5 EOS-3.1 \nBASOS-1.2* IM ___ AbsNeut-3.26 AbsLymp-1.76 AbsMono-0.49 \nAbsEos-0.18 AbsBaso-0.07\n___ 09:30AM PLT COUNT-237\n___ 09:30AM ___ PTT-27.5 ___\n___ 09:30AM cTropnT-<0.01\n___ 09:30AM CK-MB-3\n___ 02:40PM cTropnT-<0.01\n___ 09:30AM GLUCOSE-321* UREA N-17 CREAT-1.0 SODIUM-139 \nPOTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-27 ANION GAP-13\n___ 09:30AM ALT(SGPT)-16 AST(SGOT)-19 CK(CPK)-190 ALK \nPHOS-49 TOT BILI-0.1\n___ 09:47AM LACTATE-2.0\n___ 09:30AM %HbA1c-9.7* eAG-232*\n___ 09:30AM VALPROATE-33*\n\nLABS ON DISCHARGE\n====================================\n___ 04:01AM BLOOD Type-ART pO2-58* pCO2-45 pH-7.44 \ncalTCO2-32* Base XS-5\n___ 06:50AM BLOOD WBC-7.4 RBC-3.97* Hgb-11.3* Hct-34.0* \nMCV-86 MCH-28.5 MCHC-33.2 RDW-12.5 RDWSD-38.6 Plt ___\n___ 06:50AM BLOOD Plt ___\n___ 06:50AM BLOOD Glucose-162* UreaN-17 Creat-1.0 Na-143 \nK-3.7 Cl-104 HCO3-27 AnGap-16\n___ 06:50AM BLOOD Calcium-9.3 Phos-4.1 Mg-1.8\n___ 04:00AM BLOOD CK(CPK)-141\n___ 04:00AM BLOOD CK-MB-2 cTropnT-<0.01\n___ 04:00AM BLOOD Valproa-58\n___ 04:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n\n___: EKG: ECG: Sinus rhythm. Possible anteroseptal \ninfarct. Inferior/lateral ST-T changes- may be due to myocardial \nischema. Do not have previous EKG to compare with in system. \nVent rate: 61 PR: 150 QRS: 450 QTc: 451\n\n___: Chest X-ray:No relevant change is noted. No \nevidence of \npneumothorax. Moderate cardiomegaly. No pulmonary edema. No \npleural \neffusions. No pneumonia. \n \n\n \nBrief Hospital Course:\nPatient is a ___ yo man who with a PMH significant for MI s/p 2 \nstent placements earlier this year, HTN, Bipolar disease, and \nDM2 who presents with worsening left sided reproducible chest \npain associated with shortness of breath, palpitations, and \nincreased anxiety. \n\n# Chest Pain: \nPatient presented with 3 week history of chest pain. Per \ndiscussion with patient he had undergone recent stress life \nevents including homelessness. He did endorse hitting his chest \nin setting of emotional upset. On exam patient noted to have \nreproducible chest pain to palpation. Troponin X 2 was negative. \nPatient did have biphasic T-waves changes in anterior leads of \nECG concerning for apical aneurysm.\n\nWe recommended pharmacologic MIBI testing but he left against \nmedical advice. He was evaluated by psychiatry who felt the \npatient had capacity. He was able to state understanding of the \nrisk of leaving the hospital including heart attack and death. \nIt was recommended that he follow up with his outpatient \nproviders. He was continued on home dose of Plavix 75 PO daily, \nASA 81, Metoprolol succinate 25 mg daily, and Atorvastatin 80 mg \nPO daily. \n\n \n# Bipolar Disease: \nPatient was evaluated by psychiatry and was diagnosed with \npossible hypomania with preserved capacity. They recommended \nthat he continue Depakote 500 mg in am and 1000 mg in evening \nand clonidine 0.5 mg PO BID. Patient's valproic acid level on \ndischarge was 58. Patient stated that he took Valium 10 mg at \nhome, but it was not listed in as a prescribed medication in his \npharmacy. UDS and Serum Urine Toxic was negative. \n\nPatient's endorsement of anxiety and frustration with some harm \nto self with repetitive chest strikes was concerning. On the \nnight of ___ patient was given 10 mg Valium PO. Patient was \nfound unresponsive, but had a pulse and awoke with increased \nagitation. Was thought that this was due to valium and not \nrelated to cardiac issues as EKG and Troponins were normal. His \nmental status was intact and he denied any history of seizures. \n\nSocial work was also consulted. Patient evaluated by psychiatry \nwho felt the patient had capacity. He was able to state \nunderstanding of the risk of leaving the hospital including \nheart attack and death. It was recommended that he follow up \nwith his outpatient providers.\n\n# Scrotal pain with dysuria: Scrotal US in the ED normal. \nPatient was also having dysuria and a recent history of penile \ndischarge. This was concerning for an infection. UA/Urine \nculture and Gonnorrhea/Chlamydia testing were not collected in \ntime for discharge given patient left against medical advice. \n\n# HTN: Continued metoprolol succinate \n\n# Diabetes: \nOn Diabetic diet. ISS in hospital. Metformin 1000 BID as home \nmed. \n\nTransition issues\n==================================================\n# Chest pain: Recommend f/u with stress MIBI\n#Bipolar disease: Recommend f/u with outpatient psychiatrist. \n# Scrotal pain and dysuria: Recommend outpatient management. \nUrine Analysis and GC and Chlamydia were not able to be collect \nas patient left against medical advice\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Clopidogrel 75 mg PO DAILY \n2. MetFORMIN (Glucophage) 1000 mg PO BID \n3. Valproic Acid ___ mg PO QAM \n4. Valproic Acid ___ mg PO QPM \n5. Metoprolol Succinate XL 50 mg PO DAILY \n6. Omeprazole 40 mg PO DAILY \n7. CloniDINE 0.1 mg PO BID \n8. Aspirin 81 mg PO DAILY \n9. Atorvastatin 80 mg PO QPM \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. CloniDINE 0.1 mg PO BID \n3. Clopidogrel 75 mg PO DAILY \n4. Metoprolol Succinate XL 50 mg PO DAILY \n5. Omeprazole 40 mg PO DAILY \n6. Valproic Acid ___ mg PO QAM \n7. Valproic Acid ___ mg PO QPM \n8. MetFORMIN (Glucophage) 1000 mg PO BID \n9. Atorvastatin 80 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\nChest pain\n\nSecondary:\nBipolar Disorder\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 came to the hospital with chest pain and we recommended you \nhave further testing of your heart but you left against medical \nadvice. We explained the risk of leaving with you including \ndeath and you had understanding of this and wanted to leave \ndespite this. We also had our psychiatry team see you. They \nrecommend that you continue your current medication and continue \nyour home psychiatric medications.\n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "R079", "F319", "R42", "E119", "I10", "E780", "I2510", "Z9861", "N508", "Z9079", "H9190", "Z590", "F17210", "I252" ]

[ "R079: Chest pain, unspecified", "F319: Bipolar disorder, unspecified", "R42: Dizziness and giddiness", "E119: Type 2 diabetes mellitus without complications", "I10: Essential (primary) hypertension", "E780: Pure hypercholesterolemia", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z9861: Coronary angioplasty status", "N508: Other specified disorders of male genital organs", "Z9079: Acquired absence of other genital organ(s)", "H9190: Unspecified hearing loss, unspecified ear", "Z590: Homelessness", "F17210: Nicotine dependence, cigarettes, uncomplicated", "I252: Old myocardial infarction" ]

[ "E119", "I10", "I2510", "F17210", "I252" ]

[]

[ " \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\n \nHistory of Present Illness:\nMs. ___ is a ___ who presented as a transfer from an OSH \nwith a chief complaint of fall that resulted in a C2 lateral \nmass fracture and an non displaced ___ posterior rib fx. \nPatient reports being in her usual state of health when she \nexperienced a fall from a bunk bed (from around 5 feet) and \nlanded on the floor. She remembers the event but indicates that \nit took her a few minutes to realize that she had fallen to the \nground. She was able to get up after the fall, get in the car \nand go to the hospital (her uncle was driving). She does not \nbelieve that she had any head strike. Upon arrival to the OSH \nshe started experiencing more pain throughout her back and her \nchest. On examination from the ___ team she is laying in bed \nwith a C-collar in place. She reports pain in her back and \nbilaterally in her mid chest. She is breathing comfortable. She \ndenies any alcohol consumption prior to this event. She \nattributes the fall to the rail of the bed bunk malfunctioning. \n \nPast Medical History:\nPast Medical History:\nUlcer in small bowel- diagnosed with EGD ___ food intolerances \n\nPast Surgical History:\nNone\n \nSocial History:\n___\nFamily History:\nFather died from heart attack at an early age\nBrother has SVT\nGrandfather suffered from cancer unsure what type\n \nPhysical Exam:\nVitals: T97.4. BP94 / 62, HR 74, RR 18, O2 98% RA\nGEN: A&O, NAD\nHEENT: No scleral icterus, mucus membranes moist\nCV: RRR\nPULM: Clear to auscultation b/l; tender on the left posterior \nlower ribs.\nABD: Soft, nondistended, nontender\nExt: No ___ edema, ___ warm and well perfused\n \nPertinent Results:\n___ 08:36AM BLOOD WBC-10.6* RBC-3.92 Hgb-10.3* Hct-32.0* \nMCV-82 MCH-26.3 MCHC-32.2 RDW-14.6 RDWSD-42.4 Plt ___\n___ 08:36AM BLOOD Neuts-87.6* Lymphs-8.5* Monos-3.2* \nEos-0.0* Baso-0.2 Im ___ AbsNeut-9.29* AbsLymp-0.90* \nAbsMono-0.34 AbsEos-0.00* AbsBaso-0.02\n___ 08:36AM BLOOD Glucose-105* UreaN-4* Creat-0.5 Na-139 \nK-4.4 Cl-107 HCO3-17* AnGap-15\n\nCT CHEST without contrast ___: Nondisplaced fracture of the \nleft eleventh posterior rib. Ground-glass opacity in the left \nlower lobe likely secondary to poor respiratory effort.\n\nMRI ___:\n1. Nondisplaced fracture of the right lateral mass at C 2, which \nextends to \nthe anterior margin of the right transverse foramen, is better \nassessed on the \npreceding CT. \n2. Fluid in the joint between the right lateral masses of C1 and \nC 2. Mild \nposterior paravertebral edema along the right lateral mass of \nC2.Mild edema \nin the C1-C2 interspinous ligament without clear evidence for \nligamentum \nflavum involved. \n3. Anterior and posterior longitudinal ligaments appear intact. \nNo spondylolisthesis, disc edema, vertebral body marrow edema. \n4. No epidural collection. Normal spinal cord signal. \n \nBrief Hospital Course:\nThe patient presented to Emergency Department on ___. Upon \narrival to ED, she underwent CT scan which demonstrated 11th rib \nfracture, pulmonary contusion, and C2 fracture. She was \nevaluated by neurosurgery, who determined this fracture should \nbe treated nonoperatively with hard cervical collar use at all \ntimes until follow up imaging in 4 weeks. She was admitted for \nfurther monitoring and pain control. She was given Tylenol, \nibuprofen, and oxycodone PRN with good pain relief. She was \ntolerating a regular diet without issue and her pain was \ncontrolled with deep breathing and inspiratory spirometer use. \nShe also utilized a lidocaine patch over her fractured ribs. At \nthe time of discharge on HD2, the patient was doing well, \nafebrile and hemodynamically stable. The patient was tolerating \na diet, ambulating, voiding without assistance, and pain was \nwell controlled. She was discharged home with plan to follow up \nwith Dr. ___ primary care doctor, ___. \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 650 mg PO Q6H:PRN Pain - Mild \n2. Docusate Sodium 100 mg PO BID:PRN Constipation - Second Line \n\nhold for loose stool. \n3. Lidocaine 5% Patch 1 PTCH TD QPM \nRX *lidocaine 5 % Apply 1 patch to affected area 12 hours on; 12 \nhours off Disp #*30 Patch Refills:*0 \n4. TraMADol ___ mg PO Q4H:PRN Pain - Moderate \n Reason for PRN duplicate override: dc oxycodone\nTake lowest effective dose. \nRX *tramadol 50 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*30 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nNon displaced L ___ posterior rib fx \nlateral mass fracture of C2\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the Acute Care Surgery Service on ___nd found to have a fracture in your cervical spine \nand Left sided rib fractures. You had a CT scan that showed a \nfracture at the level of C2 but the spinal cord was intact. You \nwere seen by the Neurosurgery team for this injury who \nrecommended non-operative management. You should continue to \nwear your hard cervical collar at all times until cleared to \nremove it. Your breathing was closely monitored because rib \nfractures can make it difficult to take deep breaths. You were \ngiven pain medication to help your breath and move around. \n\nYou may remove the hard neck collar briefly for a daily shower \nbut otherwise you should wear the collar full time including \nduring sleep. Do not lift anything greater than 30 pounds and \navoid strenuous physical activity. \n\nYou are now doing better, pain is better controlled, and you are \nready to be discharged to home to continue your recovery.\n\nPlease note the following discharge instructions:\n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon.\n\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\n* 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\n \nFollowup Instructions:\n___\n" ]

[ "S12190A", "S2232XA", "W06XXXA", "Y92003", "K269" ]

[ "S12190A: Other displaced fracture of second cervical vertebra, initial encounter for closed fracture", "S2232XA: Fracture of one rib, left side, initial encounter for closed fracture", "W06XXXA: Fall from bed, initial encounter", "Y92003: Bedroom of unspecified non-institutional (private) residence as the place of occurrence of the external cause", "K269: Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation" ]

[]

[]

[ " \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:\nBrain mass\n \nMajor Surgical or Invasive Procedure:\n___ - Left frontal stereotactic brain biopsy\n\n \nHistory of Present Illness:\n___ is a ___ year old male with history of left frontal \nanaplastic astrocytoma, discovered after a first time seizure \nduring sleep. He had a resection in ___ with subsequent \nchemoradiation. He is on Keppra. He denies further seizure \nactivity. Surveillance MRI shows progression of the lesion. He \npresents for elective stereotactic brain biopsy.\n\n \nPast Medical History:\n1. Left frontal anaplastic astrocytoma\n2. Seizure\n3. Asthma\n4. Seasonal allergies\n5. Obesity\n6. Surgery at age ___ to resect a growth in mouth\n7. Right otitis externa\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nOn Discharge:\nXXX\n \nPertinent Results:\n___ ___\nNo significant change since CT earlier today status post brain \nbiopsy via a left frontal burr hole. No acute hemorrhage or \nmidline shift. \n\n \nBrief Hospital Course:\n___ is a ___ year old male with history of anaplastic \nastrocytoma S/P resection in ___ with recurrence of a left \nfrontal brain mass found on surveillance imaging. He presents \nfor elective stereotactic biopsy of the lesion. The procedure \nwas uncomplicated. For further details, please see separately \ndictated operative report by Dr. ___. The patient was \nextubated in the OR and transported to the PACU for \npost-procedure monitoring. A post-operative NCHCT showed \nexpected post operative changs. Once stable, he was transferred \nto the floor and was discharged on ___. \n \nMedications on Admission:\n1. FLUTICASONE 110 mcg/actuation 2 puffs inh twice a day\n2. LEVETIRACETAM 1000 mg by mouth twice daily\n3. MONTELUKAST 10 mg by mouth once a day\n4. NETTLE ROOT 1 tablet at night \n5. PROBIOTICS \n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nDo not exceed 4 G in a 24 hours period. \n2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*20 Tablet Refills:*0\nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*15 Tablet Refills:*0 \n3. Fluticasone Propionate 110mcg 2 PUFF IH BID \n4. Hydrocortisone ___. Cream 0.2% 1 Appl TP BID \n5. LevETIRAcetam 1000 mg PO BID \nRX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n6. Montelukast 10 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nBrain mass\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nBrain Tumor\nSurgery\n•You underwent a biopsy. A sample of tissue from the lesion in \nyour brain was sent to pathology for testing. \n•Frozen preliminary was: radiation necrosis \n•Please keep your incision dry until your sutures dissolve. \n•You may shower at this time but keep your incision dry.\n•It is best to keep your incision open to air but it is ok to \ncover it when outside. \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 once you are symptom free at rest. \n___ try to do 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 may use Acetaminophen (Tylenol) for minor discomfort if \nyou are not otherwise restricted from taking this medication.\n\nWhat You ___ Experience:\n•You may experience headaches and incisional pain. \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•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•Feeling more tired or restlessness is 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\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•Sudden numbness or weakness in the face, arm, or leg\n•Sudden confusion or trouble speaking or understanding\n•Sudden trouble walking, dizziness, or loss of balance or \ncoordination\n•Sudden severe headaches with no known reason\n \nFollowup Instructions:\n___\n" ]

[ "I6789", "R569", "E669", "Z85841", "J45909", "Z6834", "Y842", "Y929" ]

[ "I6789: Other cerebrovascular disease", "R569: Unspecified convulsions", "E669: Obesity, unspecified", "Z85841: Personal history of malignant neoplasm of brain", "J45909: Unspecified asthma, uncomplicated", "Z6834: Body mass index [BMI] 34.0-34.9, adult", "Y842: Radiological procedure and radiotherapy 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", "J45909", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nNo Allergies/ADRs on File\n \nAttending: ___.\n \nChief Complaint:\nPolytrauma\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ year old male w/ hx of HTN s/p MCC at high speed, -\nLOC,+EOTH, GCS 15 at the scene, c-collar in place, helmeted w/o\nintrusion. Patient complaining of right shoulder pain, right arm\npain, and back pain requiring frequent redirection while on the\nscene. On imaging pt. found to have right mid-shaft claviclular\nfx, rib fx ___, right scapular fx. right lung contusions,right\npneumothorax w/ effusion, 4 mm right glut hematoma, right renal\nhilum hematoma, right SAH/SDH, and right abdominal road rash. \nPt.\nwas then transferred to ___ for further\ntrauma workup.\n\n \nPast Medical History:\nHTN\n \nSocial History:\n___\nFamily History:\nNon-contributory\n \nPhysical Exam:\nPhysical Exam \nHead:Head abrasion, no bony crepitus, no c-spine tenderness/step\noffs\nEyes:PERRLA \nENT: Trachea midline, obvious signs of hematoma formation \nRespiratory: Diminished on the right, \nCardiovascular: RRR on monitor,2+ radial, ___ btl \nChest:No chest wall tenderness\nGI:soft, nondistended, right abdomen road rash w/ tenderness \nGenitourinary:No blood in urethral meatus \nMusculoskeletal:Btl chest wall tenderness, Abraisions to right\nshoulder, btl knees and RLE. Right shoulder clavicular, and\nscapular tenderness. \nNeurologic: ___ strength on right, ___ LLE\n\nDischarge exam:\nPhysical Exam \n___: NAD\nCardiac: RRR\nChest: right chest wall tenderness over ribs \nPulm: CTAB \nGI: soft, nondistended, nontender\nNeurologic: ___ strength of extremities \n\n \nPertinent Results:\nMRI spine:\nIMPRESSION: \n1. Normal cord. No vertebral body fracture. No ligamentous \ninjury.. \n2. Dependent consolidations in the right greater than left \nlungs, largely \natelectasis, consider component of contusion, aspiration. \n3. Rib fractures.. \n4. Degenerative changes lumbar spine, as above. \n \nCT head and torso obtained at ___ \n \nBrief Hospital Course:\nThis is a ___ yo M, s/p MCC who presented with R SAH/SDH, R \nclavicle & scapula & ___ Lateral rib fx, R PTX,R R renal hilum \nhematoma, R gluteal hematoma.\n\nRegarding his MSK injuries, the patient was managed \nnon-operatively. He is scheduled for follow up with the ___ \n___ clinic to assess interval improvement and further \nmanagement on ___. \n\nRegarding his neurological status, there was initially some \nconcern for spinal cord pathology given his lower extremity \nweakness on presentation but given his normal MRI spine this was \nthen felt to be secondary to traumatic brain injury involving \nhis premotor/motor cortex. The patient continued to re-gain \nfunction in the course of this hospitalization working with \nphysical therapy. He is intermittently not oriented to time but \nit is unclear how much of this is chronic vs secondary to his \nTBI. Neurosurgery has no further recommendations for \nevaluation/care at this time. \n\n \nMedications on Admission:\n3. Enalapril Maleate 10 mg PO DAILY \n4. Famotidine 20 mg PO BID \n5. FoLIC Acid 1 mg PO DAILY \n6. Hydrochlorothiazide 25 mg PO DAILY \n\n \nDischarge Medications:\n1. amLODIPine 5 mg PO DAILY \n2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe \nDuration: 20 Doses \nDO not drink or drive with this med. \n3. Enalapril Maleate 10 mg PO DAILY \n4. Famotidine 20 mg PO BID \n5. FoLIC Acid 1 mg PO DAILY \n6. Hydrochlorothiazide 25 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPolytrauma with ___/SDH; r clavicle, scapula, and ___ lateral \nrib fx, right renal hilum hematoma, r gluteal hematoma \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\n\n \nDischarge Instructions:\nDear Mr. ___,\nYou came here after a motorcycle crash and had head trauma with \nbleeding and multiple fractures including those of the rib, \nclavicle, and scapula. The orthopedic team evaluated you and \nfelt your fractures were non-operative at this time. The \nneurosurgery team was reassured by your improving neurologic \nexam and did not pursue further intervention. \n\nYou are being discharged to a rehabilitation facility to help \nyou regain function. \n\nYou have an orthopedic appointment on ___. Please arrive at \n9:30 to take x-rays beforehand. \n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n\n *You experience new chest pain, pressure, squeezing or \ntightness.\n\n *New or worsening cough, shortness of breath, or wheeze.\n\n *If you are vomiting and cannot keep down fluids or your \nmedications.\n\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\n *You see blood or dark/black material when you vomit or have a \nbowel movement.\n\n *You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n\n *You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n\n *Any change in your symptoms, or any new symptoms that concern \nyou.\n\n Please resume all regular home medications , unless \nspecifically advised not to take a particular medication. Also, \nplease take any new medications as prescribed.\n\n \nFollowup Instructions:\n___\n" ]

[ "S066X9A", "S225XXA", "S272XXA", "Z006", "S27321A", "S37011A", "S065X9A", "I10", "S42021A", "L98411", "V274XXA", "Y92411", "S300XXA", "F1290", "D649", "F10129", "S42111A", "R402132", "R402242", "R402352", "R32" ]

[ "S066X9A: Traumatic subarachnoid hemorrhage with loss of consciousness of unspecified duration, initial encounter", "S225XXA: Flail chest, initial encounter for closed fracture", "S272XXA: Traumatic hemopneumothorax, initial encounter", "Z006: Encounter for examination for normal comparison and control in clinical research program", "S27321A: Contusion of lung, unilateral, initial encounter", "S37011A: Minor contusion of right kidney, initial encounter", "S065X9A: Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter", "I10: Essential (primary) hypertension", "S42021A: Displaced fracture of shaft of right clavicle, initial encounter for closed fracture", "L98411: Non-pressure chronic ulcer of buttock limited to breakdown of skin", "V274XXA: Motorcycle driver injured in collision with fixed or stationary object in traffic accident, initial encounter", "Y92411: Interstate highway as the place of occurrence of the external cause", "S300XXA: Contusion of lower back and pelvis, initial encounter", "F1290: Cannabis use, unspecified, uncomplicated", "D649: Anemia, unspecified", "F10129: Alcohol abuse with intoxication, unspecified", "S42111A: Displaced fracture of body of scapula, right shoulder, initial encounter for closed fracture", "R402132: Coma scale, eyes open, to sound, at arrival to emergency department", "R402242: Coma scale, best verbal response, confused conversation, at arrival to emergency department", "R402352: Coma scale, best motor response, localizes pain, at arrival to emergency department", "R32: Unspecified urinary incontinence" ]

[ "I10", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nIodinated Contrast- Oral and IV Dye / aspirin / atenolol\n \nAttending: ___.\n \nChief Complaint:\ngeneralized weakness \n \nMajor Surgical or Invasive Procedure:\nCentral line placement \nBronchoscopy \n \nHistory of Present Illness:\nMr. ___ is an ___ year-old male with MDS ___ at ___ who \ninitially presented to ___ with generalized \nweakness and was transferred to ___ for ICU admission after ___ \nwas found to be hypotensive with systolic BPs in the ___ \nrequiring pressors and imaging concerning for multifocal \npneumonia. \n\n___ was in his usual state of health until approximately three \nweeks ago when ___ began feeling fatigued with generalized \nweakness. ___ describes his fatigue as feeling more tire and \nsleeping more than usual. His weakness ___ feels was due to lack \nof energy. ___ did not experience shortness of breath or chest \npain on exertion or at rest. His wife was concerned that ___ was \nnot eating as much as usual. ___ believes ___ has lost some weight \nbut is not sure how much. ___ denies experiencing any fevers, \nchills, cough, hemoptysis, or night sweats. \n \nDuring this time ___ also reports having developed bilateral \nlower extremity edema and some swelling in his hands. ___ first \nnoticed the swelling about 3 weeks ago and it has since \ncontinued to worsen. ___ denies any history of heart failure or \nheart problems in the past, though ___ follows a cardiologist at \n___ for \"leaky heart valves\". ___ denies orthopnea or PND. No \nchest pain. ___ reports that ___ takes Lasix which is prescribed \nfor hyperkalemia. \n\nAt ___ the patient was found to have SBPs in \nthe ___ and a Hb of 7. A CT Chest/abdomen/pelvis was concerning \nfor a multifocal pneumonia. The patient was given cefepime and \nvancomycin. ___ also received 1.5L fluids and 2uPRBCs without \nimprovement in his bp. A femoral CVL was placed and levophed was \nstarted and the patient was transferred to ___ for admission \nto the ICU. \n\nIn the ED, initial vitals: 92.7 67 103/64 22 94% 3L ___ \n\nLabs notable for:\n-CBC: 4.4 > 9.6 < 134\n-Chem: 134/4.6 | 101/15 | 78/1.2\n-LFT: 39/42 | 2.1/137\n-BNP ___ / TnT 0.81\n-VBG: 7.31/34/___/18, lact 1.3\n-UA: WBC 1\n-Flu A/B: neg\n\nEKG w/ NSR, rate 70, slightly prolonged QRS, c/w possible LBBB, \nno baseline in system\n\nImaging: \nCT Chest from ___ w/ b/l pleural effusions L > \nR, pulmonary edema, multifocal consolidations b/l c/f multifocal \npna \n\nCXR at ___ ED \"Bilateral perihilar opacities appear more \nconfluent [compared with CT chest] concerning for worsening \nmultifocal pneumonia\" \n\nPatient was continued on NEpi infusion\n\nCardiology was consulted with c/f cardiogenic shock. Cardiology \nevaluated the patient and did not feel the patient was in \ncardiogenic shock and recommended treatment of possible \nmultifocal pna. \n\nVitals on transfer: 76 115/81 22 92% 4L NC \n\nUpon arrival to ___, patient is comfortable and in no distress. \n___ confirms the above story. ___ denies coughing or choking on \nany food. ___ has not had any recent illnesses. No cough or chest \npain. No shortness of breath. ___ does report constipation, no \ndiarrhea. \n\n \nPast Medical History:\nPAST MEDICAL HISTORY: \n- MDS ___ grade, not on chemotherapy, gets epo injections and \ntransfusions prn and DFCI) \n- Hypothermia (patient has had low temperatures for years and \nwas discovered to have a pituitary mass that has been resected \ntwice) \n- Pituitary mass s/p resection x2 at ___ \n- Thyroid carcinoma (s/p resection) \n- Prostate cancer (s/p prostatectomy several years ago, has PSA \nchecked and most recently was 0 per patient) \n- CAD (not on ASA d/t nosebleeds or statin d/t muscle weakness)\n- CHF \n \nSocial History:\n___\nFamily History:\nNon-contributory \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n==================================\nGENERAL: Calm, alert, no distress \nHEENT: Sclera anicteric, dry mucous membranes, oropharynx clear \n\nNECK: mild JVD, no LAD \nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nSKIN: warm, dry, no rashes \nNEURO: CN II-XII, strength ___ in all extremities. Oriented x4 \nACCESS: CVL fem\n\nDISCHARGE PHYSICAL EXAM:\n========================\nDeceased\n \nPertinent Results:\nADMISSION LABS:\n==============================\n___ 02:17AM BLOOD WBC-4.4 RBC-3.46* Hgb-9.6* Hct-30.3* \nMCV-88 MCH-27.7 MCHC-31.7* RDW-22.2* RDWSD-67.5* Plt ___\n___ 02:17AM BLOOD Hypochr-1+* Anisocy-1+* Poiklo-1+* \nMacrocy-1+* Microcy-1+* Polychr-1+* Ovalocy-2+* Burr-1+* Tear \nDr-1+*\n___ 02:17AM BLOOD ___ PTT-33.5 ___\n___ 02:17AM BLOOD Glucose-87 UreaN-78* Creat-1.2 Na-134* \nK-4.6 Cl-101 HCO3-15* AnGap-18\n___ 02:17AM BLOOD ALT-42* AST-39 AlkPhos-137* TotBili-2.1* \nDirBili-0.5* IndBili-1.6\n___ 02:17AM BLOOD ___\n___ 02:17AM BLOOD CK-MB-19* MB Indx-14.7* cTropnT-0.81*\n___ 08:19AM BLOOD CK-MB-19* MB Indx-19.8* cTropnT-0.87*\n___ 03:31PM BLOOD CK-MB-16* MB Indx-21.3* cTropnT-0.95*\n___ 08:39PM BLOOD CK-MB-14* MB Indx-22.2* cTropnT-0.90*\n___ 02:00AM BLOOD CK-MB-13* MB Indx-22.0* cTropnT-0.85*\n___ 02:17AM BLOOD Albumin-3.3* Calcium-8.3* Phos-3.6 Mg-2.5\n___ 08:19AM BLOOD Cortsol-21.1*\n___ 02:17AM BLOOD TSH-1.4\n___ 02:31AM BLOOD ___ pO2-41* pCO2-34* pH-7.31* \ncalTCO2-18* Base XS--8\n___ 02:31AM BLOOD Lactate-1.3\n\nPERTINENT IMAGING:\n==================\nEcho ___:\nThe left atrium is markedly dilated. No left atrial \nmass/thrombus seen (best excluded by transesophageal \nechocardiography). Overall left ventricular systolic function is \nnormal (LVEF>60%). [Intrinsic left ventricular systolic function \nis likely more depressed given the severity of mitral \nregurgitation.] The right ventricular cavity is mildly dilated \nwith moderate global free wall hypokinesis. The aortic valve \nleaflets (3) are mildly thickened but aortic stenosis is not \npresent. Mild to moderate (___) aortic regurgitation is seen. \nThe mitral valve leaflets are mildly thickened. There is no \nmitral valve prolapse. An eccentric, inferolaterally directed \njet of severe (4+) mitral regurgitation is seen. There is \nmild-moderate pulmonary artery systolic hypertension. There is \nno pericardial effusion. A left pleural effusion is present. \n\nIMPRESSION: Normal left ventricular caivty size and global \nsystolic function. Severe mitral regurgitation. Mild-moderate \npulmonary artery systolic hypertension. Right ventricular cavity \ndilation with free wall hypokinesis. \n\nCompared with the prior study (images reviewed) of ___, \nthe right ventricular caviity is now more dilated with free wall \nhypokinesis and lower estimated PA systolic pressure. This may \nreflect interim RV dysfunction rather than a true improvement.\n\nCT Head ___:\n1. Dental amalgam streak artifact and motion limits examination. \n\n2. No evidence of intracranial hemorrhage or large territorial \ninfarction. \nPlease note MRI of the brain is more sensitive for the detection \nof acute \ninfarct. \n3. Atrophy, probable small vessel ischemic changes, and \natherosclerotic \nvascular disease as described. \n\nLabs prior to expiration:\n============================\n___ 02:30AM BLOOD WBC-4.7 RBC-2.46* Hgb-6.9* Hct-23.3* \nMCV-95 MCH-28.0 MCHC-29.6* RDW-22.6* RDWSD-77.0* Plt ___\n___ 02:30AM BLOOD Plt ___\n___ 02:30AM BLOOD Glucose-120* UreaN-39* Creat-1.2 Na-149* \nK-3.2* Cl-114* HCO3-22 AnGap-13\n___ 02:30AM BLOOD Albumin-2.2* Calcium-7.6* Phos-2.6* \nMg-2.0\n \nBrief Hospital Course:\nFICU Course: \nMr. ___ is an ___ year-old male with a history of MDS ___ at \n___ who initially presented to ___ with \ngeneralized weakness and was transferred to ___ for ICU \nadmission for hypotension & imaging concerning for multifocal \npneumonia. His FICU course was complicated by mucous plugging \nsecondary to clots from epistaxis, recurrent aspiration, \ndelirium, hypotension, and septic shock. ___ died peacefully with \nfamily at bedside on ___.\n\n================= \nACTIVE ISSUES \n================= \n# Goals of care\nDiscussion with patient's family throughout this entire \nadmission. His family felt f patient has ability to recover \nneurological function, they would like to do everything \npossible. ___ was full code for the initial part of his ICU stay, \nhowever was made DNR after discussions with his HCP, his wife. \nPrior to extubation, the decision was made that ___ will be do \nnot re-intubate if ___ should have needed it. On ___, the \ndecision was made to transition Mr. ___ to ___ \ncare. ___ was able to eat which the family felt would bring him \npleasure and comfort, however they understood the risk of \naspiration. ___ died peacefully on the evening ___. \n\n# Hypotension (present on initial admission to ICU). Was likely \nmultifactorial. Hypovolemic (elevated BUN, poor PO intake and \nlasix), sepsis (was hypothermic though has been a problem at \nbaseline, imaging c/f pna), cardiogenic (elevated troponin, BNP, \nand edema), obstructive (has risk factors for PE but not tachy \nor hypoxemic), adrenal insufficiency (has had mltpl pituitary \nprocedures and is on fludrocortisone).\nBlood and urine cultures were sent and were negative. Stress \ndose steroids were started (see below for more details). Bolused \nfluids as needed while being mindful of CHF history. ___ was \nstarted on levophed but this was weaned as soon as possible \n(about 12h after admission to the ICU). ___ was retransferred to \nthe FICU on ___ for hypotension and shock; ___ was re-started \non pressors. This was discontinued when his blood pressure was \nmore stable on ___. \n\n# Multifocal PNA. (present on initial admission to ICU). Unclear \netiology. No infectious symptoms or leukocytosis. Ddx included \ninfection (flu was negative; atypical bacterial; though no \nleukocystosis), aspiration (though has not choked on food, could \nbe silent), malignancy (given history, though no clear masses on \nCT). Was treated with broad spectrum antibiotics: \nvanc/cefepime/azithro. Once the decision was made to make Mr. \n___ CMO, ___ was able to eat with the family's understanding \nthat aspiration could occur. \n\n# Respiratory Failure:\nSoon after admission to the ICU, the pt was intubated for \nrespiratory distress. CXR showed collapsed both right and left \nside of lungs on ___, requiring intubation. Suspect this might \nbe related to occult nose bleeds leading to formed collections. \n___ was found to have significant clots/blood in the oropharynx, \nincluding a very large golf ball sized clot that was suctioned. \nRigid bronchoscopy was performed in the OR by Interventional \nPulmonology, but no material was found to remove or intervene \non. Because of the patients significant altered mental status \n(see below), the patient remained intubated until ___. Once \nthere was improved responsiveness, following more commands, and \nhad a gag and cough reflex, ___ was extubated and tolerated this \nwell. His CXR on ___ when ___ was re-transferred to the ICU \ndemonstrated interval worsening bilateral consolidations, \npossibly aspiration vs. pneumonia. ___ was continued on \nantibiotics, humidified O2, and chest ___. Diuresis was continued \nto improved respiratory status as well. \n\n#Altered Mental Status:\nPersistently worsening mental status, very different from \nbaseline. Initially was felt to be likely metabolic process \n(hypernatremia, renal failure) vs primary neurologic process. CT \nhead negative. EEG preliminary early phase interpretation did \nidentify sharp epileptiform spikes concerning for possible foci \nthat could progress to NCSE, however, without continuous spikes \npresent. Largely notable for EEG waveforms consistent with that \nof metabolic encephalopathy. Keppra was started. Neurology felt \nthat this could be Cefepime- Induced non-convulsive status \nepilepticus. ___ gradually and minimally improved; prior to \nextubation ___ was able to follow simple commands. After \nextubation ___ was able to speak some words and interact \nminimally, however this is quite far from his baseline prior to \nthis hospitalization. \n\n# Adrenal Insufficiency\nChronic issue. Was initially on stress dose steroids - \nhydrocortisone 50mg q6. This was tapered as tolerated and \neventually the pt was back on his home dose of fludrocortisone. \nWhen ___ was re-transferred back to the ICU, his dose of steroids \nwas increased and ___ was also started on midodrine for extra \nblood pressure support. \n\n# ___\nHis Cr baseline was 1.2. This was an issue for the duration of \nthis ICU course. The cause was presumed to be ATN, supported by \nevidence of muddy brown casts on urinalysis. Pt continued to \nmake urine. We monitored urine output very closely and avoided \nnephrotoxic medications. Nephrology was consulted and \nrecommended supportive treatment for ATN (as described). His \nrenal function gradually improved. \n\n#Anemia\nAcute decrease in Hgb to 6s while in the ICU. There were no \nactive signs of bleeding. Patient does have hx of MDS. ___ \nreceived pRBCs ___ and ___. This was monitored closely. \n\n#Coagulopathy\nINR trending upward during portion of ICU stay. Suspected to be \ndue to poor nutrition iso antibiotic use. Coags were monitored \nclosely and the pt was given IV vitamin K to correct this. \n\n# NSTEMI, Type II (supply-demand) vs Primary\n# Acute Systolic HF Exacerbation (mildly reduced EF, 40%)\nTroponin downtrended to 0.68. Cardiology was on consult. Likely \ntype II vs primary NSTEMI and missed event. Repeated TTE as \nabove. Continued ASA 81 mg. Was diuresed with Lasix as renal \nfunction tolerated to improve respiratory status and avoid \npulmonary edema. \n\n# Severe Protein Calorie Malnutrition\nFelt to be related to poor PO intake and with hypoalbuminemia \nwith low body mass, very poor intake in setting of acute illness \nand encephalopathy. Nutrition was consulted and followed \nclosely. During intubated period ___ had an OG placed; tube feed \nwere given as tolerated. \n\n# Urinary retention\nAfter extubation, foley was DCd, but the pt was found on bladder \nscan several times to have over 500cc in his bladder. \nIntermittent straight cath was used as needed to avoid \nre-placing foley. \n\nCHRONIC/STABLE PROBLEMS:\n# Low Grade MDS. ___ to follow daily CBC. Transfusion \nthreshold was < ___.\n\n# Hypothyroid\nContinued home levothyroxine converted to IV (PO:IV, 2:1 ratio) \n62.5 mg IV daily to continue dosing. \n\n# Inclusion body myositis. Stable throughout course. Avoided \nbenzodiazepines.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ferrous Sulfate 325 mg PO DAILY \n2. Levothyroxine Sodium 125 mcg PO DAILY \n3. Fludrocortisone Acetate 0.05 mg PO 4X/WEEK (___) \n4. Furosemide 30 mg PO DAILY \n5. PreserVision AREDS 2 (vit C,E-Zn-coppr-lutein-zeaxan) \n250-200-40-1 mg-unit-mg-mg oral DAILY \n\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" ]

[ "A419", "I21A1", "N170", "J9601", "E43", "R579", "J189", "I5021", "D696", "E2740", "D684", "E872", "E871", "J9819", "R040", "D469", "Z66", "Z515", "Z8546", "Z85850", "I2510", "R339", "E875", "E806", "E8809", "Z781" ]

[ "A419: Sepsis, unspecified organism", "I21A1: Myocardial infarction type 2", "N170: Acute kidney failure with tubular necrosis", "J9601: Acute respiratory failure with hypoxia", "E43: Unspecified severe protein-calorie malnutrition", "R579: Shock, unspecified", "J189: Pneumonia, unspecified organism", "I5021: Acute systolic (congestive) heart failure", "D696: Thrombocytopenia, unspecified", "E2740: Unspecified adrenocortical insufficiency", "D684: Acquired coagulation factor deficiency", "E872: Acidosis", "E871: Hypo-osmolality and hyponatremia", "J9819: Other pulmonary collapse", "R040: Epistaxis", "D469: Myelodysplastic syndrome, unspecified", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "Z8546: Personal history of malignant neoplasm of prostate", "Z85850: Personal history of malignant neoplasm of thyroid", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "R339: Retention of urine, unspecified", "E875: Hyperkalemia", "E806: Other disorders of bilirubin metabolism", "E8809: Other disorders of plasma-protein metabolism, not elsewhere classified", "Z781: Physical restraint status" ]

[ "J9601", "D696", "E872", "E871", "Z66", "Z515", "I2510" ]

[]

[ " \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:\nabd pain, diarrhea\n \nMajor Surgical or Invasive Procedure:\nColonoscopy ___\n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old man with PMHx of Crohn's disease,\nCAD (s/p coronary stent ___ years ago), and polymyalgia rheumatica\nwho presents today with complaint of 2 weeks of nonbloody\ndiarrhea (worse at night), periumbilical/mid-abdominal pain, and\ninability to tolerate PO. Patient had GI appointment today and\nwas sent to ED.\n\nPt states that symptoms began 2 weeks ago. Previously his \nCrohn's\ndisease had generally been controlled for the past ___ years on\nmesalamine. He had a colonoscopy most recently on ___ which\nshowed multiple areas of scarred mucosa c/f worsening Crohn's\ncolitis. \n\nHe describes his pain as constant and \"achy, sharp, dull,\nstabbing, and throbbing.\" He reports pain immediately after\neating and he hasn't eaten solid food \"for weeks\". No nausea or\nvomiting. He reports some improvement of his abdominal pain \nafter\nhis gastroenterologist increased his home prednisone to 40mg\ndaily one week ago, but the diarrhea has not improved with this\ntherapy. He is presently having 2 BM per day, ___ BM per night.\n\nPt required 2 visits to ___ for these\ncomplaints, including one stay x1 day, without significant\ntherapeutic improvement. Per review of records, one visit\nresulted in a CT abd/pelvis which showed moderate colitis from\nthe transverse to descending colon. Further workup from OSH\nnotable for: Negative C. diff, Shiga toxin, stool cultures. \n\nPt has not had any recent travel, ill contacts, new/exotic food\nconsumption, or antibiotic use. He complains of some achiness in\nhis neck and shoulders bilaterally, which started shortly after\nthe diarrhea and abdominal pain. He denies any fevers, chills,\nSOB, CP, palpitations, lightheadedness/dizziness, syncope,\nnausea/vomiting, hematochezia, melena, dysuria, hematuria, and\nnumbness/tingling. \n\nIn the ED, patient had one large bloody BM around ___. GI was\nmade aware. \n\nIn the ED, initial vitals: T 96.2 HR 100 BP 110/84 RR 16 Pox\n100% RA \n\n- Exam notable for: tachycardia; TTP in periumbilical area,\nepigastrium, RUQ, and LUQ; rebound tenderness in epigastrium and\nperiumbilical area\n- Labs notable for: WBS 14.5; CRP 94.5; ALT 48; Alk Phos 137;\nnegative stool cultures ; Lactate 1.2\n- Imaging notable for: OSH CT A/P showed colitis from transverse\nto descending; chest CT showed inflammation in the colon but\nnothing else. \n- Pt given: 1L NS, IV Tylenol 1 g, and 20 mg IV solumedrol\n- Vitals prior to transfer: T 97.4 HR 66 BP 112/70 RR 16 Pox 99%\nRA \n \nGI team recommended prepping for colonoscopy and holding further\nsteroids and mesalamine.\n\nUpon arrival to the floor, the patient reports some improvement\nin abdominal pain.\n\n \nPast Medical History:\nCrohn's disease (previously well controlled for 30+ years)\nCAD (s/p stent ___ years ago, unclear site)\nPolymyalgia rheumatic (on prednisone, recently uptitrated)\nAnemia\n \nSocial History:\n___\nFamily History:\nno history of IBD\n \nPhysical Exam:\n============================\nADMISSION PHYSICAL EXAM: \n============================\nVITALS: T 97.8 HR 66 BP 114/70 (lying down) Pox 97% RA\nGeneral: Alert, oriented, no acute distress \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,\nneck supple, no LAD \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops \nLungs: Clear to auscultation bilaterally, no wheezes, rales,\nrhonchi \nAbdomen: Soft, tender in all quadrants, rebound tenderness in\nepigastrium, LUQ, and RUQ; bowel sounds present; no guarding\nRectal: deferred given colonoscopy in AM\nGU: No foley \nExt: Warm, well perfused, 2+ pulses, no cyanosis or edema\nSkin: Warm, dry, no rashes. Puncture wound on right elbow from\ndog bite \nNeuro: ___ strength upper/lower extremities, grossly normal\nsensation \n\n==============================\nDISCHARGE PHYSICAL EXAM: \n==============================\nVitals: 97.4, 108 / 72, 72, 16, 96 Ra \nGeneral: Alert, oriented, in bed in no acute distress\nHEENT: Sclerae anicteric\nNeck: supple \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\ngallops \nLungs: CTAB on anterior exam, comfortable on RA \nAbdomen: Soft, nondistended, no TTP, no guarding or rebound \nExt: thin, Warm, no ___ edema \nNeuro: alert and oriented, moving all extremities spontaneously\n\n \nPertinent Results:\n=======================\nADMISSION LABS: \n=======================\n___ 02:35PM BLOOD WBC-14.5* RBC-3.79* Hgb-11.0* Hct-34.3* \nMCV-91 MCH-29.0 MCHC-32.1 RDW-15.5 RDWSD-50.1* Plt ___\n___ 02:35PM BLOOD Neuts-92* Bands-4 Lymphs-2* Monos-2* \nEos-0 Baso-0 ___ Myelos-0 AbsNeut-13.92* \nAbsLymp-0.29* AbsMono-0.29 AbsEos-0.00* AbsBaso-0.00*\n___ 02:35PM BLOOD Hypochr-NORMAL Anisocy-NORMAL \nPoiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL \nOvalocy-OCCASIONAL\n___ 02:35PM BLOOD ___ PTT-25.9 ___\n___ 02:35PM BLOOD Glucose-113* UreaN-26* Creat-0.9 Na-139 \nK-5.1 Cl-100 HCO3-24 AnGap-15\n___ 02:35PM BLOOD ALT-48* AST-31 AlkPhos-137* TotBili-0.3\n___ 02:35PM BLOOD Lipase-15\n___ 02:35PM BLOOD Albumin-3.0* Calcium-8.8 Phos-3.9 Mg-2.3\n___ 02:35PM BLOOD CRP-94.6*\n___ 02:46PM BLOOD Lactate-1.2\n\n=======================\nRELEVANT LABS: \n=======================\n___ 02:35PM BLOOD CRP-94.6*\n___ 07:45AM BLOOD CRP-79.8*\n___ 10:23AM BLOOD CRP-86.1*\n___ 07:45AM BLOOD CRP-196.5*\n___ 08:31AM BLOOD CRP-93.4*\n___ 07:49AM BLOOD CRP-47.5*\n___ 07:36AM BLOOD CRP-42.9*\n___ 07:17AM BLOOD CRP-19.7*\n___ 07:20AM BLOOD CRP-18.1*\n___ 10:23AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG\n___ 12:00AM BLOOD WBC-14.2* RBC-3.38* Hgb-10.1* Hct-30.9* \nMCV-91 MCH-29.9 MCHC-32.7 RDW-15.4 RDWSD-51.0* Plt ___\n___ 07:45AM BLOOD WBC-10.0 RBC-3.15* Hgb-9.3* Hct-29.1* \nMCV-92 MCH-29.5 MCHC-32.0 RDW-15.6* RDWSD-52.6* Plt ___\n___ 07:25AM BLOOD WBC-11.9* RBC-3.13* Hgb-9.6* Hct-29.1* \nMCV-93 MCH-30.7 MCHC-33.0 RDW-15.7* RDWSD-52.9* Plt ___\n___ 06:30AM BLOOD WBC-11.0* RBC-3.08* Hgb-9.0* Hct-27.6* \nMCV-90 MCH-29.2 MCHC-32.6 RDW-15.3 RDWSD-50.4* Plt ___\n___ 07:45AM BLOOD WBC-10.0 RBC-3.26* Hgb-9.4* Hct-29.7* \nMCV-91 MCH-28.8 MCHC-31.6* RDW-15.2 RDWSD-50.6* Plt ___\n___ 08:31AM BLOOD WBC-15.9*# RBC-3.64* Hgb-10.6* Hct-33.4* \nMCV-92 MCH-29.1 MCHC-31.7* RDW-15.3 RDWSD-51.0* Plt ___\n___ 07:49AM BLOOD WBC-16.0* RBC-3.52* Hgb-9.9* Hct-31.7* \nMCV-90 MCH-28.1 MCHC-31.2* RDW-15.4 RDWSD-50.5* Plt ___\n___ 07:36AM BLOOD WBC-13.5* RBC-3.25* Hgb-9.5* Hct-29.1* \nMCV-90 MCH-29.2 MCHC-32.6 RDW-15.2 RDWSD-49.9* Plt ___\n___ 07:17AM BLOOD WBC-13.7* RBC-3.39* Hgb-9.8* Hct-30.9* \nMCV-91 MCH-28.9 MCHC-31.7* RDW-15.4 RDWSD-50.8* Plt ___\n\n=======================\nDISCHARGE LABS: \n=======================\n___ 07:20AM BLOOD WBC-13.8* RBC-3.51* Hgb-10.3* Hct-32.0* \nMCV-91 MCH-29.3 MCHC-32.2 RDW-15.5 RDWSD-50.9* Plt ___\n___ 07:20AM BLOOD Glucose-131* UreaN-23* Creat-0.8 Na-136 \nK-4.7 Cl-100 HCO3-25 AnGap-11\n___ 07:20AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.3\n___ 07:20AM BLOOD CRP-18.1*\n\n=======================\nMICROBIOLOGY: \n=======================\n\n___: \n CLOSTRIDIUM DIFFICILE. \n Positive for toxigenic C difficile by the Cepheid \nnucleic\n amplification assay. \n\n=======================\nIMAGING: \n=======================\n\nKUB ___ \nGaseous distention of the large and small bowel which tapers at \nthe level of the descending and sigmoid colon. Decreased \nhaustral markings are noted in the descending colon. There is no \ngross pneumoperitoneum, however evaluation for free \nintraperitoneal air is limited on supine radiographs. \n\nSECOND OPINION CT TORSO: CT from outside hospital dated ___.\nExtensive colitis from the splenic flexure to the mid portion of \nthe \ndescending colon with extension to the transverse colon without \nsigns of \nperforation. Small bowel and terminal ileum are intact. \n\n====================\nPATHOLOGY \n====================\nPATHOLOGY (from colonoscopy ___\nIntestinal mucosal biopsies, seven:\n1. Terminal ileum:\nSmall intestinal mucosa, within normal limits.\n2. Cecum:\nColonic mucosa, within normal limits.\n3. Ascending:\nColonic mucosa within normal limits.\n4. Transverse:\nColonic mucosa, within normal limits.\n5. Descending:\nChronic severely active colitis with ulceration.\n6. Sigmoid:\nPaneth cell metaplasia consistent with chronic inactive colitis.\n7. Rectum:\nFocal Paneth cell metaplasia consistent with chronic inactive \ncolitis.\n\n \nBrief Hospital Course:\n==================\nBRIEF SUMMARY \n==================\nMr. ___ is a ___ year old male with history of Crohn's \ndisease previously well controlled on mesalamine, CAD s/p stent \n___ years ago, and polymyalgia rheumatica who presented with 2 \nweeks of abdominal pain, diarrhea and poor PO, found to have a \nCrohn's flare as well as concurrent c diff infection. He was \ntreated with IV methylprednisolone without marked improvement, \nso he was started on infliximab on ___, to good effect, and \ntransitioned to PO prednisone for discharge. He is receiving PO \nVancomycin for the c diff infection. \n\n=====================\nPROBLEM-BASED SUMMARY \n=====================\n\nACUTE/ACTIVE PROBLEMS: \n\n# Crohn's disease \nPatient has a long history of Crohn's disease, previously well \ncontrolled on mesalamine with the last flare ___ years ago. CT \nA/P performed on ___ at ___, and reviewed \nby ___ radiology, showed colitis from the transverse to the \ndescending colon. Colonoscopy this admission showed deep \ncircumferential ulcerations from the transverse colon through to \nthe sigmoid colon, with pathology revealing chronic severely \nactive colitis with ulceration in the descending colon. \nPresentation felt to be most consistent with Crohn's flare. He \nreceived IV methylprednisolone without appropriate improvement, \nso was started on infliximab (first infusion ___, 10 mg/kg), \nwhich he tolerated well. He was evaluated by colorectal surgery; \nno need for acute intervention. He improved symptomatically \nafter the infliximab and was transitioned to PO prednisone for \ndischarge. He is planned for a repeat infusion of infliximab at \n1 week (10mg/kg), for an escalated induction dosing, arranged \nwith his outpatient GI, Dr. ___ ___. He will be \ndischarged on prednisone PO 40mg daily. \n\n# C Diff \nPatient presented with abdominal pain and diarrhea, WBC 14.5 on \nadmission, positive c diff. He was treated with PO Vancomycin, \nfor a planned 14-day course (day ___, last day will be on \n___. To our knowledge, this is his first episode of c diff \ninfection. \n\n# Hematochezia \nPatient had one episode of hematochezia in the ED, with no other \nevents. Possible source may be related to colitis. There was no \nconcern for active GI bleeding during admission. \n\n# Malnutrition\nPatient was followed by nutrition while inpatient. By discharge, \nhe was tolerating improved PO and eating well. \n\nCHRONIC PROBLEMS: \n\n# Anemia \nPatient reports a history of chronic anemia on home B12. \nDischarge hemoglobin was 10.3. \n\n# CAD \nHome clopidogrel was held this admission, as his last stent was \nplaced ___ years ago. He was continued on home atorvastatin and \naspirin. Attempt was made to reach out to outpatient \ncardiologist Dr. ___ by email regarding the clopidogrel. \nPlease readdress clopidogrel at his outpatient cardiology \nappointment. \n\n# PMR: Stable. \n\n====================\nTRANSITIONAL ISSUES\n====================\n\n- Please evaluate for depression and consider starting an \nantidepressant as an outpatient. Wife notes that patient seems \nto have depressed mood at home, does not leave the house. \n- Follow up with cardiology, to readdress clopidogrel \n(clopidogrel was held this admission, as his last stent was ___ \nyears ago). \n- Patient is to complete 14-day course of PO Vancomycin for c \ndiff (day ___, last day on ___. \n- He will need HBV/HAV vaccines, pneumovax, prevnar and flu \nvaccines as an outpatient. \n- He will need regular skin check with either dermatology or PCP \nas an outpatient. \n\nNew medications: PO Vancomycin, Remicade\nStopped medications: Clopidogrel, mesalamine \nChanged medications: Prednisone 40 daily \n\n# Code status: Full\n# Health care proxy/emergency contact: ___, wife, \n___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 40 mg PO QPM \n2. Clopidogrel 75 mg PO DAILY \n3. PredniSONE 40 mg PO DAILY \n4. Mesalamine ___ 1200 mg PO TID \n5. Cyanocobalamin ___ mcg PO DAILY \n6. Aspirin 81 mg PO DAILY \n7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n\n \nDischarge Medications:\n1. Vancomycin Oral Liquid ___ mg PO Q6H \nRX *vancomycin 125 mg/2.5 mL 125 mg by mouth every 6 hours Disp \n#*21 Syringe Refills:*0 \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 40 mg PO QPM \n4. Cyanocobalamin ___ mcg PO DAILY \n5. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n6. PredniSONE 40 mg PO DAILY \n7. HELD- Clopidogrel 75 mg PO DAILY This medication was held. \nDo not restart Clopidogrel until you discuss it with your \ncardiologist. \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n=====================\nPRIMARY DIAGNOSIS:\n=====================\nCrohn's disease\nClostridium difficile infection\nHematochezia\n=====================\nSECONDARY DIAGNOSIS:\n=====================\nAnemia\nCoronary artery disease\nPolymyalgia rheumatica\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___, \n\nIt was a pleasure to care for you at the ___ \n___. Please find detailed discharge instructions \nbelow: \n\nWHY WERE YOU ADMITTED TO THE HOSPITAL? \n- You were admitted because you had abdominal pain and diarrhea. \n\n\nWHAT HAPPENED TO YOU IN THE HOSPITAL? \n- Your symptoms were thought to be primarily from a flare of \nyour Crohn's disease.\n- You were also found to have a GI infection, called \"c diff\", \nthat can also cause diarrhea and abdominal pain. \n- You received a colonoscopy, which showed inflammation in parts \nof your large intestine. \n- You required IV steroids for your Crohn's flare. \n- You required an additional therapy to suppress inflammation \ncalled Remicade (infliximab) to treat your Crohn's flare. \n- You did well after receiving the Remicade, so you were \ntransitioned to oral steroids for discharge. \n- You were treated with oral antibiotics (vancomycin) for your c \ndiff infection. \n\nWHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL? \n- Please go to all your appointments as scheduled. \n- Please take all your medications as prescribed. \n- You will need another infusion of the Remicade 1 week after \nthe first one, so please make sure to follow up at your GI \ndoctor appointment. \n\nWe wish you the best! \n- Your ___ treatment team \n \nFollowup Instructions:\n___\n" ]

[ "K5010", "K921", "E46", "A047", "D649", "I2510", "Z955", "M353", "Z6822" ]

[ "K5010: Crohn's disease of large intestine without complications", "K921: Melena", "E46: Unspecified protein-calorie malnutrition", "A047: Enterocolitis due to Clostridium difficile", "D649: Anemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z955: Presence of coronary angioplasty implant and graft", "M353: Polymyalgia rheumatica", "Z6822: Body mass index [BMI] 22.0-22.9, adult" ]

[ "D649", "I2510", "Z955" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nHaldol / pollen / Actos / NSAIDS (Non-Steroidal \nAnti-Inflammatory Drug) / ibuprofen / cefazolin\n \nAttending: ___.\n \nChief Complaint:\nLightheadedness and dizziness \n \nMajor Surgical or Invasive Procedure:\nTunneled HD Line Replacement ___ \n\n \nHistory of Present Illness:\nMr. ___ is a ___ year old man with ESRD (___\nHD), DM, bipolar disorder and recent hospitalization for \ninfected\nright upper extremity fistula who presents with lightheadedness\nand dizziness and was found to have anemia. \n \nPatient was discharge on ___ and returned home with OPAT\nfollowing for IV antibiotics. He developed a rash around ___ and\nhis antibiotics were changed from cefazolin to vancomycin. Seen\nby dermatology on ___ who thought most likely leukocytoclastic\nvasculitis and agreed with changing antibiotic regimen. He's \nbeen\nusing a steroid cream with some improvement in his pruritis. \n\nHad HD on ___ with reportedly poor HD catheter function. Patient\nwas seen at outside facility today for a catheter exchange when\nhe was noted to have a Hgb of 6.3 (baseline ___. He was sent \nto\nthe ED for further management. Of note, his last dialysis was\n___. \n\nPatient reports 8 episodes of diarrhea last night (not atypical\nfor him given IBS) with some hematochezia. He reports the\nhematochezia began just a few days ago and his last episode of\nhematochezia was the evening on ___. He describes \"a very small\namount\" of blood along with yellow/brown stool. He endorses\nlightheadedness and dizziness as well. His allergies have been\nsignificantly bothering him, causing shortness of breath in\naddition to nasal congestion. \n\n \nPast Medical History:\nESRD on HD\nHTN\nHLD\nNIDDM\nSchizoaffective disorder\nGout\nTremors \nH/o uremic pericarditis s/p emergent pericardiocentesis\nR radiocephalic AVF (___)\nAVF ulceration w/ AV loop graft on ___ \nR ankle arthrocentesis (___)\nB/l cataract surgery \n \nSocial History:\n___\nFamily History:\nMother: Passed away at age ___ from non-Hodgkins lymphoma, \novarian cancer\nFather: Alive and well at ___\nGrandfather: ___\nOtherwise, no family history of heart disease or kidney disease\n \nPhysical Exam:\n==============================\nADMISSION PHYSICAL EXAMINATION\n==============================\nVITALS: BP:152/80 HR:69 RR:20 O2:91RA \nGENERAL: Comfortable appearing man lying in bed and speaking to\nme in no apparent distress. \nHEENT: Pupils equal and reactive, no scleral icterus or\ninjection. Moist mucous membranes. \nNECK: No submandibular lymphadenopathy. \nCARDIAC: S1/S2 regular with no murmurs, rubs or S3/S4. \nLUNGS: Clear bilaterally. No wheezing, rhonchi, crackles. No use\nof accessory muscles. Occassional dry cough. \nABDOMEN: Soft, non-distended, non-tender to palpation. \nEXTREMITIES: 1+ pitting edema to the knee bilaterally. \nSKIN: Purpuric macules and papules and patches on the bilateral\nlower\nextremities extending onto the thighs. Two biopsies sites on \nleft\nthigh. Hyperkaratotic lesion on forehead and L groin. Fungal \nrash\nin L groin. \nNEUROLOGIC: CNII-XII intact. A+Ox3. Able to recall all\nmedications and doses. Grossly normal strength. \n\n==============================\nDISCHARGE PHYSICAL EXAMINATION\n==============================\nVS: 97.8F 146/72 HR 88 RR 18 99% RA\nGENERAL: lying on bed, comfortable \nHEENT: PERRL, mmm, oropharynx clear\nCARDIAC: regular rate and rhythm, no murmurs, left HD cath c/d/i\nLUNGS: CTAB, no wheezing, crackles, rhonchi \nABDOMEN: Soft, non-distended, non-tender to palpation. \nEXTREMITIES: Non-edematous bilaterally, non-tender \nSKIN: erythematous macules on biliateral lower extremities,\nimproving; Dressing covering right forearm graft wound. \nNEUROLOGIC: CNII-XII intact. A+Ox3. moving all extremities with\npurpose \n\n \nPertinent Results:\nADMISSION LABS \n==============\n___ 11:50AM BLOOD WBC-3.6* RBC-1.91* Hgb-6.0* Hct-18.9* \nMCV-98 MCH-31.4 MCHC-31.9* RDW-14.9 RDWSD-53.0* Plt ___\n___ 11:50AM BLOOD Neuts-60.4 ___ Monos-9.0 Eos-3.4 \nBaso-0.0 Im ___ AbsNeut-2.15 AbsLymp-0.82* AbsMono-0.32 \nAbsEos-0.12 AbsBaso-0.00*\n___ 11:50AM BLOOD Plt ___\n___ 11:50AM BLOOD ___ PTT-28.2 ___\n___ 11:50AM BLOOD Glucose-110* UreaN-36* Creat-8.0*# Na-135 \nK-5.2 Cl-99 HCO3-22 AnGap-14\n___ 09:59AM BLOOD cTropnT-0.04*\n___ 04:15PM BLOOD cTropnT-0.08*\n___ 08:21AM BLOOD cTropnT-0.06*\n___ 07:55AM BLOOD calTIBC-248* Hapto-238* Ferritn-1378* \nTRF-191*\n___ 09:18AM BLOOD Vanco-12.6\n___ 07:10AM BLOOD Vanco-21.6*\n___ 07:00AM BLOOD Vanco-28.2*\n\nDISCHARGE LABS \n==============\n___ 06:00AM BLOOD WBC-4.6 RBC-2.34* Hgb-7.3* Hct-22.2* \nMCV-95 MCH-31.2 MCHC-32.9 RDW-16.1* RDWSD-54.5* Plt Ct-73*\n___ 06:00AM BLOOD Plt Ct-73*\n___ 06:00AM BLOOD Glucose-107* UreaN-27* Creat-5.3*# \nNa-134* K-4.3 Cl-92* HCO3-26 AnGap-16\n\nIMAGING \n=======\n\nCXR ___ \nThere has been placement of a left subclavian hemodialysis \ncatheter whose tip projects over the right atrium. \nThere are low bilateral lung volumes with moderate pulmonary \nedema. The size of the cardiac silhouette is enlarged but \nunchanged. Layering bilateral pleural effusions are suspected. \nNo pneumothorax. \n\nCXR ___ \nComparison to ___. Decrease in severity of the \npre-existing pulmonary edema. The edema is now mild to \nmoderate. No larger pleural effusions. Low lung volumes and \nborderline size of the cardiac silhouette persist. \n\n___ ___ \n1. No evidence of deep venous thrombosis in the right or left \nlower extremity \nveins. \n2. Multiple, prominent/enlarged left groin lymph nodes, likely \nreactive PA \n\nTTE ___ \nAdequate image quality. Moderate symmetric left ventricular \nhypertrophy with normal cavity size and regional/global \nbiventricular systolic function. Bilateral pleural effusions \nwithout pericaridal effusion.\nNo pathologic valvular flow identified.\n\nCXR ___ \n1. Hemodialysis catheter in appropriate position. \n2. Interval resolution of previously seen pulmonary edema. \nPersistent small left pleural effusion. \n\nMICROBIOLOGY \n============\nBlood culture ___: No growth to date \n\n \nBrief Hospital Course:\nSUMMARY STATEMENT \n=================\nMr. ___ is a ___ year old man with ESRD (___ HD), DM, bipolar \ndisorder and recent hospitalization for infected right upper \nextremity fistula who presents with symptomatic anemia and \nclotting of dialysis access. \n\nACUTE ISSUES\n============\n#Dyspnea\nPatient reports several days of dyspnea and dry cough that he \nfeels is related to allergies. Occasionally takes allergra but \nhas not done so recently. Lungs clear to auscultation and no \nevidence of pneumonia. Likely secondary to volume overload from \nmissing hemodialysis sessions as he was weaned from 5L to RA \nafter two sessions of HD and ~5L removed. Low Wells score and \nnegative LENIs argue against PE. TTE did not show new CHF. \nStarted on fexofenadine for allergies. \n\n#Bradycardia\nPatient presented with HRs ___ early during admission. EKG \nshowed sinus bradycardia. Bradycardia improved during and after \ndialysis suggesting electrolyte abnormalities were the cause, \nparticularly hyperkalemia (K 8.2). Patient had one episode of \nbradycardia to HR ___ overnight during sleep but was \nasymptomatic. No clear evidence for heart block. No further \nbradycardic events on telemetry were discovered after another 48 \nhours. \n\n# Acute on chronic anemia\nPresented with 1.3 point drop in Hgb over 3 weeks. Hgb 6.8 to \n10.4 at various points in ___. In ___ consistently Hgb in 7's, \nand discharged ___ with Hgb 7.3. Iron studies this admission \nsuggest AOCD. No hematochezia observed while inpatient. Guaiac \nnegative in the ED. History of colonic polyps, though none seen \n___ colonoscopy. EGD in ___ with gastritis, but \nunlikely upper GI bleed given hematochezia. Highest likelihood \nis hemorrhoids on top of chronic anemia. Transfused with 1U RBC \nwith HD. Hemoglobin remained stable thereafter. \n\n#HTN \nPatient has been hypertensive during this admission with SBP up \nto 190s particularly with activity. Increased home amlodipine to \n10 mg daily and started lisionpril 5 mg daily. Potassium levels \nremained stable after starting lisinopril. Held home propranolol \nin the setting of bradycardia.\n\n# ESRD \n# Non-functioning tunneled HD line\n___ exchanged HD line on ___ for poor line function discovered at \ndialysis. Underwent HD on ___ and ___ with improvement of \nsymptoms. Continued on nephrocaps, low potassium diet. \n\n#Hyperkalemia \nPatient had hyperkalemia to 8.2 on morning after admission, \nwhich increased from 5.2 over the course of 1 day. Unclear cause \nfor hyperkalemia. Possibly due to missing a session of dialysis. \nAlso received a transfusion, but labs do not suggest hemolysis. \nHis potassium remained wnl after dialysis. Nutrition consulted \nto educate patient about low potassium diet. \n\n#Infected Graft\nPatient presented to ___ in ___ with sepsis and high grade \nMSSA bacteremia and RUE AV graft infection. ___ drainage ___ \ngrew MSSA. ___ blood cultures grew four of four bottles MSSA\nbacteremia, and also ___ positive on ___. Blood cultures \nnegative ___. Course complicated by lower extremity rash \nconsistent with LCV and changed from cefazolin to vancomycin on \n___. Continued vancomycin post-HD. Vancomycin with goal trough \n___ until ___.\n\n#Leukocytoclastic Vasculiits \nSeen by dermatology and punch biopsy performed on left thigh. \nThought likely secondary to cefazolin. ___ skin biopsy shows \nIgA and C3 deposition within papillary dermal vessel walls, \nsuggestive of IgA vasculitis. Discussed with renal who \nrecommended no further work-up or treatment given chronic ESRD. \nContinued triamcinolone cream 0.1% 14 day course (___). \n\n#Thrombocytopenia \n#Lymphocytopenia\nThrombocytopenia dating back to at least ___. Also noted to \nhave lymphocytopenia and 1 atypical form in ___. \nDifferential is broad and likely explanations in this patient \ninclude alcohol use, renal failure, valproic acid use. Zinc \ndeficiency, sarcoidosis, bone marrow disorder, ITP, liver \ndisease are less\nlikely. HIV previously negative. Consider further workup as an \noutpatient.\n\nCHRONIC ISSUES\n==============\n#Tremor- Continued Benztropine and held propranolol due to \nbradycardia \n#HLD- Continued pravastatin 40mg daily \n#NIDDM- Held home glipizide and managed on ISS \n#Schizoaffective disorder- Continued risperdal and depakote\n\nTI: \n[ ] Patient will need to continue post-HD vancomycin until ___ \nto complete antibiotic course for RUE AV graft infection. Per \npharmacy, patient should receive 1000 mg vancomycin with HD on \n___ and then dose should be adjusted based on trough levels \ndrawn at HD per HD protocol.\n[ ] Started on fexofenadine 60 mg daily for seasonal allergies \n[ ] Please continue to monitor HTN. Increased amlodipine to 10 \nmg daily, started lisinopril 5 mg daily. Held home propranolol \nfor bradycardia. \n[ ] Continue triamcinolone cream 0.1% to finish 14 day course \n(___)\n[ ] Consider outpatient work-up of chronic thrombocytopenia \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild \n2. Benztropine Mesylate 2 mg PO QHS \n3. Nephrocaps 1 CAP PO DAILY \n4. Pravastatin 40 mg PO DAILY \n5. Propranolol 20 mg PO BID \n6. RisperiDONE 3 mg PO DAILY \n7. Vitamin D 1000 UNIT PO DAILY \n8. amLODIPine 7.5 mg PO DAILY \n9. Divalproex (DELayed Release) 1000 mg PO QHS \n10. GlipiZIDE 20 mg PO QAM \n11. GlipiZIDE 10 mg PO QPM \n12. Viagra (sildenafil) 20 mg oral PRN \n13. Vancomycin 1000 mg IV POST HD (___) \n14. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID \n\n \nDischarge Medications:\n1. Fexofenadine 60 mg PO DAILY \nRX *fexofenadine 60 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0 \n2. Fluticasone Propionate NASAL 2 SPRY NU BID \nRX *fluticasone 50 mcg/actuation 2 SPRY daily Disp #*1 Spray \nRefills:*0 \n3. Lisinopril 5 mg PO DAILY \nRX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n4. amLODIPine 10 mg PO DAILY \nRX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n5. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild \n6. Benztropine Mesylate 2 mg PO QHS \n7. Divalproex (DELayed Release) 1000 mg PO QHS \n8. GlipiZIDE 10 mg PO QPM \n9. GlipiZIDE 20 mg PO QAM \n10. Nephrocaps 1 CAP PO DAILY \n11. Pravastatin 40 mg PO DAILY \n12. RisperiDONE 3 mg PO DAILY \n13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID \n14. Vancomycin 1000 mg IV POST HD (___) \n15. Viagra (sildenafil) 20 mg oral PRN \n16. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nEnd Stage Renal Disease\nAnemia of Chronic 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\nIt was a pleasure caring for you at ___ \n___!\n\nWHY WERE YOU ADMITTED?\n-You were admitted for shortness of breath and lightheadedness. \n\nWHAT HAPPENED IN THE HOSPITAL?\n-You had your dialysis line exchanged. \n-You underwent hemodialysis to treat your electrolyte \nabnormalities and remove excess fluid. \n-Your symptoms were most likely due to missing hemodialysis. \n-You received blood transfusions for anemia, which improved \nafter transfusions. \n\nWHAT SHOULD YOU DO AT HOME?\n-You should continue to take your medications as prescribed. \n-You should follow-up with your doctors based on the \nappointments listed below. \n\nThank you for allowing us be involved in your care, we wish you \nall the best!\n\nYour ___ Team\n\n \nFollowup Instructions:\n___\n" ]

[ "T82868A", "N186", "D62", "I120", "J811", "R251", "T827XXA", "E785", "F259", "Y832", "Y929", "Z87891", "B9561", "I776", "D696", "K649", "D72810", "E1122", "Z992", "E875", "R001", "R0902" ]

[ "T82868A: Thrombosis due to vascular prosthetic devices, implants and grafts, initial encounter", "N186: End stage renal disease", "D62: Acute posthemorrhagic anemia", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "J811: Chronic pulmonary edema", "R251: Tremor, unspecified", "T827XXA: Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter", "E785: Hyperlipidemia, unspecified", "F259: Schizoaffective disorder, unspecified", "Y832: Surgical operation with anastomosis, bypass or graft as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "Z87891: Personal history of nicotine dependence", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere", "I776: Arteritis, unspecified", "D696: Thrombocytopenia, unspecified", "K649: Unspecified hemorrhoids", "D72810: Lymphocytopenia", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "Z992: Dependence on renal dialysis", "E875: Hyperkalemia", "R001: Bradycardia, unspecified", "R0902: Hypoxemia" ]

[ "D62", "E785", "Y929", "Z87891", "D696", "E1122" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nHaldol / pollen / Actos / NSAIDS (Non-Steroidal \nAnti-Inflammatory Drug) / ibuprofen / cefazolin / coriander\n \nAttending: ___.\n \nChief Complaint:\nArm Swelling\n \nMajor Surgical or Invasive Procedure:\nFistulogram with angioplasty ___\n\n \nHistory of Present Illness:\n___ y/o male with ESRD ___ DM on Dialysis MWF with recent right\narm graft placement in ___ presenting from dialysis center\ntoday given concern for swelling of the RUE. \n\nPatient states that he has had swelling in the right arm, from\nelbow down for a long time but has been having new, worsening\nswelling in the right upper arm. During Last dialysis session on\n___, swelling was noted but was able to complete\ndialysis. However, swelling has gotten worse since then and he\nwas sent in directly from dialysis without starting the session. \n\n\nOf note, patient had an AV fistulogram in ___ without \nevidence\nof stenosis or other significant abnormality in the access or\noutflow venous system. The SCV stenosis that was previously \nknown\nshowed ~30% stenosis after angioplasty in ___. However, given\npatient's symptoms of ongoing swelling in the arm, angioplasty\nwas performed with 10%residual stensosis. He was later seen by\nDr. ___ in ___ with plan for possible repeat procedure by Dr.\n___ central vein stenosis evaluation with possible banding \nof\nthe access due to persistent high flow to reduce the persistent\nright arm swelling. \n\n- In the ED, initial vitals were:\nT 97.6 HR 88 BP 129/79 RR 16 O2 99% RA \n\n- Exam was notable for:\nGen: Lying in bed comfortably, eyes closed but conversant and\nopens eyes to command\nCV: RRR, no r/m/g\nPulm: CTAB\nAbdom: soft, NTND\nExt: Right arm with significant swealling throughout without\nevidence of erythema or warmth, no pain on plapation. RUE AV\ngraft with palpable thrill in the distal end and without clear\nthrill on the proximal side, +bruit\n\n- Labs were notable for:\n139 98 50 AGap=19 \n-------------< 175\n4.3 22 9.9 \n\n 8.7\n4.8>----<66 \n 27.4 \n\nCa: 9.5 Mg: 1.6 P: 8.1\n\n- Studies were notable for:\nRUQUS\n1. Patent right brachiocephalic AV graft.\n2. No evidence of deep vein thrombosis in the right upper\nextremity, though exam limited for evaluation of compressibility\nof the axillary and brachial veins.\n\n- The patient was given:\n___ 19:02 PO/NG Benztropine Mesylate 2 mg \n___ 19:02 PO Pravastatin 40 mg \n\nConsults in the ED included:\n- Renal: No acute HD needs. Pending ___ fistulogram. Will need to\nbe re-assessed for HD need post-procedure\n- ___: will plan on tomorrow pending schedule\n- Transplant surgery: Progressively swollen right arm iso RUE AV\ngraft, has had prior SCV angioplasty as well as angioplasty\nw/stenting of venous anastamosis earlier this year for similar\nissue. Patient needs ___ fistulogram. Would have patient seen by\nrenal dialysis team as well, as he missed his dialysis today due\nto his RUE swelling.\n\nOn arrival to the floor, the patient endorses the history as\nabove. Endorses 1 day history of right arm swelling without pain\nor parathesias. Does endorse a cough for the last ___ days,\nwithout fevers or chills.\n\n \nPast Medical History:\nESRD on HD\nHTN\nHLD\nNIDDM\nSchizoaffective disorder\nGout\nTremors \nH/o uremic pericarditis s/p emergent pericardiocentesis\nR radiocephalic AVF (___)\nAVF ulceration w/ AV loop graft on ___ \nR ankle arthrocentesis (___)\nB/l cataract surgery \n\n \nSocial History:\n___\nFamily History:\nMother: Passed away at age ___ from non-Hodgkins lymphoma, \novarian cancer\nFather: Alive and well at ___\nGrandfather: ___\nOtherwise, no family history of heart disease or kidney disease\n \nPhysical Exam:\nADMISSION EXAM:\n===============\nVITALS: 97.5 PO 164 / 60 Lying 88 18 99 Ra \nGENERAL: Alert and interactive. In no acute distress.\nHEENT: Sclera anicteric and without injection. MMM.\nNECK: No JVD.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. \nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants.\nEXTREMITIES: Ext: RUE AVG with +thrill, palpable distal radial\npulse, ___ grip strength, intact sensation to light touch. RUE\nwith marked\nswelling and edema from fingers up to shoulder. \nSKIN: Warm. Cap refill <2s. No rashes.\nNEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. ___ strength\nthroughout. Normal sensation.\n\nDISCHARGE EXAM:\n===============\n___ 0817 Temp: 97.9 PO BP: 137/81 L Sitting HR: 71 RR: 18 \nO2\nsat: 96% O2 delivery: Ra FSBG: 124 \nGENERAL: Alert and interactive. In no acute distress.\nHEENT: Sclera anicteric and without injection. MMM.\nNECK: No JVD.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. \nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants.\nEXTREMITIES: Ext: RUE AVG with +thrill, palpable distal radial\npulse, ___ grip strength, intact sensation to light touch. RUE\nwith marked swelling and edema from fingers up to shoulder. LUE\nerythema and tenderness proximal to elbow\nSKIN: Warm. Cap refill <2s. No rashes.\nNEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. ___ strength\nthroughout. Normal sensation.\n \nPertinent Results:\nADMISSION LABS:\n==============\n\n___ 12:18PM BLOOD WBC-4.8 RBC-2.69* Hgb-8.7* Hct-27.4* \nMCV-102* MCH-32.3* MCHC-31.8* RDW-13.8 RDWSD-51.2* Plt Ct-66*\n___ 12:18PM BLOOD Glucose-175* UreaN-50* Creat-9.9*# Na-139 \nK-4.3 Cl-98 HCO3-22 AnGap-19*\n___ 12:18PM BLOOD Calcium-9.5 Phos-8.1* Mg-1.6\n\nPERTINENT RESULTS:\n=================\nUpper Extremity Ultrasound: ___\n\"1. Patent right brachiocephalic AV graft.\n2. No evidence of deep vein thrombosis in the right upper \nextremity, though\nexam limited for evaluation of compressibility of the axillary \nand brachial\nveins.\"\n\nFistulogram with angiogram: ___\n\"FINDINGS: The procedure indications, risks, benefits and \nalternatives were explained in detail to the patient and \nwritten,\ninformed consent was obtained. The patient was placed supine on \nthe table in the OR suite. The right upper extremity\nwas prepped and draped in usual sterile fashion.\nUsing 1% lidocaine for local anesthesia, the dialysis access was \ncannulated at the upper arm AV graft using a 21 gauge\nmicropuncture kit in the antegrade direction.\nA complete dialysis access angiogram was performed which \nrevealed 80% stenosis at the brachiocephalic vein.\nRetrograde angiogram was performed by injecting contrast through \nthe sheath while occluding the outflow. It revealed\nno evidence of stenosis of the arterial portion of the access \nand adjacent artery.\nA wire was advanced through the sheath under fluoroscopic \nguidance and across the area of stenosis. The angioplasty\nballoon (12 MM Conquest ) was advanced over the wire to the \nbrachiocephalic vein stenosis. Angioplasty was\nperformed. The balloon was then removed. A post angioplasty \nangiogram was performed which revealed no residual\nstenosis.\nA wire was advanced through the sheath under fluoroscopic \nguidance and across the area of stenosis. The angioplasty\nballoon (12 MM x 40 mm Lutonix drug eluting balloon) was \nadvanced over the wire to the brachiocephalic vein stenosis.\nAngioplasty was performed. The balloon was then removed. A post \nangioplasty angiogram was performed which\nrevealed no residual stenosis.\nCONCLUSIONS: The patient has a right upper arm straight graft. - \nPercutaneous angioplasty of the brachiocephalic\nvein with a 12 mm lutonix drug eluting balloon and no residual \nstenosis.\"\n\nDISCHARGE LABS:\n==============\n\n___ 06:05AM BLOOD WBC-4.3 RBC-2.70* Hgb-8.8* Hct-26.2* \nMCV-97 MCH-32.6* MCHC-33.6 RDW-13.7 RDWSD-48.7* Plt Ct-71*\n___ 07:53AM BLOOD Glucose-117* UreaN-30* Creat-6.0*# Na-135 \nK-4.2 Cl-89* HCO3-28 AnGap-18\n___ 07:53AM BLOOD Calcium-9.7 Phos-5.6* Mg-1.8\n \nBrief Hospital Course:\nSUMMARY:\n========\n___ y/o male with ESRD ___ DM on Dialysis MWF with recent right \narm graft placement in ___ presenting from dialysis center w/ \nseverely edematous RUE concerning for possible SCV stenosis. \nFistula was able to be accessed for dialysis and patient \nunderwent HD without complication this admission with \nfistulogram with angioplasty notable for proximal stenosis of \nthe brachiocephalic vein without residual stenosis\n\nACUTE/ACTIVE ISSUES:\n====================\n#RUE swelling c/f subclavian stenosis\n#ESRD on HD (___)\nPatient presenting with progressively swollen right arm in the \nsetting of RUE AV graft. He has had prior SCV angioplasty as \nwell as angioplasty w/ stenting of venous anastamosis earlier \nthis year for similar issue. He was admitted for fistulogram and \nunderwent this procedure ___. Fistulogram was notable for \nproximal stenosis of the brachiocephalic vein now s/p \nangioplasty with drug eluting balloon and no residual stenosis. \nFistula was still functional during hospitalization and he was \nable to continue with his normal dialysis schedule (MWF). Will \nrecommend R arm elevation at home and AV care will arrange \nfollow up within ___ weeks as an outpatient. \n\nCHRONIC/STABLE ISSUES:\n======================\n#Macrocytic anemia\nStable from prior. Chronic. No signs of active bleeding. Vitamin \nB12, folate within normal limits. No evidence of iron \ndeficiency. Likely ___ renal disease and chronic illness. Please \ncontinue follow up with renal and primary care provider as an \noutpatient. \n\n#Thrombocytopenia\nStable from prior. Chronic dating back to ___. Will differ \nfurther workup to PCP as an outpatient.\n\n#Hyperlipidemia: Continue home pravastatin 40 mg PO QPM. \n\n#NIDDM: Resume home glipizide at discharge.\n\n#Schizoaffective disorder: Continue home divaloproex, \nrisperidone, benztropine. \n\n#HTN: Continue home lisinopril.\n\nTRANSITIONAL ISSUES:\n====================\n[ ] Underwent angioplasty of RUE AV graft with good result per \nAV care team during admission. Please ensure follow up with AV \ncare team within ___ weeks of discharge and continued R arm \nelevation at home. The AV care team will call Mr. ___ within \nthe next ___ days to schedule this appointment. \n[ ] Please continue to monitor anemia as an outpatient per renal \nteam/PCP\n[ ] Workup of chronic thrombocytopenia as per PCP\n\n# CONTACT: ___ \nRelationship: Brother \nPhone number: ___ \n\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Benztropine Mesylate 2 mg PO QHS \n2. Divalproex (DELayed Release) 1000 mg PO QHS \n3. Divalproex (DELayed Release) 500 mg PO QAM \n4. RisperiDONE 2 mg PO DAILY \n5. Pravastatin 40 mg PO QPM \n6. Calcium Acetate 1334 mg PO TID W/MEALS \n7. sildenafil 50 mg oral DAILY:PRN \n8. GlipiZIDE 20 mg PO DAILY \n9. GlipiZIDE 10 mg PO QHS \n10. amLODIPine 10 mg PO DAILY \n11. Lisinopril 5 mg PO DAILY \n\n \nDischarge Medications:\n1. amLODIPine 10 mg PO DAILY \n2. Benztropine Mesylate 2 mg PO QHS \n3. Calcium Acetate 1334 mg PO TID W/MEALS \n4. Divalproex (DELayed Release) 1000 mg PO QHS \n5. Divalproex (DELayed Release) 500 mg PO QAM \n6. GlipiZIDE 10 mg PO QHS \n7. GlipiZIDE 20 mg PO DAILY \n8. Lisinopril 5 mg PO DAILY \n9. Pravastatin 40 mg PO QPM \n10. RisperiDONE 2 mg PO DAILY \n11. sildenafil 50 mg oral DAILY:PRN \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis:\nAV fistula stenosis\n\nSecondary Diagnosis:\nESRD on HD\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 the ___ \n___! \n\nWhy was I admitted to the hospital? \n-You were admitted because you had R arm swelling. \n\nWhat happened while I was in the hospital? \n-You underwent a fistulogram procedure to evaluate your dialysis \ngraft. The procedure showed a blockage in your graft which was \nlikely causing your symptoms. This blockage was opened during \nthe procedure to allow adequate blood flow.\n\nWhat should I do after leaving the hospital? \n- Please take your medications as listed in discharge summary \nand follow up at the listed appointments. \n\nThank you for allowing us to be involved in your care, we wish \nyou all the best! \n\nSincerely,\n\nYour ___ Healthcare Team \n \nFollowup Instructions:\n___\n" ]

[ "T82858A", "N186", "I120", "I871", "E1122", "Z992", "D539", "D696", "Z7984", "E785", "Z87891", "F259", "Z7289" ]

[ "T82858A: Stenosis of other vascular prosthetic devices, implants and grafts, initial encounter", "N186: End stage renal disease", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "I871: Compression of vein", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "Z992: Dependence on renal dialysis", "D539: Nutritional anemia, unspecified", "D696: Thrombocytopenia, unspecified", "Z7984: Long term (current) use of oral hypoglycemic drugs", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence", "F259: Schizoaffective disorder, unspecified", "Z7289: Other problems related to lifestyle" ]

[ "E1122", "D696", "E785", "Z87891" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nHaldol / pollen / Actos / NSAIDS (Non-Steroidal \nAnti-Inflammatory Drug)\n \nAttending: ___\n \nChief Complaint:\nRUE Fistula ulcer\n \nMajor Surgical or Invasive Procedure:\nRight AV Fidtula ligation and revision with AV loop graft\n\n \nHistory of Present Illness:\nMr. ___ is a ___ with a PMH pertinent for schizoaffective\ndisorder, HTN, and ESRD ___ DM2 who presents with a draining\nulcer from his RUE AV fistula. He has had a dry scab overlying\nthe distal aspect of his fistula for nearly a month, but today \nat\nHD the scab flaked off and the ulcer was noted by his\nnephrologist, who recommended he present to the ED. There he was\nfound to be afebrile and hemodynamically appropriate with a\nshallow, clean-based violaceous-rimmed ulcer without active\nbleeding or drainage. The puncture site from his recent HD was\nalso noted to be hemostatic. He denied fever, chills, nausea,\nvomiting, SOB, chest pain, presyncope, melena, hematochezia,\ndysuria and hematuria. He does endorse regular diarrhea. He\ndenies any issues with his dialysis today, and states it was \nable\nto be completed as expected despite the presence of the ulcer,\nwithout any unusual hemodynamic events.\n\n \nPast Medical History:\nESRD on HD\nHTN\nHLD\nNIDDM\nSchizoaffective disorder\nGout\nH/o uremic pericarditis s/p emergent pericardiocentesis\nR radiocephalic AVF (___)\nR ankle arthrocentesis (___)\nB/l cataract surgery \n \nSocial History:\n___\nFamily History:\nMother: Passed away at age ___ from non-Hodgkins lymphoma, \novarian cancer\nFather: Alive and well at ___\nGrandfather: ___\nOtherwise, no family history of heart disease or kidney disease\n \nPhysical Exam:\nAdmission: \nGEN: NAD, well-nourished, appropriately groomed, tremulous\nNEURO: AOx3, CN II-XII grossly intact\nHEENT: Sclerae anicteric, trachea midline, no JVD\nCV: RRR, 2+ peripheral pulses bilaterally \nRESP: No respiratory distress\nGI: Abdomen soft, non-tender and non-distended. No rebound\ntenderness or guarding. Rectal exam deferred\nEXT: RUE edematous with an AV fistula in the forearm with\npalpable thrill, clean proximal puncture sites and a violaceous,\nclean-based ~1cm ulcer, mildly tender to palpation without\nsurrounding erythema, with a proximal dry scab and no \nparethesias\nor numbness in his hand\n\nDischarge: \nGEN: NAD, well-nourished, appropriately groomed, tremulous\nNEURO: AOx3, CN II-XII grossly intact\nHEENT: Sclerae anicteric, trachea midline\nCV: RRR, no M/R/G \nRESP: No respiratory distress\nGI: Abdomen soft, non-tender and non-distended. No rebound\ntenderness or guarding. Rectal exam deferred\nEXT: RUE edematous with an AV fistula in the forearm with\ndressings covering hand which were clean dry and intact \n \nPertinent Results:\nAdmission:\n\n___ 09:00PM BLOOD WBC-5.2 RBC-3.18* Hgb-10.4* Hct-31.1* \nMCV-98 MCH-32.7* MCHC-33.4 RDW-13.2 RDWSD-46.9* Plt Ct-71*\n___ 09:00PM BLOOD Neuts-62.9 ___ Monos-11.0 Eos-1.2 \nBaso-0.4 Im ___ AbsNeut-3.26 AbsLymp-1.19* AbsMono-0.57 \nAbsEos-0.06 AbsBaso-0.02\n___ 09:00PM BLOOD ___ PTT-29.9 ___\n___ 09:00PM BLOOD Plt Ct-71*\n___ 09:00PM BLOOD Glucose-112* UreaN-12 Creat-3.6*# Na-141 \nK-3.3 Cl-94* HCO3-38* AnGap-12\n___ 05:10AM BLOOD Calcium-9.3 Phos-5.2* Mg-2.1\n\nIMAGING: \n___ \nChest ___ silhouette is within normal limits. There are \nno focal \nconsolidations, pleural effusion, or pulmonary edema. There are \nno \npneumothoraces. \n\nDISCHARGE:\n\n___ 09:50AM BLOOD WBC-4.2 RBC-2.63* Hgb-8.8* Hct-25.7* \nMCV-98 MCH-33.5* MCHC-34.2 RDW-13.1 RDWSD-46.1 Plt Ct-71*\n___ 09:50AM BLOOD Plt Ct-71*\n___ 05:05AM BLOOD ___ PTT-28.6 ___\n___ 09:50AM BLOOD Glucose-116* UreaN-61* Creat-10.0* Na-134 \nK-3.5 Cl-84* HCO3-28 AnGap-26*\n___ 09:50AM BLOOD Calcium-9.6 Phos-7.1* Mg-2.1\n \nBrief Hospital Course:\nMr ___ presented to ___ on ___ due to a R AV fistula \nulceration. On ___ he underwent a R AV fistula ligation and \nrevision with AV loop graft. He tolerated the procedure well \nwithout complications (Please see operative note for further \ndetails). After a brief and uneventful stay in the PACU, the \npatient was transferred to the floor for further post-operative \nmanagement. \n Neuro: Pain was well controlled on PO pain medication. \n CV: Vital signs were routinely monitored during the patient's \nlength of stay. He did have two episodes of hypertension up to \n180s which responded to hydralazine. He received HD on ___ \nafter which his blood pressure was well controlled. Post \nprocedure he was instructed to elevate his arm and apply ice to \nthe surgical sight. Upon discharge he tolerated HD without \nepisodes of bleeding. \n Pulm: The patient was encouraged to ambulate, sit and get out \nof bed, use the incentive spirometer, and had oxygen saturation \nlevels monitored which remained within normal limits. \n GI: After the procedure the patient was advanced to and \ntolerated a regular diet at time of discharge. \n GU: At time of discharge, the patient was voiding without \ndifficulty. \n ID: The patient's vital signs and labs were monitored and did \nnot show any signs of infection.\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 On ___, the patient was discharged to home. At discharge, \nhe was tolerating a regular diet, passing flatus, stooling, \nvoiding, and ambulating independently. He will follow-up in the \nclinic. This information was communicated to the patient \ndirectly prior to discharge. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. RisperiDONE 2 mg PO DAILY \n2. Divalproex (DELayed Release) 1500 mg PO BID \n3. Benztropine Mesylate 2 mg PO QHS \n4. GlipiZIDE 20 mg PO QPM \n5. GlipiZIDE 10 mg PO QAM \n6. Cialis (tadalafil) 10 mg oral prn \n7. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild \n8. Nephrocaps 1 CAP PO DAILY \n9. Pravastatin 40 mg PO DAILY \n10. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp \n#*12 Tablet Refills:*0 \n2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain - \nSevere \nRX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp \n#*24 Tablet Refills:*0 \n3. Senna 8.6 mg PO BID:PRN constipation \nRX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*12 \nTablet Refills:*0 \n4. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild \n5. Benztropine Mesylate 2 mg PO QHS \n6. Cialis (tadalafil) 10 mg oral prn \n7. Divalproex (DELayed Release) 1500 mg PO BID \n8. GlipiZIDE 20 mg PO QPM \n9. GlipiZIDE 10 mg PO QAM \n10. Nephrocaps 1 CAP PO DAILY \n11. Pravastatin 40 mg PO DAILY \n12. RisperiDONE 2 mg PO DAILY \n13. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAV fistula ulceration. \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 ulcerations of your \nfistula. During your hospital stay you went for a procedure to \nligate the ulcerations and to revise the fistula with a graft. \nYou are recovering well and successfully underwent hemodialysis \ntoday and are ready to go home. Please call doctor ___ office \nwith any concerns @ ___. Continue to elevate and ice \nyour right arm. \n\nYou are being prescribed a narcotic for pain relief. Only take \nit if you think you need it. Do not drive while taking this \nmedication. You may experience constipation while taking this \nmedication. and have been given laxative prescriptions to help. \nIf you have any bleeding or increased pain at the operation \nsight please return to the hospital. \n\nIt has been a pleasure caring for you.\nYour ___ team. \n \nFollowup Instructions:\n___\n" ]

[ "T82898A", "Y832", "Y929", "L98491", "I120", "E1122", "N186", "Z992", "E7800", "F250", "D631", "E785", "Z87891" ]

[ "T82898A: Other specified complication of vascular prosthetic devices, implants and grafts, initial encounter", "Y832: Surgical operation with anastomosis, bypass or graft as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "L98491: Non-pressure chronic ulcer of skin of other sites limited to breakdown of skin", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N186: End stage renal disease", "Z992: Dependence on renal dialysis", "E7800: Pure hypercholesterolemia, unspecified", "F250: Schizoaffective disorder, bipolar type", "D631: Anemia in chronic kidney disease", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence" ]

[ "Y929", "E1122", "E785", "Z87891" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nHaldol / pollen / Actos / NSAIDS (Non-Steroidal \nAnti-Inflammatory Drug) / ibuprofen / cefazolin / coriander\n \nAttending: ___.\n \nMajor Surgical or Invasive Procedure:\nFistulogram ___ revealing 99% subclavian vein stenosis\nattach\n \nPertinent Results:\nADMISSION LABS\n===================\n___ 03:20PM URINE HOURS-RANDOM\n___ 03:20PM URINE UHOLD-HOLD\n___ 03:20PM URINE COLOR-Straw APPEAR-CLEAR SP ___\n___ 03:20PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-200* \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NORMAL PH-7.0 \nLEUK-NEG\n___ 03:20PM URINE RBC-4* WBC-2 BACTERIA-FEW* YEAST-NONE \nEPI-<1\n___ 03:20PM URINE HYALINE-1*\n___ 03:20PM URINE MUCOUS-RARE*\n___ 12:30PM GLUCOSE-58* UREA N-55* CREAT-11.7*# \nSODIUM-139 POTASSIUM-5.0 CHLORIDE-100 TOTAL CO2-19* ANION \nGAP-20*\n___ 12:30PM estGFR-Using this\n___ 12:30PM WBC-4.2 RBC-2.78* HGB-9.8* HCT-29.9* MCV-108* \nMCH-35.3* MCHC-32.8 RDW-13.9 RDWSD-55.4*\n___ 12:30PM NEUTS-64.0 ___ MONOS-8.8 EOS-1.4 \nBASOS-0.2 IM ___ AbsNeut-2.69 AbsLymp-0.99* AbsMono-0.37 \nAbsEos-0.06 AbsBaso-0.01\n___ 12:30PM PLT COUNT-66*\n\nDISCHARGE LABS\n===================\n___ 06:50AM BLOOD WBC-3.4* RBC-2.75* Hgb-9.4* Hct-28.3* \nMCV-103* MCH-34.2* MCHC-33.2 RDW-13.5 RDWSD-50.9* Plt Ct-54*\n___ 06:50AM BLOOD Neuts-60.4 ___ Monos-12.2 Eos-1.8 \nBaso-0.3 Im ___ AbsNeut-2.03 AbsLymp-0.76* AbsMono-0.41 \nAbsEos-0.06 AbsBaso-0.01\n___ 06:50AM BLOOD Glucose-110* UreaN-35* Creat-8.0* Na-136 \nK-4.1 Cl-92* HCO3-25 AnGap-19*\n___ 06:50AM BLOOD Calcium-9.3 Phos-7.1* Mg-2.0\n\nIMAGING\n===============\nRUE US ___\nNo evidence of deep vein thrombosis in the right upper \nextremity.\n\nCXR ___\nNo acute cardiopulmonary abnormality.\n\nFISTULOGRAM ___\nThe patient has a right upper arm loop graft. - Percutaneous \nangioplasty of the subclavian vein with no residual stenosis. - \nPercutaneous angioplasty of the brachial vein with no residual \nstenosis.\n \nBrief Hospital Course:\nBRIEF HOSPITAL COURSE\n========================\nMr. ___ is a ___ year old man with ESRD ___ type 2 diabetes \nwith HD MWF with right arm graft placement in ___ \ncomplicated by multiple stenoses, who presented from dialysis \ncenter with edematous RUE concerning for possible stenosis. He \nwas seen by the transplant team in the ED who felt he likely had \nanother stenosis. He had a fistulogram with ___ on ___ that \nrevealed 99% stenosis of the right subclavian vein, and he had \nballoon angioplasty with residual 0% stenosis. He had iHD during \nhis stay on ___ and ___ and ___.\n\n===================\nTRANSITIONAL ISSUES\n=====================\n[] Please continue to monitor for increased bleeding at dialysis \nthat would suggest that the graft has developed stenosis\n[] Please continue to monitor his right arm for swelling. It was \nstill swollen on ___ when discharged but with full ROM and \nsensation and 2+ pulses.\n\nLAST DIALYSIS: ___\n\nCODE: FULL\nCONTACT: ___, brother, ___\n\nACTIVE ISSUES\n===================\n#RUE swelling c/f subclavian stenosis\n#ESRD on HD (___)\nPatient presented with progressively swollen right arm with RUE \nAV graft. He has had prior subclavian angioplasty with stenting \nof venous anastomosis twice so far this year. He most recently \nsaw transplant surgery on ___ who noted recurring outflow\nstenosis that they decided to treat conservatively. He had mild \nswelling at that point. On exam this admission he had \nsignificant right arm swelling from hand up to shoulder, did not \nhave any RUE pain but did have few paresthesias. He had good \nradial pulses and no loss of sensation or motor function. ___ was \nconsulted and he underwent a fistulogram on ___ that showed \n99% stenosis of subclavian vein that underwent successful \nballoon angioplasty. He underwent iHD on ___ and ___ and \n___ without complication.\n\n# Anion Gap\nLikely anion gap metabolic acidosis with bicarb 19, AG 20, \nsecondary to uremia from last HD 3 days prior to admission. \nImproved with dialysis during admission.\n\n#Hypoglycemia\nLikely given he was NPO for ___ procedure. Glucose was monitored \nduring his stay and he was given dextrose while NPO.\n\nCHRONIC ISSUES:\n===============\n#Macrocytic anemia\nStable from prior, Hb range in ___ as a chronic issue. No signs\nof active bleeding this admisison. Prior workups while inpatient \nhave shown normal vitamin B12, folate and no evidence of iron \ndeficiency. Likely ___ renal disease and chronic illness.\n\n#Thrombocytopenia\nStable from prior. Chronic dating back to ___.\n\n#NIDDM:\nPatient takes glipizide as an outpatient. He was given ISS while \ninpatient\n\n#Hyperlipidemia:\n- Continued home pravastatin 40 mg PO QPM.\n\n#Schizoaffective disorder:\n- Continued home divaloproex, risperidone, benztropine.\n\n#HTN:\n- Continued home lisinopril.\n\n>30 minutes spent on complex discharge \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 2.5 mg PO DAILY \n2. Divalproex (DELayed Release) 1000 mg PO QHS \n3. Divalproex (DELayed Release) 500 mg PO QAM \n4. amLODIPine 2.5 mg PO DAILY \n5. Benztropine Mesylate 2 mg PO QHS \n6. Calcium Acetate 1334 mg PO TID W/MEALS \n7. Pravastatin 40 mg PO QPM \n8. RisperiDONE 2 mg PO DAILY \n9. GlipiZIDE 20 mg PO DAILY \n10. sildenafil 50 mg oral DAILY:PRN \n11. GlipiZIDE 10 mg PO QHS \n12. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Medications:\n1. amLODIPine 2.5 mg PO DAILY \n2. Benztropine Mesylate 2 mg PO QHS \n3. Calcium Acetate 1334 mg PO TID W/MEALS \n4. Divalproex (DELayed Release) 1000 mg PO QHS \n5. Divalproex (DELayed Release) 500 mg PO QAM \n6. GlipiZIDE 20 mg PO DAILY \n7. GlipiZIDE 10 mg PO QHS \n8. Lisinopril 2.5 mg PO DAILY \n9. Pravastatin 40 mg PO QPM \n10. RisperiDONE 2 mg PO DAILY \n11. sildenafil 50 mg oral DAILY:PRN \n12. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nRUE AV graft 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 Mr. ___,\n\nIt was a pleasure taking care of you at the ___ \n___! \n\nWHY WAS I IN THE HOSPITAL? \n========================== \n- Your right arm was swollen because your veins had become very \nnarrow\n\nWHAT HAPPENED IN THE HOSPITAL? \n============================== \n- You had HD while you were in the hospital\n- You were seen by the interventional radiology team and had a \nstudy done of the graft in your upper arm. They found that the \nveins in your upper arm were narrowed, so they opened them up \nand now there is no more narrowing.\n\nWHAT SHOULD I DO WHEN I GO HOME? \n================================ \n- Please continue to take all of your medications as directed\n- Please follow up with all the appointments scheduled with your \ndoctor\n\n___ 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" ]

[ "T82858A", "Y832", "Y929", "I871", "E1122", "I120", "N186", "Z992", "E11649", "D539", "D696", "E785", "F259", "Z87891", "R569", "R251" ]

[ "T82858A: Stenosis of other vascular prosthetic devices, implants and grafts, initial encounter", "Y832: Surgical operation with anastomosis, bypass or graft as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "I871: Compression of vein", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N186: End stage renal disease", "Z992: Dependence on renal dialysis", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "D539: Nutritional anemia, unspecified", "D696: Thrombocytopenia, unspecified", "E785: Hyperlipidemia, unspecified", "F259: Schizoaffective disorder, unspecified", "Z87891: Personal history of nicotine dependence", "R569: Unspecified convulsions", "R251: Tremor, unspecified" ]

[ "Y929", "E1122", "D696", "E785", "Z87891" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nHaldol / pollen / Actos / NSAIDS (Non-Steroidal \nAnti-Inflammatory Drug) / ibuprofen / cefazolin\n \nAttending: ___.\n \nChief Complaint:\nweakness\n \nMajor Surgical or Invasive Procedure:\nNone\nLast hemodialysis session on ___\n\n \nHistory of Present Illness:\nMr. ___ is a ___ gentleman with ESRD (on HD MWF),\nchronic anemia, BPD, who is being admitted for further \nevaluation\nand management of suspected symptomatic anemia. \n\nThe patient was recently admitted from ___ to ___ with \ndizziness\nattributed to acute on chronic anemia. The patient endorsed\nhematochezia, but was guaiac negative with no recurrent blood \nper\nrectum inpatient. Iron studies were obtained and consistent with\nchronic inflammation. He was given 1u pRBCs and Hg remained\nstable on that admission and was 7.3 on discharge. Following\ndischarge, he resumed HD on his usual MWF schedule. On today's\nsession, labs allegedly revealed worsening anemia and he was \nsent\ninto ___ for further evaluation. \n\nIn the ED, initial VS were: T98, HR 95, BP 139/82, RR 20, 98% \nRA.\n\nLabs showed: Hg 7.5, plt 95, WBC 3.5; Na 138, K 4.2, bicarb 29\nImaging showed: CXR with mild pulm edema; no focal\nconsolidations. \nConsults: none.\nPatient received: 1u pRBCs\nTransfer VS were: T99, HR 100, BP 178/77, RR 20, 99% RA.\n\nOn arrival to the floor, patient reports that he felt dizzy\nearlier today during HD, which improved after he ate something.\nHe denies any associated chest pain. While he does endorse SOB,\nhe attributes this to having a cold with significant nasal\ncongestion. \n\nOf note, the patient was also admitted in ___ of this year as \na\ntransfer from CHA with high grade MSSA bacteremia and RUE AV\ngraft infection and was started on six weeks of cefazolin.\nHowever, his course was complicated by new ___ rash with biopsy\nconsistent with leukocytoclastic vasculitis attributed to the\ncefazolin and therefore his antibiotic regimen was changed to\nvancomycin on ___. Plan is continue 1g vancomycin post-HD until\n___. \n\n \nPast Medical History:\nESRD on HD\nHTN\nHLD\nNIDDM\nSchizoaffective disorder\nGout\nTremors \nH/o uremic pericarditis s/p emergent pericardiocentesis\nR radiocephalic AVF (___)\nAVF ulceration w/ AV loop graft on ___ \nR ankle arthrocentesis (___)\nB/l cataract surgery \n\n \nSocial History:\n___\nFamily History:\nMother: Passed away at age ___ from non-Hodgkins lymphoma, \novarian cancer\nFather: Alive and well at ___\nGrandfather: ___\nOtherwise, no family history of heart disease or kidney disease\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVS: \n___ 0050 Temp: 98.7 PO BP: 159/75 L Sitting HR: 100 RR: 20\nO2 sat: 95% O2 delivery: RA \nGENERAL: disheveled appearing man in NAD. \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,\nMMM\nNECK: supple, no LAD, no JVD\nHEART: RRR, + systolic ejection murmur.\nLUNGS: diffuse crackles bilaterally\nABDOMEN: nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly\nEXTREMITIES: no cyanosis, clubbing, or edema\nPULSES: 2+ DP pulses bilaterally\nNEURO: A&Ox3, moving all 4 extremities with purpose\nSKIN: RUE with healing AV graft wound with wet to dry bandage in\nplace, no purulence or eryhtema; warm and well perfused,\nresolving petechial rash bilaterally\n\nDISCHARGE PHYSICAL:\n___ 1551 Temp: 98.7 PO BP: 170/82 HR: 93 RR: 18 O2 sat: 94%\nO2 delivery: Ra \nGENERAL: NAD, laying back in bed\nHEENT: Sclerae anicteric, AT/NC, EOMI, no JVD\nHEART: RRR, + systolic ejection murmur.\nLUNGS: Mild bibasilar crackles bilaterally\nABDOMEN: +BS, soft, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly\nEXTREMITIES: no cyanosis, clubbing, or edema\nPULSES: 2+ DP pulses bilaterally\nNEURO: A&Ox3, moving all 4 extremities with purpose\nSKIN: RUE with healing AV graft wound with wet to dry bandage in\nplace, no purulence or eryhtema; warm and well perfused,\nresolving petechial rash bilaterally\n \nPertinent Results:\nADMISSION LABS:\n___ 07:59PM ___ PTT-28.3 ___\n___ 06:24PM GLUCOSE-73 UREA N-11 CREAT-3.5*# SODIUM-138 \nPOTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-29 ANION GAP-14\n___ 06:24PM estGFR-Using this\n___ 06:24PM ALT(SGPT)-13 AST(SGOT)-37 ALK PHOS-104 TOT \nBILI-0.5\n___ 06:24PM LIPASE-76*\n___ 06:24PM ALBUMIN-3.6 CALCIUM-9.6 PHOSPHATE-3.1 \nMAGNESIUM-1.8 IRON-56\n___ 06:24PM calTIBC-259* FERRITIN-1305* TRF-199*\n___ 06:24PM VANCO-26.0*\n___ 06:24PM WBC-3.5* RBC-2.38* HGB-7.5* HCT-22.2* MCV-93 \nMCH-31.5 MCHC-33.8 RDW-16.1* RDWSD-53.3*\n___ 06:24PM NEUTS-65.6 ___ MONOS-9.4 EOS-2.3 \nBASOS-0.3 IM ___ AbsNeut-2.31 AbsLymp-0.73* AbsMono-0.33 \nAbsEos-0.08 AbsBaso-0.01\n___ 06:24PM PLT COUNT-95*\n\nDISCHARGE LABS:\n___ 04:56AM BLOOD WBC-4.0 RBC-2.41* Hgb-7.5* Hct-22.2* \nMCV-92 MCH-31.1 MCHC-33.8 RDW-16.2* RDWSD-54.4* Plt Ct-73*\n___ 04:56AM BLOOD Plt Ct-73*\n___ 04:56AM BLOOD Glucose-71 UreaN-29* Creat-6.3*# Na-135 \nK-4.1 Cl-91* HCO3-30 AnGap-14\n___ 04:56AM BLOOD Calcium-9.6 Phos-4.4 Mg-1.8\n___ 06:21AM BLOOD Vanco-18.3\n\nIMAGING:\n___ CXR:\nMild interstitial pulmonary edema with central pulmonary \nvascular congestion, increased compared the prior study. \nTrace bilateral pleural effusions. \n\nMICRO:\n___ 12:17 pm STOOL CONSISTENCY: NOT APPLICABLE\n Source: Stool. \n\n **FINAL REPORT ___\n\n C. difficile DNA amplification assay (Final ___: \n Reported to and read back by ___ (___) @ \n2130,\n ___. \n CLOSTRIDIUM DIFFICILE. \n Positive for toxigenic C difficile by the Cepheid \nnucleic\n amplification assay. (Reference \nRange-Negative). \n___ Blood Cx 2x: PND\n \nBrief Hospital Course:\nMr. ___ is a ___ gentleman with ESRD (on HD MWF), \nchronic anemia, BPD, who was admitted from his outpatient \ndialysis center due to dizziness and weakness during dialysis, \nconcerning for recurrent anemia. His hemoglobin stable was on \narrival. He received 1u PRBC transfusion which improved his \nsymptoms, and he did not have any further dizziness.\n\nACTIVE ISSUES:\n# DIZZINESS/WEAKNESS: Possibly due to volume shifts of \nhemodialysis vs. hypovolemia from his chronic diarrhea. He did \nnot have any recurrent dizziness here, and tolerated his \ndialysis session on ___ without issue.\n\n# ANEMIA OF CHRONIC INFLAMMATION, STABLE: Blood counts stable \nfrom his last admission. Given 1uPRBC on ___.\n\n# DIARRHEA: Chronic outpatient issue per brother and prior \nnursing staff. Positive C diff toxin assay in house. Started on \nPO vanc overnight on ___ to complete a 2 week total course \non ___.\n\n# RECENT RUE AV GRAFT INFECTION: Continuing IV vancomycin until \n___.\n\n# LOWER EXTREMITY LEUKOCYTOCLASTIC VASCULITIS: Taking home \ntopical triamcinolone, but can likely be discontinued as has \ncompleted 2 weeks of therapy and having improved rash on the \nlegs.\n\nCHRONIC/STABLE ISSUES:\n# ESRD ON HD MWF: Last HD session on ___. Should continue on \nhis usual schedule, and receive concurrent vancomycin.\n\n# PANCYTOPENIA: Stable. Would likely benefit from outpatient \nheme/onc evaluation.\n\n# ALLERGIC RHINITIS: Home fluticasone and fexofenadine.\n\n# TREMOR: Propranolol held after his last admission due to sinus \nbradycardia. Continued home benztropine.\n\n# HYPERLIPIDEMIA: Home pravastatin\n\n# NIDDM: \nPer brother, Pt had been considered for insulin initiation at a \nprevious ___ visit. His blood sugars on ISS here were \neuglycemic. Pt was seen by the ___ Diabetes educator, who \nrecommended no insulin at this time. However he was set up for \nan outpatient appointment for this discussion.\n\n# SCHIZOAFFECTIVE DISORDER: Home risperidone, home Depakote\n\nTRANSITIONAL ISSUES:\n#CODE: Full (confirmed) \n#CONTACT: ___ (brother/HCP) ___ cell ___\n\n[ ] Consider outpatient heme/onc follow up for evaluation of his \nthrombocytopenia and anemia. Check CBC in the next visit.\n[ ] Per brother had previously been considered for insulin \ninitiation, though Pt with normal glucoses in house while on \nlow-dose ISS. Scheduled for outpatient appointment at ___ for \nthis discussion on ___.\n[ ] Continue PO vancomycin for C diff treatment until ___ to \ncomplete a 2 week course.\n[ ] Continue vancomycin 1000mg IV with HD until ___ ___V graft infection.\n[ ] f/u on recurrence of dizziness and lightheadedness. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild \n2. Benztropine Mesylate 2 mg PO QHS \n3. Nephrocaps 1 CAP PO DAILY \n4. Pravastatin 40 mg PO DAILY \n5. RisperiDONE 3 mg PO DAILY \n6. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID \n7. Vancomycin 1000 mg IV POST HD (___) \n8. Divalproex (DELayed Release) 1000 mg PO QHS \n9. GlipiZIDE 20 mg PO QAM \n10. GlipiZIDE 10 mg PO QPM \n11. Viagra (sildenafil) 20 mg oral PRN \n12. Vitamin D 1000 UNIT PO DAILY \n13. Fexofenadine 60 mg PO DAILY \n14. Fluticasone Propionate NASAL 2 SPRY NU BID \n15. amLODIPine 10 mg PO DAILY \n16. Lisinopril 5 mg PO DAILY \n\n \nDischarge Medications:\n1. Vancomycin Oral Liquid ___ mg PO QID \nRX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp \n#*52 Capsule Refills:*0 \n2. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild \n3. amLODIPine 10 mg PO DAILY \n4. Benztropine Mesylate 2 mg PO QHS \n5. Divalproex (DELayed Release) 1000 mg PO QHS \n6. Fexofenadine 60 mg PO DAILY \n7. Fluticasone Propionate NASAL 2 SPRY NU BID \n8. GlipiZIDE 20 mg PO QAM \n9. GlipiZIDE 10 mg PO QPM \n10. Lisinopril 5 mg PO DAILY \n11. Nephrocaps 1 CAP PO DAILY \n12. Pravastatin 40 mg PO DAILY \n13. RisperiDONE 3 mg PO DAILY \n14. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID \n15. Vancomycin 1000 mg IV POST HD (___) \n16. Viagra (sildenafil) 20 mg oral PRN \n17. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\nAnemia of chronic inflammation\nDizziness\n\nSECONDARY DIAGNOSES:\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nIt was a pleasure to care for you at the ___ \n___.\n\nWhy was I seen in the hospital?\n–You were feeling unwell after your scheduled session of \ndialysis.\n–Some of the people caring for you worried about your blood \ncounts.\n\nWhat happened while I was in the hospital?\n–You received a blood transfusion.\n–We checked your blood counts. These were stable.\n-You did not have any more dizziness.\n-We checked your diarrhea for signs of an infectious diarrhea \n(\"C. diff\"); this test showed that you do have C. diff, and you \nwere started on treatment which you should continue for 2 weeks \ntotal.\n–You received your scheduled session of hemodialysis on ___.\n\nWhat should I do when I leave the hospital?\n-Please follow up with your primary care doctor as previously \nscheduled.\n-Please see your diabetes doctor at ___ to discuss whether or \nnot you need to start insulin.\n\nWe wish you the best,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "D61818", "N186", "J810", "A0472", "I120", "D631", "Z992", "E1122", "T827XXD", "Y841", "L958", "J309", "F209", "F319", "Z87891", "E785", "R251", "B9561" ]

[ "D61818: Other pancytopenia", "N186: End stage renal disease", "J810: Acute pulmonary edema", "A0472: Enterocolitis due to Clostridium difficile, not specified as recurrent", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "D631: Anemia in chronic kidney disease", "Z992: Dependence on renal dialysis", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "T827XXD: Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, subsequent encounter", "Y841: Kidney dialysis as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "L958: Other vasculitis limited to the skin", "J309: Allergic rhinitis, unspecified", "F209: Schizophrenia, unspecified", "F319: Bipolar disorder, unspecified", "Z87891: Personal history of nicotine dependence", "E785: Hyperlipidemia, unspecified", "R251: Tremor, unspecified", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere" ]

[ "E1122", "Z87891", "E785" ]

[]

[ " \nName: ___. Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nHaldol / pollen / Actos / NSAIDS (Non-Steroidal \nAnti-Inflammatory Drug) / ibuprofen\n \nAttending: ___.\n \nChief Complaint:\nDizziness\nFever\nMalaise\n \nMajor Surgical or Invasive Procedure:\nAV graft excision\nTransesophageal echo\n \nHistory of Present Illness:\n___ yo m w/ h/o ESRD on HD ___ at ___, T2DM,\nand Schizoaffective disorder presented to ___ on ___ with cough, fever/rigors and non-bloody \ndiarrhea\nfound to have RUE abscess at the site of AV graft with MSSA\nbacteremia now transferred to ___ for evaluation of graft by\ntransplant surgery. \n\nPatient found to have fever/tachycardia concerning for sepsis \nand\nwas started on vanc/CTX/azithromycin for ?PNA due to small\nopacity on CXR but w/out respiratory symptoms. Found to have\nright arm with swelling, redness, and warmth increased from\nbaseline. Ultrasound showed fluid collection lateral to graft\nwith superficial thrombosis. CT scan of the RUE re-demonstrated\nthe fluid collection along the graft. He underwent drainage by \n___\non ___ aspirating 2cc of purulent fluid positive for GPC pairs\nand clusters. Blood cultures from ___ w/ MSSA. Antibiotics\nnarrowed to cefazolin on ___. TTE negative for vegetation.\nVascular surgery at OS___ recommended transfer to ___ as he was\nlast admitted in ___ for R AV fistula ligation and revision\nwith AV loop graft by Dr. ___.\n\nOn arrival to the floor, patient notes that right arm had been\nswollen for many weeks prior to his presentation and he believed\nthe swelling might be related to dialysis. Denies fevers or\nchills since transfer. Has had ongoing dry cough. Shortness of\nbreath at baseline that has remained stable over the past ___ \nyears\nand improved with dialysis. Notes he has a history of IBS with\ndiarrhea and was having significant diarrhea prior to admission\nbut none over the past 24 hours. No dysuria, headache, changes \nin\nvision, numbness or weakness, heart palpitiatoins. Intermitenet\nlightheadedness yesterday that's improved now. \n \nPast Medical History:\nESRD on HD\nHTN\nHLD\nNIDDM\nSchizoaffective disorder\nGout\nTremors \nH/o uremic pericarditis s/p emergent pericardiocentesis\nR radiocephalic AVF (___)\nAVF ulceration w/ AV loop graft on ___ \nR ankle arthrocentesis (___)\nB/l cataract surgery \n \nSocial History:\n___\nFamily History:\nMother: Passed away at age ___ from non-Hodgkins lymphoma, \novarian cancer\nFather: Alive and well at ___\nGrandfather: ___\nOtherwise, no family history of heart disease or kidney disease\n \nPhysical Exam:\nADMISSION EXAM:\n===============\nT 97.2 PO BP 177 / 79 L Lying 81 18 ___ 96 RA \nGENERAL: Alert and interactive. In no acute distress. slow to\nrespond to questions at times but appropriate and alert AOx3 \nHEENT: Normocephalic, atraumatic. Pupils equal, round, and\nreactive bilaterally, extraocular muscles intact. Sclera\nanicteric and without injection. Moist mucous membranes, poor\ndentition. Oropharynx is clear.\nNECK: Right dialysis IJ in place without surrounding erythema or\ntenderness \nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: Clear to auscultation bilaterally w/appropriate breath\nsounds appreciated in all fields. No wheezes, rhonchi or rales.\nNo increased work of breathing.\nBACK No CVA tenderness.\nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. No organomegaly.\nEXTREMITIES: RUE with generalized edema and AV graft with\npalpable thrill and bruit, C/d/I dressing at site of ___ \ndrainage,\nmildly warm to plapation but no eryhemea, no ___ edema \nNEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal\nsensation. Gait is normal. Normal finger to nose testing, AOx3.\n\nDISCHARGE EXAMINATION\n=====================\nVITALS: ___ 0002 Temp: 97.5 PO BP: 143/76 HR: 70 RR: 20 O2\nsat: 96% O2 delivery: Ra; fingerstick BS 74\nGENERAL: Patient appears more despondent this AM, though alert\nand interactive. Patients tremors more pronounced in arms, left\nleg, and mouth.\nHEENT: Anicteric, EOMI\nNECK: Right IJ dialysis line removed and bandaged\nCARDIAC: RRR, Normal S1/S2, subtle systolic murmur\nLUNGS: CTAB, no crackles, wheezes, ronchi \nABDOMEN: Soft, non-distended, non-tender.\nEXTREMITIES: RUE with bandaged dressing, no purulence \nappreciated\non inspection. Bounding radial pulse without prominent thrill.\nSome swelling and mild pain to palpation in area of RUE fistula\non proximal forearm. \nNEUROLOGIC: alert, appropriately interactive on exam, able to \nsit\nup and turn in bed on his own. Patient's tremor appears worse\ntoday, evident in arms, left leg, and mouth\nPSYCH: Linear thought but diminished affect this morning\n \nPertinent Results:\nADMISSION LABS:\n===============\n\n___ 10:19PM BLOOD WBC-3.6* RBC-2.14* Hgb-7.1* Hct-20.6* \nMCV-96 MCH-33.2* MCHC-34.5 RDW-13.8 RDWSD-48.5* Plt Ct-54*\n___ 05:11AM BLOOD Neuts-69 Bands-3 Lymphs-6* Monos-8 Eos-2 \nBaso-0 Atyps-1* Metas-7* Myelos-4* AbsNeut-3.24 AbsLymp-0.32* \nAbsMono-0.36 AbsEos-0.09 AbsBaso-0.00*\n___ 10:19PM BLOOD ___ PTT-27.1 ___\n___ 10:19PM BLOOD Glucose-176* UreaN-45* Creat-9.6* Na-135 \nK-4.1 Cl-92* HCO3-26 AnGap-17\n___ 10:19PM BLOOD ALT-<5 AST-13 LD(LDH)-200 AlkPhos-74 \nTotBili-0.3\n___ 10:19PM BLOOD Calcium-9.2 Phos-4.2 Mg-2.3\n\nCHEST X-RAY (___):\n===================\nIMPRESSION: \nLung volumes are low accentuating the cardiac silhouette and \npulmonary vasculature. Heart size is normal. Hilar contours \nare preserved. Right-sided central line terminates in the high \nright atrium. Hazy peribronchial densities are seen, primarily \nover the lung bases, and could reflect a subtle infection. \nThere is no large effusion or pneumothorax.\n\nTRANSESOPHAGEAL ECHO (___):\n============================\nThere is no spontaneous echo contrast or thrombus in the body of \nthe left atrium/left atrial appendage. The left atrial appendage \nejection velocity is normal. No spontaneous echo contrast or \nthrombus is seen in the body of the right atrium/right atrial \nappendage. The right atial appendage ejection velocity is \nnormal. There is no evidence for an atrial septal defect by \n2D/color Doppler. Global left ventricular systolic function is \nnormal. There are no aortic arch atheroma with simple atheroma \nin the descending aorta. The aortic valve leaflets (3) are \nmildly thickened. A filamentous strand(s) is seen on the aortic \nvalve c/w Lambl's excresence (normal variant; clip 28). No \nabscess is seen. There is no aortic regurgitation. The mitral \nleaflets appear structurally normal with no mitral valve \nprolapse. No masses or vegetations are seen on the mitral valve. \nNo abscess is seen. There is mild to moderate [___] mitral \nregurgitation. The tricuspid valve leaflets appear structurally \nnormal. No mass/vegetation are seen on the tricuspid valve. No \nabscess is seen. There is physiologic tricuspid regurgitation.\n\nIMPRESSION: Good image quality. Mild aortic leaflet thickening, \nbut no discrete vegetation or abscess or regurgitation. \nMIld-moderate mitral regurgitation with normal leaflet \nmorphology.\n\nMRI BRAIN (___):\n=================\nFINDINGS: \nThere is no evidence of acute infarction. No intracranial \nhemorrhage. No mass, mass effect, edema or midline shift.\n \nThe ventricles and sulci are mildly prominent. There is a \nright-sided dominant vertebral basilar system, with a diminutive \nleft V4 segment, which is unchanged from ___. Otherwise, the \nremainder of the principal intracranial vascular flow voids \nappear preserved.\n \nTrace mastoid fluid is seen bilaterally. The remainder of the \nvisualized paranasal sinuses and middle ear cavities are grossly \nclear. The patient is status post bilateral lens replacement.\n \nIMPRESSION: \n1. No evidence for acute intracranial hemorrhage or infarction.\n2. Age advanced, mild-to-moderate global parenchymal volume \nloss.\n3. Trace bilateral mastoid fluid.\n4. Additional findings, as above.\n\nDISCHARGE LABORATORY STUDIES\n============================\n___ 04:45AM BLOOD WBC-3.7* RBC-2.25* Hgb-7.3* Hct-22.0* \nMCV-98 MCH-32.4* MCHC-33.2 RDW-15.3 RDWSD-54.1* Plt Ct-81*\n___ 04:45AM BLOOD Glucose-293* UreaN-38* Creat-10.7*# \nNa-138 K-4.3 Cl-87* HCO3-30 AnGap-21*\n___ 04:45AM BLOOD Calcium-8.9 Phos-4.9* Mg-2.0\n___ 07:00AM BLOOD HBsAg-NEG\n___ 05:24AM BLOOD CRP-87.5*\n \nBrief Hospital Course:\n___ yo m w/ h/o ESRD on HD ___ at ___, T2DM, \nand Schizoaffective disorder presented to ___ \n___ on ___ with cough, fever and diarrhea, found to have \nRUE abscess at the site of AV graft with MSSA bacteremia, last \npositive blood cx ___.\n\nACUTE ISSUES:\n=============\n#Right AV graft infection\nThe patient initially presented to ___ on ___ with symptoms of dizziness and generalized malaise. He was \nfound to have a fluid collection along the right AV graft with \nsuperficial thrombophlebitis and concern for superimposed \ninfection. He underwent ___ drainage of the adjacent abscess on \n___ with drainage of 2 mL of purulent fluid, which subsequently \ngrew staph aureus. The patient was transferred to ___ on ___ \nfor consideration of graft removal and TEE for work-up of \nendocarditis. After transfer, the patient underwent partial \ngraft excision on the morning of ___. The graft culture \neventually grew methicillin sensitive Staph aureus. A TEE found \nno evidence of vegetations. The patient was maintained on \ncefazolin dosed with HD. \n\n#Sepsis secondary to MSSA bacteremia:\nAt presentation, the patient initially exhibited fever to 103 \nrigors, and tachycardia, concerning for sepsis of unknown \norigin. He was initially treated with ceftriaxone, azithromycin, \nand vancomycin for question of PNA on CXR, but switched to \nvancomycin and\nultimately cefazolin once BCX with MSSA. ___ drained 2cc of \npurulent fluid from abscess around graft which grew Coag pos \nStaph aureus and likely source of bactermeia. He was started on \ncefazolin 2 g q24 hours on ___. TTE was negative for \nvegetations. Following transfer to ___, the patient underwent \nTEE which did not demonstrate any vegetations. MRI was also \nperformed and did not demonstrate any septic emboli. The patient \nwas continued on cefazolin dosed with HD for antibiotic \ncoverage.\n\n#ESRD on ___\nThe patient had a temporary right IJ dialysis catheter placed at \n___ on ___ and received dialysis through this \nline initially. The line was subsequently pulled on ___ due to \nconcern for an infected line, since the last positive blood \nculture was on ___. An HD tunneled line was placed in the left \nIJ on ___.\n\nCHRONIC ISSUES:\n===============\n#Anemia/Thrombocytopenia- consider outpatient workup for \npotential anemia of chronic inflammation\n#Tremor- Continue Benztropine and propranolol \n#HLD- Continue pravastatin 40mg daily \n#NIDDM- Hold home glipizide and on ISS \n#Schizoaffective disorder- continue risperdal and depakote\n\nTRANSITIONAL ISSUES:\n====================\n\n[] Dialysis access: patient had partial graft excision due to \nbacteremia. He will need follow-up with transplant surgery at a \nlater date to reconstruct his graft site to allow for long term, \ndurable dialysis access. Follow-up appointment with Dr. ___ \n___ has been scheduled for ___.\n[] Antibiotic plan: cefazolin after HD, 3 grams on ___ and 2 \ngrams on ___ and ___ \nStart Date: ___ (date of graft explant/removal)\nProjected End Date: ___\n[] Please obtain weekly CBC with differential, BUN, Cr and CRP. \nALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC - \nFAX: ___\n[] amlodipine 7.5 mg was started iso elevated BPs, if BPs remain \nelevated please consider increasing to 10mg daily.\n[] consider outpatient workup for potential anemia of chronic \ninflammation\n\nGreater than ___ hour spent on care on day of discharge. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild \n2. Benztropine Mesylate 2 mg PO QHS \n3. Divalproex (DELayed Release) 1000 mg PO QHS \n4. GlipiZIDE 20 mg PO QAM \n5. GlipiZIDE 10 mg PO QPM \n6. Nephrocaps 1 CAP PO DAILY \n7. Pravastatin 40 mg PO DAILY \n8. RisperiDONE 3 mg PO DAILY \n9. Vitamin D 1000 UNIT PO DAILY \n10. Docusate Sodium 100 mg PO BID \n11. Viagra (sildenafil) 20 mg oral PRN \n12. Propranolol 20 mg PO BID \n\n \nDischarge Medications:\n1. amLODIPine 7.5 mg PO DAILY \nRX *amlodipine 5 mg 1.5 tablet(s) by mouth once a day Disp #*45 \nTablet Refills:*0 \n2. CeFAZolin 3 g IV POST HD (FR) \n3. CeFAZolin 2 g IV POST HD (MO,WE) \n4. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild \n5. Benztropine Mesylate 2 mg PO QHS \n6. Divalproex (DELayed Release) 1000 mg PO QHS \n7. GlipiZIDE 10 mg PO QPM \n8. GlipiZIDE 20 mg PO QAM \n9. Nephrocaps 1 CAP PO DAILY \n10. Pravastatin 40 mg PO DAILY \n11. Propranolol 20 mg PO BID \n12. RisperiDONE 3 mg PO DAILY \n13. Viagra (sildenafil) 20 mg oral PRN \n14. Vitamin D 1000 UNIT PO DAILY \n15.Outpatient Lab Work\nPlease obtain weekly CBC with differential, BUN, Cr and CRP. ALL \nLAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC - FAX: \n___. ICD 790.7\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n==================\nRight upper extremity abscess\n\nSECONDARY DIAGNOSIS:\n====================\nMethicillin-sensitive Staphylococcus aureus sepsis\nEnd stage renal disease\nhypertension\n\n \nDischarge Condition:\nMental Status: Oriented, sometimes confused.\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 in the hospital!\n\nWHY WERE YOU ADMITTED:\n- You had an infection near your dialysis graft site that caused \nyou to get bacteria into your blood stream\n\nWHAT HAPPENED IN THE HOSPITAL:\n- The surgeons removed part of your dialysis graft\n- We gave you dialysis\n- We looked at your heart using an ultrasound in your esophagus \nto confirm that your bloodstream infection hadn't spread to your \nheart\n- We gave you antibiotics that you should continue on discharge. \n\n\nWHAT SHOULD YOU DO AFTER LEAVING:\n- Continue to take your antibiotic at dialysis on your ___ \nschedule\n- Go to your follow up appointments with your Infectious Disease \nand Transplant Surgery doctors\n- Please call your PCP's office to get an appointment at \n___. \n- Take your lab work prescription and make sure you get labs \ndrawn every week!\n\nThank you for allowing us to take part in your care!\n\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "T827XXA", "N186", "A4101", "I120", "Y838", "Z992", "E119", "F259", "A4901", "Z87891", "I809", "D696", "E785", "D631", "R251", "R197" ]

[ "T827XXA: Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter", "N186: End stage renal disease", "A4101: Sepsis due to Methicillin susceptible Staphylococcus aureus", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "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", "Z992: Dependence on renal dialysis", "E119: Type 2 diabetes mellitus without complications", "F259: Schizoaffective disorder, unspecified", "A4901: Methicillin susceptible Staphylococcus aureus infection, unspecified site", "Z87891: Personal history of nicotine dependence", "I809: Phlebitis and thrombophlebitis of unspecified site", "D696: Thrombocytopenia, unspecified", "E785: Hyperlipidemia, unspecified", "D631: Anemia in chronic kidney disease", "R251: Tremor, unspecified", "R197: Diarrhea, unspecified" ]

[ "E119", "Z87891", "D696", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nportabello mushrooms\n \nAttending: ___.\n \nChief Complaint:\nRight Upper Quadrant Abdominal Pain \n \nMajor Surgical or Invasive Procedure:\n___: Laparoscopic Cholecystectomy \n\n \nHistory of Present Illness:\n___ with 1 month history of biliary colic presents with an acute \nepisode of RUQ pain radiating to her back. She states that she \nhas had biliary colic symptoms on and off for the past month; \nhowever, this episode has been persistent RUQ pain radiation to \nher back since ___ (x3 days). It is associated with nausea, \nbut she has not vomited. Denies fever/chills/changes in her\nbowels. The pain is made worse with PO intake. She states that \nshe had a RUQ US as an outpatient for her work-up of biliary \ncolic, and states that there was inflammation and ?recently \npassed stone (I do not have this report). Her abdominal pain \nworsened over the course of today, and she came in to seek\nmedical attention. \n \nPast Medical History:\nPostpartum Depression\n \nSocial History:\n___\nFamily History:\nNon-contributory \n \nPhysical Exam:\nPhysical Exam on Discharge:\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, no rebound or guarding, no palpable \nmasses\nINCISION: Clean dry and intact\nExt: No ___ edema, ___ warm and well perfused\n \nPertinent Results:\nLABS:\n-----\n___ 07:00PM BLOOD WBC-5.6 RBC-4.11 Hgb-12.7 Hct-39.6 MCV-96 \nMCH-30.9 MCHC-32.1 RDW-12.7 RDWSD-44.7 Plt ___\n___ 07:00AM BLOOD WBC-3.9* RBC-3.97 Hgb-11.9 Hct-38.2 \nMCV-96 MCH-30.0 MCHC-31.2* RDW-12.9 RDWSD-45.8 Plt ___\n___ 07:55AM BLOOD WBC-6.6# RBC-3.78* Hgb-11.7 Hct-36.4 \nMCV-96 MCH-31.0 MCHC-32.1 RDW-12.6 RDWSD-44.6 Plt Ct-UNABLE TO\n\n___ 07:00PM BLOOD Glucose-87 UreaN-13 Creat-1.0 Na-140 \nK-4.2 Cl-103 HCO3-27 AnGap-14\n___ 07:00AM BLOOD Glucose-89 UreaN-11 Creat-0.8 Na-138 \nK-3.9 Cl-101 HCO3-28 AnGap-13\n___ 07:55AM BLOOD Glucose-102* UreaN-7 Creat-0.7 Na-138 \nK-4.6 Cl-102 HCO3-27 AnGap-14\n\nIMAGINING:\n----------\nRUQ US (___)\nIMPRESSION: \n \n1. Cholelithiasis.\n2. Hepatic steatosis.\n\nOPERATIVE REPORT: \n-----------------\n\nPREOPERATIVE DIAGNOSIS: Biliary colic.\n\nPOSTOPERATIVE DIAGNOSIS: Biliary colic.\n\nPROCEDURES: Laparoscopic cholecystectomy.\n\nASSISTANT: Dr. __________.\n\nANESTHESIA: General and local.\n\nESTIMATED BLOOD LOSS: Minimal.\n\nINDICATIONS: This is a ___ female who presented\nyesterday with presumed biliary colic/cholecystitis who was\nprepped and brought to the operating room today for semi\nurgent cholecystectomy.\n\nDESCRIPTION OF PROCEDURE: She was brought to the operating\nroom, placed supine on the operating table. After adequate\ninduction of general anesthesia and placement of endotracheal\ntube, the abdomen was prepped and draped in standard surgical\nfashion. After appropriate timeout was performed, local\nanesthesia was provided and a supraumbilical incision made\nwith a #15 blade. Blunt dissection used to identify the\nfascia which was elevated with stay sutures that were placed\non either side. The fascia was divided sharply in the\nmidline. Peritoneum was identified, elevated and divided\nsharply. The 11 ___ port was placed under direct\nvision. The abdominal cavity was insufflated with CO2.\nUnder direct vision using local anesthesia, we placed two 5\nmm ports in the right upper quadrant and a 12 mm port in the\nepigastric region. Gallbladder was identified. It was\nretracted cephalad and laterally. There were some omental\nadhesions indicating chronic cholecystitis that were taken\ndown with blunt dissection. There was a moderate amount of\nacute inflammatory change and edema in the gallbladder. We\ndissected from lateral to medial and took down the peritoneum\nwith hook cautery. We identified a single cystic artery and\na single cystic duct, cleared them of the areolar\nattachments, identified the critical view. The duct was\ntriply clipped on the patient's side, singly clipped on the\nspecimen side and divided with scissors. The artery was\ndoubly clipped on the patient's side, singly clipped on the\nspecimen side and divided with scissors. The remainder of\nthe gallbladder was removed with hook cautery. There was no\nbile spillage. It was placed in an EndoCatch bag and removed\nthrough the umbilical port and passed off the table. The\narea was irrigated and inspected. Fluid was removed with\nsuction. There was no bleeding. Clips were in good\nposition. The CO2 was evacuated from the abdomen. There was\nsome bleeding from the medial 5 mm port that was cauterized\ninternally with the hook cautery to stop the bleeding at the\nabdominal wall. The CO2 was evacuated from the abdomen. The\nfascia of the umbilical site was closed with figure-of-eight\n0 Vicryl suture. The wounds were irrigated. Local was\napplied and the skin was closed in subcuticular manner,\ncovered with Steri-Strips and sterile dressing. The patient\ntolerated this well.\n\nCOUNTS: Sponge, needle and instrument counts were correct at\nthe end of the case.\n\n \nBrief Hospital Course:\nMs. ___ was admitted on ___ under the acute care surgery \nservice for management of her acute cholecystitis. She was taken \nto the operating room and underwent a laparoscopic \ncholecystectomy. Please see operative report for details of this \nprocedure. She tolerated the procedure well and was extubated \nupon completion. She was subsequently taken to the PACU for \nrecovery.\n\nShe was transferred to the surgical floor and remained \nhemodynamically stable. Her vital signs were routinely monitored \nand she remained afebrile and hemodynamically stable. She was \ninitially given IV fluids postoperatively, which were \ndiscontinued when she was tolerating PO's. Her diet was advanced \npost operatively to clear liquids and as tolerated subsequently \nto regular, which she tolerated without abdominal pain, nausea, \nor vomiting. She was voiding adequate amounts of urine \npost-operatively. She was encouraged to mobilize out of bed and \nambulate as tolerated, which she was able to do independently. \nHer pain was well controlled at discharge with an oral regimen \nas needed. \n\nOn POD1, she was ready for discharge. At the time of discharge \nshe was afebrile, vital signs stable, tolerating a regular diet, \nambulating independently. She was discharged home with scheduled \nfollow up in ___ clinic. \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. BuPROPion XL (Once Daily) 150 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild \n2. Docusate Sodium 100 mg PO BID \nPlease take as needed while taking oxycodone for constipation \n3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nplease take ___ tablets at needed for severe pain \n4. BuPROPion XL (Once Daily) 150 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAcute Cholecystitis \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___. You were admitted to the hospital with \nacute cholecystitis. You were taken to the operating room and \nhad your gallbladder removed laparoscopically. You tolerated the \nprocedure well and are now being discharged home to continue \nyour recovery with the following instructions.\n \nPlease follow up in the Acute Care Surgery clinic at the \nappointment listed below.\n \nACTIVITY:\n \no Do not drive until you have stopped taking pain medicine and \nfeel you could respond in an emergency.\no You may climb stairs. \no  You may go outside, but avoid traveling long distances until \nyou see your surgeon at your next visit.\no  Don't lift more than ___ lbs for 4 weeks. (This is about \nthe weight of a briefcase or a bag of groceries.) This applies \nto lifting children, but they may sit on your lap.\no You may start some light exercise when you feel comfortable.\no You will need to stay out of bathtubs or swimming pools for a \ntime while your incision is healing. Ask your doctor when you \ncan resume tub baths or swimming.\n \nHOW YOU MAY FEEL: \no  You may feel weak or \"washed out\" for a couple of weeks. You \nmight want to nap often. Simple tasks may exhaust you.\no  You may have a sore throat because of a tube that was in your \nthroat during surgery.\no  You might have trouble concentrating or difficulty sleeping. \nYou might feel somewhat depressed.\no  You could have a poor appetite for a while. Food may seem \nunappealing.\no  All of these feelings and reactions are normal and should go \naway in a short time.  If they do not, tell your surgeon.\n \nYOUR INCISION:\no Tomorrow you may shower and remove the gauzes over your \nincisions. Under these dressing you have small plastic bandages \ncalled steri-strips. Do not remove steri-strips for 2 weeks. \n(These are the thin paper strips that might be on your \nincision.) But if they fall off before that that's okay).\no Your incisions may be slightly red around the stitches. This \nis normal.\no You may gently wash away dried material around your incision.\no Avoid direct sun exposure to the incision area.\no Do not use any ointments on the incision unless you were told \notherwise.\no You may see a small amount of clear or light red fluid \nstaining your dressing or clothes. If the staining is severe, \nplease call your surgeon.\no You may shower. As noted above, ask your doctor when you may \nresume tub baths or swimming.\n \nYOUR BOWELS:\no Constipation is a common side effect of narcotic pain \nmedications. If needed, you may take a stool softener (such as \nColace, one capsule) or gentle laxative (such as milk of \nmagnesia, 1 tbs) twice a day. You can get both of these \nmedicines without a prescription.\no If you go 48 hours without a bowel movement, or have pain \nmoving the bowels, call your surgeon. \n \nPAIN MANAGEMENT:\no It is normal to feel some discomfort/pain following abdominal \nsurgery. This pain is often described as \"soreness\". \no Your pain should get better day by day. If you find the pain \nis getting worse instead of better, please contact your surgeon.\no You will receive a prescription for pain medicine to take by \nmouth. It is important to take this medicine as directed. o Do \nnot take it more frequently than prescribed. Do not take more \nmedicine at one time than prescribed.\no Your pain medicine will work better if you take it before your \npain gets too severe.\no Talk with your surgeon about how long you will need to take \nprescription pain medicine. Please don't take any other pain \nmedicine, including non-prescription pain medicine, unless your \nsurgeon has said its okay.\no If you are experiencing no pain, it is okay to skip a dose of \npain medicine.\no Remember to use your \"cough pillow\" for splinting when you \ncough or when you are doing your deep breathing exercises.\nIf you experience any of the following, please contact your \nsurgeon:\n- sharp pain or any severe pain that lasts several hours\n- pain that is getting worse over time\n- pain accompanied by fever of more than 101\n- a drastic change in nature or quality of your pain\n \nMEDICATIONS:\nTake all the medicines you were on before the operation just as \nyou did before, unless you have been told differently.\nIf you have any questions about what medicine to take or not to \ntake, please call your surgeon.\n\n \nFollowup Instructions:\n___\n" ]

[ "K812", "K828", "D696" ]

[ "K812: Acute cholecystitis with chronic cholecystitis", "K828: Other specified diseases of gallbladder", "D696: Thrombocytopenia, unspecified" ]

[ "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:\nAbdominal distension, lower extremity edema\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with history of hypertension and daily alcohol use \npresenting with ___ weeks of worsening pedal edema, now \nprogressing to involve his thighs. He also noted increased \nabdominal girth, mild orthopnea and dyspnea on exertion. He \ninitially presented to ___ where he was found to have \nsmall pockets of ascites and new diagnosis of atrial \nfibrillation on ECG. He also noted some diarrhea.\n\nLabs there showed macrocytic anemia, mild thrombocytopenia \n(141), Chem panel with Na 128, BUN 23, Cr 1.2, AST/ALT 96/25, \nTB 7.6, alb 3.7, INR 1.4. BNP slightly elevated at 1100. He was \ngiven IV thiamine, 1L NS IVF.\n\nHe usually receives care at ___, but they were not accepting \ntransfers, so he was routed to ___ for Hepatology consultation \nand further care.\n\nIn the ED, initial vital signs were T98.6, HR 78, BP 102/72, RR \n18, SpO2 97% RA.\nRepeat labs showed similar abnormalities with hemoglobin \ndecreased to 10.9. UA with 11WBC, few bacteria 300 protein, \nnitrate negative. \nCXR showed - top-normal heart size, some hilar fullness, no \neffusions, mild cephalization, no obvious consolidation of \ninfiltrate to suggest infection (my read)\nRUQ U/S showed - \n1. 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.\n2. Splenomegaly and a small amount of ascites.\n3. Main portal vein findings which could be due to slow flow or \nthrombus.\n\nVitals prior to transfer were T98.2, HR 77, BP 106/76, RR 17, \nSpo2 98%RA.\n\nOn arrival to the floor, the patient states that he knows his \nalcohol use has been a problem for some time. he drinks ___ \nbeers each day., Last drink was 5 pm ___. No history of \nwithdrawal but has never gone more than a few days without \ndrinking. Drinking escalated after his second divorce, but calls \nhimself \"an alcoholic\" and a \"lifelong drinker\". Has never \nsought treatment. His wife reports that his PCP sent him for an \nabdominal MRI this past fall and that the result was within \nnormal limits.\n\nHe denies dysuria, although notes some dark urine, no change in \nbowel movements. No chest pain, palpitations, syncope, although \ndid feel pre-syncopal earlier. No headaches or vision changes.\n \nPast Medical History:\nHypertension\nEsophageal stricture, ___, found on evaluation for \ndysphagia\nHSV keratitis, followed at ___\nHistory of basal cell carcinoma\nElevated PSA\n \nSocial History:\n___\nFamily History:\nMother died of lung cancer. Father died of brain aneurysm. One \nbrother was shot while in the line of duty as ___ \n___.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\nVital Signs: T97.6, BP 114/76, HR 98, RR 20, Sp2 96% RA. Wt \n117.3kg.\nGeneral: Alert, oriented, no acute distress \nHEENT: Icteric sclera, palatal jaundice, MMM, oropharynx clear, \nmild nystagmus on rightward gaze, PERRL, neck is thick\nCV: Irregular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nAbdomen: Soft, liver edge palpable 5cm below costal margin\nGU: No foley \nExt: 2+ DP pulses, pitting edema up to the sacrum, somewhat \ntender to palpation\nNeuro: CNII-XII intact, ___ strength upper/lower extremities, \ngrossly normal sensation, no asterixis. \n\nDISCHARGE PHYSICAL EXAM:\nVS: Tm 98.5| 90-113/50-80s| 80-90| 18| 100% on RA\n24H: 152___ 8H: 56/400\nWeight: 114kg->112.6->107.1kg->104.5->103.3 -> 100.2 > 99.1 kg \non discharge \nGENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. \n+jaundice. No asterixis.\nHEENT: NCAT. Sclera icteric. PERRL, EOMI.\nNECK: Supple with JVP at clavice at 45 degrees. \nCARDIAC: Irregularly irregular, normal S1, S2. No \nmurmurs/rubs/gallops. \nLUNGS: Resp were unlabored, no accessory muscle use. CTAB, no \nwheezes or rhonchi, crackles\nABDOMEN: Distended, non-tender. BS+ No hepatomegaly appreciated. \nEXTREMITIES: No pitting edema \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \n \nPertinent Results:\n-------------------\nADMISSION LABS: \n------------------- \n___ 02:06AM BLOOD WBC-7.2 RBC-3.01* Hgb-10.9* Hct-31.7* \nMCV-105* MCH-36.2* MCHC-34.4 RDW-14.0 RDWSD-53.3* Plt ___\n___ 02:06AM BLOOD Glucose-98 UreaN-24* Creat-1.2 Na-127* \nK-3.8 Cl-94* HCO3-20* AnGap-17\n___ 02:06AM BLOOD ALT-26 AST-100* AlkPhos-134* TotBili-7.5*\n___ 09:30AM BLOOD HBsAg-Negative HBsAb-Negative \nHBcAb-Negative HAV Ab-Negative\n___ 02:06AM BLOOD Triglyc-111 HDL-25 CHOL/HD-6.3 \nLDLcalc-111\n\n-----------------\nRELEVANT LABS:\n------------------\n___ 06:20AM BLOOD Hapto-28*\n___ 04:40AM BLOOD calTIBC-207* Ferritn-500* TRF-159*\n___ 06:20AM BLOOD %HbA1c-4.3* eAG-77*\n___ 02:06AM BLOOD Triglyc-111 HDL-25 CHOL/HD-6.3 \nLDLcalc-111\n___ 02:06AM BLOOD TSH-1.8\n___ 09:30AM BLOOD HBsAg-Negative HBsAb-Negative \nHBcAb-Negative HAV Ab-Negative\n___ 04:40AM BLOOD AMA-NEGATIVE Smooth-POSITIVE *\n___ 09:30AM BLOOD ___\n___ 06:20AM BLOOD HIV Ab-Negative\n___ 09:30AM BLOOD HCV Ab-Negative\n\n--------\nMICRO:\n--------\nURINE CULTURE (Final ___: NO GROWTH. \n___ Blood Cx x2 NGTD \n\n--------------------\nIMAGING/STUDIES:\n--------------------\n___ STRESS\nINTERPRETATION: ___ yo man with HTN and new onset hepatitis was\nreferred for systolic CHF and LVEF of 20% associated with \ndyspnea and\nperipheral edema. The patient was administered 0.142 mg/kg/min \nof\nPersantine over 4 minutes. No chest, back, neck or arm \ndiscomforts were\nreported. No significant ST segment changes were noted from \nbaseline.\nThe rhythm was atrial fibrillation with frequent VEA noted \nthroughout\nthe procedure; frequent multiformed VPBs with frequent \nventricular\ncouplets. Occasional RBBB aberration was noted during the \nprocedure. The\nhemodynamic response to the Persantine infusion was appropriate.\nPost-infusion, the patient was administered 125 mg Aminophylline \nIV.\n \nIMPRESSION: No anginal symptoms or ischemic ST segment changes.\nFrequent VEA noted throughout the procedure. Nuclear report sent\nseparately.\n\n___ CARDIAC PERFUSION \nIMPRESSION:\n1. Predominantly fixed moderate inferior wall perfusion defect. \n2. Enlarged left\nventricle with global hypokinesis and calculated ejection \nfraction of 32%.\n\n___ TTE:\nIMPRESSION: Biventricular cavity dilation with severe global \nbiventricular hypokinesis in a pattern most suggestive of a \nnon-ischemic cardiomyopathy. Moderate to severe mitral \nregurgitation. Pulmonary artery systolic hypertension. \n\nCT Abdomen ___\n1. Nodular and dysmorphic liver suggestive underlying cirrhotic \nchange. Spot small to moderate amount of ascites. No portal \nvein thrombosis. \n2. Nonspecific 7 mm arterially enhancing lesion at the periphery \nof segment 2 as detailed above, does not meet OPTN criteria. \nThis should be reassessed on future follow-ups. No hepatic \nlesions meeting OPTN criteria are identified. \n \nCXR ___\nThere is no focal consolidation, effusion, or pneumothorax. \nCardiomegaly is mild. The cardiomediastinal silhouette is \notherwise normal. Imaged osseous structures are intact. No free \nair below the right hemidiaphragm is seen. \n\nRUQ-US ___:\n1. 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. \n2. Splenomegaly and a small amount of ascites. \n3. Main portal vein findings which could be due to slow flow or \nthrombus. \nRECOMMENDATION(S): CT abdomen to evaluate the portal vein. \n\nLABS AT DISCHARGE:\n___ 05:25AM BLOOD WBC-9.9 RBC-3.31* Hgb-11.8* Hct-34.3* \nMCV-104* MCH-35.6* MCHC-34.4 RDW-14.0 RDWSD-54.1* Plt ___\n___ 05:25AM BLOOD ___ PTT-64.8* ___\n___ 05:25AM BLOOD Glucose-94 UreaN-17 Creat-0.9 Na-130* \nK-3.9 Cl-89* HCO3-29 AnGap-16\n___ 05:25AM BLOOD ALT-25 AST-65* AlkPhos-98 TotBili-10.1*\n___ 05:25AM BLOOD Calcium-9.6 Phos-4.4 Mg-1.___RIEF HOSPITAL COURSE\n___ with history of obesity, ETOH abuse, and HTN presenting from \nOSH with elevated LFTS, lower extremity edema, new onset atrial \nfibrillation, who was found to have new acute systolic heart \nfailure, likely secondary to ETOH cardiomyopathy. \n\n----------------\nACUTE ISSUES: \n----------------\n#ACUTE DECOMPENSATED SYSTOLIC CONGESTIVE HEART FAILURE: \nPt presented to OSH with ___ weeks of progressive b/l ___ edema, \nDOE, orthopnea. EKG at OSH revealed new onset atrial \nfibrillation without RVR, pro-BNP of 1100, and elevated LFTS. He \nwas admitted to the liver service for further hepatic \nevaluation, during which time he underwent a TTE to evaluate for \nvalvular atrial fibrillation. TTE revealed biventricular cavity \ndilation with severe global biventricular hypokinesis (EF 21%) \nsuggestive of non-ischemic cardiomyopathy, 3+ MR, and mild \npulmonary HTN. Etiology of cardiomyopathy likely secondary to \nETOH. Other possible causes were considered, including \ntachycardia induced (in afib, although HR remained wnl \nthroughout hospitalization), hemochromatosis (ferritin only \nmildly elevated, prior work up at ___ reportedly negative), \nischemia (pMIBI with fixed inferior wall defect, no \nischemia/anginal sx on stress), hormonal (TSH wnl), and HIV \n(negative). Patient transferred to cardiology service for \nfurther management and initiated on IV diuresis, ultimately \nplaced on lasix gtt at 10 mg/hr with good response. He was \ntransitioned to PO torsemide 80 mg qD. During hospitalization, \nhe was placed on metoprolol XL 12.5 daily, home lisinopril \ndecreased to 2.5 BID given low SBPs (90-110s), spironolactone \n12.5 daily, and torsemide 80 daily. Patient will return for \nTEE/___ in 4 weeks. \n\n___: \nPresented with Cr 1.2 (baseline ~ Cr 0.7), that peaked at 1.4 \nafter receiving albumin. Creatinine normalized after aggressive \ndiuresis, supporting the diagnosis of cardiorenal syndrome. \n\n#Atrial fibrillation: \nNew onset. Remained without evidence of sustained RVR \nthroughout hospitalization. CHADS2Vasc = 2 (HTN, CHF). \nMetoprolol initially started for rate control given HRs of \n110-120s but discontinued in setting of acute decompensated \nheart failure. Patient stared on metoprolol once near euvolemia. \nHe was anticoagulated with IV heparin and then switched to \napixiban for anticoagulation. He will return 4 weeks from \ndischarge for TEE/___. \n\n#Cirrhosis/Elevated LFTs: \nSuspected alcoholic hepatitis given AST/ALT ratio 2:1 and \nhistory of heavy drinking daily. On presentation with small \nascites, ___ edema, jaundice. No history of hepatic \nencephalopathy and EGD in ___ w/o evidence of varices. ___ \nconsider if some contribution of cardiac cirrhosis. MELD 10 on \nadmission, ___ Discriminant Function < 32. so steroid \ntherapy not initiated. Prior workup at ___ (followed by \noutpatient ___ hepatology) included hereditary hemochromatsis \nwhich was negative. Hepatitis serologies and HIV negative. CT \nA/P showed nodular liver consistent with cirrhosis. \nTransaminases downtrending, T. bili stable (peak of 10.8) and \ndowntrending at time of discharge. \n \n#Ascites: \nLikely secondary to increased portal pressures and \nhypoalbuminemia. No abdominal pain to suggest infection, and per \n___, pocket very small for dx para. No paracentesis done during \nthis hospitalization. \n\n#Alcohol abuse: \nNo history of durable sobriety. No history of withdrawal. \nPatient initially on CIWA and received Ativan x2, but did not \ndevelop severe withdrawal syndrome. He was given thiamine, \nfolate, and MVI. Social work met with the patient to offer \nsobriety resources and patient endorsed desire to attend AA \nmeetings with his brother, who is also a recovering alcoholic. \n\n#Hyponatremia: \nLikely hypervolemic hypernatremia secondary to hepatitis and \nacute systolic CHF. Urine studies show Na undetectable and UOSM \n500. Patient started on free water restriction of < 2L, Na \nrestriction, and diuresis as above. Na remained stable \nthroughout hospitalizaiton. \n \n# HSV Right Eye: \nContinued on home valacyclovir. \n\nTRANSITIONAL ISSUES\n- Patient will need comprehensive metabolic panel one week after \ndischarge at appointment with ___.\n- Patient to return in 4 weeks for TEE/DCCV\n-Nonspecific 7 mm arterially enhancing lesion at the periphery \nof segment 2 as detailed above, does not meet OPTN criteria. \nThis should be reassessed on future follow-ups. No hepatic \nlesions meeting OPTN criteria are identified.\n-Needs HepB vaccinations given lack of immunity to hepatitis B.\n-Repeat Echo in ~ 8 months (___)\n-Started Lisinopril 2.5 BID, spirinolactone 25, apixiban 5 mg \nBID (___)\n-Started torsemide 80 daily, consider uptitrating if weight is \nincreasing.\n-Started multivitamins, folic acid, thiamine.\n-Patient should make appt to follow with his ___ hepatologist. \n\n#DISCHARGE WEIGHT: 99.1 kg \n#INPATIENT DIURETIC REGIMEN: LASIX GTT at 10mg/hr\n#OUTPATIENT DIURETIC REGIMEN: torsemide 80mg daily\n#CODE: Full \n#HCP: ___ (sister) ___ \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Sucralfate 1 gm PO QID \n2. Omeprazole 40 mg PO BID \n3. amLODIPine 5 mg PO DAILY \n4. dutasteride 0.5 mg oral DAILY \n5. Lisinopril 40 mg PO DAILY \n6. Vitamin D ___ UNIT PO DAILY \n7. ValACYclovir 1000 mg PO Q8H \n\n \nDischarge Medications:\n1. Omeprazole 40 mg PO BID \n2. Sucralfate 1 gm PO QID \n3. ValACYclovir 1000 mg PO Q8H \n4. Vitamin D ___ UNIT PO DAILY \n5. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n6. Multivitamins 1 TAB PO DAILY \nRX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n7. Thiamine 100 mg PO DAILY \nRX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily \nDisp #*30 Tablet Refills:*0\n8. Apixaban 5 mg PO BID \nRX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0\n9. Lisinopril 2.5 mg PO BID \nRX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0\n10. Metoprolol Succinate XL 12.5 mg PO DAILY \nRX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth \ndaily Disp #*30 Tablet Refills:*0\n11. Spironolactone 12.5 mg PO DAILY \nRX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily \nDisp #*30 Tablet Refills:*0\n12. Torsemide 80 mg PO DAILY \nRX *torsemide 20 mg 4 tablet(s) by mouth daily Disp #*120 Tablet \nRefills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n====================\n-Acute systolic congestive heart failure\n-Atrial fibrillation\n-Cirrhosis\n-Alcohol abuse\n\nSECONDARY DIAGNOSIS\n=====================\n-Hypertension \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 came to our hospital with progressive swelling of your lower \nextremity and shortness of breath when lying flat. You were \ntreated by the liver service initially and then transferred to \ncardiology service. You have cirrhosis of your liver, likely \nfrom drinking excessive alcohol. It will be extremely \nimportantly to stop all types of alcohol (wine, hard liquor, \nbeer) in order to avoid serious illness and progression of your \nliver disease. In addition, your heart was also not pumping \nproperly, which may also be due to your alcohol consumption. \nHaving both your liver and heart not working at their full \ncapacity is very dangerous and the only way to help prevent \nprogression of disease is by stopping alcohol completely. Your \nheart was also found to be in an abnormal rhythm that \npredisposes you to blood clots and stroke, and you will need to \nbe on a blood thinner called \"apixaban.\"\n\nWe started you on several very important medications to help \nprotect your heart and decrease fluid accumulation (which occurs \nboth due to heart and liver disease). Please make sure to review \ncarefully and ask your doctor about any question or concerns. \n\nYou will need to return in 4 weeks to have a procedure called a \n\"cardioversion\" to get your heart back into normal heart rhythm. \nThis appointment will be scheduled for you. \n\nYou will need to follow-up your heart failure within one week. \nYou will be called with an appointment. \n\nPlease weigh yourself daily and keep a log of your weights. If \nyou gain more than 3lbs, please call your doctor. \n\nWe wish you the very best,\n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "K7031", "I5021", "K7011", "N179", "I426", "E871", "I4891", "B0052", "I10", "F1020", "Z7901", "K219", "N400", "D638" ]

[ "K7031: Alcoholic cirrhosis of liver with ascites", "I5021: Acute systolic (congestive) heart failure", "K7011: Alcoholic hepatitis with ascites", "N179: Acute kidney failure, unspecified", "I426: Alcoholic cardiomyopathy", "E871: Hypo-osmolality and hyponatremia", "I4891: Unspecified atrial fibrillation", "B0052: Herpesviral keratitis", "I10: Essential (primary) hypertension", "F1020: Alcohol dependence, uncomplicated", "Z7901: Long term (current) use of anticoagulants", "K219: Gastro-esophageal reflux disease without esophagitis", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "D638: Anemia in other chronic diseases classified elsewhere" ]

[ "N179", "E871", "I4891", "I10", "Z7901", "K219", "N400" ]

[]

[ " \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 renal failure and hyperbilirubinemia\n \nMajor Surgical or Invasive Procedure:\nEGD ___\n\n \nHistory of Present Illness:\n___ year old gentleman with history of alcohol abuse with \nresultant cirrhosis, sCHF (LV EF 20%) thought to be secondary to \nnon-ischemic cardiomyopathy/alcohol induced, hypertension, \nesophageal stricture s/p dilation, HZ keratitis, atrial \nfibrillation on apixiban, who presents with two week history of \nnausea, vomiting, diarrhea after stopping drinking. He noted \napproximately ___ weeks ago he had an episode of drinking 5 \nbeers x 1 day with subsequent development of jaundice over the \npast week. Also experienced weakness and lightheadedness. \n\nOf note, patient did have a history of fall one week prior to \nadmission in which he struck his left rib cage, leading to left \nupper quadrant abdominal discomfort. \n\nIn the ED initial vitals were 97.1, 68, 70/37, 16, 99% on RA. \nLabs were notable for WBC 15.8, H/H 11.5/31.3, platelets 211.\nChemistry notable for creatinine 9.0 (from baseline 1.0), \npotassium 6.4 (EKG without acute changes).\nLFT's notable for AST 146, ALT 45, Alk Phos 127, Lipase 87, T. \nbili 38.5, D. bili 27.9, Albumin 3.3. INR 2.0. \nTrop 0.13, BNP 1210. \nLactate 3.8.\nUA showed few bacteria but no leuks and negative nitrites.\nUrine toxicology negative for benzos, barbs, opiates, cocaine, \namphetamine, methadone, oxycodone.\nSerum toxicology negative for ASA, EtOH, acetaminophen, Benzo, \nbarb, tricyclics. \nCT A/P showed acute left seventh through ninth anterior rib \nfracturesm 2. cirrhotic liver with mild splenomegaly/no ascites, \n3. ectatic common iliac arteries.\"\nCXR showed no acute findings. \n\nIn the ED: patient received 2 L normal saline, 4.5 grams \npiperacillin-tazobactam, 1000 mg vancomycin, 125 mg \nmethylprednisolone, 10 units regular insulin x ___ grams 50% \ndextrose x 2, 1 gram calcium gluconate.\n\nGiven hypotension, patient had a right IJ placed. \n\nDenies any fevers, chills, night sweats, but has had numerous \nepisodes of non-bilious, non-bloody emesis. Denies melena. No \ncough or urinary urgency. \n \nReview of systems: Please see HPI. \n \n\n \nPast Medical History:\nEsophageal stricture, ___, found on evaluation for \ndysphagia s/p dilation\nHSV keratitis, followed at ___\nHistory of basal cell carcinoma\nElevated PSA\nAlcoholic cirrhosis\nAlcohol abuse\nNon-ischemic cardiomyopathy\nHypertension\nAtrial fibrillation \n \nSocial History:\n___\nFamily History:\nMother died of lung cancer. Father died of brain aneurysm. One \nbrother was shot while in the line of duty as ___ ___ \n___. \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n=================\nVitals: 98, 99, 107/53, 22, 100% on RA. \nGENERAL: Alert and oriented x 3, appears somewhat fidgety, but \ncomfortable, does not appear in any acute distress.\nHEENT: Sclera icteric, dry mucous membranes. \nNECK: supple, JVP not elevated. \nLUNGS: Clear to auscultation, no wheezes, rales or rhonchi. \nCV: tachycardic, irregularly irregular. \nABD: slightly distended but non-tender to palpation, no rebound \nor guarding. \nEXT: Warm, well perfused, 2+ pulses, no lower extremity edema. \nSKIN: Jaundiced\nNEURO: CN II-XII intact, minimal asterixis. \n\nDISCHARGE PHYSICAL EXAM\n=================\nVS: 98.1 94-118/47-71 ___ 98-100 2L\nGEN: resting comfortably in bed though with increased work of \nbreathing, AAOx3\nHEENT: Sclera icteric\nNECK: supple\nLUNGS: Wheezes on expiration diffusely\nCV: irregularly irregular, NL S1 S2 \nABD: distended but non-tender to palpation, no rebound or \nguarding. \nEXT: Warm, well perfused, 2+ pulses, no lower extremity edema. \nSKIN: Jaundiced \nNEURO: no asterixis\n \nPertinent Results:\nADMISSION LABS:\n===========\n___ 09:14AM BLOOD WBC-15.8*# RBC-2.76* Hgb-11.5* Hct-31.3* \nMCV-113*# MCH-41.7* MCHC-36.7 RDW-17.0* RDWSD-70.7* Plt ___\n___ 09:14AM BLOOD Neuts-77.6* Lymphs-11.3* Monos-6.4 \nEos-2.8 Baso-0.8 Im ___ AbsNeut-12.23*# AbsLymp-1.78 \nAbsMono-1.01* AbsEos-0.44 AbsBaso-0.13*\n___ 09:14AM BLOOD Glucose-153* UreaN-121* Creat-9.0*# \nNa-132* K-6.4* Cl-90* HCO3-13* AnGap-35*\n___ 09:14AM BLOOD ALT-45* AST-146* AlkPhos-127 \nTotBili-38.5* DirBili-27.9* IndBili-10.6\n___ 09:14AM BLOOD cTropnT-0.13* proBNP-1210*\n___ 04:51PM BLOOD CK-MB-6 cTropnT-0.07*\n___ 09:14AM BLOOD Lipase-87*\n___ 09:14AM BLOOD Albumin-3.3* Calcium-10.3 Phos-6.3*# \nMg-1.7\n___ 09:14AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 09:25AM BLOOD Lactate-3.8* K-5.7*\n\nPERTINENT INTERMITTENT LABS\n==========\n___ 06:55AM BLOOD WBC-22.2* RBC-2.13* Hgb-9.4* Hct-25.8* \nMCV-121* MCH-44.1* MCHC-36.4 RDW-15.8* RDWSD-70.2* Plt ___\n___ 07:05AM BLOOD WBC-15.5* RBC-1.82* Hgb-8.0* Hct-21.8* \nMCV-120* MCH-44.0* MCHC-36.7 RDW-15.4 RDWSD-68.1* Plt Ct-69*\n___ 07:05AM BLOOD Plt Ct-69*\n___ 06:39AM BLOOD Glucose-153* UreaN-119* Creat-2.4*# \nNa-136 K-4.7 Cl-94* HCO3-18* AnGap-29*\n___ 06:03AM BLOOD Glucose-149* UreaN-117* Creat-1.8* Na-135 \nK-3.9 Cl-94* HCO3-18* AnGap-27*\n___ 05:35AM BLOOD Glucose-87 UreaN-116* Creat-2.1*# Na-137 \nK-3.8 Cl-96 HCO3-18* AnGap-27*\n___ 07:05AM BLOOD Glucose-99 UreaN-69* Creat-1.4* Na-128* \nK-4.4 Cl-89* HCO3-25 AnGap-18\n___ 06:50AM BLOOD Glucose-155* UreaN-68* Creat-1.5* Na-127* \nK-4.1 Cl-88* HCO3-24 AnGap-19\n___ 04:40AM BLOOD Glucose-126* UreaN-39* Creat-1.0 Na-129* \nK-3.9 Cl-90* HCO3-24 AnGap-19\n___ 04:34AM BLOOD Glucose-122* UreaN-43* Creat-1.4* Na-127* \nK-3.8 Cl-88* HCO3-25 AnGap-18\n___ 07:06PM BLOOD Glucose-105* UreaN-48* Creat-1.5* Na-129* \nK-4.1 Cl-89* HCO3-21* AnGap-23*\n___ 07:30AM BLOOD ALT-49* AST-93* AlkPhos-177* \nTotBili-38.7*\n___ 07:01AM BLOOD ALT-42* AST-87* AlkPhos-197* \nTotBili-35.3*\n___ 07:05AM BLOOD ALT-42* AST-89* AlkPhos-162* \nTotBili-36.4*\n___ 06:50AM BLOOD ALT-41* AST-87* AlkPhos-174* \nTotBili-37.9*\n___ 07:09AM BLOOD ALT-36 AST-85* AlkPhos-148* TotBili-36.4*\n___ 07:05AM BLOOD ALT-41* AST-90* AlkPhos-142* \nTotBili-39.6*\n___ 06:16AM BLOOD ALT-44* AST-99* AlkPhos-150* \nTotBili-43.3*\n___ 04:40AM BLOOD ALT-39 AST-86* AlkPhos-167* TotBili-37.3*\n___ 04:34AM BLOOD ALT-41* AST-83* AlkPhos-179* \nTotBili-40.0*\n\nMICROBIOLOGY\n=========\n___ 11:42AM URINE Color-Yellow Appear-Clear Sp ___\n___ 11:42AM URINE Blood-TR Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-MOD Urobiln-NEG pH-6.5 Leuks-NEG\n___ 11:42AM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE \nEpi-<1\n___ 11:42AM URINE Mucous-RARE\n___ 06:50PM URINE Hours-RANDOM UreaN-297 Creat-61 Na-70\n___ 11:42AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG \ncocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG\nTime Taken Not Noted Log-In Date/Time: ___ 11:42 am\n URINE\n **FINAL REPORT ___\nURINE CULTURE (Final ___: NO GROWTH. \n C. difficile DNA amplification assay (Final ___: \n Negative for toxigenic C. difficile by the Cepheid nucleic \nacid\n amplification assay.\nFECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA \nFOUND. \nCAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER \nFOUND.\nBlood Culture, Routine (Final ___: NO GROWTH.\nURINE CULTURE (Final ___: NO GROWTH.\n\nIMAGING\n___: CHEST (PORTABLE AP) \nIMPRESSION: No acute findings on this limited chest radiograph. \n\n\n___: CT ABDOMEN AND PELVIS WITHOUT CONTRAST \nIMPRESSION: \n1. Acute left seventh through ninth anterior rib fractures. \n2. Cirrhotic liver with mild splenomegaly. No ascites. \n3. Ectatic common iliac arteries. \n\n___: RUQ US\n1. Echogenic liver consistent with steatosis. Other forms of \nliver disease including steatohepatitis, hepatic fibrosis, or \ncirrhosis cannot be excluded \non the basis of this examination. \n2. Patent portal vein with slow flow. \n3. Mild splenomegaly. \n\n___ RENAL DOPPLER ULTRASOUND\nRenal Doppler: Intrarenal arteries show normal waveforms with \nsharp systolic\npeaks and continuous antegrade diastolic flow. The resistive \nindices of the\nright intra renal arteries range from 0.70-0.75, which is normal \nto minimally\nelevated. The resistive indices on the left range from \n0.63-0.73, which is\nnormal to minimally elevated. Bilaterally, the main renal \narteries are patent\nwith normal waveforms. The peak systolic velocity on the right \nis ___\ncentimeters/second. The peak systolic velocity on the left is \napproximately\n150 centimeters/second. Main renal veins are patent bilaterally \nwith normal\nwaveforms.\nThe bladder is moderately well distended and normal in \nappearance.\nIMPRESSION: \nNormal renal ultrasound. No specific evidence of renal artery \nstenosis.\n\n___ CXR\nCompared to chest radiographs starting ___, most recently \n___. Mild cardiomegaly is chronic. Pulmonary \nvasculature is\nunremarkable. Lungs are clear. No pleural abnormality. \nFeeding tube passes\ninto the stomach and out of view\n\n___ Abd US\nTransverse ultrasound images were obtained of the 4 quadrants of \nthe abdominal\ncavity. No intra-abdominal free fluid is identified.\nIMPRESSION: \nNo evidence of ascites.\n\n___ CXR:\nIMPRESSION: \nNew mild pulmonary edema, evidenced by peribronchial cuffing and \nincreased \ninterstitial lung markings. No new focal consolidation. \n\n___ RUQ Doppler:\nIMPRESSION: \n1. No portal vein thrombus identified. \n2. Coarsened nodular hepatic architecture consistent with the \npatient's known cirrhosis. \n3. Splenomegaly. \n4. Moderate ascites. \n\n___ CXR:\nIn comparison to previous radiograph of 1 day earlier, the \ncardiac silhouette remains enlarged. Mild pulmonary vascular \ncongestion is present without overt pulmonary edema. No focal \nareas of consolidation are evident within the lungs. \n\nDISCHARGE LABS\n==========\nNo labs drawn on day of discharge.\n\n \nBrief Hospital Course:\nMr. ___ is a ___ year old man with alcohol cirrhosis c/b \nascites and possible hepatic encephalopathy with active drinking \nat the time of admission, non-ischemic cardiomyopathy/alcohol \ninduced sCHF (LV EF 40%) and atrial fibrillation on apixiban at \nhome, who presented alcohol hepatitis and acute kidney failure. \nPatient was discharged with home hospice ___.\n\n#Alcohol Hepatitis/Childs C Alcohol cirrhosis:\nPatient was actively drinking as an outpatient and then after a \nbinge developed symptoms consistent with etoh hepatitis. DF 86 \non admission, elevated to 107 at maximum. After initial \ninfectious workup yielded no growth, patient was started on \nprednisone for treatment. He received prednisone for 7 days \n(___). Lille 0.7 on day 7 of steroids indicated he was not \nsteroid responsive and steroids were stopped. He also has had a \nfeeding tube placed for maximal nutrition along with thiamine \nand folate supplemention. He was given ursodiol for cholestasis. \nBilirubin remained stably elevated between low ___ after \nsteroids completed. He was started on 400mg Pentoxifylline TID \non ___, with some improvement in renal failure but no \nimprovement in liver function. The patient's kidneys then began \nto worsen again, and diuresis became challenging. He was 20 \npounds up from his admission weight, and grossly volume \noverloaded. He had been comfortable during most of his \nadmission, and then began to develop shortness of breath due to \nvolume overloaded, requiring multiple doses of 80-100 mg IV \nLasix, which he did respond to. Given his failure to improve and \nworsening respiratory status and difficulty diuresing without \ncausing worsening renal failure, a family meeting was held on \n___, and patient expressed his clear desire to go home with \nhome hospice. He wants to be at home with his family, and to \nmaximize comfort and quality of life at this point in time.\n\n#Acute renal failure: Admission creatinine was 9.0 from baseline \n___. Workup yielded like prerenal from \ndecreased PO intake, diarrhea, alcohol hepatitis. He improved \nwith albumin and supportive care. However, when we attempted to \nrestarted diuresis, creatinine markedly came up, and diuresis \nwas again held. His kidney function began to improve, and then \nslowly began to decline again, and his volume status worsened as \nabove. Volume status was then what team focused on as he was \ndyspneic. \n\n#Afib: CHADS: 2. Metoprolol was started after the patient was \nhemodynamically stable. Apixaban was held as it is \ncontraindicated in Childs C patients, and his INR was ___ from \nliver disease.\n\n#Leukocytosis: Elevated to 27 on ___ from 20. No focal signs \nof infection. A repeat infectious workup was negative x2. Likely \nsecondary to alcohol hepatitis.\n\n# Alcohol Induced Cardiomyopathy: EF 40% on echo this admission. \nLisinopril was held in the setting of acute renal failure. \nMetoprolol was restarted when he was hemodynamically stable.\n\n# Rib Fracture: Patient admitted with left sided rib fracture \ndue to fall, pain initially was controlled with lidocaine \npatches and oxycodone prn, both of which he was not requiring at \ndischarge.\n\n# Herpes Keratitis: He was started on acyclovir and \ntransitioned to his home valacyclovir 1000mg BID as renal \nfunction improved. He shared he did not want to continue this \nmedication when discharged with hospice, and therefore it was \ndiscontinued.\n\nTRANSITIONAL ISSUES\n================\n#Patient discharged with home hospice to maximize comfort and \nquality of life\n#Code: DNR/DNI, MOLST filled out with patient.\n#Contact/HCP: ___, Wife.\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Apixaban 5 mg PO BID \n2. FoLIC Acid 1 mg PO DAILY \n3. Lisinopril 10 mg PO BID \n4. Metoprolol Succinate XL 25 mg PO DAILY \n5. Omeprazole 40 mg PO BID \n6. Potassium Chloride 20 mEq PO DAILY \n7. Spironolactone 25 mg PO DAILY \n8. Sucralfate 1 gm PO TID \n9. Torsemide 80 mg PO DAILY \n10. ValACYclovir 1000 mg PO Q12H \n11. Vitamin D ___ UNIT PO DAILY \n12. Multivitamins 1 TAB PO DAILY \n13. Thiamine 100 mg PO DAILY \n\n \nDischarge Medications:\n1. Lactulose 30 mL PO TID constipation \nPlease take this so that you have ___ bowel movements per day. \nRX *lactulose 20 gram/30 mL 30 ml by mouth three times a day \nRefills:*0 \n2. Ursodiol 300 mg PO BID \n***If you feel like this isn't helping you, you can stop it*** \nRX *ursodiol 300 mg 1 capsule(s) by mouth twice a day Disp #*60 \nCapsule Refills:*0 \n3. Metoprolol Succinate XL 25 mg PO DAILY \n4. Torsemide 80 mg PO PRN shortness of breath \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___ \n \nDischarge Diagnosis:\nPrimary: Alcoholic Hepatitis, acute kidney failure\n\nSecondary: Alcoholic Cirrhosis, 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\nIt was a pleasure taking care of you during your hospitalization \nat the ___. You were admitted \nto ___ because your liver and kidneys became very sick from \ndrinking too much alcohol. You were supported with IV fluids, \nand watched very closely. You were also given one week of \nsteroids to help treat your liver injury, but that medication \nwas stopped because it did not help much. You were started on a \nnew medication, Pentoxifylline, to attempt to improve you liver \nfunction and kidney function. This also did not work very well.\n\nBecause your liver and kidneys were both very sick, and you have \na history of heart failure, your body became very full of fluid. \nIt became difficult to manage the fluid in your body without \nhurting your kidneys.\n\nAfter many discussions with you and your family, you decided you \nwould prefer to go home and spend your time with your family and \nfocus on comfort and quality of life at this time. If you ever \ndecide you want to come back to the hospital, you absolutely \ncan. \n\nYou are being discharged with home hospice care, and can \ncontinue to contact us, your primary care team, and your liver \ndoctor, for whatever you may need or questions you might have. \n\nIt was a pleasure caring for you.\n\nSincerely,\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "K7010", "I5023", "K7030", "N179", "K831", "E46", "I959", "E872", "I110", "D684", "I426", "S2242XA", "E871", "B0052", "Z23", "F1010", "I4891", "Z7902", "E875", "Z515", "Z66", "W19XXXA", "Y929", "K222" ]

[ "K7010: Alcoholic hepatitis without ascites", "I5023: Acute on chronic systolic (congestive) heart failure", "K7030: Alcoholic cirrhosis of liver without ascites", "N179: Acute kidney failure, unspecified", "K831: Obstruction of bile duct", "E46: Unspecified protein-calorie malnutrition", "I959: Hypotension, unspecified", "E872: Acidosis", "I110: Hypertensive heart disease with heart failure", "D684: Acquired coagulation factor deficiency", "I426: Alcoholic cardiomyopathy", "S2242XA: Multiple fractures of ribs, left side, initial encounter for closed fracture", "E871: Hypo-osmolality and hyponatremia", "B0052: Herpesviral keratitis", "Z23: Encounter for immunization", "F1010: Alcohol abuse, uncomplicated", "I4891: Unspecified atrial fibrillation", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "E875: Hyperkalemia", "Z515: Encounter for palliative care", "Z66: Do not resuscitate", "W19XXXA: Unspecified fall, initial encounter", "Y929: Unspecified place or not applicable", "K222: Esophageal obstruction" ]

[ "N179", "E872", "I110", "E871", "I4891", "Z7902", "Z515", "Z66", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \npenicillin G / hydrochlorothiazide\n \nAttending: ___\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ female presenting with ___ days of abdominal pain (sharp in \nnature) mostly on her left abdomen who reports a 2 day hx of \nblood in her stool beginning ___ evening after eating. She \npresented to her PCP yesterday with this complaint and was sent \nfor a CT scan revealing distal transverse and proximal \ndescending colitis. She reports that over the last two days, her \nbloody bowel movements have continued. She reports that \ninitially they seemed to just have blood, but now, she reports \nshe has had normal caliber stool with some blood intermixed. She \nreports some nausea. No emesis. After her PCP appointment, she \nstopped taking ASA per MD orders. She endorses decreased \nappetite and nausea. She denies any acute illness prior to the \nabdominal pain and blood in stool. She also denies any hx of \npalpitations or\narrhythmias. Last colonoscopy was ___ years ago.\n\nOf note, patient is a poor historian. She is accompanied by her \ngrandson who provides additional history.\n \nPast Medical History:\nPMH: \nPREDIABETES \nPreviously on metformin; A1C 5.6% off of metformin as of ___ \nHYPERTENSION \nGLAUCOMA \nFollowed at ___ optho \nARTHRITIS \nSCIATICA \nRight \nLOW BACK PAIN\n?DVT \n \nSocial History:\n___\nFamily History:\nRelative Status Age Problem \nMother ___ ___ \nFather ___ OLD AGE \nComments: NO known MI or COLON cancer. \n \nPhysical Exam:\nDISCHARGE PHYSICAL EXAM:\n\nVitals: T 98.5 HR 72 BP 132/64 RR 18 SpO2 98% RA\n\nGeneral: awake, alert, no acute distress\nHEENT: trachea midline\nCV: regular rate and rhythm\nPulm: CTAB\nGI: abdomen soft, non-distended, non-tender\nExtremities: warm and well perfused\n \nPertinent Results:\nADMISSION LABS:\n\n___ 07:55PM WBC-8.2 RBC-4.57 HGB-10.6* HCT-35.8 MCV-78* \nMCH-23.2* MCHC-29.6* RDW-16.8* RDWSD-47.2*\n___ 07:55PM NEUTS-75.0* LYMPHS-15.7* MONOS-8.2 EOS-0.5* \nBASOS-0.2 IM ___ AbsNeut-6.13* AbsLymp-1.28 AbsMono-0.67 \nAbsEos-0.04 AbsBaso-0.02\n___ 07:55PM ___ PTT-26.2 ___\n___ 08:04PM LACTATE-2.4*\n___ 07:55PM GLUCOSE-128* UREA N-10 CREAT-1.0 SODIUM-145 \nPOTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-26 ANION GAP-14\n___ 07:55PM ALT(SGPT)-11 AST(SGOT)-21 ALK PHOS-75 TOT \nBILI-0.4\n\nIMAGING:\n\nCT abdomen/pelvis ___:\nIMPRESSION:\n1. Severe colitis involving the distal transverse and proximal \ndescending colon.\n2. Small bowel lateral to the cecum and ascending colon, \nsuggesting the\npresence of partial malrotation.\n\nCT chest ___:\nIMPRESSION: 2 calcified granulomas. No evidence of pneumonia\n\nTTE ___:\nIMPRESSION: Normal left ventricular wall thickness, cavity size, \nand regional/global systolic\nfunction. Mild right ventricular cavity dilation with normal \nsystolic function (may be UNDERestimated\ngiven severity of tricuspid regurgitation). Severe tricuspid \nregurgitation in the setting of failure of\nleaflets to fully coapt. Mild mitral regurgitation. At least \nmild pulmonary systolic hypertension.\n\nCT abdomen/pelvis ___:\nIMPRESSION:\n1. Interval improvement colitis of the splenic flexure. The \ndistribution of findings is compatible with ischemic colitis.\n2. No large arterial splanchnic branch occlusion. This does not \nexclude an ischemic episode from low flow state.\n \nBrief Hospital Course:\nMs. ___ is an ___ year old female who presented to ___ \n___ on ___ with abdominal pain \nand bloody stools. Her imaging demonstrated colitis of the \nsplenic flexure, concerning for possible ischemic etiology. She \nwas admitted to the Acute Care Surgery service for bowel rest, \nIV fluid resuscitation, and serial abdominal exams. She \nunderwent an echocardiogram which showed no evidence of cardiac \nthrombotic source for mesenteric ischemia. On ___, she underwent \na CTA of the abdomen and pelvis which demonstrated patent \nmesenteric vessels and interval improvement in her colitis. Her \nabdominal pain had resolved at this point, so she was given a PO \nchallenge and advanced to a regular diet as tolerated. \n\nOn ___, the patient was tolerating a regular diet, voiding \nspontaneously without issue, and her abdominal pain had \nresolved. She had had no bloody bowel movements. She was deemed \nready for discharge to home with PCP follow up. ___ was told to \nfollow up in surgery clinic as needed. \n\n \nMedications on Admission:\nMedications - Prescription\nBRIMONIDINE - brimonidine 0.2 % eye drops. 1 drop ophthalmic\nthree times a day - (Prescribed by Other Provider)\nDORZOLAMIDE-TIMOLOL - dorzolamide 22.3 mg-timolol 6.8 mg/mL eye\ndrops. 1 drop opthalmic three times a day - (Prescribed by \nOther\nProvider)\nLOSARTAN [COZAAR] - Cozaar 50 mg tablet. 1 tablet(s) by mouth\ndaily\nNIFEDIPINE - nifedipine ER 30 mg tablet,extended release 24 hr.\nTAKE 1 TABLET BY MOUTH DAILY\nOMEPRAZOLE - omeprazole 20 mg capsule,delayed release. TAKE 1\nCAPSULE BY MOUTH DAILY\n \nMedications - OTC\nACETAMINOPHEN - acetaminophen 500 mg tablet. ___ tablet(s) by\nmouth three times a day as needed for pain\nASPIRIN - aspirin 81 mg chewable tablet. 1 tablet(s) by mouth\ndaily\nBLOOD SUGAR DIAGNOSTIC [ONETOUCH ULTRA TEST] - OneTouch Ultra\nTest strips. use to test blood glucose daily\nLANCETS - lancets 33 gauge. use to test blood glucose daily\n \nDischarge Medications:\nMedications - Prescription\nBRIMONIDINE - brimonidine 0.2 % eye drops. 1 drop ophthalmic\nthree times a day - (Prescribed by Other Provider)\nDORZOLAMIDE-TIMOLOL - dorzolamide 22.3 mg-timolol 6.8 mg/mL eye\ndrops. 1 drop opthalmic three times a day - (Prescribed by \nOther\nProvider)\nLOSARTAN [COZAAR] - Cozaar 50 mg tablet. 1 tablet(s) by mouth\ndaily\nNIFEDIPINE - nifedipine ER 30 mg tablet,extended release 24 hr.\nTAKE 1 TABLET BY MOUTH DAILY\nOMEPRAZOLE - omeprazole 20 mg capsule,delayed release. TAKE 1\nCAPSULE BY MOUTH DAILY\n \nMedications - OTC\nACETAMINOPHEN - acetaminophen 500 mg tablet. ___ tablet(s) by\nmouth three times a day as needed for pain\nASPIRIN - aspirin 81 mg chewable tablet. 1 tablet(s) by mouth\ndaily\nBLOOD SUGAR DIAGNOSTIC [ONETOUCH ULTRA TEST] - OneTouch Ultra\nTest strips. use to test blood glucose daily\nLANCETS - lancets 33 gauge. use to test blood glucose daily\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nIschemic colitis of the splenic flexure\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, \n\nYou were admitted to ___ on \n___ with abdominal pain and inflammation of the bowel. You \nare recovering well and are now ready for discharge. Please \nfollow the instructions below to continue your recovery:\n\nACTIVITY: \n o You may resume normal activity as tolerated.\n o You may climb stairs. \n o You may go outside, but avoid traveling long distances until \nyou see your surgeon at your next visit. \n o You may start some light exercise when you feel comfortable. \n \nHOW YOU MAY FEEL: \n o You may feel weak or \"washed out\" for a couple of weeks. You \nmight want to nap often. Simple tasks may exhaust you. \n o You could have a poor appetite for a while. Food may seem \nunappealing. \n o All of these feelings and reactions are normal and should go \naway in a short time. If they do not, tell your surgeon. \n \nYOUR BOWELS: \n o Constipation is a common side effect of narcotic pain \nmedications. If needed, you may take a stool softener (such as \nColace, one capsule) or gentle laxative (such as milk of \nmagnesia, 1 tbs) twice a day. You can get both of these \nmedicines without a prescription. \n o If you go 48 hours without a bowel movement, or have pain \nmoving the bowels, call your surgeon. \n \nPAIN MANAGEMENT: \n o Your pain should get better day by day. If you find the pain \nis getting worse instead of better, please contact your surgeon. \n\n o You will receive a prescription for pain medicine to take by \nmouth. It is important to take this medicine as directed. o Do \nnot take it more frequently than prescribed. Do not take more \nmedicine at one time than prescribed. \n o Your pain medicine will work better if you take it before \nyour pain gets too severe. \n o Talk with your surgeon about how long you will need to take \nprescription pain medicine. Please don't take any other pain \nmedicine, including non-prescription pain medicine, unless your \nsurgeon has said its okay. \n o If you are experiencing no pain, it is okay to skip a dose of \npain medicine. \n o Remember to use your \"cough pillow\" for splinting when you \ncough or when you are doing your deep breathing exercises.\n\nIf you experience any of the following, please contact your \nsurgeon: \n - sharp pain or any severe pain that lasts several hours \n - pain that is getting worse over time \n - pain accompanied by fever of more than 101 \n - a drastic change in nature or quality of your pain \n \nMEDICATIONS: \n Take all the medicines you were on before the operation just as \nyou did before, unless you have been told differently. \n If you have any questions about what medicine to take or not to \ntake, please call your surgeon.\n\n \nFollowup Instructions:\n___\n" ]

[ "K558", "Q433", "R7303", "Z7901", "I10" ]

[ "K558: Other vascular disorders of intestine", "Q433: Congenital malformations of intestinal fixation", "R7303: Prediabetes", "Z7901: Long term (current) use of anticoagulants", "I10: Essential (primary) hypertension" ]

[ "Z7901", "I10" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nseizure, hypoxic resp failure\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ male with a history of prior CVA x2 \n(___) on ___, ___ x2 and polysubstance use disorder who \npresents with seizure.\n\nHe is visiting family from ___. Reported feeling weak \nat 1500 while showering but was able to walk downstairs. Per his \ncousin, he appeared ___ a daze. At 1600 he then was witnessed by \nfamily to have seizure activity at approximately 1700 that last \na few minutes described as hand shakiness, faint breath, and \ndiaphoresis. EMS was called, he then had a second seizure for \nwhich he was given versed bolus which aborted the seizure. He \nwas then post-ictal and brought to ___ where he \nwas noted to be unresponsive, diaphoretic, and had horizontal \nnystagmus with possible \"deviated gaze to the left.\" He was then \nintubated for airway protection. Keppra load of 2g. Lactate 3.8. \nTrop negative. Head CT was reportedly negative for acute \nintracranial abnormalities. He was then transferred to ___.\n\nOf note, his wife and daughter reported that he has a history of \npolysubstance use and suspect that he and his cousin were \nactively using whatever they could acquire. Unclear what exactly \nwas consumed though per family member likely various muscle \nrelaxants Reportedly he does not live with either of them. They \narrived to see him when he came to the ED, though left shortly \nafter back to ___ but left contact info.\n \nPast Medical History:\nCVA w/ residual left sided weakness\nMI X2\nDVT on anticoagulation ___\nAmputation of left ___ toes ___\nknee replacement\nhip replacement\n \nSocial History:\n___\nFamily History:\nunable to obtain\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n======================== \nVS: 98.4 | 59 | 122/107 | 24 at 99% on APV with PEEP 5, FiO2 \n50%, TV 450 and RR set at 20 \nGEN: Sedated\nHEENT: Intubated. No icteric sclera. PERRLA\nCV: RRR, no r/m/g\nRESP: CTAB, no wheezes/crackles/rhonchi\nGI: Nondistended, soft, nontender\nMSK: No gross deformities\nNEURO: No hyperreflexia. Unable to assess cranial nerves\n\nDISCHARGE PHYSICAL EXAM:\n=========================\nVITALS: Temp: 98.3 BP: 175/94 HR: 78 RR:20 O2: 99 on 2L\nGENERAL: Alert and interactive. ___ no acute distress. Tan. \nHEENT: Sclera anicteric and without injection. Moist mucous\nmembranes. No cervical lymphadenopathy or thyroid nodules.\nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops.\nLUNGS: Clear to auscultation bilaterally w/appropriate breath\nsounds appreciated ___ all fields. No wheezes, rhonchi or rales.\nNo increased work of breathing.\nABDOMEN: Hyperactive bowels sounds, non distended, non-tender to\ndeep palpation ___ all four quadrants. \nEXTREMITIES: No clubbing, cyanosis, or edema. Left lower leg \nwith\nscar on medial portion with 3 lesser toe amputations. Dorsalis\npedis felt bilaterally, decreased on left.\nNEUROLOGIC: CN2-12 intact. ___ strength on right, ___ strength \non\nLUE and LLE. EOMI with no gaze preference.\n\n \nPertinent Results:\nADMISSION LABS:\n========================================\n___ 11:00PM BLOOD WBC-4.7 RBC-3.93* Hgb-11.6* Hct-37.4* \nMCV-95 MCH-29.5 MCHC-31.0* RDW-14.4 RDWSD-50.5* Plt ___\n___ 11:00PM BLOOD Neuts-79.8* Lymphs-13.1* Monos-5.9 \nEos-0.2* Baso-0.4 Im ___ AbsNeut-3.77 AbsLymp-0.62* \nAbsMono-0.28 AbsEos-0.01* AbsBaso-0.02\n___ 11:00PM BLOOD ___ PTT-28.8 ___\n___ 11:00PM BLOOD Glucose-127* UreaN-12 Creat-0.8 Na-138 \nK-4.4 Cl-104 HCO3-24 AnGap-10\n___ 11:00PM BLOOD ALT-87* AST-91* AlkPhos-114 TotBili-0.5\n___ 11:00PM BLOOD Lipase-20\n___ 11:00PM BLOOD cTropnT-0.02*\n___ 02:35AM BLOOD cTropnT-0.01\n___ 11:00PM BLOOD Albumin-3.5 Calcium-7.9* Phos-4.0 Mg-1.8\n___ 10:00AM BLOOD VitB12-375 Folate->20\n___ 04:48AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG\n___ 10:00AM BLOOD HAV Ab-NEG\n___ 11:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nTricycl-NEG\n___ 04:48AM BLOOD HCV Ab-POS*\n___ 04:48AM BLOOD CHCV VL-PND\n___ 11:15PM BLOOD Type-CENTRAL VE pO2-210* pCO2-53* \npH-7.32* calTCO2-29 Base XS-0 Intubat-INTUBATED\n___ 11:15PM BLOOD Lactate-1.0\n\nDISCHARGE LABS:\n========================================\n___ 08:30AM BLOOD WBC-6.9 RBC-4.35* Hgb-13.0* Hct-40.5 \nMCV-93 MCH-29.9 MCHC-32.1 RDW-14.0 RDWSD-47.9* Plt ___\n___ 08:30AM BLOOD ___ PTT-31.3 ___\n___ 08:30AM BLOOD Glucose-98 UreaN-9 Creat-0.6 Na-135 \nK-3.4* Cl-97 HCO3-28 AnGap-10\n___ 08:30AM BLOOD ALT-72* AST-57* AlkPhos-121 TotBili-0.8\n___ 08:30AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.9\n___ 05:18AM BLOOD ___ pO2-211* pCO2-40 pH-7.41 \ncalTCO2-26 Base XS-1 Comment-GREEN TOP\n\nMICROBIOLOGY:\n========================================\n___ 12:00 pm SPUTUM Site: ENDOTRACHEAL\n Source: Endotracheal. \n\n GRAM STAIN (Final ___: \n ___ PMNs and <10 epithelial cells/100X field. \n 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. \n ___ PAIRS AND SINGLY. \n 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). \n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). \n\n RESPIRATORY CULTURE (Preliminary): \n SPARSE GROWTH Commensal Respiratory Flora. \n__________________________________________________________\n___ 11:00 pm BLOOD CULTURE\n\n Blood Culture, Routine (Pending): No growth to date. \n__________________________________________________________\n___ 11:00 pm BLOOD CULTURE\n\n Blood Culture, Routine (Pending): No growth to date. \n__________________________________________________________\n___ 11:05 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: < 10,000 CFU/mL. \n\nIMAGING:\n========================================\n\n___ Imaging CHEST (PORTABLE AP) \n1. ET tube approximately 5.5 cm from carina. \n2. Possible right hilar adenopathy and bronchial obstruction. \nFollow-up with conventional radiographs advised. \n\n___ Imaging CHEST (PORTABLE AP) \nCompared to the only prior chest radiograph available, ___ \np.m. on ___. Right suprahilar atelectasis has improved, but \nright lung volume remains low. There is suggestion of fullness \n___ the right hilum and poor definition of the right bronchial \ntree. This region should be re-evaluated with conventional \nradiographs when feasible. Mild left basal atelectasis improved. \n No pneumothorax. Pleural effusions small if any. Heart size \nnormal. ET tube ___ standard placement. Nasogastric drainage \ntube passes into a nondistended stomach and out of view. \n\n___ Imaging CT HEAD \nFINDINGS: \nLarge area of hypodensity involving the right \nparietal/temporal/occipital \nlobes, likely representing a chronic infarction involving the \nPCA territory or encephalomalacia due to prior traumatic injury. \nSmaller focal left frontal lobe hypodensity (4:66), likely \nrepresenting chronic infarction. Nonspecific periventricular and \nsubcortical white matter hypodensities, likely reflecting \nchronic small vessel ischemic disease. There is no evidence of \nnew acute infarction,hemorrhage,edema,or mass effect. The \nventricles and sulci are prominent, suggestive of involutional \ndisease. There is no evidence of acute calvarial fracture. Mild \nmucosal thickening of the ethmoid air cells. The mastoid air \ncells, and middle ear cavities are clear. The visualized \nportion of the orbits are unremarkable. \nIMPRESSION: \n1. No evidence of acute intracranial abnormalities. \nSpecifically, no evidence of acute infarction or hemorrhage. \n2. Large area of hypodensity involving the right \nparietal/temporal/occipital \nlobes, likely representing chronic infarction involving the PCA \nterritory or encephalomalacia due to prior traumatic injury. \n3. Small focal left frontal lobe hypodensity (4:66), likely \nrepresenting \nchronic infarction. \n\n___ Imaging LIVER OR GALLBLADDER US \nFINDINGS: \nLIVER: Limited windows due to gas-related artifact. The hepatic \nparenchyma appears within normal limits. The contour of the \nliver is smooth. There is no focal liver mass. The main portal \nvein is patent with hepatopetal flow. There is no ascites. \nBILE DUCTS: There is no intrahepatic biliary dilation. \n CHD: 4 mm \nGALLBLADDER: There is no evidence of stones or gallbladder wall \nthickening. \nPANCREAS: The imaged portion of the pancreas appears within \nnormal limits, \nwithout masses or pancreatic ductal dilation, with portions of \nthe pancreatic tail obscured by overlying bowel gas. \nRETROPERITONEUM: The visualized portions of aorta and IVC are \nwithin normal limits. \nIMPRESSION: \nNormal abdominal ultrasound. \n\n___ Imaging MR HEAD W/O CONTRAST \nFINDINGS: \nThere is chronic infarct ___ the right posterior cerebral artery \ndistribution involving the occipital, parietal, and temporal \nlobes. No acute infarct is seen. Low GRE signal throughout \nthis area is consistent with blood products, probably chronic \nhemorrhage. There is extensive tissue loss ___ this area. Small \nchronic infarct ___ the left frontal lobe is also demonstrated. \nMild prominence of the ventricles and sulci suggestive of \nage-related volume loss. Periventricular and subcortical T2 and \nflair hyperintensities are nonspecific but likely represent \nsmall vessel ischemic disease. There is mild mucosal thickening \nof the ethmoidal air cells. The maxillary sinuses and mastoid \nair cells are clear. The orbits are unremarkable. \nIMPRESSION: \n1. No acute infarct. \n2. Chronic infarct ___ the right posterior cerebral artery \ndistribution \ncontaining blood products, likely chronic hemorrhage. No mass \neffect or \nmidline shift. \n\nEEG:\nEEG showed intermittent right frontal predominant periodic\ndischarges. Since starting Keppra, EEG has looked better. No \nseizures.\n\n \nBrief Hospital Course:\nSUMMARY:\n===========================================================\nMr. ___ is a ___ man with a history of prior CVA x2 \n(___) on apixaban, CAD with MI x2, and polysubstance use \ndisorder who presented with a seizure. \n\nACUTE ISSUES:\n===========================================================\n\n# Seizure\nHe was witnessed by family to have seizure activity described as \nhand shakiness and diaphoresis at home. EMS was called and he \nhad a second seizure for which he was given a midazolam bolus \nthat aborted the\nseizure. He was brought to ___ where he was noted to be \nunresponsive, diaphoretic, and had horizontal nystagmus with \npossible \"deviated gaze to the left.\" He was then intubated for \nairway protection. He was given a levetiracetam load of 2g. His \nlactate was noted to be elevated at 3.8. Head CT was negative \nfor acute intracranial abnormalities. He was then transferred to \n___, where he was monitored for 24 hours with EEG which showed \nno aberrant spikes. MRI showed no acute stroke, evidence of \nchronic infarct ___ R posterior cerebral artery distribution with \nlikely chronic hemorrhage. Blood-work demonstrated elevated LFTs \nand positive HCV Ab, VL pending at discharge. During his \nhospitalization he has been seizure free and at baseline mental \nstatus. \n\n# Elevated LFTs\n# HCV infection \nLFTs ___ 100s at OSH and subsequently trending down. ___ be ___ \nto EtOH vs HCV as Ab was positive during this admission (NEW \nDIAGNOSIS). HCV VL was pending at discharge. He was found to be \nHep B and A non-immune and was given first doses of both \nvaccines prior to discharge but will need to complete the \nvaccine regimens. \n\nCHRONIC ISSUES:\n===========================================================\n\n# Hx of CVA\nContinued home atorvastatin. Per Neurology, he should undergo \nCTA head/neck, TTE, and Holter or Ziopatch monitor as outpatient \nfor full work-up of stroke if this has not occurred previously. \n\n# Hx of DVT vs. PAD \nReported taking apixaban 5mg BID for DVT hx. Given DVT was \nreportedly 9 months ago, he may not require further \nanticoagulation at this time. However, anticoagulation was \ncontinued with plan to follow up with his PCP as outpatient and \ndetermine final course. \n\n# Hx ETOH use\nPt reports drinking a few times weekly, but previously heavy \nuse. Started folic acid and thiamine. \n\nTRANSITIONAL ISSUES:\n===========================================================\n[] Patient should have the following tests done to work up his \nprevious stroke:\n- ___ monitor\n- CTA head/neck\n- Transthoracic echocardiogram\n[] Please ensure follow up with Stroke neurologist\n[] Patient has newly diagnosed hepatitis C with mildly elevated \nLFTs and will need treatment. \n[] Hepatitis A and B vaccine first doses given on ___. \nPlease ensure completion of regimen for immunization. \n[] Consider discontinuation of apixaban given history of DVT 9 \nmonths ago, may not be indicated.\n\nMEDICATION CHANGES:\n===========================================================\n- Levetiracetam 1000 mg Q12H\n- Folic acid 1 mg QD\n- Thiamine 100 mg QD\n\nCODE STATUS: Full Code\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 80 mg PO QPM \n2. Apixaban 5 mg PO BID \n\n \nDischarge Medications:\n1. FoLIC Acid 1 mg PO DAILY \nRX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n2. LevETIRAcetam 1000 mg PO Q12H \nRX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth every \ntwelve (12) hours Disp #*60 Tablet Refills:*0 \n3. 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 \n4. Apixaban 5 mg PO BID \n5. Atorvastatin 80 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY:\nSeizure\n\nSECONDARY:\nHistory of stroke\nPolysubstance use\nDeep vein thrombosis\nMyocardial infarction\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - ___ a boot for L foot.\n\n \nDischarge Instructions:\nDear Mr. ___,\nYou were seen ___ ___ after your recent seizure. We performed \nseveral tests, including monitoring your brain activity to look \nfor increased firing that could predispose to seizures as well \nas other metabolic reasons for the seizure; these results were \nreassuring. Given you were positive for hepatitis C we also gave \nyou vaccines for hepatitis A and B as you were not previously \nimmunized.\nIf you experience any of the following please return to the ED:\nDizziness or lightheadedness\nNumbness or tingling\nChange ___ vision\nConfusion\nHeadache\nWeakness ___ arm, leg, or face\nDifficulty walking\nDifficulty talking\nLoss of balance\nIncontinence of urine or stool\n\nIt was a pleasure taking care of you!\nYour ___ medical team\n\n \nFollowup Instructions:\n___\n" ]

[ "R569", "I69954", "Z86718", "Z7902", "Z7289", "I252", "I10", "E785", "Z89422", "D696", "D649" ]

[ "R569: Unspecified convulsions", "I69954: Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side", "Z86718: Personal history of other venous thrombosis and embolism", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z7289: Other problems related to lifestyle", "I252: Old myocardial infarction", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "Z89422: Acquired absence of other left toe(s)", "D696: Thrombocytopenia, unspecified", "D649: Anemia, unspecified" ]

[ "Z86718", "Z7902", "I252", "I10", "E785", "D696", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: CARDIOTHORACIC\n \nAllergies: \nPercocet / morphine / Percodan\n \nAttending: ___.\n \nChief Complaint:\ncough/respiratory distress likely secondary to bronchogenic cyst\n \nMajor Surgical or Invasive Procedure:\nRight VATS bronchogenic cyst excision ___ Dr. ___\n \n___ of Present Illness:\n___ year old man with history of a subcarinal lesion thought to \nbe a bronchogenic cyst identified first in ___. Patient \nreports it was aspirated at its initial presentation and his \nclinicians were unsure whether this represented lymphoma, \ninfectious, or other pathology. Since then, the patient has a \nrecent CT that shows a persistent lesion in the same area that \nappears similar to back in ___. The patient reports that over \nthe past year, he has been having progressive dyspnea and \ncoughing daily. Cough is productive of thin, semi-clear, yellow \nsputum. No hemoptysis. Denies fevers, chills, sweats. Reports \northopnea and dyspnea on exertion. Last month he went to \nhospital briefly and was thought to have possible pneumonia and \n3 weeks ago he underwent PFTs and had a coughing fit to the \npoint where he syncopized. Recently, symptoms have been \nworsening.\n \nPast Medical History:\nPAST MEDICAL HISTORY:\nHTN\nHLD\nUlcerative Colitis\n\nPAST SURGICAL - \nleft and right ACL repair (___)\ntonsillectomy ___\n \nSocial History:\n___\nFamily History:\nMother\nFather deceased CHF, lymphoma\nSiblings\nOffspring ___ old son w neuroblastoma; other son with\nthyroglossal duct cyst\nOther\n \nPhysical Exam:\nVS 97.8 HR:80 BP: 151/91 18 95% RA\nHEENT: MMM, no scleral icterus or injection\nCV: rrr, mild systolic murmur\nPULM: no acute distress, slightly coarse on expiration on left \nbase; \nabd: soft, nt nd, + BS\next: wwp, no peripheral edema\n \n \nPertinent Results:\n___ 05:42AM BLOOD WBC-7.7 RBC-3.88* Hgb-11.7* Hct-36.2* \nMCV-93 MCH-30.2 MCHC-32.3 RDW-13.2 RDWSD-44.7 Plt ___\n___ 04:25AM BLOOD WBC-9.8 RBC-4.08* Hgb-12.2* Hct-37.1* \nMCV-91 MCH-29.9 MCHC-32.9 RDW-13.0 RDWSD-43.0 Plt ___\n___ 02:27AM BLOOD WBC-14.2* RBC-3.99* Hgb-12.2* Hct-36.9* \nMCV-93 MCH-30.6 MCHC-33.1 RDW-13.1 RDWSD-43.9 Plt ___\n___ 05:42AM BLOOD Glucose-110* UreaN-9 Creat-0.9 Na-140 \nK-4.1 Cl-104 HCO3-26 AnGap-14\n___ 05:42AM BLOOD Calcium-8.3* Phos-3.8 Mg-2.1\n___ 05:42AM BLOOD Vanco-12.7\n \nBrief Hospital Course:\nOn ___ the patient presented at ___ for right VATS \nexcision of bronchogenic cyst. Post-procedurally, the patient \nwas taken to the PACU where he was found to have low blood \noxygen saturation. BiPAP was placed, which improved his oxygen \nlevels, and nebulizer treatments were administered three times. \nHis heart rate was also found to be between 100-120. Out of \nconcern for his oxygenation status and airway, he was admitted \nto the ICU for close monitoring. Broad spectrum antibiotics \nwere initiated after the procedure based on the appearance and \nsmell of the contents of the cyst. He did well in the ICU, and \non post operative day #1 he was transferred out of the ICU and \nbrought to the floor. He did not require any additional \nnebulizer treatments after his stay in the ICU. Broad spectrum \nantibiotics were continued on the floor.\n\nHe was advanced to a regular diet, which he tolerated well. The \npatient, who usually takes diltiazem at home, was started on \nmetoprolol 25mg po twice a day, which kept his heart rate \nbetween 70 and 100. His pain was well controlled with standing \ntoradol and oxycodone as needed. \n\nOn POD#2 his antibiotics were switched from vancomycin, ceftaz, \nand flagyl to vancomycin and zosyn per AST recommendations. He \ncontinued breathing treatments.\n\nOn POD #3 the patient was doing well enough to be discharged to \nhome. Antibiotics were switched to Augmentin by mouth twice a \nday for 7 days. Pain control was via oxycodone. A stool \nsoftener was given with instructions to be taken when taking \npain medication. No home oxygen was required. The patient will \nfollow up with Dr. ___ in clinic in ___ days.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 40 mg PO QPM \n2. Diltiazem Extended-Release 180 mg PO DAILY \n3. Escitalopram Oxalate 20 mg PO DAILY \n4. Pantoprazole 40 mg PO Q24H \n5. biotin 10,000 mcg oral DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \n2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H \nRX *amoxicillin-pot clavulanate 875 mg-125 mg 1 (One) by mouth \ntwice a day Disp #*14 Tablet Refills:*0 \n3. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 (One) capsule(s) by mouth twice a \nday Disp #*45 Capsule Refills:*0 \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 to 2 tablet(s) by mouth every four (4) to \nsix (6) hours Disp #*40 Tablet Refills:*0 \n5. Atorvastatin 40 mg PO QPM \n6. biotin 10,000 mcg oral DAILY \n7. Diltiazem Extended-Release 180 mg PO DAILY \n8. Escitalopram Oxalate 20 mg PO DAILY \n9. Pantoprazole 40 mg PO Q24H \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nbronchogenic cyst status post excision\nright pneumothorax\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 ___ after your right \nsided video assisted thoracic surgery to remove your \nbronchogenic cyst. You has a small pneumothorax (air in your \nchest outside of your lung) and needed breathing treatments and \nwere therefore in the ICU. You have recovered from this \nprocedure well and you are now ready to return home. Samples \nfrom your cyst were sent to the microbiology lab and based on \nthese, you are being sent home to continue antibiotics. \nYou are breathing well, have tolerated a regular diet, are \npassing gas, and your pain is controlled with pain medications \nby mouth. You may return home to finish your recovery. \n\nPlease monitor your breathing function. Continue to use your \nincentive spirometer 10 times an hour while awake. Check your \nincisions daily and report any increased redness or drainage. \nCover the area with a gauze pad if it is draining. Your chest \ntube dressing may be removed in 48 hours. If it starts to drain, \ncover it with a clean dry dressing and change it as needed to \nkeep site clean and dry. If you experience worsening shortness \nof breath, severe chest pain, please come to the emergency room \nfor immediate evaluation. \n You will be prescribed narcotic pain medication oxycodone. This \nmedication should be taken when you have pain and as needed as \nwritten on the bottle. This is not a standing medication. You \nshould continue to take Tylenol for pain around the clock and \nyou can also take Advil. Please do not take more than 3000mg of \nTylenol in 24 hours. Do not drink alcohol while taking narcotic \npain medication or Tylenol. Please do not drive a car while \ntaking narcotic pain medication. If you are taking narcotic pain \nmedications there is a risk that you will have some \nconstipation. Please take an over the counter stool softener \nsuch as Colace or Miralax, and if the symptoms do not improve \ncall the office. If you have any of the following symptoms \nplease call the office for advice or go to the emergency room if \nsevere: increasing abdominal distension, increasing abdominal \npain, nausea, vomiting, inability to tolerate food or liquids, \nprolonged loose stool, or extended constipation. If your doctor \nallows you may also take Ibuprofen to help relieve the pain. \nContinue to stay well hydrated and eat well to heal your \nincisions \n You have ___ laparoscopic surgical incisions on the side of \nyour chest which are closed with internal sutures and a skin \nglue called Dermabond. These are healing well, however it is \nimportant that you monitor these areas for signs and symptoms of \ninfection including: increasing redness of the incision lines, \nwhite/green/yellow/malodorous drainage, increased pain at the \nincision, increased warmth of the skin at the incision, or \nswelling of the area. Please call the office if you develop any \nof these symptoms or a fever. You may go to the emergency room \nif your symptoms are severe. \n You may shower; pat the incisions dry with a towel, do not rub. \nThe small incisions may be left open to the air. If closed with \nsteri-strips (little white adhesive strips) instead of \nDermabond, these will fall off over time, please do not remove \nthem. Please no baths or swimming for 6 weeks after surgery \nunless told otherwise by your surgical team. Please no lotions \nor creams to incision site until at least your postop visit. \n Please walk ___ times a day and gradually increase your \nactivity as you can tolerate. No heavy lifting greater than 6 \nlbs for until your first post-operative visit after surgery, \nunless otherwise instructed. Please no strenuous activity until \nthis time unless instructed otherwise by Dr. \n___. \n Call Dr. ___ office at ___ or visit the \nemergency room if you experience any of the following: \n -Temp > 101, chills, increased shortness of breath, chest pain \nor any other symptoms that concern you. \n Thank you for allowing us to participate in your care! Our hope \nis that you will have a quick return to your life and usual \nactivities. \n\n \nFollowup Instructions:\n___\n" ]

[ "Q341", "J95811", "J398", "I10", "E785", "J9809", "Y838", "Y92239", "R0902", "J42" ]

[ "Q341: Congenital cyst of mediastinum", "J95811: Postprocedural pneumothorax", "J398: Other specified diseases of upper respiratory tract", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "J9809: Other diseases of bronchus, not elsewhere classified", "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", "R0902: Hypoxemia", "J42: Unspecified chronic bronchitis" ]

[ "I10", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: PSYCHIATRY\n \nAllergies: \nBactrim / shellfish derived\n \nAttending: ___.\n \nChief Complaint:\n\"talked about coming in haven't left the house for a\nmonth...I just started not going out, not sleeping , not\nshowering and I started getting suicidal... it would be easier \nif\nI wasn't here.\"\n \nMajor Surgical or Invasive Procedure:\nECT MWF ___. Total of 15 treatments.\n \nHistory of Present Illness:\nThe patient is a ___ yo single cauc. gay male, with HIV, Hep C \nand\nhx of Major Depression, PTSD, Panic disorder, past hx of PSA and\nalcohol misuse in remission with hx of multiple psychiatric\nadmissions the last in ___ @ ___.\nThe patient was referred to the ED by his outpatient treaters as\nhe has been suicidal and his depression intensifies this time of\nyear. They reported that he has not been able to leave his house\nfor the past few weeks, not sleeping at night or will sleep all\nday and he has been thinking about hanging himself. \nThe patient was treated with ECT on his last admission in \n___ with some improvement and was to continue treatment on an\noutpatient basis, 3x /week, but reports that he could not find\nsomeone to stay with him at home for 6 hours post treatment so \nhe\nwas not able to continue treatment.\nHe reports that his psychiatrist is in he process of titrating\ndown is Klonopin from 6mg qd to 3mg, and his Buspar has been\nincreased in he last 6 months and as has his Hydroxyzine.\n\n*Collateral:In speaking to his psychiatrist, Dr. ___\nreports the patient is very depressed, unsafe and believes he\nneeds to be hospitalized. She requested to please not make any\nmedications changes without consulting her first.\n\n \nPast Medical History:\nPCP ___ @ ___ ___\nHIV ___\nHep C ___\nCrohn's Disease\nCervical Radiculopathy\nAsthma\nHerniated discs 3\nSpinal Stenosis\nreported past hx of seizures from hypoglycemia and septicemia\n \nSocial History:\nHe lives alone in ___. in a triple ___ in ___ with his \ndog. He volunteers at the ___ and runs a group, \nin\nthe past worked as a mental health counselor on a psychiatric\nunit. He reported hx of academic and behavior problems and\nrelated to \"anger\" and, not participating, bored and was labeled\nlearning disabled. He has achieved a Bachelor's degree in\nPsychology from ___, although he told PCP he has\n\"some college\". He identified as gay at age ___ is attracted to\nmen but has had sex with both men and women and his first\nconsensual sexual encounter was at age ___ with a female.\nHis parents divorced when hew was ___ and his mother worked and\nraised the family, alone. Mother is ___ yo healthy and lives in\n___. Father is also ___ lives out ___. He has a sister, who\nlives in ___, who is older, a brother who is\ndeceased,{suicide} and a younger brother in ___. He was\nraised in ___ in a chaotic household, he reports that his\nfather ridiculed him for being gay and was that father was\nemotionally, physically abusive and sexually abusive. He was\nsexually molested as a child from ages ___ on 7 occasions by 5\ndifferent people including 5 men and his best friend's mother.\n \nFamily History:\n- brother committed suicide in his ___ by asphyxiation\n- paternal aunt attempted suicide\n- father bipolar, antisocial and a \"child molester\" per patient\n- sister with depression and hx of anorexia\n- mother's side of the family with alcoholism\n- reports a total of 3 completed suicides in his family\n \nPhysical Exam:\nADMIT EXAM:\nT: 97.8 PO BP: 116/74 HR: 90 RR: 16 O2 Sat: 99% \nGeneral: NAD. Well-nourished, well-developed. Appears stated \nage.\nHEENT: Normocephalic, atraumatic. PERRL, EOMI. Oropharynx clear.\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\nNEUROLOGIC EXAMINATION:\nCranial Nerves:\n-Pupils symmetry and responsiveness to light and accommodation:\nPERRLA\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\n- Motor: Normal bulk and tone bilaterally. No abnormal \nmovements,\nno tremor \n- Strength: full power ___ throughout \n- Coordination: Finger to nose WNL\n- Sensation: Intact to light touch throughout. \n- Gait: Steady. Normal stance and posture. No truncal ataxia.\n\nCOGNITIVE EXAM: \n- Wakefulness/alertness: awake and alert\n- Attention: DOWB (slow, mixes up ___ and ___\n- Orientation: oriented to person, time, place, situation\n- Memory: intact to recent and past history\n- Fund of knowledge: knows first and current president\n- Calculations: correctly states 7 quarters in $1.75\n- Abstraction: apple/orange = \"pieces of fruit\"\n- Visuospatial: not assessed\n- Speech: normal rate, volume, and tone\n- Language: native ___ speaker, no paraphasic errors,\nappropriate to conversation\n\nMENTAL STATUS EXAM:\n- Appearance: Caucasian M, appears stated age, well groomed,\ndressed in hospital gown\n- Behavior: Good eye contact, no PMR/PMA, calm and cooperative\nwith interview\n- Mood: \"depressed\"\n- Affect: dysthymic, restricted\n- Thought Process: Linear, logical, no LoA\n- Thought Content: SI with thoughts of hanging himself, denies\ncurrent suicidal intent denies HI, denies AVH, denies PI\n- Judgment/Insight: Impaired/impaired\n\nDISCHARGE EXAM:\nCOGNITIVE EXAM: \n- Wakefulness/alertness: awake and alert\n- Attention: completes MOWB accurately, though with some \nhesitation after ___\n- Orientation: oriented to person, hospital/city/state/country, \nand date\n- Memory: ___ registration and ___ delayed recall which improves \nto ___ with category cue\n- Fund of knowledge: knows current president and vice-president, \nas well as current events (\"A lot of executive orders\")\n- Calculations: correctly states 22 nickels in $1.10\n- Abstraction: apple/orange = fruit\n- Visuospatial: not assessed\n- Speech: somewhat monotone but otherwise regular in rate\n- Language: native ___ speaker, no paraphasic errors, \nappropriate to conversation\n\nMENTAL STATUS EXAM:\n- Appearance: Caucasian M, appears stated age, well groomed, \ndressed in hospital gown\n- Behavior: Good eye contact, no PMR/PMA, calm and cooperative \nwith interview\n- Mood: \"Good\" rated at ___\n- Affect: euthymic and reactive, though somewhat flattened\n- Thought Process: Linear, logical, no LoA\n- Thought Content: Denies SI, denies HI, denies AH/VH, no \ndelusions\n- Judgment/Insight: Good/Good\n\n \nPertinent Results:\n CBC WBC RBC Hgb Hct MCV MCH MCHC RDW \nRDWSD Plt Ct \n___ 04:17 5.9 3.85* 12.1* 36.2* 94 31.4 33.4 12.9 \n43.8 ___ 04:17 181 \n \n\nChemistry \n RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap \n___ 04:17 105 10 0.9 142 4.1 ___ \n\n ENZYMES & BILIRUBIN ALT AST AlkPhos TBil \n___ 04:17 ___ 0.4 \n\n CHEMISTRY Albumin Ca Phos Mg \n___ 04:17 4.0 9.0 4.5 1.9 \n\n PITUITARY TSH \n___ 04:17 2.___. LEGAL & SAFETY: \nOn admission, the patient signed a conditional voluntary \nagreement (Section 10 & 11) and remained on that level \nthroughout their admission. He 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 Depression, recurrent, severe\nOn admission, pt endorsing continued suicidal ideation with \nblunted and dysphoric affect. He was agreeable at that time to \nstart ECT as soon as possible which began ___ on a ___ \nschedule. Following initial procedure pt reported headache, \nmuscle soreness and fatigue, relieved somewhat by NSAIDs given \npost-op by ECT team. He began to show response after 4 \ntreatments, reporting improved mood rated at ___ with continued \nimprovement as treatments progressed. The patient's ECT course \nwas interrupted briefly by gastrointestinal illnesses with \nintermittent episodes of diarrhea (as below). Immediately prior \nto individual ECT treatments the patient felt significant \nanxiety related to the upcoming treatments. He described a fear \nthat he would wake up during the treatments and reported that a \nsimilar experience occurred in the past during an appendectomy. \nOther than pre-treatment anxiety (managed with hydroxyzine PRN, \nwhich discontinued upon discharge), he responded to ECT \ntreatments well during admission: depression and anxiety \nimproved, affect was brighter, and he was caring for ADLs. After \n15 total ECT treatments, his reported mood was ___, without \nsuicidal ideation. The possibility of completing the treatment \ncourse on an outpatient basis was discussed but pt was unable to \nmake this work logistically as he had no one to pick him up and \nstay with him after procedures. \n\nMedication changes: the patient had been non-compliant with \nWellbutrin prior admission. This was resumed after admission. \nDischarge dose was Wellbutrin XL 300 mg per day. The patient was \nalso on high doses of Kolopin (up to 6 mg per day) prior to \nadmission. This was successfully reduced to 1 mg BID. Quetiapine \n50 mg QHS was added on an as needed basis for insomnia. \n\n3. SUBSTANCE USE DISORDERS:\n#) Alcohol use disorder: in remission since last drink ___. He \nhas history of other illicits, however denies all since ___. \nSubstance use disorders were not a focus of this admission, but \nthe team reinforced patient's decision to remain abstinent.\n\n4. MEDICAL\n\n#Crohn's Disease:\nOn admission the patient was continued on Asacol 800 mg TID. \nThis was continued throughout admission and on discharge. During \nadmission he had several brief episodes of diarrhea with crampy \nabdominal pain. These episodes tended to resolve after ___ days \nwith the use of PRN Imodium and/or Lamotil and increased PO \nfluid intake. One of these episodes appears to have been \nprecipitated by antibiotic use (as discussed below the patient \nwas started on a prophylactic course of Cephalexin to avoid \nonset of strep throat. This course was terminated following the \npatient's development of diarrhea and abdominal pain). Basic lab \nstudies were checked periodically during the patient's diarrheal \nillnesses and showed no leukopenia (the patient's outpatient \ngastroenterologist reports that the patient has history of \nleukopenia during Crohn's flares). The patient's episodes of \ndiarrhea and associated crampy abdominal pain were thought to be \npotentially related to mild Crohn's flares as well as potential \nantibiotic induced diarrhea. C. diff infection was low on the \ndifferential given the patient's mild pain, lack of \nleukocytosis, and lack of fever. Upon discharge, he had had \nregular once daily bowel movements for several days. These \nissues were discussed with the patient's gastroenterologist. \nVital signs were stable throughout the admission.\n\n# Strep throat prophylaxis:\nDue to multiple cases of Strep throat on the unit, the patient \nwas started on a prophylactic course of Cephalexin (500 mg PO/NG \nQ12H, 10 Day course Started ___. This was started after \ndiscussing the risks and benefits of the medication with the \nhospital public health / infectious disease team as well as the \npatient. This antibiotic course was discontinued on ___ due \nto new onset\nof diarrhea (per ID team recommendations) as discussed above.\n\n# ___: pt had Cr of 1.3 and hyaline casts on UA on admission, \nlikely in the setting of poor PO intake/dehydration. Pt \nencouraged to take fluids, Cr returned to 1.0 per BMP ___ \ndemonstrating resolution.\n\n#HIV Infection\nPer patient, last viral load in ___ was undetectable (gets\nchecked twice per year.) During admission, Abacavir 600 mg \ndaily, lamivudine 300 mg daily ordered in place of Epzicom per \nhome regimen. Kaletra 2 tabs BID continued. Acyclovir 400mg BID \nordered in place of home valacyclovir for herpes prophylaxis. \nThese medication replacements were made temporarily in \naccordance with hospital formulary; he was returned to his \noutpatient regimen upon discharge.\n\n#Chronic Back Pain ___ spinal stenosis c/b cervical \nradiculopathy\nThe patient reported intermittent pain during admission which \nwas similar to symptoms experienced prior to admission. He was \ncontinued on Tizanidine 2 mg QAM, QNoon, 4 mg QHS and continued \nOxycodone 10 mg q6h PRN per home regimen.\n\n#GERD\nContinued Omeprazole 20 mg daily\n\n#Hyperlipidemia\nContinued fenofibrate 145 mg daily\n\n#Asthma\nContinued Proair inhaler 2 puffs Q4h PRN for wheezing\n\n#Hepatitis C\n-s/p Harvoni 2 months ago with full clearance of virus per PCP, \npending second test in several months. \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. The patient was frequently \nvisible and social in the milieu.\n\n#) COLLATERAL CONTACTS & FAMILY INVOLVEMENT:\nSpoke with outpatient provider ___ on admission \nand she reported that he tends to respond well to ECT without \nany medication changes. Pt does not have any family involvement. \nUpdated Dr. ___ therapies ___ intermittently \nthroughout the admission and upon discharge (Both are at ___ \n___, Behavioral ___, ___. Left a message with \nthe office of PCP ___ (___).\n\nINFORMED CONSENT: The team discussed the indications for, \nintended benefits of, and possible side effects and risks of \nstarting X medication, and risks and benefits of possible \nalternatives, including not taking the medication, with this \npatient. We discussed the patient's right to decide whether to \ntake this medication as well as the importance of the patient's \nactively participating in the treatment and discussing any \nquestions 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 himself and/or others based upon \nstated suicidal ideation with a plan to hang himself. Their \nstatic factors noted at that time include chronic medical and \npsychiatric illness, hx of suicide attempts, past \nhospitalizations, chronic mental illness, past hx of \npoly-substance abuse, un-partnered gay male and lives alone. The \nmodifiable risk factors were also addressed at that time. \nSuicidal ideation w/ plan was discussed with pt regularly, \nutilizing exploratory and supportive techniques. It was also \ntreated with course of ECT and continuation of home medications. \nSocial withdrawal was addressed by helping pt to identify ways \nin which he can re-engage in the community including returning \nto the ___ to work/attend groups. Finally, the \npatient is being discharged with many protective risk factors, \nincluding help-seeking behavior, good therapeutic relationship \nwith outpatient treaters, medication compliance, some social \nsupport and history of employment and some college education.\n\nBased on the totality of our assessment at this time, the \npatient is not at imminent risk of self-harm nor imminent risk \nof harming others. \n\nOur Prognosis of this patient is guarded given the numerous \nstatic risk factors noted above.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Epzicom (abacavir-lamivudine) 600-300 mg oral DAILY \n2. Mesalamine ___ 800 mg PO TID \n3. BuPROPion XL (Once Daily) 300 mg PO DAILY \n4. BusPIRone 10 mg PO TID \n5. ClonazePAM 1 mg PO TID \n6. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - \nModerate \n7. Lopinavir-Ritonavir 2 TAB PO BID \n8. ValACYclovir 500 mg PO DAILY \n9. Fenofibrate 145 mg PO DAILY \n10. HydrOXYzine ___ mg PO QHS insomnia \n11. Omeprazole 20 mg PO DAILY \n12. Tizanidine 2 mg PO QAM \n13. Tizanidine 2 mg PO NOON \n14. Tizanidine 4 mg PO QHS \n15. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing \n16. Ketoconazole 2% 1 Appl TP BID \n\n \nDischarge Medications:\n1. QUEtiapine Fumarate 50 mg PO QHS:PRN insomnia \nRX *quetiapine 50 mg 1 tablet(s) by mouth at bedtime Disp #*14 \nTablet Refills:*0 \n2. ClonazePAM 1 mg PO BID \n3. Tizanidine 2 mg PO NOON Duration: 1 Dose \n4. Tizanidine 2 mg PO QAM \n5. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing \n6. BuPROPion XL (Once Daily) 300 mg PO DAILY \nRX *bupropion HCl 300 mg 1 tablet(s) by mouth Every morning Disp \n#*14 Tablet Refills:*0 \n7. Epzicom (abacavir-lamivudine) 600-300 mg oral DAILY \n8. Fenofibrate 145 mg PO DAILY \n9. Ketoconazole 2% 1 Appl TP BID \n10. Lopinavir-Ritonavir 2 TAB PO BID \n11. Mesalamine ___ 800 mg PO TID \n12. Omeprazole 20 mg PO DAILY \n13. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - \nModerate \n14. Tizanidine 4 mg PO QHS \n15. ValACYclovir 500 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nMajor Depressive Disorder, recurrent, severe\n\n \nDischarge Condition:\nAmbulatory. \n\nMENTAL STATUS EXAM:\n- Appearance: Caucasian M, appears stated age, well groomed, \ndressed in hospital gown \n- Behavior: Good eye contact, no PMR/PMA, calm and cooperative \nwith interview\n- Mood: 'Good' rated at ___ \n- Affect: euthymic and reactive, though somewhat flattened\n- Thought Process: Linear, logical, no LoA\n- Thought Content: Denies SI, denies HI, denies AH/VH, no \ndelusions\n- Judgment/Insight: Good/Good\n \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" ]

[ "F332", "N179", "B20", "K5090", "R45851", "M4802", "G4700", "J45909", "E785", "K219", "F419", "M5412", "B1920", "E860", "F4312", "J00" ]

[ "F332: Major depressive disorder, recurrent severe without psychotic features", "N179: Acute kidney failure, unspecified", "B20: Human immunodeficiency virus [HIV] disease", "K5090: Crohn's disease, unspecified, without complications", "R45851: Suicidal ideations", "M4802: Spinal stenosis, cervical region", "G4700: Insomnia, unspecified", "J45909: Unspecified asthma, uncomplicated", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "F419: Anxiety disorder, unspecified", "M5412: Radiculopathy, cervical region", "B1920: Unspecified viral hepatitis C without hepatic coma", "E860: Dehydration", "F4312: Post-traumatic stress disorder, chronic", "J00: Acute nasopharyngitis [common cold]" ]

[ "N179", "G4700", "J45909", "E785", "K219", "F419" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: PSYCHIATRY\n \nAllergies: \nBactrim / shellfish derived\n \nAttending: ___.\n \nChief Complaint:\n\"I was suicidal.\"\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nThe patient is a ___ yo single gay male HIV, Hep C, with hx of \nmajor depression, PTSD, panic disorder, PSA, alcohol misuse in \nremission, hx of multiple\nsuicide attempts and hospitalizations, ___ to the ED by \nhis\npsychiatrist for worsening depression, suicidal ideation with\nplan to hang himself. The patient reports that he has been \ndepressed for the past 5 months, and for the past 4 weeks he has \nbeen socially isolated, not leaving his apt, not shopping, not \nfunctioning. He reports that he has hx of\nsevere depression that responds to ECT and said \"I should be on\nmaintanance..I go down fast\".\n\nThe patient started treatment with a new psychiatrist last ___\nand she is tapering him off Klonopin and they both agreed he\nneeds ECT. His psychiatrist and the patient had been in touch\nwith Dr. ___ to discuss ECT, but the patient reported\nthat he felt too overwhelmed and amotivated to set up an\nappointment for ECT. He reported to his psychiatrist that he \ndoes\nwell with ECT but usually has a recurrence of severe depression\nafter 6 months and \"I get better then I stop,(ECT},I nose dive\nand then I get suicidal.\" He said \"I don't want to be here. I'm\njust done I don't know what I'm getting better for and I don't\ncare. It worries me, I think it would be really easy to hang\nmyself in the basement\".\n\nThe patient is currently on 6mg a day of Klonopin and is\ncurrently be tapered off and he briefly decreased the dose more\nrapidly than planned and started to experience auditory and\nvisual hallucinations, tremulousness which resolved once he\nresumed 4mg daily dose. \n\nThe patient reports that he has not slept in 2 days and last\nnight he heard things \"falling off the wall all night that\nsounded like magnets\". He said that over New Years he\nhallucinated for over 30 hours. Was hallucinating about birds in\nhis apt that looked like small pheasants. He said \" I was really\nmad they were everywhere under the furniture I was trying to\ncatch them and kill them I was really mad.\" He said \"I know ECT\nis the only thing that will keep me alive\".\n\nHe now reports that he is severely depressed, anxious, suicidal,\nwith plan of hanging himself, not sleeping, with poor appetite,\nno energy, not leaving the house and has lost interest in most \nof\nhis outside activities.\n\n \nPast Medical History:\nPCP ___ @ ___ ___\nHIV ___\nHep C ___\nCrohn's Disease\nCervical Radiculopathy\nAsthma\nHerniated discs 3\nSpinal Stenosis\nreported past hx of seizures from hypoglycemia and septicemia\n \nSocial History:\nHe lives alone in ___. in a triple ___ in ___ with his \n2 dogs.\nHe volunteers at the ___ and runs a group and \nin\nthe past worked as a mental health ___ on a psychiatric\nunit. He reported hx of academic and behavior problems and\nrelated to \"anger\" and , not participating, bored and was \nlabeled\nlearning disabled. He has achieved a Bachelor's degree in\nPsychology from ___, although he told PCP he has\n\"some college\". He identified as gay at age ___ is attracted to\nmen but has had sex with both men and women and his first\nconsensual sexual encounter was at age ___ with a female.\nHis parents divorced when hew was ___ and his mother worked and\nraised the family, alone. Mother is ___ yo healthy and lives in\n___. Father is also ___ lives out ___. He has a sister, who\nlives in ___ is older, a brother who is\ndeceased,{suicide} and a younger brother in ___. He was\nraised in ___ in a chaotic household, he reports that his\nfather ridiculed him for being gay and was that father was\nemotionally, physically abusive and sexually abusive. He was\nsexually molested as a child from ages ___ on 7 occasions by 5\ndifferent people including 5 men and his best friend's mother\n \nFamily History:\n- brother committed suicide in his ___ by asphyxiation\n- paternal aunt attempted suicide\n- father bipolar, antisocial and a \"child molester\" per patient\n- sister with depression and hx of anorexia\n- mother's side of the family with alcoholism\n- reports a total of 3 completed suicides in his family\n \nPhysical Exam:\nVS: T 97.7, HR 98, BP 150/88, SPO2 98% RA \nGeneral- NAD\nSkin- no rashes or bruises\nHEENT- PERRLA, MMM, normal oropharynx\nLungs- CTA bilaterally\nCV- RRR, N S1 and S2, no m/r/g\nAbdomen- Soft, NT, ND, +BS, no guarding or rebounding\nExtremities- No edema, normal tone\nNeuro- CN II-XII grossly intact, normal gait, strength not\nformally assessed - moves all extremities anti-gravity, normal\nsensation throughout\nNeuropsychiatric Examination:\n *Appearance: middle-aged Caucasian male dressed in hospital\ngown, appropriate grooming and hygiene, tattoo on left arm\n Behavior: cooperative, overall pleasant, fair eye contact, no\nabnormal movements, pt does report he feels sedated from just\ntaking his Seroquel in the ED\n *Mood and Affect: \"okay\", affect is dysphoric\n *Thought process: linear, goal-directed, no LOA\n *Thought Content: denies active SI, reports passive SI, denies\nplan, denies HI, reports that he experienced VH as in HPI when\nbenzos were tapered, denies AH\n *Judgment and Insight: impaired/impaired\n Cognition: of note, pt declined to complete full cognitive \nexam\nas he was feeling sedated from just having taken QHS meds in the\nED\n *Attention: attentive to interview\n *Orientation: fully oriented to person, place, and time\n *Memory: did not assess, however earlier today in the ED pt\nhad ___ registration, ___ recall with prompting\n *Fund of knowledge: appropriate, did not formally assess\n Calculations: did not assess, cognitive exam earlier today \npt\nreported 9 quarters=$2.25\n *Speech: Normal rate, tone and volume\n *Language: Fluent\n\n \nPertinent Results:\n___ 05:55PM URINE HOURS-RANDOM\n___ 05:55PM URINE HOURS-RANDOM\n___ 05:55PM URINE UHOLD-HOLD\n___ 05:55PM URINE GR HOLD-HOLD\n___ 05:55PM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 10:55AM GLUCOSE-111* UREA N-15 CREAT-0.9 SODIUM-144 \nPOTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-24 ANION GAP-15\n___ 10:55AM estGFR-Using this\n___ 10:55AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG \nbnzodzpn-NEG barbitrt-NEG tricyclic-NEG\n___ 10:55AM WBC-7.0 RBC-3.90* HGB-12.8*# HCT-36.8* MCV-94 \nMCH-32.8* MCHC-34.8 RDW-12.9 RDWSD-43.9\n___ 10:55AM NEUTS-49.1 ___ MONOS-9.4 EOS-1.1 \nBASOS-0.6 IM ___ AbsNeut-3.46 AbsLymp-2.78 AbsMono-0.66 \nAbsEos-0.08 AbsBaso-0.04\n___ 10:55AM PLT COUNT-181\n \nBrief Hospital Course:\n*) LEGAL / SAFETY\nThe patient was admitted to an locked inpatient psychiatric \nunit. He signed a CV which was accepted on ___. On admission \nhe was placed on Q15 minute checks which is the lowest level of \nobservation provided on this unit. On admission he was placed on \nmonitored access of sharps\n \n\nPSYCHIATRIC\n#)Major Depression Disorder: On admission, pt endorses worsening \ndepression over the past 3 months, and SI with plans to hang \nhimself in the past 1 months. He reports full neurovegetative \nsymptoms, and social withdrawal. \nDuring hospitalization, we continued his home medication \nBurpopion 150mg daily. Unilateral ECT is started on ___, and \nscheduled for MWF at inpatient setting. Pt completed 10 ECT \ntreatments prior to discharge. Pt is held off for the night dose \n0.5mg Klonipin on the night before the ECT, and receive morning \ndose klonipin after the ECT treatment.\n\n#)Complex PTSD with anxiety/nightmares: Pt reports multiple \ntraumatic life experiences, including being sexually malaise in \nchildhood, witnessed his partner hanging himself in the closet, \nand brother committed suicide. He endorses PTSD symptoms, \nincluding hypervigilance, nightmares, flashbacks, and avoidance. \nDuring this hospitalization, we continued his home Klonipin dose \n(1mg BID, 2mg qAM) and home dose Buspirone 30mg BID for anxiety. \nPt was given Prazosin 4mg QHS for nightmares. Pt was initially \ngiven home dose Seroquel 50mg QHS for anxiety and sleep, but his \nsymptoms did not improve. Hence on ___, he was switched from \nSeroquel to SL Zydis 5mg QHS and PRN Zydis 5mg q6h. After \ndiscussing with his outpatient treater Dr. ___ was given \nPRN hydroxyzine 25mg q6h for anxiety. Pt reports much improved \nsleep and diminished nightmare by taking hydroxyzine at night. \nHence, the team added the standing order hydroxyzine 25mg QHS to \nhelp with his insomnia and nightmare.\n\nOn discharge, pt has stable mood and affect. He has much \nimproved neurovegetative symptoms, denies SI. He is forthcoming. \nHe is motivated to participate in the Bridge Program at the \n___, and follow up with his outpatient \npsychiatrist and therapist regularly. He will continue \noutpatient maintenance ECT as outpatient. \n\nSafety: The patient remained in good behavioral control \nthroughout this hospitalization and did not require physical or \nchemical restraint. The patient remained on 15 minute checks, \nwhich is our lowest acuity level of checks.\n\nGENERAL MEDICAL CONDITIONS\n#HIV\n- Continue Kaletra (200mg-50mg), 2 tablets PO BID\n- Abacavir 600 mg PO daily (pt normally takes combo of\nAbacavir/Lamivudine, which pharmacy does not carry)\n- Lamivudine 300 mg PO daily (pt normally takes combo of\nAbacavir/Lamivudine, which pharmacy does not carry)\n- Recommend f/u with outpt providers as clinically indicated\n\n#Shingles PPX\n- Per ID recommendation, switched from Valacyclovir 500 mg PO \ndaily to Acyclovir 400mg BID\n- Recommend f/u with outpt providers as clinically indicated\n\n#Herniated disc/spinal stenosis\n- Continue Oxycodone 10 mg tablet PO Q6H:PRN back pain\n- Continue Tizanidine 2 mg, 1 capsule QAM, 1 capsule in the\nafternoon, and 2 capsules QHS\n- Recommend f/u with outpt providers as clinically indicated\n\n#Crohn's Disease\n- Continue Asacol 800 mg PO TID\n- Recommend f/u with outpt providers as clinically indicated\n\n#GERD\n- Continue Omeprazole 20 mg PO daily\n- Recommend f/u with outpt providers as clinically indicated\n\n#HTN\n- Continue Propranolol 40 mg PO daily\n- Recommend f/u with outpt providers as clinically indicated\n\n#Hypertriglyceridemia\n- Continue Fenofibrate 145 mg PO daily\n- Recommend f/u with outpt providers as clinically indicated\n\nPSYCHOSOCIAL\n#) MILIEU/GROUPS\nThe patient was highly animated, euthymic, and participatory in \nthe milieu. The patient was very visible on the unit and \nfrequently had conversations with his peers. He/She attended \nsome groups. He never engaged in any unsafe behaviors. The pt \nate all meals in the milieu, slept well, and cooperated with \nunit rules.\n#) FAMILY CONTACTS\nPt is not in contact with any family members. So no family \nmeeting was conducted during this hospitalization.\n\n#) COLLATERAL\nWe spoke with the patient's outpatient psychiatrist. Updated her \nwith the hospital course and treatment plan. \n\n#) INTERVENTIONS:\n- Medications: \nSL Zydis 5mg QHS\nBupropion 150mg TID\nBuspirone 30mg BID\nKlonipin 1mg BID, 2mg qAM\nPrazosin 4mg QHS\nHydroxyzine 25mg QHS\n\n- Psychotherapeutic Interventions: Individual, group, and milieu \ntherapy.\n- Coordination of aftercare: \n- Behavioral Interventions (e.g. encouraged DBT skills, ect):\n- Guardianship:\n- ___ Referral: The team submitted a DMH application for the \npatient to receive services. \nLEGAL STATUS\nThe pt remained on a CV throughout the duration of this \nadmission.\n\n#RISK ASSESSMENT\nLow imminent risk of harm/violence to self/others.\n\nCHRONIC/STATIC RF\n-White\n-Man\n-Sex orientation\n-h/o numerous psychiatric admissions w/ frequent decompensation\n\nMODIFIABLE RF\n- Depression - we mitigated this by treating the patient with \nECT and medications. He tolerated therapies well and was much \nimproved at time of d/c with stable mood.\n- Trouble sleeping - we mitigated this risk by providing \nmedications to help with sleep, pt was able to get significant \namounts of sleep \n-Supports -.........\n-Substance Use - pt is actively involved in ___ for HIV/recovered alcoholics\n\nPROTECTIVE FACTORS\n\n-Employment hx - pt has a h/o maintaining jobs and working in \nthe community\n- Supports - pt has a strong community of friends in his AA \nmeeting group\n- Stable housing - pt has a secure place to live \n- Help seeking behavior - pt was able to acknowledge that he \nneeds help and willing to be admitted \n- Outpatient providers - pt has a positive therapeutic \nrelationship with his outpatient providers\n\n#PROGNOSIS\n___ - Pt is prone to relapse into depression given hx of \nrefractory symptoms, multiple ECT treatments and significant hx \nof SA's. \n\n \nMedications on Admission:\n \nThe Preadmission Medication list is accurate and complete.\n1. OxycoDONE (Immediate Release) 10 mg PO Q4-6H:PRN back pain \n2. QUEtiapine Fumarate 50 mg PO QHS \n3. BusPIRone 30 mg PO BID \n4. Fenofibrate 145 mg PO DAILY \n5. ValACYclovir 500 mg PO Q24H \n6. BuPROPion (Sustained Release) 150 mg PO QAM \n7. Tizanidine 2 mg PO BID \n8. Propranolol 20 mg PO BID \n9. Mesalamine ___ 800 mg PO DAILY \n10. ClonazePAM 1 mg PO BID \n11. ClonazePAM 2 mg PO QAM \n12. Epzicom (abacavir-lamivudine) 600-300 mg oral DAILY \n13. Lopinavir-Ritonavir 2 TAB PO DAILY \n14. Omeprazole 20 mg PO DAILY \n15. Tizanidine 4 mg PO QHS \n16. Prazosin 4 mg PO QHS \n17. Albuterol Inhaler ___ PUFF IH Q4H:PRN respiratory distress \n\n \nDischarge Medications:\n1. BuPROPion (Sustained Release) 150 mg PO QAM \n2. BusPIRone 30 mg PO BID \n3. ClonazePAM 1 mg PO BID \n4. ClonazePAM 2 mg PO QAM \n5. Fenofibrate 145 mg PO DAILY \n6. Lopinavir-Ritonavir 2 TAB PO DAILY \n7. Mesalamine ___ 800 mg PO DAILY \n8. Omeprazole 20 mg PO DAILY \n9. OxycoDONE (Immediate Release) 10 mg PO Q4-6H:PRN back pain \n10. Prazosin 4 mg PO QHS \n11. Propranolol 20 mg PO BID \n12. Tizanidine 2 mg PO BID \n13. Tizanidine 4 mg PO QHS \n14. Albuterol Inhaler ___ PUFF IH Q4H:PRN respiratory distress \n15. Epzicom (abacavir-lamivudine) 600-300 mg oral DAILY \n16. ValACYclovir 500 mg PO Q24H \n17. HydrOXYzine 25 mg PO QHS \nRX *hydroxyzine HCl 25 mg 1 tablet by mouth at bedtime Disp #*30 \nTablet Refills:*0\n18. OLANZapine (Disintegrating Tablet) 5 mg PO QHS \nRX *olanzapine 5 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nMajor Depression Disorder\nh/o Complex PTSD\n\n \nDischarge Condition:\nNeurological:\n *station and gait: normal station and gait\n *tone and strength: Deferred\n *Appearance: mid-aged man, sitting in the chair, wearing a\nT-shirt, does not respond to internal stimuli\n Behavior: cooperative with interview. make fair eye contact.\n *Mood and Affect: 'fine' / Restricted affect, congruent with \nthe\nconversation\n *Thought process: Mostly linear, but preservative at times\n *Thought Content: Denies SI/HI/AVH\n *Judgment and Insight: fair/fair\n Cognition:\n *Attention, *orientation, and executive function: Attentive\nto interview, oriented to context and history\n *Memory: Intact to history\n *Fund of knowledge: Appropriate\n *Speech: Regular rate, rhythm, and volume.\n *Language: Fluent ___\n\n \nDischarge Instructions:\nDischarge Instructions\n-Please follow up with all outpatient appointments as listed - \ntake this discharge paperwo\nrk\n to your appointments.\n-Please continue all medications as directed.\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.\n*It was a pleasure to have worked with you, \nand we wish you the best of health.*\n\n \nFollowup Instructions:\n___\n" ]

[ "F329", "B20", "R45851", "K5090", "B029", "F4310", "F419", "K219", "I10", "E781", "G4700", "M4800" ]

[ "F329: Major depressive disorder, single episode, unspecified", "B20: Human immunodeficiency virus [HIV] disease", "R45851: Suicidal ideations", "K5090: Crohn's disease, unspecified, without complications", "B029: Zoster without complications", "F4310: Post-traumatic stress disorder, unspecified", "F419: Anxiety disorder, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "I10: Essential (primary) hypertension", "E781: Pure hyperglyceridemia", "G4700: Insomnia, unspecified", "M4800: Spinal stenosis, site unspecified" ]

[ "F329", "F419", "K219", "I10", "G4700" ]

[]

[ " \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:\nNone\n\nattach\n \nPertinent Results:\nADMISSION LABS:\n================\n___ 06:21PM BLOOD WBC-8.1 RBC-4.38 Hgb-12.1 Hct-39.0 MCV-89 \nMCH-27.6 MCHC-31.0* RDW-15.2 RDWSD-49.9* Plt ___\n___ 06:21PM BLOOD Neuts-64.7 ___ Monos-10.0 Eos-2.2 \nBaso-1.1* Im ___ AbsNeut-5.23 AbsLymp-1.74 AbsMono-0.81* \nAbsEos-0.18 AbsBaso-0.09*\n___ 06:21PM BLOOD ___ PTT-28.1 ___\n___ 06:21PM BLOOD Glucose-91 UreaN-18 Creat-0.8 Na-144 \nK-5.4 Cl-110* HCO3-23 AnGap-11\n___ 06:21PM BLOOD ALT-542* AST-153* CK(CPK)-52 AlkPhos-109* \nTotBili-0.6\n___ 06:21PM BLOOD Albumin-3.4* Calcium-10.0 Phos-2.4* \nMg-2.2\n___ 06:29PM BLOOD Lactate-1.2\n\nNOTABLE INTERVAL LABS:\n======================\n___ 07:02AM BLOOD ALT-353* AST-70* AlkPhos-94 TotBili-0.6 \nDirBili-0.2 IndBili-0.4\n___ 06:59AM BLOOD ALT-242* AST-40 AlkPhos-89 TotBili-0.4\n___ 07:17AM BLOOD ALT-183* AST-30 AlkPhos-87 TotBili-0.3\n\nMICBIOLOGY:\n============\nBlood Cultures x2 on ___ - negative to date at time of \ndischarge\n\nIMAGING/STUDIES:\n=================\nNone - Prior imaging had been completed at ___ before \ntransfer\n\nDISCHARGE LABS:\n================\n___ 07:17AM BLOOD WBC-5.4 RBC-4.33 Hgb-11.8 Hct-37.1 MCV-86 \nMCH-27.3 MCHC-31.8* RDW-14.7 RDWSD-45.9 Plt ___\n___ 07:17AM BLOOD Glucose-95 UreaN-12 Creat-0.7 Na-140 \nK-3.9 Cl-104 HCO3-24 AnGap-12\n___ 07:17AM BLOOD ALT-183* AST-30 AlkPhos-87 TotBili-0.3\n___ 07:17AM BLOOD Calcium-9.8 Phos-2.5* Mg-2.___RIEF HOSPITAL COURSE SUMMARY:\n================================\nMs. ___ is a ___ y/o F with PMH significant for Alzheimer's \ndementia, hypertension, hypercholesterolemia, PMR who was \nadmitted cholecystitis. She was deemed not a surgical candidate. \nPercutaneous drain was considered however she continued to \nimprove clinically, including improving LFTs, and so drain was \ndeferred. She was managed with antibiotics and discharged on a \ntotal course of 2 weeks. \n\nTRANSITIONAL ISSUES:\n=======================\nPCP:\n[ ] Patient had cholecystitis though is not a surgical \ncandidate. She was discharged on a total of 2-weeks antibiotics. \nGiven surgery is the only definitive treatment, she will need \nongoing assessment if continuing antibiotics is indicated. She \nis high risk for repeat cholecystitis. If within ___, perc drain \ncould be placed if she was to become unstable secondary to \nrecurrent cholecystitis otherwise it would be managed medically.\n[ ] Repeat LFTs and CBC at follow-up appointment to ensure \nnormalization of LFTs and no new leukocytosis\n[ ] Statin held at time of discharge given elevated LFTs. This \ncan be restarted once LFTs are normalized though consider \nstopping indefinitely given her age, low probability of long \nterm benefits and minimizing medications for patient\n[ ] Held home ASA given no history of MI or CVA and ASA is no \nlonger recommended for primary prevention.\n[ ] Daughter was concerned that liquid Augmentin may be \ndifficult to take. A prescription for pills was also given in \ncase the patient has difficulty and the daughter would like to \nground the pill in applesauce\n\n___\n[ ] Patient will complete her course of liquid Augmentin 15ml \nBID on ___. Please continue to assess her for signs/symptoms \nof infection as related to cholecystitis/risk for cholangitis.\n[ ] Patient is significantly frail, please evaluate for home \nsafety and physical therapy/occupational therapy\n[ ] Given advanced dementia, please evaluate for home aide \nservices\n\nACTIVE ISSUES:\n===============\n#Uncomplicated cholecystitis\n#Elevated LFTs\nRUQ/US and elevated hepatocellular LFTs c/f cholecystis. Non \nverbal and so unclear if symptomatic. Remained hemodynamically \nstable, without fever or leukocytosis throughout hospital \ncourse. LFTs were initially elevated though downtrended \nthroughout hospital stay. Surgery was consulted at ___, \ndid not feel she was a surgical candidate. She was started on \nCTX 1g q24 + metronidazole 500mg TID (___) and \ntransitioned to Augmentin (___) on discharge for a two \nweek total course of antibiotics. Blood cultures remained \nnegative. Will require ___ services for skilled nursing \nassessment while still taking ABx, home safety evaluation, ___ \nevaluation and home\naide evaluation\n\n#Uncomplicated UTI\nBI-N UCx grew pansensitive E. coli. Patient was unable to \ncommunicate if she has symptoms of UTI. Regardless she received \nappropriate treatment for uncomplicated UTI \n\n#Poor PO intake \n#Weight loss\nHistory of weight loss over months associated with anorexia. \nNoted to have low phosphate on admission. In the context of her \nhistory, this may be concerning for end stage dementia. Patient \nseen feeding self during hospital stay. However family noted \nthat at times at home she cheeks food/water and spits it out.\n\nCHRONIC ISSUES:\n===============\n#Alzheimer's dementia\nPreviously evaluated by neurology. No longer on medications. \n\n#Hypothyroidism\nContinued levothyroxine\n\n#Hypercholesterolemia\nHeld statin given elevated LFTs. Held aspirin as it was \nprescribed for primary prevention in attempt to reduce home \nmeds.\n\n#Hypertension\nHeld atenolol and amlodipine given normotensive and concern for \ninfection\n\n#CODE: DNR/DNI confirmed\n#CONTACT: ___ (daughter/HCP) ___\n \n\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. amLODIPine 10 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Atenolol 25 mg PO DAILY \n4. Levothyroxine Sodium 25 mcg PO DAILY \n5. Simvastatin 10 mg PO QPM \n\n \nDischarge Medications:\n1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days \n\nRX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by \nmouth twice a day Disp #*20 Tablet Refills:*0 \n2. amLODIPine 10 mg PO DAILY \n3. Atenolol 25 mg PO DAILY \n4. Levothyroxine Sodium 25 mcg PO DAILY \n5. HELD- Simvastatin 10 mg PO QPM This medication was held. Do \nnot restart Simvastatin until you follow-up with your PCP\n\n \n___:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n====================\nAcute Cholecystitis\nSECONDARY DIAGNOSIS:\n======================\nAdvanced Alzheimer's Disease\nhypertension\nhypercholesterolemia\npolymyalgia rheumatica\n \nDischarge Condition:\nMental Status: Confused - always.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\n \nDischarge Instructions:\nDear Ms. ___, \nIt was a pleasure taking care of you at the ___ \n___! \n\nWHY WAS I IN THE HOSPITAL? \n========================== \n- You had a blockage of your gallbladder with a stone leading to \ncholecystitis, or inflammation of your gallbladder\n\nWHAT HAPPENED IN THE HOSPITAL? \n============================== \n- At ___, surgery evaluated you and determined that you \nwere not a candidate for surgery\n- We treated you with antibiotics which you will continue at \nhome\n- Our case management team and social worker team were also \ninvolved and helped set up home services which you require on \ndischarge\n\nWHAT SHOULD I DO WHEN I GO HOME? \n================================ \n- Please continue to take all of your medications as directed\n- Please follow up with all the appointments scheduled with your \ndoctor\n\n___ you for allowing us to be involved in your care, we wish \nyou all the best! \nYour ___ Healthcare Team \n \nFollowup Instructions:\n___\n" ]

[ "K8000", "E870", "N390", "G309", "F0280", "I10", "E7800", "K219", "R634", "R630", "R748", "E8339", "E039", "B9620", "Z66", "Z85820", "Z87891", "Z6821" ]

[ "K8000: Calculus of gallbladder with acute cholecystitis without obstruction", "E870: Hyperosmolality and hypernatremia", "N390: Urinary tract infection, site not specified", "G309: Alzheimer's disease, unspecified", "F0280: Dementia in other diseases classified elsewhere without behavioral disturbance", "I10: Essential (primary) hypertension", "E7800: Pure hypercholesterolemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "R634: Abnormal weight loss", "R630: Anorexia", "R748: Abnormal levels of other serum enzymes", "E8339: Other disorders of phosphorus metabolism", "E039: Hypothyroidism, unspecified", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "Z66: Do not resuscitate", "Z85820: Personal history of malignant melanoma of skin", "Z87891: Personal history of nicotine dependence", "Z6821: Body mass index [BMI] 21.0-21.9, adult" ]

[ "N390", "I10", "K219", "E039", "Z66", "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:\nScheduled Chemotherapy\n \nMajor Surgical or Invasive Procedure:\n___ - Port Placement\n \nHistory of Present Illness:\nMrs. ___ is a ___ year-old lady with a history of \nulcerative colitis and a high grade diffuse large B cell \nlymphoma s/p C2 R-CHOP who presents today for schedule \nprophylactic high dose methotrexate.\n\nOn arrival to the floor, patient reports feeling well. She has a \nmild frontal headache which she feels whenever her allergies act \nup. She has no other complaints.\n\nPatient denies fevers/chills, night sweats, headache, vision \nchanges, dizziness/lightheadedness, weakness/numbnesss, \nshortness of breath, cough, hemoptysis, chest pain, \npalpitations, abdominal pain, nausea/vomiting, diarrhea, \nhematemesis, hematochezia/melena, dysuria, hematuria, and new \nrashes. \n \nPast Medical History:\n-___: Referred to Dr ___ in our dept for \nprobable malignancy. 30 pound wt loss over the past year and 8 \npound drop over the fall. Developed worsening confusion and \nunsteadiness in early ___ and found to be hypercalcemic (Ca ___. \nAdmitted to ___ where she was given iv fluids, \nCalcitonin and Pamidronate. Low PTH and normal PTHrp. Her CBC \nshowed early myeloid forms and some nuc rbc and her LDH was \nelevated at 656. CT scans of chest, abd, pelvis did not show any \nadenopathy or splenomegaly. There was a 5mm low attenuation \nlesion in the panc head and a 1.3 cm lesion in the right adrenal \ngland. There was a large 8.7x7.7x6.5 mass inseparable from the \nuterus where a fibroid had been noted previously. Subsequent MRI \nshowed diffused dilatation of the panc duct raising concern for \nIPM of the main panc duct and endoscopic ultrasound was \nsuggested as well as a dedicated adrenal washout CT for the \nsmall adrenal lesion.\n-Dr. ___ a BM asp and Bx that day which did not \nshow any abnormal lymphocytes in the aspirate and the \ncytogenetics and FISH were normal. However, the biopsy showed a \nmultifocal infiltrate of malignant lymphocytes with Ki67 of \n50-60%, felt to be an aggressive B cell lymphoma of germinal \ncenter origin.\n-___: Upper endoscopy showed mult gastric ulcers - bx \nshowed lymphoma, cytogenetics showed BCL6, no myc or BCL2 \ntranslocations.\n-___: First cycle Rit/CHOP with split dose Rituxan.\n-___ for febrile neutropenia despite neulasta \nthen ulc colitis flare. Restarted Pred.\n-___: Fever, diarrhea due to C.dif. Rx'd po vanco \nand pneumonia, rx'd Levoflox.\n-___: cycle 2 Rit/CHOP.\n\nPAST MEDICAL HISTORY:\n- Ulcerative Colitis\n- Rhinitis, allergic\n- Eczema\n- Headache, common migraine. *MRI performed ___ due to \ncomplaints of headache, and was unremarkable.\n- Hyperlipidemia\n- Fatty Liver\n- Fibroids\n- Osteoarthritis\n- Adrenal Nodule\n- Pancreatic Cyst\n \nSocial History:\n___\nFamily History:\nPaternal aunt with breast CA. Sister with breast CA in her ___. \n\n \nPhysical Exam:\n========================\nAdmission Physical Exam:\n========================\nVS: 98.3 | 100/52 | 81 | 18 | 100%RA\nGENERAL: Pleasant lady, in no distress lying, in bed \ncomfortably.\nHEENT: Anicteric, PERLL, OP clear.\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: Appears in no respiratory distress, clear to auscultation \nbilaterally, no crackles, wheezes, or rhonchi.\nABD: Soft, non-tender, non-distended, normal bowel sounds, no \nhepatomegaly, no splenomegaly.\nEXT: Warm, well perfused, no lower extremity edema, erythema or \ntenderness.\nNEURO: A&Ox3, good attention and linear thought, CN II-XII \nintact. Strength full throughout. Sensation to light touch \nintact.\nSKIN: No significant rashes.\nACCESS: Port.\n\n========================\nDischarge Physical Exam:\n========================\nVS: Temp 98.7, BP 110/55, HR 102, RR 16, O2 sat 99% RA.\nExam otherwise unchanged.\n \nPertinent Results:\n===============\nAdmission Labs:\n===============\n___ 09:45AM BLOOD WBC-9.7 RBC-2.72* Hgb-9.3* Hct-27.5* \nMCV-101* MCH-34.2* MCHC-33.8 RDW-19.9* RDWSD-72.7* Plt ___\n___ 09:45AM BLOOD Neuts-84* Bands-1 Lymphs-6* Monos-5 Eos-0 \nBaso-0 ___ Metas-4* Myelos-0 NRBC-1* AbsNeut-8.25* \nAbsLymp-0.58* AbsMono-0.49 AbsEos-0.00* AbsBaso-0.00*\n___ 09:45AM BLOOD ___ PTT-28.5 ___\n___ 09:45AM BLOOD Glucose-166* UreaN-13 Creat-0.4 Na-134 \nK-4.1 Cl-98 HCO3-26 AnGap-14\n___ 09:45AM BLOOD ALT-16 AST-12 LD(LDH)-277* AlkPhos-87 \nTotBili-0.3\n___ 09:45AM BLOOD Albumin-3.6 Calcium-7.8* Phos-4.3 Mg-2.1\n\n====================\nMethotrexate Levels:\n====================\n___ 09:29PM BLOOD mthotrx-0.34\n___ 09:48PM BLOOD mthotrx-0.04\n___ 06:01AM BLOOD mthotrx-0.03\n\n===============\nDischarge Labs:\n===============\n___ 06:01AM BLOOD WBC-3.6* RBC-2.43* Hgb-7.8* Hct-25.3* \nMCV-104* MCH-32.1* MCHC-30.8* RDW-19.1* RDWSD-73.9* Plt ___\n___ 06:01AM BLOOD Glucose-143* UreaN-7 Creat-0.4 Na-141 \nK-3.6 Cl-97 HCO3-36* AnGap-12\n___ 06:01AM BLOOD ALT-76* AST-79* AlkPhos-57 TotBili-0.3\n___ 06:01AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.2\n \nBrief Hospital Course:\nMrs. ___ is a ___ year-old lady with a history of \nulcerative colitis and a high grade diffuse large B cell \nlymphoma s/p C2 R-CHOP who presents for scheduled prophylactic \nhigh dose methotrexate. \n\n# High Grade B-Cell Lymphoma: Here for cycle 1 HD methotrexate. \nShe had a port placed. She received methotrexate, leucovorin, \nand bicarb per protocol. She tolerated the chemotherapy well. \nHer LFTs were slightly increased at time of discharge. Her \nmethotrexate levels were monitored and she was discharged with \nlevel less than 0.1. She will repeat labs next week.\n\n# Frontal Headache/Allergic Rhinitis: Continued fluticasone and \ntylenol.\n\n# Ulcerative Colitis: Recent flare in setting of CDI during \nprevious admission. Currently on prednisone taper which she will \ncontinue at home.\n\n# Sjogren Syndrome: Continued cyclosporine eye drops.\n\n====================\nTransitional Issues:\n====================\n- Please note LFTs slightly increased at time of discharge (ALT \n76, AST 79). Patient will have labs checked prior to follow-up \nappointment.\n- Please ensure follow-up with Oncology.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic Q12H \n2. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n3. Simvastatin 40 mg PO QPM \n4. Acyclovir 400 mg PO Q12H \n5. Acetaminophen 650 mg PO Q6H:PRN Headache \n6. Sodium Bicarbonate 650 mg PO QID \n7. PredniSONE 15 mg PO DAILY \n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Headache \n2. Acyclovir 400 mg PO Q12H \n3. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic Q12H \n4. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n5. PredniSONE 15 mg PO DAILY \n6. PredniSONE 10 mg PO DAILY Duration: 7 Doses \nThis is dose # 2 of 3 tapered doses\nTapered dose - DOWN \n7. PredniSONE 5 mg PO DAILY Duration: 7 Doses \nThis is dose # 3 of 3 tapered doses\nTapered dose - DOWN \n8. Simvastatin 40 mg PO QPM \n9. Sodium Bicarbonate 650 mg PO QID\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis:\n- High Grade B-Cell Lymphoma\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Ms. ___,\n\nIt was a pleasure taking care of you at the ___ \n___ ___. You were admitted for your scheduled \nchemotherapy with methotrexate which you tolerated well. Please \ncontinue your home medications and follow-up with your \nOncologist.\n\nPlease have your labs checked at your Oncologist's office on \n___ or ___.\n\nAll the best,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C8330", "K5190", "R51", "J309", "M3500", "R740", "E785", "Z87891" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C8330: Diffuse large B-cell lymphoma, unspecified site", "K5190: Ulcerative colitis, unspecified, without complications", "R51: Headache", "J309: Allergic rhinitis, unspecified", "M3500: Sicca syndrome, unspecified", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence" ]

[ "E785", "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:\nFebrile Neutropenia \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with a history of \nhigh-grade diffuse large B-cell lymphoma (primary bone marrow \nlymphoma) diagnosed in ___ with noted CNS involvement with \nprogression of CNS disease started on ___ and plan to \nstart ___ who is being admitted today with fever and \nneutropenia.\n\nPatient reports she had been feeling well until this morning \nwhen she noted fever to 100.4-100.2 at home with chills. She \nalso awoke with a frontal headache that is constant. The \nheadache is not affected by position changes or light. She feels \nvery fatigued. She has had no known sick contacts. She denies \ncough, sore throat, congestion, shortness of breath, or chest \npain. She has\nsome nausea which started this morning but no vomiting or \ndiarrhea. Denies any visual changes, blurry or double vision. No \nweakness of extremities. Denies neck pain or stiffness.\n\nVitals in clinic were Temp 98.7, BP 124/66, HR 105, RR 18, O2 \nsat 99% RA. Labs were notable for WBC 3.1 (ANC 650), H/H \n11.0/33.6, Plt 443, Na 134, K 3.3, BUN/Cr ___, LFTs wnl. She \nhad blood cultures and viral studies sent. She was given \ncefepime 2g IV, vancomycin 1g IV, Tylenol ___ PO, Tamiflu 75mg \nPO, and NS at 150ml/hr. She had episode of nausea with vomiting \nafter dinner\nwhich improved with Ativan.\n\nOn arrival to the floor, patient reports fatigue and ___ \nfrontal headache. She denies vision changes, \ndizziness/lightheadedness, weakness/numbnesss, shortness of \nbreath, cough, hemoptysis, chest pain, palpitations, abdominal \npain, nausea/vomiting, diarrhea, hematemesis, \nhematochezia/melena, dysuria, hematuria, and new rashes.\n\n \nPast Medical History:\nPast Oncologic History:\nMs. ___ is a ___ woman with a history of \nulcerative colitis, previously treated with ___ who in ___ presented with worsening confusion, fogginess and \nunsteadiness with noted 30 pound weight loss over the preceding \nyear and 8 pound weight loss over the preceding month. She was\nnoted to be hypercalcemic with a calcium of 15. She was \nadmitted to ___ and received IV fluids, calcitonin and \npamidronate. CBC was notable for some early myeloid forms and \nnucleated red blood cells and her LDH was elevated at 656. CT \nscan done on ___ showed no definite evidence of \nmalignancy\nin the chest, abdomen or pelvis with no adenopathy or \nsplenomegaly. Note was made of an 8.7 cm mass in the right \naspect of the pelvis which was inseparable from the uterus \nfavored to represent an exophytic fibroid. There was an \nindeterminate 1.3 cm right adrenal nodule, three small \nhypervascular hepatic lesions, and a 0.5 cm low-attenuation \nlesion in the pancreatic ___ felt to represent a side branch \nIPMN. Subsequent MRI showed dilatation of the pancreatic duct \nraising concern for IPMN of the main pancreatic duct; endoscopic \nultrasound was suggested as well as a dedicated adrenal washout \nCT for the small adrenal lesion.\n\nBone marrow aspirate and biopsy on ___ showed a \nhypercellular marrow with multifocal infiltrates of atypical \ncells of medium to large in size with moderate amounts of \ncytoplasm, irregular nuclear contours, vesicular chromatin and \noccasionally prominent nuclei. By immunohistochemistry, the \nneoplastic cells are B cells, immunoreactive for CD45 (LCA) and \nCD20. They expressed CD10 (large proportion of cells), BCL6 \n(dim, small subset) and MUM1 (major subset). BCL2 expression is \nseen only in rare neoplastic cells. By Ki-67 immunostaining, the \nproliferation index is approximately 50%-60%. The cells are \nnegative for CD30, BCL1, CD56, synaptophysin, chromogranin, WT1, \nPAX8, cytokeratin cocktail, EMA, and S100. Overall, the \nmorphologic and immunophenotypic findings are in keeping with \ninvolvement by a high-grade B-cell lymphoma with a germinal\ncenter phenotype. Full cytometric and cytogenetics studies are \nnoncontributory due to underrepresentation of the neoplastic \ncells in the aspirate material.\n\nFor further workup, Ms. ___ also underwent an endoscopy, \nwhich was noted for a gastric ulcer with biopsy consistent with \nan abnormal lymphoid infiltrate composed of large lymphoid cells \nwith small-to-moderate amounts of cytoplasm. By\nimmunohistochemistry, CD20 highlights the abnormal infiltrate \nwhich shows co-expression of CD10 (dim), BCL6 and MUM1. Ki-___ \nimmunostain reveals a high proliferation fraction, which is \ngreater than 95%. ___ stain is negative. These features are in \nkeeping with involvement by the patient's previously diagnosed \nhigh-grade B-cell lymphoma with germinal center phenotype. \nThere\nwas no evidence of rearrangements of the BCL6 or MYC genes by \ncytogenetic report. Further staging by FDG tumor imaging on \n___ was notable for a diffuse FDG avid osseous \ninvolvement with FDG avid left intraparotid lymph node. There \nwas nodular FDG avid left adrenal gland worrisome for \nlymphomatous\ninvolvement, nodular FDG uptake with thickened gastric fundus. \nThere was focal FDG uptake within the right upper central \nbreast.\n\nMs. ___ was initiated on treatment with ___ cycle \nRituxan/CHOP on ___. This cycle was complicated by \nadmission for febrile neutropenia despite receiving Neulasta. \nShe also had an ulcerative colitis flare at the time and C. \ndifficile infection. She received Cycle 2 of Rituxan/CHOP on \n___ followed by prophylactic dosing of high-dose \nmethotrexate at 3.5 g/m2 on ___. Cycle 3 R-CHOP was \ngiven on ___. She was admitted for fever on ___ \nwith infectious workup felt related to a viral illness. Follow \nup PET imaging on ___ for restaging after three cycles of \nR-CHOP showed decreased uptake in the left parotid gland with \nresolution of multiple focal FDG avid osseous lesions as well as \nresolution of FDG avidity within the left adrenal gland, gastric \nfundus, right breast and subcutaneous tissues.\n\nIn ___, Ms. ___ noted double vision with \nheadache. She was admitted for further evaluation. She had no \nfevers, chills or night sweats. She had progression of symptoms \nwith development of right ptosis and some right leg weakness. \n___ CT without contrast as well as MRI of the ___ with and\nwithout contrast did not show any significant abnormality. MRI \nof the orbit revealed thickening and enhancement of the left \nocular motor nerve from the interpeduncular cistern to the \ncavernous sinus, as well as mild enhancement of the right ocular \nmotor nerve near the cavernous sinus. Lumbar puncture was\nperformed which showed involvement by CNS lymphoma.\n\nMs. ___ received a dose of Rituxan as well as high-dose \nmethotrexate at 8 gm/m2 on ___. She was discharged home \non ___ after clearing the methotrexate with the plan for \nevery two-week high-dose methotrexate along with weekly Rituxan. \nShe has received another dose of Rituxan on ___. When she \nwas seen for further evaluation, she was noted to have continued\ndouble vision and also development of some thigh numbness, leg \nweakness and back pain. Because she needed treatment for both \nher systemic as well as CNS disease, she received a dose of \nRituxan on ___ and then was admitted on ___ for \ndifferent treatment with high dose Methotrexate, Ifosfamide and\nIT Ara-C. She received another dose of IT Ara-C as outpatient on \n___. Of note, her neurological symptoms had markedly \nimproved with this treatment.\n\nMs. ___ was due for her ___ cycle of this treatment on \n___ but was admitted on the day for increasing shoulder \npain, hip pain and headaches. She developed emesis and MRI of \nthe ___ showed significant progression of her CNS disease. She \nreceived high dose Methotrexate 12 gm/m2 on ___ and cleared\nthis without issues. She was discharged on ___. Because of \nthe progression of her CNS disease, it was decided to start \ntreatment with TEDDI-R with ___ (Phase I study presented \nat ___ ___ meetings). This treatment includes Temozolomide, \nEtoposide, Doxil, Dexamethasone and Rituximab. ___ is \ngiven as a single agent in a pre-phase before starting the \nCytotoxic agents. Ms. ___ started her ___ on \n___ and received a dose of Rituxan on that day. \nShe slowly increased to 3 pills (420 mg) as of ___ with \nthe plan to increase to 4 pills(560 mg) as of ___. The\nchemotherapy would start on ~ ___.\n\nPAST MEDICAL HISTORY:\n1. Diffuse large B-cell lymphoma(Primary bone marrow lymphoma) \nas\nnoted above with CNS involvement.\n2. Ulcerative colitis, last flare in ___ with fever and\nneutropenia admission. Previously treated with ___ for about \none\nand a half years as well as prednisone during flares.\n3. Sjogren's with dry eyes, uses Restasis. \n4. Osteoarthritis.\n5. Eczema.\n6. Hypercholesterolemia.\n7. Fatty liver.\n8. Pre-diabetes. \n9. Pancreatic cyst\n10. Allergic rhinitis.\n\n \nSocial History:\n___\nFamily History:\nA paternal aunt with breast cancer. Sister with breast cancer in \nher ___ but died from other medical issues.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n==========================\nVS: Temp 98.7, BP 114/74, HR 97, RR 20, O2 sat 95% RA.\nGENERAL: Pleasant woman, in no distress, lying in bed \ncomfortably.\nHEENT: Anicteric, PERRL, OP clear.\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: Appears in no respiratory distress, clear to auscultation\nbilaterally, no crackles, wheezes, or rhonchi.\nABD: Soft, non-tender, non-distended, normal bowel sounds, no \nhepatomegaly, no splenomegaly.\nEXT: Warm, well perfused, no lower extremity edema, erythema or \ntenderness.\nNEURO: A&Ox3, good attention and linear thought, CN II-XII \nintact. Strength full throughout. Sensation to light touch \nintact. No nuchal rigidity and negative Kernig's sign.\nSKIN: No significant rashes.\nACCESS: Right chest wall port without erythema.\n\nDISCHARGE PHYSICAL EXAM:\n===========================\nVS - T 97.6-98.3, BP 121-135/70-77, P 51-73, RR 18, O2sat 98-99% \non RA \nGeneral: Pleasant woman, sitting up in bed, no acute distress. \nHEENT: Anicteric sclerae, EOMI, PERRL, MMM\nCV: RRR, no m/r/g\nLungs: CTA bilaterally\nAbdomen: Soft, nontender, nondistended\nExt: Warm, well perfused, no ___ edema\nNeuro: A&O x3, grossly intact\nSkin: R chest wall port site without \nerythema/fluctuance/tenderness\n \nPertinent Results:\nADMISSION LABS:\n===================\n___ 10:55AM BLOOD WBC-3.1* RBC-3.34* Hgb-11.0* Hct-33.6* \nMCV-101* MCH-32.9* MCHC-32.7 RDW-17.1* RDWSD-62.2* Plt ___\n___ 10:55AM BLOOD Neuts-20* Bands-1 ___ Monos-39* \nEos-2 Baso-2* ___ Metas-2* Myelos-0 AbsNeut-0.65* \nAbsLymp-1.05* AbsMono-1.21* AbsEos-0.06 AbsBaso-0.06\n___ 10:55AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL \nMacrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL \nTear Dr-OCCASIONAL\n___ 10:55AM BLOOD Plt Smr-HIGH Plt ___\n___ 10:55AM BLOOD UreaN-21* Creat-0.4 Na-134 K-3.3 Cl-97 \nHCO3-27 AnGap-13\n___ 10:55AM BLOOD ALT-14 AST-9 LD(LDH)-204 AlkPhos-70 \nTotBili-0.3\n___ 10:55AM BLOOD Albumin-3.7 Calcium-8.6 Phos-4.0 Mg-1.9 \nUricAcd-4.2\n___ 12:30PM OTHER BODY FLUID FluAPCR-NEGATIVE \nFluBPCR-NEGATIVE\n\nOTHER RELEVANT LABS:\n========================\n___ 11:00PM BLOOD WBC-2.4* RBC-3.29* Hgb-10.6* Hct-32.6* \nMCV-99* MCH-32.2* MCHC-32.5 RDW-15.9* RDWSD-57.8* Plt ___\n___ 12:00AM BLOOD WBC-4.5 RBC-3.13* Hgb-10.0* Hct-31.9* \nMCV-102* MCH-31.9 MCHC-31.3* RDW-16.0* RDWSD-60.0* Plt ___\n___ 12:00AM BLOOD WBC-7.8 RBC-2.90* Hgb-9.2* Hct-28.4* \nMCV-98 MCH-31.7 MCHC-32.4 RDW-15.8* RDWSD-56.5* Plt ___\n___ 12:00AM BLOOD Neuts-16* Bands-3 ___ Monos-56* \nEos-0 Baso-2* Atyps-1* ___ Myelos-3* AbsNeut-0.46* \nAbsLymp-0.48* AbsMono-1.34* AbsEos-0.00* AbsBaso-0.05\n___ 12:00AM BLOOD Neuts-9* Bands-2 ___ Monos-45* \nEos-3 Baso-0 ___ Metas-3* Myelos-5* AbsNeut-0.57* \nAbsLymp-1.72 AbsMono-2.34* AbsEos-0.16 AbsBaso-0.00*\n___ 12:32AM BLOOD Neuts-61 Bands-8* Lymphs-12* Monos-9 \nEos-0 Baso-0 Atyps-1* Metas-2* Myelos-7* AbsNeut-4.35 \nAbsLymp-0.82* AbsMono-0.57 AbsEos-0.00* AbsBaso-0.00*\n___ 12:00AM BLOOD Neuts-77* Bands-2 Lymphs-8* Monos-5 Eos-0 \nBaso-0 ___ Metas-4* Myelos-4* AbsNeut-6.16* AbsLymp-0.62* \nAbsMono-0.39 AbsEos-0.00* AbsBaso-0.00*\n___ 11:00PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ \nMacrocy-2+ Microcy-1+ Polychr-1+ Spheroc-OCCASIONAL Ovalocy-1+ \nSchisto-OCCASIONAL Tear Dr-OCCASIONAL\n___ 12:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ \nMacrocy-2+ Microcy-1+ Polychr-1+ Ovalocy-1+ Schisto-1+ \nBurr-OCCASIONAL Tear Dr-1+\n___ 12:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+ \nMacrocy-2+ Microcy-1+ Polychr-OCCASIONAL Spheroc-1+ Ovalocy-1+ \nSchisto-OCCASIONAL Tear Dr-OCCASIONAL\n___ 12:00AM BLOOD ___ PTT-27.5 ___\n___ 12:00AM BLOOD ___ PTT-28.9 ___\n___ 12:00AM BLOOD Glucose-109* UreaN-13 Creat-0.4 Na-139 \nK-3.5 Cl-102 HCO3-26 AnGap-15\n___ 12:00AM BLOOD Glucose-310* UreaN-19 Creat-0.5 Na-135 \nK-3.7 Cl-100 HCO3-26 AnGap-13\n___ 12:32AM BLOOD Glucose-279* UreaN-17 Creat-0.4 Na-136 \nK-4.1 Cl-103 HCO3-20* AnGap-17\n___ 12:00AM BLOOD Glucose-300* UreaN-23* Creat-0.4 Na-135 \nK-3.8 Cl-101 HCO3-21* AnGap-17\n___ 12:00AM BLOOD ALT-12 AST-8 AlkPhos-67 TotBili-0.4\n___ 12:00AM BLOOD ALT-11 AST-8 LD(LDH)-191 AlkPhos-62 \nTotBili-<0.2\n___ 12:00AM BLOOD Calcium-8.6 Phos-4.7* Mg-2.0\n___ 12:00AM BLOOD Calcium-8.5 Phos-4.3 Mg-1.9\n___ 12:32AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.1\n___ 12:00AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.0\n___ 12:32AM BLOOD HBsAg-Negative HBsAb-Negative \nHBcAb-Negative\n___ 12:32AM BLOOD HIV Ab-Negative\n___ 11:00PM BLOOD Vanco-12.9\n___ 12:00AM BLOOD HBV VL-NOT DETECT HCV VL-PND\n___ 04:32AM URINE Color-Straw Appear-Clear Sp ___\n___ 04:32AM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG\n\nBlood Culture, Routine (Final ___: NO GROWTH. \nBlood Culture, Routine (Final ___: NO GROWTH. \n\nRespiratory Viral Culture (Final ___: No respiratory \nviruses isolated. \nCulture screened for Adenovirus, Influenza A & B, Parainfluenza \ntype\n1,2 & 3, and Respiratory Syncytial Virus. \n\nRespiratory Viral Antigen Screen (Final ___: Negative for \nRespiratory Viral Antigen.\nSpecimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza \nA, B, and RSV by immunofluorescence. \n\nURINE CULTURE (Final ___: < 10,000 CFU/mL.\n\nIMAGING:\n========================\nCXR (___): No evidence of pneumonia. \n\nMR ___ w/ and w/o contrast (___): \nStudy is moderately degraded by motion. Within these confines: \n \nThere are multiple enhancing lesions demonstrating hypointense \nT2 signal with surrounding FLAIR hyperintensity and mildly slow \ndiffusion, as follow: \n-increase; 1.5 cm TV x 1.4 cm AP x 1.2 cm SI mid fornix \n(900:99), previously 1.2 cm TV x 1.3 cm AP x 1.1 cm SI. \n-decrease; 0.5 cm TV x 0.7 cm AP x 0.4 cm SI adjacent to the \ntectum (900:89), previously 0.7 cm TV x 0.8 cm AP x 0.6 cm SI. \n-decrease; 0.6 cm TV x 0.7 cm AP x 0.6 cm SI left caudate body \n(900:99), \npreviously 0.7 cm TV x 1.0 cm AP by 0.7 cm SI. \n-decrease; 0.9 cm TV x 0.6 cm AP x 0.7 cm SI adjacent to the \nsplenium \n(900:100), previously 1.2 cm TV by 0.6 cm AP x 1.0 cm SI. \n-increase; 0.8 cm TV x 0.7 cm AP x 0.8 cm SI left periatrial \nlateral ventricle (900:95), previously 0.7 cm TV x 0.6 cm AP x \n0.7 cm SI. Additional left periatrial enhancing nodule is not \nwell visualized on this study. \n-decrease; 1.4 cm TV x 2.0 cm AP x 2.0 cm SI left occipital horn \nof the \nlateral ventricle (900:91), previously 1.4 cm TV x 2.4 cm AP x \n2.3 cm SI. \n \nAgain seen is FLAIR hyperintensity surrounding the atrium and \noccipital horn of the left lateral ventricle with slight \nincrease in FLAIR hyperintensity in the splenium. The left \ncaudate body FLAIR hyperintensity has slightly decreased. \nOtherwise, there is no significant interval change. \n \nThe ventricles are normal in size without mass effect or midline \nshift. \nAdditional scattered foci of FLAIR hyperintensity within the \nperiventricular subcortical white matter is not significantly \nchanged. \n \nThere is no evidence of infarction. There is an unchanged right \noccipital GRE hypointense focus similar to the prior study, \nlikely dural calcification versus calcified meningioma. The \nparanasal sinuses and bilateral mastoid air cells appear clear. \n\n1. Study is moderately degraded by motion. \n2. Multiple enhancing intraparenchymal lesions likely related to \nknown \nlymphoma, with mixed interval change in size and white matter \nchanges, as \ndescribed above. \n\nL-spine X-ray (___): \nNaming convention loop is similar to that reported on ___ MRI. \nL5 vertebral body is partially sacralized. Mild lumbar facet \narthritis. No compression fractures. Minimal anterolisthesis \nL3-L4, stable since prior exam, stable on neutral and flexion \nview, measures 0.3 cm probably stable on extension view allowing \nfor slightly oblique position on the extension view. Narrowed \nL4-5, L5-S1 disc spaces \n\nMild degenerative changes. \n\nDISCHARGE LABS:\n======================\n___ 12:15AM BLOOD WBC-7.2 RBC-2.91* Hgb-9.4* Hct-28.7* \nMCV-99* MCH-32.3* MCHC-32.8 RDW-15.5 RDWSD-56.3* Plt ___\n___ 12:15AM BLOOD Neuts-83* Bands-2 Lymphs-6* Monos-5 Eos-0 \nBaso-0 ___ Metas-3* Myelos-1* AbsNeut-6.12* AbsLymp-0.43* \nAbsMono-0.36 AbsEos-0.00* AbsBaso-0.00*\n___ 12:15AM BLOOD Hypochr-NORMAL Anisocy-NORMAL \nPoiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-NORMAL\n___ 12:15AM BLOOD Glucose-273* UreaN-23* Creat-0.4 Na-135 \nK-4.3 Cl-102 HCO3-23 AnGap-14\n___ 12:15AM BLOOD ALT-10 AST-10 LD(LDH)-266* AlkPhos-54 \nTotBili-0.2\n___ 12:15AM BLOOD Albumin-3.1* Calcium-8.4 Phos-3.6 Mg-2.5\n \nBrief Hospital Course:\nMs. ___ is a ___ woman with a history of \nhigh-grade diffuse large B-cell lymphoma (primary bone marrow \nlymphoma) diagnosed in ___ with noted CNS involvement with \nprogression of CNS disease who was admitted with fever and \nneutropenia. \n\n#High Grade B-Cell Lymphoma with CNS Involvement- Despite HD MTX \nand IT Ara-C earlier in ___, she has had progression of her \nCNS lymphoma as demonstrated by MRI on ___. She received 4g/m2 \nMTX on ___ and 12g/m2 on ___. She was started on ___ \n(___). MRI ___ was repeated during this admission and \nwas notable for overall stable lesions with mild interval \nchange. Patient was continued on ___ and started on \nTEDDI-R regimen during this admission (C1D1 on ___. Patient \ntolerated this regimen well with no noted side effects. She was \nprescribed a dose of Neulasta that should be taken on ___ \n(C1D6) after discharge. Patient was continued on acyclovir and \nstarted on atovaquone for PCP ___. She was discharged \nwith prescriptions for voriconazole and atovaquone. Due to \ninteractions with voriconazole and ___, patient's QTC was \nmonitored during this admission and was 394 on ___ and 403 on \n___. ___ was stopped on ___. Patient initially required \nPO dilaudid for headaches, which have since resolved. She \nrequired no further doses of dilaudid after ___ during this \nadmission. Patient's HBV and HCV viral loads were pending at \ndischarge. \n\n#Hyperglycemia\n#Type 2 DM\nPatient has a history of pre-diabetes/maternal DM and was \nhyperglycemic to the 200s-400s in the setting of dexamethasone \nas part of her TEDDI-R regimen. Upon further review, HgbA1c was \n6.9% in ___, suggestive of type 2 DM. Patient was initiated \non NPH 15U at breakfast and 10U at lunch and ISS while receiving \ndexamethasone. This regimen was transitioned to metformin XR 500 \nmg BID at discharge. Patient received diabetes education from \nthe ___. She was discharged with a \nglucometer and scheduled with a PCP ___ appointment on \n___ at 12:20 pm for monitoring of her blood glucose and \nadjustment of her medications as needed. \n\n# Hyperlipidemia- Patient's simvastatin was held during this \nadmission and stopped at discharge. \n\n# Sjogren Syndrome- Continued cyclosporine eye drops\n\n# Anemia: Likely secondary to malignancy and chemotherapy. CBC \nwas monitored daily with no acute declines noted. \n\nTRANSITIONAL ISSUES:\n======================\n- New medications: Voriconzaole (due to high risk of aspergillus \non TEDDIR regimen), Atovaquone for PCP prophylaxis, ___\n- Changed medications: Acyclovir 400 from BID to TID\n- Stopped medications: Simvastatin, ___\n- Please continue to monitor QTc in outpatient setting while on \nvoriconazole\n- Please continue to monitor blood glucose and adjust metformin \nas indicated\n- F/u HBV and HCV viral loads\n \nMedications on Admission:\n1. Acyclovir 400 mg PO Q12H \n2. butalbital-acetaminophen-caff 50-300-40 mg oral Q8H:PRN \nheadache \n3. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic BID \n4. diclofenac sodium 1 % topical QID:PRN pain \n5. Halobetasol Propionate 0.05 % topical BID:PRN rash \n6. ___ 420 mg oral DAILY \n7. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/insomnia/anxiety \n8. Omeprazole 20 mg PO DAILY:PRN heartburn \n9. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n10. Simvastatin 20 mg PO QPM \n11. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n12. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n\n \nDischarge Medications:\n1. Acyclovir 400 mg PO Q8H \n2. Atovaquone Suspension 1500 mg PO DAILY \nRX *atovaquone 750 mg/5 mL 10 mL by mouth daily Refills:*0 \n3. MetFORMIN XR (Glucophage XR) 500 mg PO BID type 2 diabetes \nRX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*20 \nTablet Refills:*0 \n4. pegfilgrastim 6 mg/0.6mL subcutaneous ONCE \n5. Voriconazole 200 mg PO Q12H \nRX *voriconazole 200 mg 1 tablet(s) by mouth every 12 hours Disp \n#*20 Tablet Refills:*0 \n6. butalbital-acetaminophen-caff 50-300-40 mg oral Q8H:PRN \nheadache \n7. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic BID \n8. diclofenac sodium 1 % topical QID:PRN pain \n9. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n10. Halobetasol Propionate 0.05 % topical BID:PRN rash \n11. LORazepam 0.5 mg PO Q6H:PRN \nnausea/vomiting/insomnia/anxiety \n12. Omeprazole 20 mg PO DAILY:PRN heartburn \n13. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n14. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n15. HELD- ___ 420 mg oral DAILY This medication was held. \nDo not restart ___ until you are instructed to by Dr. \n___\n16. HELD- Simvastatin 20 mg PO QPM This medication was held. Do \nnot restart Simvastatin until you are advised to by your PCP\n\n \n___:\nHome\n \nDischarge Diagnosis:\nPrimary:\nHigh Grade B-Cell Lymphoma with CNS Involvement\nType 2 Diabetes Mellitus \n\nSecondary:\nHyperlipidemia\nSjogren Syndrome\nAnemia \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 because you were having fevers, chills, and a \nheadache. We treated you with antibiotics initially that were \nstopped when there was no source of infection identified. \n\nWe did an MRI of your ___ that showed that your lymphoma was \nrelatively stable in size. We started you on Cycle 1 of your \nchemotherapy and you completed 5 days of treatment with us. You \ntolerated the treatment well and did not experience any side \neffects. Your outpatient oncologist, Dr. ___ for \nyour Neulasta, which you should take on ___. This prescription \nwill be available for you at the ___. We also \nstarted you on an antibiotic (atovaquone) and antifungal \nmedicine (voriconazole) that you should take as prescribed to \nprevent any infections while you are on your chemotherapy. \nPlease continue taking acyclovir as well, but take it three \ntimes a day. \n\nYour sugars were elevated during this hospitalization requiring \ninsulin initially. We are discharging you with a medication \ncalled metformin that you should take twice a day to control \nyour sugars. It is important that you ___ with your PCP \non ___ at 12:20 pm. Your blood glucose will be checked \nat that time and your medication can be adjusted as needed. \n\nIf you experience any new or ongoing fevers, chills, chest pain, \nshortness of breath, vision changes, worsening headaches, \nnausea, vomiting, abdominal pain, or diarrhea, please return to \nthe Emergency Department for further care. \n\nIt was a pleasure taking care of you, and we wish you the best. \n\nSincerely, \nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "D709", "C8339", "M3500", "Z87891", "E1165", "T380X5A", "Y929", "E785", "D6489", "J309", "Y92239", "R5081" ]

[ "D709: Neutropenia, unspecified", "C8339: Diffuse large B-cell lymphoma, extranodal and solid organ sites", "M3500: Sicca syndrome, unspecified", "Z87891: Personal history of nicotine dependence", "E1165: Type 2 diabetes mellitus with hyperglycemia", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "Y929: Unspecified place or not applicable", "E785: Hyperlipidemia, unspecified", "D6489: Other specified anemias", "J309: Allergic rhinitis, unspecified", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "R5081: Fever presenting with conditions classified elsewhere" ]

[ "Z87891", "E1165", "Y929", "E785" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nPenicillins\n \nAttending: ___\n \n___ Complaint:\nShoulder pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is ___ female with a history of \nulcerative colitis and high grade DLBCL (diagnosed ___, \ns/p C3 R-CHOP, s/p C1 of prophylactic HD-MTX, s/p C1 \nof HD-MTX, ifosfamide, IT chemotherapy being admitted for HD MTX \nfor CNS lymohoma. She comes in early d/t shoulder pain, hip pain \nand headaches non responsive to 10 mg of oxycodone. \n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \n-___: Referred to Dr ___ in our dept for \nprobable malignancy. 30 pound wt loss over the past year and 8 \npound drop over the fall. Developed worsening confusion and \nunsteadiness in early ___ and found to be hypercalcemic (Ca ___. \nAdmitted to ___ where she was given iv fluids, \nCalcitonin and Pamidronate. Low PTH and normal PTHrp. Her CBC \nshowed early myeloid forms and some nuc rbc and her LDH was \nelevated at 656. CT scans of chest, abd, pelvis did not show any \nadenopathy or splenomegaly. There was a 5mm low attenuation \nlesion in the panc head and a 1.3 cm lesion in the right adrenal \ngland. There was a large 8.7x7.7x6.5 mass inseparable from the \nuterus where a fibroid had been noted previously. Subsequent MRI \nshowed diffused dilatation of the panc duct raising concern for \nIPM of the main panc duct and endoscopic ultrasound was \nsuggested as well as a dedicated adrenal washout CT for the \nsmall adrenal lesion. \n-Dr. ___ a BM asp and Bx that day which did not \nshow any abnormal lymphocytes in the aspirate and the \ncytogenetics and FISH were normal. However, the biopsy showed a \nmultifocal infiltrate of malignant lymphocytes with Ki67 of \n50-60%, felt to be an aggressive B cell lymphoma of germinal \ncenter origin. \n-___: Upper endoscopy showed mult gastric ulcers - bx \nshowed lymphoma, cytogenetics showed BCL6, no myc or BCL2 \ntranslocations. \n-___: First cycle Rit/CHOP with split dose Rituxan. \n-___ for febrile neutropenia despite neulasta \nthen ulc colitis flare. Restarted Pred. \n-___: Fever, diarrhea due to C.dif. Rx'd po vanco \nand pneumonia, rx'd Levoflox. \n-___: cycle 2 Rit/CHOP.\n-___: developed diplopia and admitted for c/f CNS lymphoma.\nNon-con head CT w/o contrast and MRI of the head with and \nwithout\ncontrast did not show any significant abnormality. MRI of the\norbit revealed thickening and enhancement of the left ocular\nmotor nerve from the interpeduncular cistern to the cavernous\nsinus, as well as mild enhancement of the right ocular motor\nnerve near the cavernous\nsinus. Lumbar puncture was performed which showed involvement by\nCNS lymphoma. \n-Rituxan and high-dose methotrexate at 8 gm/m2 on ___. \nShe -discharged home ___ after clearing the methotrexate\nwith the plan for q two-week high-dose MTX and qWeekly Rituxan. \n-another dose of Rituxan on ___\n\nPAST MEDICAL HISTORY: \n- Ulcerative Colitis\n- Rhinitis, allergic\n- Eczema\n- Headache, common migraine. *MRI performed ___ due to \ncomplaints of headache, and was unremarkable.\n- Hyperlipidemia\n- Fatty Liver\n- Fibroids\n- Osteoarthritis\n- Adrenal Nodule\n- Pancreatic Cyst\n \nSocial History:\n___\nFamily History:\nPaternal aunt with breast CA. Sister with breast CA in her ___.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n=======================\nVitals: 98.3\nPO 93 / 58 74 20 100 RA \nGen: Pleasant, calm \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. \nLYMPH: No cervical or supraclav LAD\nCV: Normocardic, regular. Normal S1,S2. No MRG. \nLUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. \nABD: NABS. Soft, NT, ND. \nEXT: WWP. No ___ edema. Shoulder with full active and passive \nROM, no pain with external rotation, negative Neer's Test and \nnegative drop arm test. Left thigh tender to palpation with \nslight TTP at the left Trapezius. No signs of swelling or \ninfection of left lower extremity or of the shoulder joint. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3.\nLINES: PIV\n\nDISCHARGE PHYSICAL EXAM:\n=========================\nVitals: Tm 98.5, 90s-150s/60s-80s, 50s-90s, >96%RA\nGen: Pleasant, calm, NAD \nHEENT: atraumatic, normocephalic, EOMI, no oropharyngeal lesions \nappreciated\nCV: RRR, no murmurs, rubs, gallops \nLUNGS: CTAB, no wheezes, ronchi, rales \nABD: NABS. Soft, NT, ND. \nEXT: WWP. no edema appreciated. \nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: A&Ox3, CN II-XII grossly intact, moving all 4 extremities \nspontaneously and purposefully\n \nPertinent Results:\nADMISSION LABS:\n================\n___ 10:33AM BLOOD WBC-15.4*# RBC-2.93* Hgb-9.5* Hct-29.6* \nMCV-101* MCH-32.4* MCHC-32.1 RDW-16.0* RDWSD-60.3* Plt ___\n___ 10:33AM BLOOD Neuts-96.1* Lymphs-2.0* Monos-0.7* \nEos-0.1* Baso-0.4 Im ___ AbsNeut-14.77*# AbsLymp-0.31* \nAbsMono-0.11* AbsEos-0.01* AbsBaso-0.06\n___ 10:33AM BLOOD ___ PTT-28.4 ___\n___ 10:33AM BLOOD Glucose-180* UreaN-15 Creat-0.4 Na-141 \nK-4.1 Cl-104 HCO3-29 AnGap-12\n___ 10:33AM BLOOD ALT-11 AST-9 LD(LDH)-213 CK(CPK)-23* \nAlkPhos-92 TotBili-0.3\n___ 10:33AM BLOOD Calcium-8.7 Phos-4.9* Mg-2.1\n___ 12:55AM BLOOD mthotrx-1.6\n\nMICRO:\n======\n___ 6:48 am STOOL CONSISTENCY: NOT APPLICABLE\n Source: Stool. \n\n **FINAL REPORT ___\n\n C. difficile DNA amplification assay (Final ___: \n Negative for toxigenic C. difficile by the Cepheid nucleic \nacid\n amplification assay.. \n (Reference Range-Negative). \n\nIMAGING:\n========\n___ MR HEAD W & W/O CONTRAS\n1. Numerous new supratentorial periventricular enhancing \nlesions, with\ndistribution and signal characteristics which are characteristic \nof lymphoma. The dominant lesion in the left periatrial white \nmatter is associated withedema, causing effacement of the \noccipital horn of left lateral ventricle. No shift of midline \nstructures.\n2. Punctate focus of high signal on diffusion tracer sequence in \nthe right\nmedial parietal cortex without correlate on other sequences may \nrepresent a\npunctate subacute infarct or artifact. If there is continued \nconcern,\nshort-term follow up MRI may be helpful for differentiation.\n3. Unchanged 5 mm right parietal dural calcification versus \ncalcified\nmeningioma.\n\nDISCHARGE LABS:\n==============\n___ 12:35AM BLOOD WBC-3.9*# RBC-2.86* Hgb-9.4* Hct-28.2* \nMCV-99* MCH-32.9* MCHC-33.3 RDW-14.8 RDWSD-53.6* Plt ___\n___ 12:35AM BLOOD Neuts-83.6* Lymphs-13.3* Monos-1.8* \nEos-0.3* Baso-0.0 Im ___ AbsNeut-3.28# AbsLymp-0.52* \nAbsMono-0.07* AbsEos-0.01* AbsBaso-0.00*\n___ 12:35AM BLOOD Plt ___\n___ 12:35AM BLOOD ___ PTT-26.2 ___\n___ 12:35AM BLOOD Glucose-283* UreaN-13 Creat-0.4 Na-141 \nK-4.1 Cl-100 HCO3-28 AnGap-17\n___ 12:35AM BLOOD ALT-57* AST-10 LD(LDH)-170 AlkPhos-82 \nTotBili-0.3\n___ 12:35AM BLOOD TotProt-5.3* Albumin-3.4* Globuln-1.9* \nCalcium-8.8 Phos-4.1 Mg-1.9\n___ 12:30AM BLOOD mthotrx-0.02\n \nBrief Hospital Course:\n___ is a ___ history of ulcerative colitis and high \ngrade DLBCL (diagnosed ___, s/p C3 R-CHOP and s/p C1 of \nprophylactic HD-MTX, admitted for HD-MTX for CNS lymphoma found \nto have rapidly progressing CNS lymphoma on MRI ___. She \nreceived 4g MTX on ___, and cleared in 24h. ___ she got an MRI \nbecause she was having vomiting in the morning, and it showed \nsignificant progression of her CNS involvement compared to her \nprevious MRI one month ago. The decision was then made to give \nher 12g/m2 of methotrexate on ___. She tolerated it well and \ncleared it within 72h. As she had cleared the methotrexate and \nher symptoms had improved she was discharged home with \noutpatient follow up.\n\nTransitional Issues:\n[] Was given inhaled pentamidine on ___ for PCP ___\n[] Discharged on dexamethasone 2mg BID, can be tapered as \ntolerated\n[] FYI voriconazole is covered by her insurance for future \nreference with future treatments\n[] Had mucositis on discharge, please follow up if improving or \ngetting worse\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Acyclovir 400 mg PO BID \n2. Halobetasol Propionate 0.05 % topical BID:PRN \n3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\n4. Restasis (cycloSPORINE) 0.05 % ophthalmic BID \n5. butalbital-acetaminophen-caff 50-300-40 mg oral Q8H:PRN \n\n \nDischarge Medications:\n1. Caphosol 30 mL ORAL QID:PRN mucositis \nRX *saliva substitute combo no.2 [Caphosol] 30mL swish and spit \nQID:PRN Refills:*1 \n2. Dexamethasone 2 mg PO BID \nRX *dexamethasone 1 mg 2 tablet(s) by mouth twice a day Disp \n#*30 Tablet Refills:*0 \n3. Fluconazole 100 mg PO Q24H Duration: 5 Days \nRX *fluconazole [Diflucan] 100 mg 1 tablet(s) by mouth DAILY \nDisp #*5 Tablet Refills:*0 \n4. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Severe \nRX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth Q6H:PRN \nDisp #*10 Tablet Refills:*0 \n5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity \n6. Acyclovir 400 mg PO BID \n7. butalbital-acetaminophen-caff 50-300-40 mg oral Q8H:PRN \n8. Halobetasol Propionate 0.05 % topical BID:PRN \n9. Restasis (cycloSPORINE) 0.05 % ophthalmic BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\nHigh grade diffuse large B-cell lymphoma with CNS involvement\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 pain and \nnausea. We did an MRI of your head which showed there was spread \nof your cancer to your brain. You were started on high dose \nsteroids to decrease the inflammation. This helped resolve the \nnausea and the pain you were having.\n\nIn order to treat the cancer, you were given high doses of a \nmedication called methotrexate. \n\nYou will follow up with your outpatient oncologist to discuss \nfurther treatment. The regimen that had been talked about while \nyou were in the hospital is called TEDDI-R, and it contains \ntemozolomide, etoposide, doxil, dexamethasone, ibrutinib and \nrituximab. \n\nBecause your symptoms improved and you completed the \nmethotrexate, you were discharged home.\n\nPlease attend your follow up appointments as listed below.\n\nThank you for choosing ___ for your healthcare needs. It was a \npleasure taking care of you.\n\nSincerely,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "G038", "C8339", "M3500", "R112", "K1230", "M25512", "M25559", "E785", "R7303", "H532", "H02431" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "G038: Meningitis due to other specified causes", "C8339: Diffuse large B-cell lymphoma, extranodal and solid organ sites", "M3500: Sicca syndrome, unspecified", "R112: Nausea with vomiting, unspecified", "K1230: Oral mucositis (ulcerative), unspecified", "M25512: Pain in left shoulder", "M25559: Pain in unspecified hip", "E785: Hyperlipidemia, unspecified", "R7303: Prediabetes", "H532: Diplopia", "H02431: Paralytic ptosis of right eyelid" ]

[ "E785" ]

[]

[ " \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:\nFever\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ is a ___ year old woman with a history of \nrecently diagnosed DLBCL, s/p 1 cycle R-CHOP with split dose \nRituxan, who presents with complaints of fever this morning. \n\nNotably, she was seen by her oncologist Dr ___ in clinic on \n___ after completion of cycle 1 R-CHOP. At that time she \nstated that she had been feeling well after chemo, up until the \n___, at which point she began to feel \"somewhat tired and very \nachy\", and also complained of a mild headache. She had just \ncompleted a taper of Prednisone (100mg daily, last day ___, \nand her symptoms were attributed to discontinuation of the \nsteroid. Plans were made to start back on 20 mg Prednisone that \nday, then 10 mg the day after, and 5 mg the day after that. She \ncompleted this and felt well in the interim.\n\nHowever, she awoke this morning feeling very fatigued. She also \nnoted a headache focused behind her left eye. She took her \ntemperature and found it to be 100.8. She subsequently presented \nto ___ Urgent Care, where her temperature was 99.5. \nShe was then referred to the ___ ED.\n\nIn the ED, initial vitals: T 101.2, BP 99/62, P ___, RR 14, O2 \n99% RA \n- Exam unremarkable. \n- Labs were notable for: WBC 300 with ANC 10, chemistry \nunremarkable, lactate 1.2, UA without infection. BCx, UCx sent. \n- Imaging: CXR obtained\n- Patient was given: Tylenol 1g (11:30), Vancomycin 1g (12:50)\n- Decision was made to admit to ___ for neutropenic fever\n- Vitals prior to transfer were T 99.6, BP 93/52, P ___, RR 18, \nO2 100% RA.\n \nOn arrival to the floor, she reports feeling better than this \nmorning, although still somewhat fatigued. She states her \nheadache is ___ in severity, much improved from earlier. She \ndenies visual changes, stiff neck, congestion, sore throat, \nsinus tenderness, cough, dyspnea, chest pain, palpitations, \nabdominal pain, nausea/vomiting, diarrhea, constipation, rash, \nmuscle/joint ache. No sick contacts at home or work. No recent \ntravel.\n \n\n \nPast Medical History:\nUlcerative colitis \nRhinitis, allergic \nEczema \nHeadache, common migraine. *MRI performed ___ due to \ncomplaints of headache, and was unremarkable.\nHyperlipidemia \nFatty liver \nFibroids \nOsteoarthritis \nAdrenal nodule \nPancreatic cyst \nHypercalcemia \nDiffuse large B-cell lymphoma of extranodal site excluding \nspleen and other solid organs\n \nSocial History:\n___\nFamily History:\npat aunt- breast CA. Sister with breast CA in her ___.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVS: T 98.7 HR 96 BP 99/59 RR 16 SAT 99% O2 on RA\nGENERAL: Pleasant, lying in bed comfortably\nHEENT: EOMI, PERRL, oropharynx without lesions/ulcers\nCARDIAC: Regular rate and rhythm, II/VI late peaking systolic \nmurmur at ___, no rubs or gallops\nLUNG: Appears in no respiratory distress, clear to auscultation \nbilaterally, no crackles, wheezes, or rhonchi\nABD: Normal bowel sounds, soft, nontender, nondistended, no \nhepatomegaly, no splenomegaly\nEXT: Warm, well perfused, no lower extremity edema\nPULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses\nNEURO: Alert, oriented, CN II-XII intact, motor and sensory \nfunction grossly intact\nSKIN: No significant rashes\n\nDISCHARGE PHYSICAL EXAM:\n\nVS: 98.4PO 115 / 60 109 16 98 RA \nGENERAL: Pleasant, lying in bed comfortably\nHEENT: EOMI, PERRL, oropharynx without lesions/ulcers\nCARDIAC: Regular rate and rhythm, II/VI late peaking systolic \nmurmur at ___, no rubs or gallops\nLUNG: Appears in no respiratory distress, clear to auscultation \nbilaterally, no crackles, wheezes, or rhonchi\nABD: Normal bowel sounds, soft, nontender, nondistended, no \nhepatomegaly, no splenomegaly\nEXT: Warm, well perfused, no lower extremity edema\nPULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses\nNEURO: Alert, oriented, CN II-XII intact, motor and sensory \nfunction grossly intact\nSKIN: No significant rashes\n\n \nPertinent Results:\nADMISSION LABS\n================\n___ 11:48AM BLOOD WBC-0.3*# RBC-2.47*# Hgb-8.2*# Hct-26.1*# \nMCV-106*# MCH-33.2*# MCHC-31.4* RDW-16.5* RDWSD-64.4* Plt \n___\n___ 11:48AM BLOOD Neuts-3* Bands-0 Lymphs-85* Monos-6 Eos-5 \nBaso-1 ___ Myelos-0 AbsNeut-0.01* AbsLymp-0.26* \nAbsMono-0.02* AbsEos-0.02* AbsBaso-0.00*\n___ 11:48AM BLOOD Glucose-197* UreaN-11 Creat-0.5 Na-133 \nK-4.4 Cl-94* HCO3-28 AnGap-15\n___ 12:06PM BLOOD Lactate-1.2\n\nMICROBIOLOGY\n================\nASPERGILLUS GALACTOMANNAN ANTIGEN \n Test Result Reference \nRange/Units\nINDEX VALUE 0.09 <0.50\nASPERGILLUS AG,EIA,SERUM Not Detected Not Detected\n \nURINE CULTURE (Final ___: NO GROWTH.\n\nMRSA SCREEN (Final ___: No MRSA isolated. \n\nBLOOD CX X2 ___: PENDING, NEGATIVE AT TIME OF D/C\n\n___ 1:30 pm Rapid Respiratory Viral Screen & Culture\n Source: Nasopharyngeal swab. \n\n **FINAL REPORT ___\n\n Respiratory Viral Culture (Final ___: \n No respiratory viruses isolated. \n Culture screened for Adenovirus, Influenza A & B, \nParainfluenza type\n 1,2 & 3, and Respiratory Syncytial Virus.. \n Detection of viruses other than those listed above will \nonly be\n performed on specific request. Please call Virology at \n___\n within 1 week if additional testing is needed. \n\n Respiratory Viral Antigen Screen (Final ___: \n Negative for Respiratory Viral Antigen. \n Specimen screened for: Adeno, Parainfluenza 1, 2, 3, \nInfluenza A, B,\n and RSV by immunofluorescence. \n Refer to respiratory viral culture and/or Influenza PCR \n(results\n listed under \"OTHER\" tab) for further information.. \n\nIMAGING\n================\nCXR ___:\nHeart size is normal. Mediastinum is normal. Lungs are clear \nwithin the \nlimitations of chest radiograph technique. There is no pleural \neffusion. \nThere is no pneumothorax. \nIf clinically warranted, correlation with chest CT to exclude \nthe possibility of radiographically occult neutropenic pneumonia \nis to be considered. \n\nPERTINENT RESULTS\n================\n___ 07:30AM BLOOD WBC-3.0*# RBC-2.80* Hgb-8.8* Hct-27.7* \nMCV-99* MCH-31.4 MCHC-31.8* RDW-18.2* RDWSD-66.7* Plt ___\n___ 07:30AM BLOOD Neuts-79* Bands-5 Lymphs-8* Monos-8 Eos-0 \nBaso-0 ___ Myelos-0 NRBC-1* AbsNeut-2.52 \nAbsLymp-0.24* AbsMono-0.24 AbsEos-0.00* AbsBaso-0.00*\n___ 07:35AM BLOOD Hapto-523*\n___ 07:35AM BLOOD Ret Aut-0.2* Abs Ret-0.00*\n\nDISCHARGE LABS\n================\n___ 07:40AM BLOOD WBC-4.6# RBC-2.80* Hgb-9.1* Hct-27.7* \nMCV-99* MCH-32.5* MCHC-32.9 RDW-17.7* RDWSD-64.9* Plt ___\n___ 07:40AM BLOOD Neuts-81* Bands-6* Lymphs-5* Monos-7 \nEos-0 Baso-0 ___ Myelos-0 Other-1* AbsNeut-4.00 \nAbsLymp-0.23* AbsMono-0.32 AbsEos-0.00* AbsBaso-0.00*\n___ 07:40AM BLOOD Plt Smr-NORMAL Plt ___\n___ 07:40AM BLOOD Glucose-154* UreaN-8 Creat-0.6 Na-134 \nK-4.5 Cl-96 HCO3-28 AnGap-15\n___ 07:40AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.9\n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman with a history of recently \ndiagnosed DLBCL, s/p 1 cycle R-CHOP with split dose Rituxan, who \npresented with complaints of fever I/s/o ANC 10.\n\n#Febrile neutropenia: Pt with fever 101.5 on morning of ___ at \nhome as well as in ED. Unclear source as pt with no localizing \nsymptoms other than headache. No stiff neck/meningismus to \nsuggest meningitis. Most likely cause was thought to be viral \nsource, possibly URI, given complaints of general \nfatigue/malaise and headache, although resp panel negative. \nReceived 1g Vancomycin in ED as well as 1g Tylenol. This was \ndiscontinued on admission as she did not have a central line and \nhad no signs of skin breakdown. She was instead started on \nCefepime 2g q8h but this was discontinued once ___ recovered (> \n4000 at time of d/c) and no s/s infection developed. Urine cx \nnegative, MRSA swab negative, blood cx's still pending at time \nof d/c. Patient did spike a fever on day of discharge to 101.5, \nhowever had symptoms of ulcerative colitis flare (see below). In \nsetting of UC flare symptoms and lack of other signs/symptoms of \ninfection throughout a five day hospital course, patient was \ndischarged with close follow up with Oncology and GI. \n\n#Headache: Resolved quickly after admission. As above, low \nconcern for meningitis. Recent MRI brain without signs of \nmetastases.\n\n#Ulcerative colitis: Symptoms had been absent during first few \ndays of hospitalization. Patient denied any recent flares. \nPatient on Loperamide/Mesalamine/Mercaptopurine as outpatient, \nhowever mesalamine (rectal/enema) and mercaptopurine held on \nadmission in setting of neutropenia. Patient did complain of \nflare symptoms (crampy abdominal pain and clots in stool) on \n___ AM, and then had pink stools on ___ and worsening \nabdominal pain. Patient's infectious work up remained stable \nafter 5 days in hospital, and patient noted her usual UC flares \nusually are accompanied by fevers. Therefore, patient was deemed \nsafe for discharge given she appeared clinically well and had \nstrong desire to be home. The fevers she continued to spike even \nwhile on Cefepime were thought to be from her UC flare. She was \ndischarged home with close follow up appointment with Dr. ___ \non ___. \n\n#Anemia/macrocytosis: Likely anemic from bone marrow crowding vs \neffect of chemo. MCV gradually rising over past weeks to 106 on \nadmission. CBC was monitored daily. Hemolysis labs (LDH, \nhaptoglobin, reticulocyte count) were checked and were \nunremarkable. Received 1U pRBC for Hgb 6.9 on ___, Hgb \nresponded appropriately and remained stable throughout \nadmission.\n\nCHRONIC ISSUES:\n#Osteoarthritis: pt reports she does not need Diclofenac gel \ncurrently.\n#Eczema: pt reports she does not need topical steroid cream \ncurrently.\n#Dry eyes: Continued cyclosporine drops.\n#Anxiety: Continued home Lorazepam.\n\nTRANSITIONAL ISSUES\n===================\nNEUTROPENIA\n[ ] ANC 4000 at time of d/c, consider rechecking as outpatient.\n\nINFECTION R/O\n[ ] F/u pending blood cx, urine cx to ensure negative.\n\nULCERATIVE COLITIS \n[ ] Pt to follow up with Dr. ___ on ___.\n[ ] Prednisone 20mg QAM and Prednisone 10mg QPM for UC flare, \ntaper to be determined by outpatient GI. \n[ ] Restarted Mesalamine rectal enema and suppository. \n[ ] Holding Mercaptopurine, plan to restart per outpatient GI. \n\nSINUS TACHYCARDIA\n[ ] Patient with sinus tachycardia in 100s-110s. Asymptomatic. \nLikely from fevers, malignancy. Should continue work up as \noutpatient. \n\n# HCP/Contact: Husband, ___ (___)\n# Code: Full, confirmed\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Ondansetron 8 mg PO Q8H:PRN nausea \n2. Prochlorperazine 10 mg PO Q6H:PRN nausea \n3. LORazepam 0.5 mg PO BID \n4. Halobetasol Propionate 0.05 % topical Q12H:PRN rash \n5. LOPERamide 4 mg PO DAILY \n6. Mesalamine (Rectal) ___AILY \n7. Mesalamine Enema 4 gm PR QHS \n8. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic Q12H \n9. Mercaptopurine 100 mg PO DAILY \n10. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n11. diclofenac sodium 1 % topical Q6H:PRN pain \n\n \nDischarge Medications:\n1. PredniSONE 20 mg PO DAILY \nRX *prednisone 10 mg 2 tablet(s) by mouth QAM Disp #*30 Tablet \nRefills:*0 \n2. PredniSONE 10 mg PO QHS \nRX *prednisone 10 mg 1 tablet(s) by mouth QPM Disp #*15 Tablet \nRefills:*0 \n3. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic Q12H \n4. diclofenac sodium 1 % topical Q6H:PRN pain \n5. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n6. Halobetasol Propionate 0.05 % topical Q12H:PRN rash \n7. LOPERamide 4 mg PO DAILY \n8. LORazepam 0.5 mg PO BID \n9. Mesalamine (Rectal) ___AILY \n10. Mesalamine Enema 4 gm PR QHS \n11. Ondansetron 8 mg PO Q8H:PRN nausea \n12. Prochlorperazine 10 mg PO Q6H:PRN nausea \n13. Simvastatin 40 mg PO QPM \n14. HELD- Mercaptopurine 100 mg PO DAILY Duration: 1 Dose This \nmedication was held. Do not restart Mercaptopurine until you see \nyour GI doctor\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY\n============\nNeutropenic fever\nUlcerative colitis flare\n\nSECONDARY\n============\nHeadache\nAnemia\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 had a fever and your white \nblood cell count was very low. We gave you with antibiotics to \ntreat you for any possible infection. All of your studies \nreturned normal, without evidence of infection, which does \nhappen at times. You likely had a viral illness which went away \non its own.\n\nHowever toward the end of your hospitalization you continued to \nspike fevers to 101.5. Given that your vitals remained stable, \nand that you did not have any new symptoms EXCEPT for symptoms \nwhich you describe as your typical Ulcerative colitis flare \nsymptoms, it is likely that these fevers are due to a UC flare. \nWe started you on steroids and your mesalamine at your home \ndose. \n\nPlease make sure to seek medical attention if you develop NEW \nsymptoms or WORSENING symptoms such as new pain, rashes, cough, \nheadache, changes in balance, changes in vision, neck pain, or \nworsening abdominal pain. \n\nPlease follow up with your specialists, see below. \n\nWe wish you the best,\n\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "D709", "K5190", "C8339", "I959", "R5081", "D7589", "D649", "H04123", "F419", "E785", "J309", "R000", "Z87891" ]

[ "D709: Neutropenia, unspecified", "K5190: Ulcerative colitis, unspecified, without complications", "C8339: Diffuse large B-cell lymphoma, extranodal and solid organ sites", "I959: Hypotension, unspecified", "R5081: Fever presenting with conditions classified elsewhere", "D7589: Other specified diseases of blood and blood-forming organs", "D649: Anemia, unspecified", "H04123: Dry eye syndrome of bilateral lacrimal glands", "F419: Anxiety disorder, unspecified", "E785: Hyperlipidemia, unspecified", "J309: Allergic rhinitis, unspecified", "R000: Tachycardia, unspecified", "Z87891: Personal history of nicotine dependence" ]

[ "D649", "F419", "E785", "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:\nDiffuse large B-cell lymphoma\n \nMajor Surgical or Invasive Procedure:\nLumbar puncture \n\n \nHistory of Present Illness:\nMs. ___ is ___ female with a history of \nulcerative colitis and high grade DLBCL (diagnosed ___, \ns/p C3 R-CHOP and s/p C1 of prophylactic HD-MTX, admitted for C1 \nof HD-MTX, ifosfamide, IT chemotherapy. \n\nShe was s/p R-chop cycle 3 in ___ and was due for C4 on \n___ but developed diplopia c/f CNS involvement prompting \nadmission on ___. CT head and MRI on admission were overall \nnegative. MRI\norbit noted thickening and enhancement of the left oculomotor \nnerve. Neuro Oncology was consulted. Third nerve palsy and \nenhancement in the left third nerve were suggestive of \nleptomeningeal involvement by her DLBCL, though the enhancement \npattern was more c/w lipomatous involvement per radiology read.\nShe had two LPs which were sent for many infectious studies \nwhich were negative. CSF cytology was neg for malignant cells \nbut IPT was c/f lymphoma. She was started on Rituxan and HD MTX \nwhich she\ntolerated well She was seen by Opthamology with no evidence of \nintraocular lymphoma and discharged on ___ with plan for weekly \nrituximab for 4 weeks and readmission for methotrexate every 2\nweeks. She received doses of rituximab on ___ and ___ prior to \nadmission. \n\nOn admission, she reports continued vertical diplopia, relieved \nby taping of her right eyeglass lens. She denies blurred vision, \nheadache, or dizziness/vertigo. She also reports pain in her \nleft anterior thigh that started a few days ago. She describes \nit as a throbbing ache, and it comes and goes. She has left \nsided low\nback pain that tends to occur at the same time though it is \nunclear if her thigh pain is associated. She reports bilateral \nlower extremity weakness starting around the time of her \ndiplopia. She is unable to say if it is proximal or distal, but \nshe now has trouble climbing stairs and stops on each step, \nleading with her right leg. She denies changes in bowel function \nor urinary retention. She has had bilateral peripheral \nneuropathy\nin both upper and lower extremities associated with R-CHOP which \nhas been stable. \n\nShe denies fever/chills, rhinorrhea, cough, CP, SOB, \nnausea/vomting, diarrhea, dysuria, or rash. \n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \n-___: Referred to Dr ___ in our dept for \nprobable malignancy. 30 pound wt loss over the past year and 8 \npound drop over the fall. Developed worsening confusion and \nunsteadiness in early ___ and found to be hypercalcemic (Ca ___. \nAdmitted to ___ where she was given iv fluids, \nCalcitonin and Pamidronate. Low PTH and normal PTHrp. Her CBC \nshowed early myeloid forms and some nuc rbc and her LDH was \nelevated at 656. CT scans of chest, abd, pelvis did not show any \nadenopathy or splenomegaly. There was a 5mm low attenuation \nlesion in the panc head and a 1.3 cm lesion in the right adrenal \ngland. There was a large 8.7x7.7x6.5 mass inseparable from the \nuterus where a fibroid had been noted previously. Subsequent MRI \nshowed diffused dilatation of the panc duct raising concern for \nIPM of the main panc duct and endoscopic ultrasound was \nsuggested as well as a dedicated adrenal washout CT for the \nsmall adrenal lesion. \n-Dr. ___ a BM asp and Bx that day which did not \nshow any abnormal lymphocytes in the aspirate and the \ncytogenetics and FISH were normal. However, the biopsy showed a \nmultifocal infiltrate of malignant lymphocytes with Ki67 of \n50-60%, felt to be an aggressive B cell lymphoma of germinal \ncenter origin. \n-___: Upper endoscopy showed mult gastric ulcers - bx \nshowed lymphoma, cytogenetics showed BCL6, no myc or BCL2 \ntranslocations. \n-___: First cycle Rit/CHOP with split dose Rituxan. \n-___ for febrile neutropenia despite neulasta \nthen ulc colitis flare. Restarted Pred. \n-___: Fever, diarrhea due to C.dif. Rx'd po vanco \nand pneumonia, rx'd Levoflox. \n-___: cycle 2 Rit/CHOP.\n-___: developed diplopia and admitted for c/f CNS lymphoma.\nNon-con head CT w/o contrast and MRI of the head with and \nwithout\ncontrast did not show any significant abnormality. MRI of the\norbit revealed thickening and enhancement of the left ocular\nmotor nerve from the interpeduncular cistern to the cavernous\nsinus, as well as mild enhancement of the right ocular motor\nnerve near the cavernous\nsinus. Lumbar puncture was performed which showed involvement by\nCNS lymphoma. \n-Rituxan and high-dose methotrexate at 8 gm/m2 on ___. \nShe -discharged home ___ after clearing the methotrexate\nwith the plan for q two-week high-dose MTX and qWeekly Rituxan. \n-another dose of Rituxan on ___\n\nPAST MEDICAL HISTORY: \n- Ulcerative Colitis\n- Rhinitis, allergic\n- Eczema\n- Headache, common migraine. *MRI performed ___ due to \ncomplaints of headache, and was unremarkable.\n- Hyperlipidemia\n- Fatty Liver\n- Fibroids\n- Osteoarthritis\n- Adrenal Nodule\n- Pancreatic Cyst\n \nSocial History:\n___\nFamily History:\nPaternal aunt with breast CA. Sister with breast CA in her ___.\n \nPhysical Exam:\nADMISSION EXAM: \nVS: Temp 98.0, BP 100/60, HR 89, RR 16, O2 sat 100% RA.\nGENERAL: Lying in bed, wearing glasses with tape on right lens,\nin no apparent distress \nHEENT: Anicteric, PERLL, OP clear. Right ptosis.\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: Appears in no respiratory distress, clear to auscultation \nbilaterally, no crackles, wheezes, or rhonchi.\nABD: Soft, non-tender, non-distended, normal bowel sounds, no \nhepatomegaly, no splenomegaly.\nEXT: Warm, well perfused, no lower extremity edema, erythema or \ntenderness.\nNEURO: A&Ox3, good attention and linear thought. Mild right eye \nptosis. ___ strength throughout UE bilat. ___ strength hip\nflexion bilat. ___ plantar flexion bilat; ___ dorsi flexion on\nright, ___ on left. \nSKIN: No significant rashes.\nACCESS: Right chest wall port without erythema.\n\nDISCHARGE EXAM: \nVS: T 98.1 BP 125/77 HR 95 RR 18 O2 99% on RA\nI/O: 600/0 // 3535/1300\nGENERAL: Lying in bed, wearing glasses with tape on right lens,\ncomfortable-appearing.\nHEENT: Right ptosis stable. Clear OP without ulcers or thrush. \nCARDIAC: RRR, normal s1/s2, grade II/VI systolic ejection murmur\nbest auscultated at the LUSB and apex.\nLUNG: CTAB, no crackles, wheezes, or rhonchi.\nABD: NABS. Abdomen is soft, non-tender, non-distended. No\nhepatomegaly to percussion.\nEXT: Warm, well perfused, no lower extremity edema, erythema or \ntenderness.\nNEURO: A&Ox3. Mild right eye ptosis. Moves all four extremities\nagainst gravity spontaneously. \nSKIN: No rash or skin breakdown.\nACCESS: Right chest wall port without erythema.\n \nPertinent Results:\n___ 12:00AM GLUCOSE-137* UREA N-16 CREAT-0.5 SODIUM-140 \nPOTASSIUM-3.2* CHLORIDE-96 TOTAL CO2-33* ANION GAP-14\n___ 12:00AM CALCIUM-7.9* PHOSPHATE-4.3 MAGNESIUM-1.8\n___ 12:00AM WBC-8.7 RBC-2.50* HGB-8.2* HCT-26.0* MCV-104* \nMCH-32.8* MCHC-31.5* RDW-15.0 RDWSD-57.5*\n___ 12:00AM NEUTS-73.6* LYMPHS-13.3* MONOS-11.6 EOS-0.8* \nBASOS-0.2 IM ___ AbsNeut-6.41* AbsLymp-1.16* AbsMono-1.01* \nAbsEos-0.07 AbsBaso-0.02\n___ 12:00AM PLT COUNT-264\n___ 10:38AM GLUCOSE-91 UREA N-21* CREAT-0.4 SODIUM-143 \nPOTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-29 ANION GAP-16\n___ 10:38AM ALT(SGPT)-11 AST(SGOT)-11 LD(LDH)-193 ALK \nPHOS-70 TOT BILI-<0.2\n___ 10:38AM ALBUMIN-3.7 CALCIUM-8.9 PHOSPHATE-4.0 \nMAGNESIUM-2.1 URIC ACID-3.9\n___ 10:38AM WBC-7.2 RBC-2.92* HGB-9.5* HCT-30.4* MCV-104* \nMCH-32.5* MCHC-31.3* RDW-15.0 RDWSD-58.2*\n___ 10:38AM NEUTS-65.1 LYMPHS-17.7* MONOS-15.9* EOS-0.6* \nBASOS-0.4 IM ___ AbsNeut-4.67 AbsLymp-1.27 AbsMono-1.14* \nAbsEos-0.04 AbsBaso-0.03\n___ 10:38AM PLT COUNT-292\n___ 10:38AM ___ PTT-31.0 ___\n\nIMAGING:\nMR ___ spine ___, IMPRESSION: \n1.No evidence of abnormal enhancement within the cervical, \nthoracic, or lumbar spine. \n2.Diffusely heterogeneous bone marrow signal, may be secondary \nto a systemic process such as anemia however an infiltrative \nneoplastic process cannot be excluded. Recommend correlation \nwith\nclinical labs. \n3. Mild disc bulges from C4-C5 through C6-C7 results in mild \nspinal canal narrowing at this level. No significant \ndegenerative changes within the thoracic or lumbar spine. \n \nBrief Hospital Course:\nMs. ___ is ___ female with a history of \nulcerative colitis and high grade DLBCL (diagnosed ___, s/p \nC3 R-CHOP and s/p C1 of prophylactic HD-MTX, admitted for C1 of \nHD-MTX/ifosfamide/IT ara-C. \n\n#High Grade B-Cell Lymphoma w/ CNS involvement: s/p 3 cycles \nR-CHOP, with last dose of chemotherapy given on ___. S/p MTX \non ___ and R-CHOP on ___. Was due for next round of chemo on \n___ but developed CNS involvement and was treated with \nrituximab and HD-MTX x1 with her last dose of rituximab given on \nthe day of admission ___ in clinic. On this admission, she \nreceived HD MTX (with leucovorin rescue), Ifosfamide (1.5 mg/M2 \nDays 3,4,5 with IVF and Mesna) and IT Ara-C (day 6) for both \ntreatment of her systemic and CNS lymphoma, tolerating the \nregimen well. Filgrastim was initiated on 24h after her last \ndose of chemo to be continued daily through her nadir and until \ncount recovery. MR ___ spine on ___ was neg for leptomeningeal \ninvolvement. Cellularity of CSF from day 6 was reassuring but \ncytology was pending at discharge. The current plan is for \nrepeat IT Ara-C on D15 vs OMMAYA catheter, continue to cycle 2 \n(day ___ based on counts and mucositis), and reassess disease \nafter 2 cycles with completion of 4 cycles if no progression. \nContinue filgrastim 300mcg daily until count nadir and recover. \nTo complete 5 days dexamethasone 4mg BID (last day ___. f/u on \nCSF studies with outpatient oncologist. \n\n#Ulcerative colitis: Her last flare occurred during treatment \naround ___ though in general the UC has improved with chemo. \nShe has previously been treated with ___ and prednisone. She \nexperienced diarrhea x1.5 days this admission and was r/o for C. \ndiff. The diarrhea resolved without intervention. \n\n#Infection: No ongoing infection on this admission. Continued on \nACV for ppx. \n\n#Hyperlipidemia: holding home simvastatin.\n\n#Sjogren Syndrome: Continued cyclosporine eye drops.\n \nMedications on Admission:\nAcyclovir 400 mg PO BID\nHalobetasol Propionate 0.05 % topical BID:PRN\nRestasis (cycloSPORINE) 0.05 % ophthalmic BID\n \nDischarge Medications:\n1. Dexamethasone 4 mg PO Q12H Duration: 5 Days \nRX *dexamethasone 4 mg 1 tablet(s) by mouth twice daily Disp #*7 \nTablet Refills:*0 \n2. Filgrastim-sndz 300 mcg SC Q24H \nRX *filgrastim-sndz [Zarxio] 300 mcg/0.5 mL 300 mcg SC daily \nDisp #*15 Syringe Refills:*0 \n3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*24 \nTablet Refills:*0 \n4. Acyclovir 400 mg PO BID \n5. Halobetasol Propionate 0.05 % topical BID:PRN \n6. Restasis (cycloSPORINE) 0.05 % ophthalmic BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\nDiffuse large B-cell lymphoma with CNS involvement\nSecondary:\nUlcerative colitis\nHyperlipidemia\nSjogren's syndrome\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 ___ for chemotherapy. You received a \ncycle of chemo, including the injection in your spine (lumbar \npuncture). You tolerated these treatments well and will return \nto your outpatient ___ clinic for follow-up the day after \ndischarge (see appointments). \n\nYou will be discharged on 3 new medications (see below for \ndetails). Please continue to take your other medications as \nprescribed unless directed otherwise. \n\nPlease contact Atrius oncology or Dr. ___ if you have \nany questions, concerns, or new concerning symptoms.\n\nIt was a pleasure taking care of you and we wish you the best, \nThe ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "Z5111", "C8339", "K5190", "E785", "M3500", "R7303", "E7800", "Z87891", "Z803", "D630", "H532" ]

[ "Z5111: Encounter for antineoplastic chemotherapy", "C8339: Diffuse large B-cell lymphoma, extranodal and solid organ sites", "K5190: Ulcerative colitis, unspecified, without complications", "E785: Hyperlipidemia, unspecified", "M3500: Sicca syndrome, unspecified", "R7303: Prediabetes", "E7800: Pure hypercholesterolemia, unspecified", "Z87891: Personal history of nicotine dependence", "Z803: Family history of malignant neoplasm of breast", "D630: Anemia in neoplastic disease", "H532: Diplopia" ]

[ "E785", "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:\nDyslexia\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year-old woman with history of DLBCL with \nknown CNS involvement on C3D2 of TEDDI-R, had intrathecal \ncytarabine yesterday, awoke this morning with word finding \ndifficulties, which had mostly resolved by the time she arrived \nto the ER. States she continues to have occasional difficulty \nfinding words. No headaches, diplopia, blurry vision, \nfevers/chills, dysarthria, numbness/weakness/tingling in her \nface, arms, or legs, bowel/bladder difficulty, or difficulty \nwalking, dyspnea, chest pain, n/v, abdominal pain.\n\nCT head showed no acute bleed or large infarct, but did show \nleft periventricular hyperdense lesions that appeared to have \nprogressed from MRI ___, MRI performed in ED with read \npending.\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \n-___ Diagnosed\n-___, Cycle 1 Rituxan/CHOP, Cycle 1. Complicated by \nadmission for febrile neutropenia despite receiving Neulasta; \nthen ulcerative colitis flare.\n-___, Cycle 2 Rituxan/CHOP\n-___, Cycle 3 Rituxan-CHOP. \n-___, PET imaging showed decreased uptake in the left \nparotid gland with resolution of multiple focal FDG avid osseous \nlesions as well as resolution of FDG avidity within the left \nadrenal gland, gastric fundus, right breast and subcutaneous \ntissues.\n-___, Admitted with diplopia, right sided ptosis, \nheadache, and RLE weakness. MRI of the orbit revealed \nthickening and enhancement of the left ocular motor nerve from \nthe interpeduncular cistern to the cavernous sinus, as well as \nmild enhancement of the right ocular motor nerve near the \ncavernous sinus. Lumbar puncture was performed which showed \ninvolvement by CNS lymphoma. \n-___, Rituxan and high-dose methotrexate at 8 gm/m2. \nDischarged to home on ___ \n-___, Rituxan. \n-___, Rituxan. Double vision better but not gone with\ndevelopment of some thigh numbness and leg weakness and back \npain\n-___, Admitted for treatment with high dose Methotrexate, \nIfosfamide and IT Ara-C(Depocyt). \n-___, Rituxan Neurological symptoms had markedly improved \nwith this treatment.\n-___, 2nd dose of IT Ara-C(Depocyt). \n-___, admitted for planned ___ cycle of treatment but \ndeveloped new headache with vomiting. MRI of the head showed\nsignificant progression of her CNS disease. \n-___, HD Methotrexate @ 4 gm/m2, then 12 gm/m2 on \n___. Discharged on ___. \n-___, Rituxan. Started on Ibrutinib at 140 mg daily. \nIncreased slowly to 420 mg per day as of ___. \n-___, Admitted with increasing fever, somnolence, \nheadache, nausea with concern for CNS progression vs. infection. \nNo progression noted on imaging.\n-___, C1D1 of TEDDI-R (Temozolomide, Etoposide, Doxil,\nDexamethasone, Ibrutinib, Rituximab). \n-___, C2D1 of TEDDI-R (Temozolomide, Etoposide, Doxil,\nDexamethasone, Ibrutinib, Rituximab) with IT Cytarabine.\n-___, C3D1 of TEDDI-R (Temozolomide, Etoposide, Doxil,\nDexamethasone, Ibrutinib, Rituximab) with IT Cytarabine\n\nPAST MEDICAL/SURGICAL HISTORY: \n1. Diffuse large B-cell lymphoma(Primary bone marrow lymphoma) \nas noted above with CNS involvement.\n2. Ulcerative colitis, last flare in ___ with fever and \nneutropenia admission. Previously treated with ___ for about \none and a half years as well as prednisone during flares.\n3. Sjogren's with dry eyes, uses Restasis. \n4. Osteoarthritis.\n5. Eczema.\n6. Hypercholesterolemia.\n7. Fatty liver.\n8. Diabetes. \n9. Pancreatic cyst\n10. Allergic rhinitis.\n\n \nSocial History:\n___\nFamily History:\nA paternal aunt with breast cancer. Sister with breast cancer in \nher ___ but died from other medical issues.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVitals: T 98.1, HR 87, BP 128/77, RR 18, O2 96% RA\nGen: Pleasant, calm \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. PERRL, \nEOMI\nLYMPH: No cervical or supraclav LAD\nCV: Normocardic, regular. Normal S1,S2. II/VI systolic murmur at \nbase \nLUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. \nABD: NABS. Soft, NT, ND. \nEXT: WWP. Trace ___ edema\nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: PERRL, EOMI, CN II-XII intact, no dysarthria or word \nfinding difficulty during interview, strength ___ in ___ \nbilaterally, sensation intact to light touch in ___ \nbilaterally\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVS T 97.8, HR 53, BP 159/67, RR 18, O2 100% RA\nGen: Pleasant, calm \nHEENT: No conjunctival pallor. No icterus. MMM. OP clear. PERRL, \nEOMI\nCV: Normocardic, regular. Normal S1,S2. II/VI systolic murmur at \nbase \nLUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi. \nABD: NABS. Soft, NT, ND. \nEXT: WWP. Trace ___ edema\nSKIN: No rashes/lesions, petechiae/purpura ecchymoses. \nNEURO: PERRL, EOMI, CN II-XII intact, no dysarthria or word \nfinding difficulty during interview, strength ___ in ___ \nbilaterally, sensation intact to light touch in ___ \nbilaterally. FNF intact\n \nPertinent Results:\nADMISSION LABS:\n===============\n___ 09:58AM BLOOD WBC-6.0 RBC-3.11* Hgb-9.4* Hct-30.4* \nMCV-98 MCH-30.2 MCHC-30.9* RDW-18.6* RDWSD-66.6* Plt ___\n___ 09:58AM BLOOD Neuts-63 Bands-1 Lymphs-9* Monos-19* \nEos-0 Baso-1 Atyps-1* Metas-5* Myelos-1* AbsNeut-3.84 \nAbsLymp-0.60* AbsMono-1.14* AbsEos-0.00* AbsBaso-0.06\n___ 09:58AM BLOOD ___ PTT-36.1 ___\n___ 09:58AM BLOOD UreaN-8 Creat-0.4 Na-141 K-4.1 Cl-105 \nHCO3-25 AnGap-15\n___ 09:58AM BLOOD ALT-29 AST-35 LD(LDH)-478* AlkPhos-300* \nTotBili-<0.2\n\nDISCHARGE LABS:\n===============\n___ 12:00AM BLOOD WBC-16.9*# RBC-3.06* Hgb-9.4* Hct-29.0* \nMCV-95 MCH-30.7 MCHC-32.4 RDW-17.2* RDWSD-59.2* Plt ___\n___ 12:00AM BLOOD Neuts-91* Bands-1 Lymphs-2* Monos-3* \nEos-0 Baso-0 ___ Metas-3* Myelos-0 AbsNeut-15.55* \nAbsLymp-0.34* AbsMono-0.51 AbsEos-0.00* AbsBaso-0.00*\n___ 12:00AM BLOOD Glucose-262* UreaN-27* Creat-0.4 Na-137 \nK-3.7 Cl-100 HCO3-24 AnGap-17\n___ 12:00AM BLOOD ALT-17 AST-14 LD(LDH)-321* AlkPhos-146* \nTotBili-0.3\n___ 12:00AM BLOOD Calcium-8.3* Phos-4.7* Mg-2.2\n\nIMAGING/STUDIES:\n================\nCT HEAD ___:\n1. No evidence of intracranial hemorrhage or acute large \nterritorial \ninfarction. \n2. Hyperdense lesions in the left periventricular area and \ncorpus callosum \nwith surrounding hypodensity that may represent vasogenic edema. \n The \nsurrounding hypodensity appears to have increased in size from \nprior MR study from ___. Please refer to nearly \nconcurrent MRI brain study for more detailed characterization. \n\nMRI HEAD ___:\n1. Interval increase in size and enhancement of several \nperiventricular \nlymphoma lesions, compared to most recent prior exam. \n2. Increase in associated edema around the largest lesion near \nthe left \noccipital horn and left periventricular atrium. \n\nCT HEAD ___:\n1. No evidence of hemorrhage or infarction. \n2. The changes of parenchymal lymphoma are far better seen on \nthe MR exam of ___. However, allowing for the difference \nin technique, there appears to be no progression. Surrounding \nedema is stable to slightly improved. \n\nEEG READ (continuous):\nIMPRESSION: This telemetry captured no pushbutton activations. \nIt showed a \nmildly slow background throughout, indicative of a mild to \nmoderate \nencephalopathy. Medications, metabolic disturbances, and \ninfection are among the most common causes. There was some \nadmixed slowing on either side but no major lateralized finding. \nThere were no epileptiform features or electrographic seizures. \nA bradycardia was noted. \n\nIMPRESSION: This telemetry captured no pushbutton activations. \nIt showed a \nnormal background in wakefulness and sleep. There were no focal \nabnormalities, epileptiform features, or electrographic \nseizures. \n \nBrief Hospital Course:\nMs. ___ is a ___ year-old woman with history of DLBCL with \nknown CNS involvement on C3D3 of TEDDI-R, presented with word \nfinding difficulties felt most likely due to seizures started on \nlevetiracetam.\n\n#APHASIA: Initial concern for stroke, MRI w/o acute ischemia, \nread stating progression of several periventricular lesions, but \non review with Dr. ___ felt may have been due to \ndifferences in contrast timing and that overall imaging \nconsistent with mixed response to treatment. LP ___ only \nremarkable for protein 119 with negative gram stain and no \ngrowth on preliminary culture. Per discussion with Dr. ___ \n___ seizure most likely etiology, started on levetiracetam \n500mg BID empirically. EEG w/o seizure activity. Difficulty \nprimarily seen in saying months backwards when questioned, and \ntexts to husband with missing or improper words.\n\n#DLBCL W/ KNOWN CNS LESIONS: Primary bone marrow lymphoma, C3D1 \nof TEDDI-R ___. On review of imaging and discussion with \nprimary oncologist and Dr. ___ MRI showing mixed \nresponse to treatment. TTE with normal EF, mild aortic \nregurgitation. Completed cycle 3 of TEDDI-R inpatient. Of note, \nmissed day two of ibrutinib due to hospitalization, resumed same \nschedule on day 3 to complete full prior course. Continued \nacyclovir, atovaquone, voriconazole prophylaxis\n\n#URINARY TRACT INFECTION, COMPLICATED: Urine culture on \nadmission growing >100,000 klebsiella pneumonia. Asymptomatic \nwith unremarkable UA. Repeat UA with >100 WBCs. Given current \nchemotherapy and steroid use decided to treat for 7 days for \ncomplicated UTI. IV ceftriaxone inpatient transitioned to \ncefpodoxime outpatient, last day ___.\n\n#BRADYCARDIA/HYPERTENSION: Several days of asymptomatic \nbradycardia to high ___ BP in 150s, above her past baseline. \nConcerning for possible ___ reflex, no headaches or visual \nchanges, and neuro exam nonfocal. CT head w/o worsening edema or \nsigns of increased ICP. Improved off of dexamethasone prior to \ndischarge and may have been related to dexamethasone and \npossibly keppra.\n\nTRANSITIONAL ISSUES:\n====================\n*Medication changes*\n[] Added levetiracetam 500mg BID\n[] Cefpodoxime 200mg BID, last day ___\n\n# EMERGENCY CONTACT: ___, husband, ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic BID \n2. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/insomnia/anxiety \n3. Atovaquone Suspension 1500 mg PO DAILY \n4. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n5. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n6. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n7. butalbital-acetaminophen-caff 50-300-40 mg oral Q8H:PRN \nheadache \n8. Omeprazole 20 mg PO DAILY:PRN heartburn \n9. MetFORMIN XR (Glucophage XR) 500 mg PO BID type 2 diabetes \n10. ibrutinib 420 mg oral DAILY \n11. Acyclovir 400 mg PO Q8H \n12. Voriconazole 200 mg PO Q12H \n13. Dexamethasone 12 mg PO Q12H \n14. Pyridoxine 100 mg PO DAILY \n15. Insulin SC \n Sliding Scale\nInsulin SC Sliding Scale using HUM Insulin\n\n \nDischarge Medications:\n1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 4 Days \nRX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*8 \nTablet Refills:*0 \n2. LevETIRAcetam 500 mg PO Q12H \nRX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a \nday Disp #*60 Tablet Refills:*0 \n3. Acyclovir 400 mg PO Q8H \n4. Atovaquone Suspension 1500 mg PO DAILY \n5. butalbital-acetaminophen-caff 50-300-40 mg oral Q8H:PRN \nheadache \n6. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic BID \n7. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n8. Ibrutinib 420 mg PO EVERY OTHER DAY \n9. Ibrutinib 560 mg PO EVERY OTHER DAY \n10. Insulin SC \n Sliding Scale\nInsulin SC Sliding Scale using HUM Insulin \n11. LORazepam 0.5 mg PO Q6H:PRN \nnausea/vomiting/insomnia/anxiety \n12. MetFORMIN XR (Glucophage XR) 500 mg PO BID type 2 diabetes \n\n13. Omeprazole 20 mg PO DAILY:PRN heartburn \n14. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n15. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n16. Pyridoxine 100 mg PO DAILY \n17. Voriconazole 200 mg PO Q12H \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAphasia\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___!\n\nWHY WERE YOU ADMITTED?\n-You were having difficulty finding words\n\nWHAT HAPPENED IN THE HOSPITAL?\n-Imaging of your brain showed that your lymphoma is overall \nstable\n-An EEG (brain tracing) did not show evidence of seizures\n-Dr. ___ your symptoms may be due to deep seizures \nthat we cannot see. \n-You were started on a medicine called keppra to prevent \nseizures\n-Testing showed signs of urine infection and you were treated \nwith antibiotics\n\nWHAT SHOULD YOU DO AT HOME?\n-Continue taking keppra (levetiracetam) 500mg twice daily\n-Continue taking cefpodoxime 200mg twice daily starting ___ to \nfinish treating your urine infection\n-Follow-up with Dr. ___ in clinic, see below\n\nThank you for allowing us be involved in your care, we wish you \nall the best!\n\nYour ___ Team\n\n \nFollowup Instructions:\n___\n" ]

[ "G40909", "G936", "C8339", "M3500", "R4701", "B961", "N390", "I10", "E119", "R001", "J309", "E785", "Z794", "F419", "L309", "Z87891", "T451X5A", "R600", "G43009", "Y929" ]

[ "G40909: Epilepsy, unspecified, not intractable, without status epilepticus", "G936: Cerebral edema", "C8339: Diffuse large B-cell lymphoma, extranodal and solid organ sites", "M3500: Sicca syndrome, unspecified", "R4701: Aphasia", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "N390: Urinary tract infection, site not specified", "I10: Essential (primary) hypertension", "E119: Type 2 diabetes mellitus without complications", "R001: Bradycardia, unspecified", "J309: Allergic rhinitis, unspecified", "E785: Hyperlipidemia, unspecified", "Z794: Long term (current) use of insulin", "F419: Anxiety disorder, unspecified", "L309: Dermatitis, unspecified", "Z87891: Personal history of nicotine dependence", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "R600: Localized edema", "G43009: Migraine without aura, not intractable, without status migrainosus", "Y929: Unspecified place or not applicable" ]

[ "N390", "I10", "E119", "E785", "Z794", "F419", "Z87891", "Y929" ]

[]

[ " \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:\nword finding difficulty\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\n___ woman with a history of high-grade diffuse large\nB-cell lymphoma(primary bone marrow lymphoma)diagnosed in \n___\nwith noted CNS involvement on TEDDI-R who is admitted from the \nED\nwith word finding difficulty and headache.\n\nOf note, patient recently admitted ___ with similar\nword finding difficulties. MRI showed overall mixed response of\nher CNS lymphoma. Although EEG was negative, keppra was started\nfor possibly seizures. She did not have any significant headache\nduring this admission and she completed C3 TEDDI-R.\n\nSince discharge, she never entirely returned to her baseline,\nalthough she was doing a bit better. ___ she went to \n___ for her son's graduation. During the trip her husband\nnoted she had increasing difficulty finding the right words. He\ndescribes forgetfulness, substitution errors, and 'jumbled' text\nmessages. ___ morning she was noted to be very quiet and on\nthe drive home she was having significant difficulty with every\nsentence. She reported a new ___ bifrontal headache while en\nroute to the ED.\n\nIn the ED, initial VS were pain 7, T 98.6, HR 90, BP 142/69, RR\n16, O2 100%RA. Labs were notable for Na 139, K 3.8, HCO3 24, Cr\n0.5, WBC 2.3 (ANC 920), HCT 26.9, PLT 331, lactate 2.6. CT head\nshowed no ICH, stable CNS lymphoma but some increased edema.\nPatient was given 1LNS along with 1000mg po Tylenol. VS prior to\ntransfer were pain 5, T 98.2, HR 72, BP 129/61, RR 16, O2 \n100%RA.\n\nOn arrival to the floor, patient reports her headache has\nresolved. She notes word finding difficulties as above. No \nfevers\nor chills. No URTI symptoms. No SOB or cough. No N/V. Appetite \nis\nOK. Nl BM prior to admission and no diarrhea. Denies dysuria. No\nfrank seizure activity. No new leg swelling or rashes.\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \n-___ Diagnosed\n-___, Cycle 1 Rituxan/CHOP, Cycle 1. Complicated by \nadmission for febrile neutropenia despite receiving Neulasta; \nthen ulcerative colitis flare.\n-___, Cycle 2 Rituxan/CHOP\n-___, Cycle 3 Rituxan-CHOP. \n-___, PET imaging showed decreased uptake in the left \nparotid gland with resolution of multiple focal FDG avid osseous \nlesions as well as resolution of FDG avidity within the left \nadrenal gland, gastric fundus, right breast and subcutaneous \ntissues.\n-___, Admitted with diplopia, right sided ptosis, \nheadache, and RLE weakness. MRI of the orbit revealed \nthickening and enhancement of the left ocular motor nerve from \nthe interpeduncular cistern to the cavernous sinus, as well as \nmild enhancement of the right ocular motor nerve near the \ncavernous sinus. Lumbar puncture was performed which showed \ninvolvement by CNS lymphoma. \n-___, Rituxan and high-dose methotrexate at 8 gm/m2. \nDischarged to home on ___ \n-___, Rituxan. \n-___, Rituxan. Double vision better but not gone with\ndevelopment of some thigh numbness and leg weakness and back \npain\n-___, Admitted for treatment with high dose Methotrexate, \nIfosfamide and IT Ara-C(Depocyt). \n-___, Rituxan Neurological symptoms had markedly improved \nwith this treatment.\n-___, 2nd dose of IT Ara-C(Depocyt). \n-___, admitted for planned ___ cycle of treatment but \ndeveloped new headache with vomiting. MRI of the head showed\nsignificant progression of her CNS disease. \n-___, HD Methotrexate @ 4 gm/m2, then 12 gm/m2 on \n___. Discharged on ___. \n-___, Rituxan. Started on Ibrutinib at 140 mg daily. \nIncreased slowly to 420 mg per day as of ___. \n-___, Admitted with increasing fever, somnolence, \nheadache, nausea with concern for CNS progression vs. infection. \nNo progression noted on imaging.\n-___, C1D1 of TEDDI-R (Temozolomide, Etoposide, Doxil,\nDexamethasone, Ibrutinib, Rituximab). \n-___, C2D1 of TEDDI-R (Temozolomide, Etoposide, Doxil,\nDexamethasone, Ibrutinib, Rituximab) with IT Cytarabine.\n-___, C3D1 of TEDDI-R (Temozolomide, Etoposide, Doxil,\nDexamethasone, Ibrutinib, Rituximab) with IT Cytarabine\n\nPAST MEDICAL/SURGICAL HISTORY: \n1. Diffuse large B-cell lymphoma(Primary bone marrow lymphoma) \nas noted above with CNS involvement.\n2. Ulcerative colitis, last flare in ___ with fever and \nneutropenia admission. Previously treated with ___ for about \none and a half years as well as prednisone during flares.\n3. Sjogren's with dry eyes, uses Restasis. \n4. Osteoarthritis.\n5. Eczema.\n6. Hypercholesterolemia.\n7. Fatty liver.\n8. Diabetes. \n9. Pancreatic cyst\n10. Allergic rhinitis.\n\n \nSocial History:\n___\nFamily History:\nA paternal aunt with breast cancer. Sister with breast cancer in \nher ___ but died from other medical issues.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\nVS: T 98.2 HR 74 BP 117/73 RR 18 SAT 98% O2 on RA\nGENERAL: Pleasant, lying in bed comfortably\nEYES: Anicteric sclerea, PERLL, EOMI; \nENT: Oropharynx clear without lesion, dry MM, 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 to person and place. Has marked word\nfinding difficulty with occaisional substitution errors. No \nmotor\naphasia. She can identify high-frequency objects but not\nlow-frequency. She registers ___ objects and recalls 0 at 5\nminutes. She cannot spontaneously name words starting with a\nparticular letter and she cannot name ___ forward or backward.\nShe repeats sentences with occasional error. Cranial nerves\nIII-XII are intact. She has symmetric and full strength\nthroughout. Cerebellar fxn is intact to FTN bilaterally.\nSKIN: No significant rashes\nLYMPHATIC: No cervical, supraclavicular, submandibular\nlymphadenopathy. No significant ecchymoses\n \n\nDISCHARGE PHYSICAL EXAM\nVitals: 98.0 95 / 62 76 18 100 Ra \nGENERAL: Pleasant, lying in bed comfortably\nEYES: Anicteric sclerea, PERLL, EOMI; \nENT: Oropharynx clear without lesion, dry MM, 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 to person and place. full sentences with \nlow frequency objects today; no difficulty moving mouth and can \nidentify objects although parts of objects are more difficult, \nCranial nerves III-XII are intact. She has symmetric and full \nstrength\nthroughout. Cerebellar fxn is intact to FTN bilaterally.\nSKIN: No significant rashes\nLYMPHATIC: No cervical, supraclavicular, submandibular\nlymphadenopathy. No significant ecchymoses\n\n \nPertinent Results:\nADMISSION LABS\n\n___ 09:06PM WBC-2.3*# RBC-2.74* HGB-8.4* HCT-26.9* MCV-98 \nMCH-30.7 MCHC-31.2* RDW-19.3* RDWSD-68.9*\n___ 09:06PM NEUTS-35 BANDS-5 ___ MONOS-25* EOS-3 \nBASOS-0 ATYPS-1* ___ MYELOS-1* AbsNeut-0.92* AbsLymp-0.71* \nAbsMono-0.58 AbsEos-0.07 AbsBaso-0.00*\n___ 09:06PM HYPOCHROM-OCCASIONAL ANISOCYT-3+ POIKILOCY-2+ \nMACROCYT-2+ MICROCYT-1+ POLYCHROM-NORMAL SCHISTOCY-1+ \nSTIPPLED-OCCASIONAL TEARDROP-1+\n___ 09:06PM GLUCOSE-186* UREA N-10 CREAT-0.5 SODIUM-139 \nPOTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15\n___ 09:18PM LACTATE-2.6*\n\nDISCHARGE LABS\n\n___ 12:00AM BLOOD WBC-2.8* RBC-2.70* Hgb-8.1* Hct-24.9* \nMCV-92 MCH-30.0 MCHC-32.5 RDW-20.2* RDWSD-62.8* Plt Ct-96*\n___ 12:00AM BLOOD Neuts-48 Bands-1 ___ Monos-12 Eos-0 \nBaso-0 ___ Metas-6* Myelos-2* NRBC-24* AbsNeut-1.37* \nAbsLymp-0.87* AbsMono-0.34 AbsEos-0.00* AbsBaso-0.00*\n___ 12:00AM BLOOD Plt Smr-LOW Plt Ct-96*\n___ 12:00AM BLOOD Glucose-135* UreaN-20 Creat-0.3* Na-138 \nK-4.0 Cl-104 HCO3-20* AnGap-18\n___ 12:00AM BLOOD TotProt-4.3* Albumin-2.8* Globuln-1.5* \nCalcium-7.8* Phos-3.8 Mg-2.0\n\nIMAGING\n___ CT CHEST\nIMPRESSION: \n \nNo acute hemorrhage. The extent of edema in bilateral splenium \nof the corpus callosum and left cerebral hemisphere is similar \nto the ___ CT. \n \n___ CT HEAD\n \nIMPRESSION: \n \n \n1. No evidence of intracranial hemorrhage. \n2. Changes of parenchymal lymphoma are better evaluated on MRI \nexamination \nfrom ___. Allowing for differences in technique, there \nappears to be no \nprogression over this short time interval. However, in \ncomparison to the \nprior head CT from ___, there is significant increase in \nassociated \nvasogenic edema. \n\n___ MR HEAD W & W/O CONTRAS \n \nIMPRESSION: \n \n1. Overall, compared to the most recent prior exam from ___, there \nappears to be slight interval progression of the heterogeneous \nmultiple \nenhancing periventricular lesions, with interval increase in \nheterogeneity and \nsurrounding FLAIR signal abnormality. Although this could be \nsecondary to \nsequelae of post treatment changes, given the interval increased \nsignal on the \ndiffusion weighted images of many of these lesions, progression \nof disease \nremains of concern. \n2. Focal area of nodular enhancement within the left internal \nauditory canal, \nappears new compared to the prior exam, may represent a venous \nstructure. \nClose attention on followup is recommended. \n3. Stable 0.4 cm enhancing lesion adjacent to the tectum. \n4. Additional findings as described above. \n\n \nBrief Hospital Course:\n___ with a history of high-grade diffuse large\nB-cell lymphoma(primary bone marrow lymphoma)diagnosed in \n___\nwith noted CNS involvement on TEDDI-R who is admitted for word \nfinding difficulties which has been persistent on prior recent \nhospitalization. \n\n# Aphasia: Concern for worsening since last hospitalization, \nwhile not completely resolved at discharge, pt notes being \nmarkedly worse. possibly component of superimposed infection, \ndehydration, active process worsening aphasia, outpatient MRI \nfinalized to read possible interval change with disease; started \non fourth cycle of TEDDI-R chemotherapy, discuss with patient \nand husband that will need to discuss more seriously with \noutpatient oncologist regarding golas of care given concern for \nlack of improvement. Completed TEDDI-R without complications. \nGiven headache, also started on po dex (start ___, decreased \nto 8mg bid (___), decreased to 4mg bid (___), decreased to 4mg \ndaily (___). At discharge will continue on 2mg dex ___ - \nongoing).\n\nNo headache after day 2 of admission. ___ evaluated and \nrecommended home with 24 hour supervision.\n\n#urinary incontinence: Pt's urinary incontinence is worsening \nper nursing staff, pt says it does not bother her, no dysuria, \nUA unrevealing, UCx however grew enterococcus that is vanc \nresistant, has had prior UTis with klebs. Pt was s/p ceftriaxone \nx 3 days prior to speciation. Did have recent UTI S/p tx. \nDiagnosed with klebsiella UTI last admission. No \ndysuria/suprapubic pain. UA clean. However worsening urinary \nurgency per RN last evening. Pt with enterococcus in urine but \nwithout symptoms. s/p ctx x 3 days (start ___. Pt started on \ndoxycycline bid x 5 days given resistance patterns. Completed 5 \ndays of doxycycline with some improvement in urinary \nincontinence. Some incontinence is reported to be baseline.\n\nWill continue doxy until ___.\n\n# headache: Pt was noted to have mild headache in the ED but has \nsince resolved on the floors, CT without new hemorrhage although \npossible increase in edema; concern for possible intracranial \npressures that can lead to seizures per prior hospitalization \nand started on prophylactic anti-epileptics. Pt was continued on \nkeppra, and started on po dexamethasone per above. Pt also \nstarted on pantoprazole with steroids. ___ was consulted \ngiven elevated sugars with dexamethasone.\n\n# High-grade primary bone marrow lymphoma with CNS involvement:\nRecent admission for neuro symptoms thought due to disease vs\npossibly seizure. MRI shows mixed response to current regimen.\nRepeat MRI done as outpatient pending. Completed cycle 4 of \n___ complications. CT head showed stable brain edema \nand started on dex. Markedly improved aphasia per above - \nunclear if dex ___ dex to 2mg daily. \nCon't acyclovir, atovaquone, voriconazole ppx and con't keppra \n500mg po q12 hours.\n\n# Neutropenia: No fever or obvious source of infection. Did get\nneupogen after last cycle of chemotherapy. Will continue \nneupogen outpatient - despite increasing WBCs, still neutropenic \non differential.\n\n# Type II DM: Known to become hyperglycemic while taking\ndexamethasone. On HISS while inpatient. ___ evaluated and \nwill start NPH outpatient in addition to restarting metformin \n500. Will have insulin teaching per RN and husband. ___ \nrecommended follow up but will favor follow up while inpatient \nfor next ___.\n\n# Sjogren's Syndrome: Eye drops prn\n\nTRANSITIONAL\n=============\n-Pt will continue doxycycline until ___ for presumed UTI.\n-Refills for keppra, acyclovir, atovaquone written. Pt with \nenough neupogen, voriconazole until next follow up.\n-___ apt recommended in 1 week ___ will call with \nappointment) given new NPH prescription and sliding scale. \nInsulin teaching explained to husband and patient.\n-Next cycle ___ for week after discharge\n-Vori level pending at discharge.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q8H \n2. Atovaquone Suspension 1500 mg PO DAILY \n3. butalbital-acetaminophen-caff 50-300-40 mg oral Q8H:PRN \nheadache \n4. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic BID \n5. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n6. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/insomnia/anxiety \n7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n8. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n9. Pyridoxine 100 mg PO DAILY \n10. Voriconazole 200 mg PO Q12H \n11. MetFORMIN XR (Glucophage XR) 500 mg PO BID type 2 diabetes \n12. LevETIRAcetam 500 mg PO Q12H \n\n \nDischarge Medications:\n1. Dexamethasone 2 mg PO DAILY \nRX *dexamethasone 2 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0 \n2. Doxycycline Hyclate 100 mg PO Q12H \nRX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day \nDisp #*6 Capsule Refills:*0 \n3. Filgrastim 300 mcg SC Q24H \n4. ibrutinib 560 mg ORAL DAILY \n5. NPH 10 Units Breakfast\nNPH 0 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin\nRX *blood sugar diagnostic [FreeStyle Lite Strips] with every \nglucose check Disp #*100 Strip Refills:*2\nRX *blood-glucose meter [FreeStyle Freedom Lite] three times a \nday Disp #*100 Kit Refills:*3\nRX *lancets 33 gauge use four times daily Disp #*100 Each \nRefills:*2\nRX *insulin NPH human recomb [Humulin N KwikPen] 100 unit/mL (3 \nmL) AS DIR 10 Units before BKFT; 0 Units before DINR; Disp #*2 \nSyringe Refills:*2\nRX *insulin syringe-needle U-100 [BD Insulin Syringe Ultra-Fine] \n31 gauge X ___ with insulin Disp #*100 Syringe Refills:*2 \n6. MetFORMIN (Glucophage) 500 mg PO BID \nRX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*30 \nTablet Refills:*0 \n7. Pantoprazole 40 mg PO Q24H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0 \n8. Artificial Tears ___ DROP BOTH EYES PRN dry eyes \n9. Artificial Tears ___ DROP BOTH EYES PRN dry eyes \n10. Acyclovir 400 mg PO Q8H \nRX *acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp \n#*30 Tablet Refills:*0 \n11. Atovaquone Suspension 1500 mg PO DAILY \nRX *atovaquone 750 mg/5 mL 10 mL by mouth daily Refills:*0 \n12. butalbital-acetaminophen-caff 50-300-40 mg oral Q8H:PRN \nheadache \n13. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic BID \n14. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n15. LevETIRAcetam 500 mg PO Q12H \nRX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp \n#*20 Tablet Refills:*0 \n16. LORazepam 0.5 mg PO Q6H:PRN \nnausea/vomiting/insomnia/anxiety \n17. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n18. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n19. Pyridoxine 100 mg PO DAILY \n20. Voriconazole 200 mg PO Q12H \n21.Outpatient Physical Therapy\nRolling walker\nDx: 202.8 (malignant lymphoma)\nPX: Good\nLength of need: 13 mon\n22.commode\nICD-9: 202.80 \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n======================\nhigh-grade diffuse large B cell lymphoma (with CNS involvement)\n\nSECONDARY DIAGNOSIS\n======================\nbacteriuria\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nMs. ___,\n\nYou were admitted for your word finding difficulty. You had \nimaging of your head which showed swelling in your brain and \nconcern for areas of good to no response from prior \nchemotherapy. You were started on steroids to help with the \nswelling in your brain. You also were on your fourth cycle of \nchemotherapy.\n\nYou improved at discharge and occupational and physical therapy \nevaluated you. They recommended that you are safe to go home but \nwill require extensive supervision (24 hour).\n\nIf you have worsening symptoms of headache, word finding \ndifficulty, pain, or new symptoms, please return for further \nevaluation. It was a pleasure taking care of you at ___!\n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "R4701", "G936", "C8339", "F05", "D709", "E1169", "B952", "N390", "M3500", "R51", "R32", "E119", "K6289", "Z9221", "Z923", "Z87891" ]

[ "R4701: Aphasia", "G936: Cerebral edema", "C8339: Diffuse large B-cell lymphoma, extranodal and solid organ sites", "F05: Delirium due to known physiological condition", "D709: Neutropenia, unspecified", "E1169: Type 2 diabetes mellitus with other specified complication", "B952: Enterococcus as the cause of diseases classified elsewhere", "N390: Urinary tract infection, site not specified", "M3500: Sicca syndrome, unspecified", "R51: Headache", "R32: Unspecified urinary incontinence", "E119: Type 2 diabetes mellitus without complications", "K6289: Other specified diseases of anus and rectum", "Z9221: Personal history of antineoplastic chemotherapy", "Z923: Personal history of irradiation", "Z87891: Personal history of nicotine dependence" ]

[ "N390", "E119", "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:\nfever\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old woman, with past history of \nDiffuse High Grade B-Cell Lymphoma (diagnosed ___, \ncurrently on active chemotherapy with R-CHOP (last received on \n___, Cycle 3D#1), and history of Ulcerative Colitis \ncurrently on steroids, who is presenting with fever. Patient to \nbe admitted to OMED service for further evaluation and workup. \n\n Patient reports that she had new onset of fever to 101 on the \nmorning of admission. She had been feeling at her usual state of \nhealth until yesterday night, where she started to feel a \npost-nasal drip, but no cough, pleuritic chest pains, or \npharyngitis type symptoms. No URI symptoms. Patient's daughter \nhas been having a viral URI these past few days. No increased \ndiarrhea, or abdominal pain per her UC. Patient then called her \n___ clinic, and was referred to the ED. \n\n In the ED, patient's lungs were clear, abdomen was benign. She \nunderwent chest radiograph which was negative for pneumonia. She \nwas given Vancomycin + Cefepime given concern for fever in the \nsetting of current chemotherapy. She also underwent blood \nculture x 2, urine culture. \n Labs were significant for WBC 22, Hgb 7.3, Hct 23.4, Platelet \n106. PMN 58, Band 9. ANC 1460. \n Influenza negative. \n Sodium 133, K 3.8, Cl 97, Bicarb 24, BUN 14, Cr 0.4, Glucose \n175 \n ALT 13, AST 17, AP 83, Lipase 37. Albumin 3.4. T-bili 0.5. \n Urinalysis: Spec ___ 1006, Epi < 1. \n Patient was given \n ___ 08:44 IV CefePIME 2 g \n ___ 09:19 IV Vancomycin \n ___ 09:19 PO Acetaminophen 1000 mg \n ___ 10:19 IVF NS ( 1000 mL ordered) \n ___ 10:20 IV Vancomycin 1 mg \n\n Vitals upon arrival: 101.4 122 110/70 16 100% RA \n Vitals upon transfer: 98.6 92 91/52 16 100% RA \n\n On arrival to the floor, pt reports feeling her normal state \nof health - only came to hospital because she had been \ninstructed to come in with the fever. Not feeling \nfeverish/chills. No cough, no N/V/D. No urinary symptoms.\n \nPast Medical History:\n PAST ONCOLOGIC HISTORY: \n -___: Referred to Dr ___ in our dept for \n probable malignancy. 30 pound wt loss over the past year and 8 \n\n pound drop over the fall. Developed worsening confusion and \n unsteadiness in early ___ and found to be hypercalcemic (Ca \n___. \n Admitted to ___ where she was given iv fluids, \n Calcitonin and Pamidronate. Low PTH and normal PTHrp. Her CBC \n showed early myeloid forms and some nuc rbc and her LDH was \n elevated at 656. CT scans of chest, abd, pelvis did not show \nany \n adenopathy or splenomegaly. There was a 5mm low attenuation \n lesion in the panc head and a 1.3 cm lesion in the right \nadrenal \n gland. There was a large 8.7x7.7x6.5 mass inseparable from the \n\n uterus where a fibroid had been noted previously. Subsequent \nMRI \n showed diffused dilatation of the panc duct raising concern for \n \n IPM of the main panc duct and endoscopic ultrasound was \n suggested as well as a dedicated adrenal washout CT for the \n small adrenal lesion. \n -Dr. ___ a BM asp and Bx that day which did not \n\n show any abnormal lymphocytes in the aspirate and the \n cytogenetics and FISH were normal. However, the biopsy showed a \n \n multifocal infiltrate of malignant lymphocytes with Ki67 of \n 50-60%, felt to be an aggressive B cell lymphoma of germinal \n center origin. \n -___: Upper endoscopy showed mult gastric ulcers - bx \n showed lymphoma, cytogenetics showed BCL6, no myc or BCL2 \n translocations. \n -___: First cycle Rit/CHOP with split dose Rituxan. \n -___ for febrile neutropenia despite neulasta \n \n then ulc colitis flare. Restarted Pred. \n -___: Fever, diarrhea due to C.dif. Rx'd po vanco \n\n and pneumonia, rx'd Levoflox. \n -___: cycle 2 Rit/CHOP. \n\n PAST MEDICAL HISTORY: \n - Ulcerative Colitis \n - Rhinitis, allergic \n - Eczema \n - Headache, common migraine. *MRI performed ___ due to \n complaints of headache, and was unremarkable. \n - Hyperlipidemia \n - Fatty Liver \n - Fibroids \n - Osteoarthritis \n - Adrenal Nodule \n - Pancreatic Cyst \n \nSocial History:\n___\nFamily History:\nPaternal aunt with breast CA. Sister with breast CA in her ___. \n \n \nPhysical Exam:\nADMISSION EXAM\n==============\n Vitals: T 98.3, BP 116/72, HR 95, RR 18, SpO2 95/RA\n GENERAL: well-appearing female, wearing cap, sitting up in \nbed, NAD\n HEENT: Without hair on head. PERRL. MMM, OP clear. \n NECK: No cervical LAD. Supple.\n LUNGS: CTAB, no W/R/C\n CV: RRR, S1+S2, II/VI SEM heard throughout\n ABD: non-distended. Soft, non-tender. Normoactive bowel sound. \nNo masses.\n EXT: WWP, no edema. No inguinal or axillary LAD\n SKIN: no rashes or lesions\n NEURO: alert, oriented x3. Moving all 4 extremities.\n\nDISCHARGE EXAM\n==============\nVS: T 99.0, BP 90-103/56-65, HR 102-108, RR 18, SpO2 99/RA\nGENERAL: well-appearing female, sitting up in bed, NAD\nHEENT: Without hair on head. PERRL. MMM, OP clear. \nNECK: No cervical LAD. Supple.\nLUNGS: CTAB, no W/R/C\nCV: RRR, S1+S2, II/VI SEM heard throughout\nABD: non-distended. Soft, non-tender. Normoactive bowel sound. \nNo masses.\nEXT: WWP, no edema. No inguinal or axillary LAD\nSKIN: no rashes or lesions\nNEURO: alert, oriented x3. Moving all 4 extremities.\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 08:29PM CRP-27.5*\n___ 09:10AM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 09:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 \nLEUK-NEG\n___ 09:10AM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE \nEPI-<1\n___ 09:10AM URINE HYALINE-1*\n___ 09:00AM OTHER BODY FLUID FluAPCR-NEGATIVE \nFluBPCR-NEGATIVE\n___ 08:49AM LACTATE-1.2\n___ 08:00AM GLUCOSE-175* UREA N-14 CREAT-0.4 SODIUM-133 \nPOTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-24 ANION GAP-16\n___ 08:00AM ALT(SGPT)-13 AST(SGOT)-17 ALK PHOS-83 TOT \nBILI-0.5\n___ 08:00AM LIPASE-37\n___ 08:00AM ALBUMIN-3.4*\n___ 08:00AM WBC-22.0*# RBC-2.21* HGB-7.3* HCT-23.4* \nMCV-106* MCH-33.0* MCHC-31.2* RDW-19.4* RDWSD-75.5*\n___ 08:00AM NEUTS-59 BANDS-9* LYMPHS-4* MONOS-11 EOS-0 \nBASOS-0 ATYPS-2* METAS-5* MYELOS-6* PROMYELO-4* NUC RBCS-2* \nAbsNeut-14.96* AbsLymp-1.32 AbsMono-2.42* AbsEos-0.00* \nAbsBaso-0.00*\n___ 08:00AM HYPOCHROM-OCCASIONAL ANISOCYT-1+ POIKILOCY-1+ \nMACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+ \nSCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL\n___ 08:00AM PLT SMR-LOW PLT COUNT-106*#\n\nMICRO\n=====\n__________________________________________________________\n___ 11:21 am Rapid Respiratory Viral Screen & Culture\n Source: Nasopharyngeal swab. \n\n **FINAL REPORT ___\n\n Respiratory Viral Culture (Final ___: \n No respiratory viruses isolated. \n Culture screened for Adenovirus, Influenza A & B, \nParainfluenza type\n 1,2 & 3, and Respiratory Syncytial Virus.. \n Detection of viruses other than those listed above will \nonly be\n performed on specific request. Please call Virology at \n___\n within 1 week if additional testing is needed. \n\n Respiratory Viral Antigen Screen (Final ___: \n Negative for Respiratory Viral Antigen. \n Specimen screened for: Adeno, Parainfluenza 1, 2, 3, \nInfluenza A, B,\n and RSV by immunofluorescence. \n Refer to respiratory viral culture and/or Influenza PCR \n(results\n listed under \"OTHER\" tab) for further information.. \n__________________________________________________________\n___ 8:29 pm BLOOD CULTURE Source: Line-port. \n\n Blood Culture, Routine (Pending): \n__________________________________________________________\n___ 8:15 am BLOOD CULTURE #2. \n\n Blood Culture, Routine (Pending): \n__________________________________________________________\n___ 9:10 am URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT \nWITH SKIN\n AND/OR GENITAL CONTAMINATION. \n__________________________________________________________\n___ 8:00 am BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n\nDISCHARGE LABS\n==============\n___ 06:33AM BLOOD WBC-12.6* RBC-2.47* Hgb-8.3* Hct-25.9* \nMCV-105* MCH-33.6* MCHC-32.0 RDW-19.0* RDWSD-72.5* Plt ___\n___ 06:33AM BLOOD Neuts-65 Bands-6* Lymphs-7* Monos-8 Eos-0 \nBaso-0 ___ Metas-4* Myelos-9* Promyel-1* AbsNeut-8.95* \nAbsLymp-0.88* AbsMono-1.01* AbsEos-0.00* AbsBaso-0.00*\n___ 06:33AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL \nMacrocy-1+ Microcy-NORMAL Polychr-1+\n___ 06:33AM BLOOD Plt Smr-NORMAL Plt ___\n___ 06:33AM BLOOD Glucose-149* UreaN-11 Creat-0.6 Na-135 \nK-3.7 Cl-97 HCO3-27 AnGap-15\n___ 06:33AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.1\n\nIMAGING\n=======\n___ (PA & LAT)\nNo acute cardiopulmonary abnormality.\n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman, with past history of High \nGrade B-Cell lymphoma currently receiving chemotherapy with \nR-CHOP (Cycle 3 on ___, and ulcerative colitis, now \npresenting with acute fever. \n \n#LEUKOCYTOSIS:\n#FEVER: Suspect infectious process given known sick contact, \nelevated leukocytosis and recent chemotherapy and relative \nimmunosuppression with lymphoma, chemotherapy, and high dose \nsteroids. U/A bland, CXR without frank pneumonia, and given PORT \nplacement recently in ___, would also cover for potential \nline infection. WBC could certainly also be from neulasta (last \ndose on ___, as well as high dose steroids (prednisone 100 mg \nwith chemotherapy). CRP elevated to 27.5 on admission, likely \nrelated to ulcerative colitis. Last febrile 0300 on ___ \ninitial blood cx from ___ at 0800 NGTD. Respiratory viral panel, \nflu negative. Viral culture pending at time of discharge. \nVancomycin and cefepime discontinued on ___ in AM; pt remained \nafebrile until the time of discharge. High suspicion that the \nfever was the result of viral infection.\n \n#HIGH GRADE B-CELL LYMPHOMA: Currently receiving chemotherapy \nwith Rituximab-CHOP, with last dose of chemotherapy given on \n___. She has been given high dose MTX on ___, with mild \nincrease in LFTs, and then administered Rit CHOP on ___. Held \noutpatient sodium bicarb as MTX is on hold. Continued home \nacyclovir 400 mg BID. \n \n#ULCERATIVE COLITIS: Recent flare in ___, during admission \nthought to be related to first chemotherapy cycle (R-CHOP on \n___, at which point was started on prednisone taper - \ncurrently on 5mg daily. CRP elevated to 27.5 on admission, \nlikely related to ulcerative colitis. Continued prednisone 5 mg \ndaily.\n\n#ANEMIA: appears worsened from baseline Hgb 9 (7.3 on \nadmission). Normocytic/macrocytic. No e/o bleeding.\n\n#ELEVATED A1c: Last hemoglobin a1c 7.6% on ___. Pt reports \nnever having been diagnosed with diabetes. Likely has elevated \nA1c and hyperglycemia in the setting of current prednisone \ntaper. Managed with insulin sliding scale. ___ need more glucose \nmanagement as an outpatient, if she remains on steroids.\n\n#HYPERLIPIDEMIA: continued simvastatin \n \n#ALLERGIC RHINITIS: continued fluticasone nasal spray daily \n\nTRANSITIONAL ISSUES\n#PET SCAN: will go to scheduled scan on ___ immediately \nfollowing discharge\n#GLYCEMIC CONTROL: pt with elevated A2c to 7.6 and FSG in high \n100s during admission, likely in the setting of ongoing \nprednisone taper. If persistent, may need medical management \nwith Dr ___ in oncology, Dr ___ in endocrinology, or \nDr. ___ (PCP).\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Headache \n2. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic Q12H \n3. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n4. PredniSONE 5 mg PO DAILY \nThis is dose # 3 of 3 tapered doses\nTapered dose - DOWN \n5. Simvastatin 40 mg PO QPM \n\n \nDischarge Medications:\n1. Capsaicin 0.025% 1 Appl TP TID \nRX *capsaicin 0.025 % Apply to shins Three times a day \nRefills:*0 \n2. Acetaminophen 650 mg PO Q6H:PRN Headache \n3. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic Q12H \n4. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n5. PredniSONE 5 mg PO DAILY \nThis is dose # 3 of 3 tapered doses\nTapered dose - DOWN \n6. Simvastatin 40 mg PO QPM \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES\n- viral upper respiratory infection\n- diffuse large B cell lymphoma\n\nSECONDARY DIAGNOSES\n- elevated A1c\n- ulcerative colitis\n- anemia\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 ___ from \n___ - ___ for a fever.\n\nWHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?\n- You had blood and urine work done to look for infection. While \nyou were in the hospital, all of these tests were negative, \nmeaning there was no sign of bacterial infection or common \nviruses causing a respiratory infection.\n- You were given antibiotics while you were here to cover for \nbacterial infection. These were stopped the day before you were \ndischarged, and you did not develop a fever off antibiotics.\n- We suspect that your fever was the result of a virus. Viruses \ndo not require antibiotics for treatment, so we sent you home \nwithout antibiotics.\n\nWHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL?\n- You will have your PET scan as soon as you leave the hospital. \nYou may call Dr ___ on ___ to discuss the results.\n- You will follow-up with Dr ___ as scheduled on ___, \nunless she instructs you otherwise.\n\nWe wish you the best with your health in the future.\n\nYour ___ Oncology Team\n \nFollowup Instructions:\n___\n" ]

[ "J069", "K5190", "Z803", "Z87891", "D72829", "D649", "E785", "R739", "J309", "T380X5A", "Y92009" ]

[ "J069: Acute upper respiratory infection, unspecified", "K5190: Ulcerative colitis, unspecified, without complications", "Z803: Family history of malignant neoplasm of breast", "Z87891: Personal history of nicotine dependence", "D72829: Elevated white blood cell count, unspecified", "D649: Anemia, unspecified", "E785: Hyperlipidemia, unspecified", "R739: Hyperglycemia, unspecified", "J309: Allergic rhinitis, unspecified", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]

[ "Z87891", "D649", "E785" ]

[]

[ " \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:\nfever\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nPatient followed by ___ oncology for high-grade B cell lymphoma \nand on chemo Patient seemed warm to touch to her husband and \nchecked temp with 101.8 12:40 am \n Has hx UC and recently hospitalized with neutropenic fever \nlast week Discharged home with occasional fevers attributed to \ncolitis flare but temps were lower at 99-100 Also discharged \nhome on prednisone Now temp tonight 101.8 Advised by oncologist \non-call Dr. ___ to go to ED for further eval \n \nIn the ED, initial vitals: 100.3 93/52 94 16 98%RA\n - Exam notable for Unremarkable, benign abd \n - Labs were notable for: \n\n7.2>8.2/24.1<450 MCV 100 76%N 2 bands 1 meta 2 myelo\n\nrepeat 10 hours later: 6.4>7.4/23.7<456 MCV 101 with 87%N 2% \nbands\n\n___\n---------<196\n4.7/24/0.6\n\nrepeat 10 hours later\n\n137/101/15\n----------<161\n3.7/24/0.7\n\nlactate 1.7->2.0\nhaptoglobin 550\nfibrinogen 533\n\n___ 14.0/1.3\nPTT 28.8\n\nUA unremarkable aside from 30 protein\n\n - Imaging: \n\nCXR PA/LAT: Consolidation in the left lower lobe, concerning for \npneumonia.\n\n - Patient was given: \n\n1000mg acetaminophen x2 (11 hours apart)\n1000mg vancomycin\n2g cefepime\n4L NS\nRIJ placed\n\n - Consults: none\n \nOn arrival to the MICU, she reports feeling mostly in her usual \nstate of health. She reports a mild tickle/cough today, but is \notherwise feeling well aside from her current UC flare. She \ncontinues to have ___ loose stools daily with a small amount of \nblood. She believes she is still in the midst of a flare. She is \ncurrently on 30mg prednisone daily (20AM and 10PM) but did not \ntake anything today prior to coming to the ED. \n\n \nPast Medical History:\nUlcerative colitis \nRhinitis, allergic \nEczema \nHeadache, common migraine. *MRI performed ___ due to \ncomplaints of headache, and was unremarkable.\nHyperlipidemia \nFatty liver \nFibroids \nOsteoarthritis \nAdrenal nodule \nPancreatic cyst \nHypercalcemia \nDiffuse large B-cell lymphoma of extranodal site excluding \nspleen and other solid organs\n \nSocial History:\n___\nFamily History:\npat aunt- breast CA. Sister with breast CA in her ___.\n \nPhysical Exam:\n==============\nADMISSION EXAM\n==============\nVITALS: 102.4 124/60 99 21 100%2L NC\nGENERAL: thin, no acute distress\nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, \nMMM, good dentition \nNECK: nontender supple neck, no LAD, no JVD \nCARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNG: crackles in bilateral lung bases, breathing comfortably \nwithout use of accessory muscles \nABDOMEN: nondistended, +BS, nontender in all quadrants, no \nrebound/guarding, no hepatosplenomegaly \nEXTREMITIES: no cyanosis, clubbing or edema, moving all 4 \nextremities with purpose \nPULSES: 2+ DP pulses bilaterally \nNEURO: CN III-XII intact \n\n==============\nDISCHARGE EXAM\n==============\nGeneral: NAD, AOx3\nVITAL SIGNS: 97.9PO 107 / 66R Lying 77 18 96 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 \nPertinent Results:\n==============\nADMISSION LABS\n==============\n___ 03:40AM BLOOD WBC-7.2# RBC-2.41* Hgb-8.2* Hct-24.1* \nMCV-100* MCH-34.0* MCHC-34.0 RDW-18.2* RDWSD-65.2* Plt ___\n___ 03:40AM BLOOD Neuts-76* Bands-2 Lymphs-7* Monos-12 \nEos-0 Baso-0 ___ Metas-1* Myelos-2* NRBC-2* AbsNeut-5.62 \nAbsLymp-0.50* AbsMono-0.86* AbsEos-0.00* AbsBaso-0.00*\n___ 03:40AM BLOOD Hypochr-NORMAL Anisocy-1+ \nPoiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL \nOvalocy-OCCASIONAL Tear Dr-OCCASIONAL\n___ 03:40AM BLOOD Plt Smr-HIGH Plt ___\n___ 02:10PM BLOOD ___\n___ 03:40AM BLOOD Glucose-196* UreaN-21* Creat-0.6 Na-135 \nK-4.7 Cl-99 HCO3-24 AnGap-17\n___ 02:10PM BLOOD Hapto-550*\n___ 03:54AM BLOOD Lactate-1.7\n\n=================\nPERTINENT IMAGING\n=================\nCXR (___): Consolidation in the left lower lobe, concerning \nfor pneumonia. \n\n==========\nMICRO DATA\n==========\nC. DIFF (___): Negative\n\n==============\nDISCHARGE LABS\n==============\n___ 07:30AM BLOOD WBC-7.0 RBC-2.56* Hgb-8.2* Hct-25.5* \nMCV-100* MCH-32.0 MCHC-32.2 RDW-18.5* RDWSD-66.2* Plt ___\n___ 07:30AM BLOOD Neuts-71 Bands-0 Lymphs-16* Monos-7 Eos-1 \nBaso-1 Atyps-1* Metas-3* Myelos-0 NRBC-3* AbsNeut-4.97 \nAbsLymp-1.19* AbsMono-0.49 AbsEos-0.07 AbsBaso-0.07\n___ 07:30AM BLOOD Plt Smr-VERY HIGH Plt ___\n \nBrief Hospital Course:\nMs. ___ is a ___ year old woman with a history of recently \ndiagnosed DLBCL, s/p 1 cycle R-CHOP with split dose Rituxan, who \npresented with complaints of fever after recent hospitalization \nfor febrile neutropenia.\n\n=============\nACTIVE ISSUES\n=============\n# Concern for HCAP: Pt with only mild symptoms of throat tickle \nand cough. Had evidence of small LLL consolidation concerning \nfor PNA. Given recent hospitalization and antibiotic exposure, \ntreated empirically for HCAP with vanc/cefepime. \n\n# Hypotension: To SBP in the 80's to low 90's. Lactates \nnegative. Minimal, typically lives in low 100's per review of \nAtrius records. Repleted with 5L IVF, to improvement of \npressures. Possibly in setting of hypovolemia from HCAP vs. \n?ongoing UC flair. \n\n# Hypoxia: Initially required up to 3L NC by oxygen when \nformerly on RA. Weaned prior to discharge.\n\n# Ulcerative colitis: Was taking 30mg daily prednisone as a \ntaper per her outpatient GI. Continued with *** instructions to \nfollow her prior weekly taper (30 mg/day for 1 week, then 20 \nmg/day for 1 week, then 15 mg/day for 1 week, then 10 mg/day for \n1 week, then 5 mg/day for 1 week, and then stop). \n\n# High grade B-cell lymphoma: In between cycles, next \noriginally planned Rit/CHOP on ___.\n\n===================\nTRANSITIONAL ISSUES\n===================\n# Communication: Husband, ___ (___)\n# Code: full, confirmed\n\n[ ] High-grade B cell lymphoma: \n- Touch base with oncology re: when to start next cycle\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic Q12H \n2. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n3. LOPERamide 4 mg PO DAILY \n4. Simvastatin 40 mg PO QPM \n5. diclofenac sodium 1 % topical Q6H:PRN pain \n6. Halobetasol Propionate 0.05 % topical Q12H:PRN rash \n7. Mesalamine (Rectal) ___AILY \n8. Mesalamine Enema 4 gm PR QHS \n9. PredniSONE 20 mg PO DAILY \n10. PredniSONE 10 mg PO QHS \n\n \nDischarge Medications:\n1. Levofloxacin 750 mg PO DAILY \nlast day ___ \nRX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*1 \nTablet Refills:*0 \n2. Vancomycin Oral Liquid ___ mg PO Q6H \nlast day ___ \nRX *vancomycin (bulk) 900 mcg/mg (not less than, USP) 125 mg PO \nevery six (6) hours Refills:*0 \n3. PredniSONE 30 mg PO DAILY Duration: 6 Doses \nThis is dose # 1 of 6 tapered doses\nRX *prednisone 10 mg 1 tablet(s) by mouth per taper Disp #*25 \nTablet Refills:*0 \n4. PredniSONE 15 mg PO DAILY Duration: 7 Doses \nThis is dose # 3 of 6 tapered doses \n5. PredniSONE 5 mg PO DAILY Duration: 7 Doses \nThis is dose # 5 of 6 tapered doses \n6. PredniSONE 5 mg PO EVERY OTHER DAY Duration: 4 Doses \nThis is dose # 6 of 6 tapered doses\nRX *prednisone 5 mg 1 tablet(s) by mouth per taper Disp #*18 \nTablet Refills:*0 \n7. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic Q12H \n8. diclofenac sodium 1 % topical Q6H:PRN pain \n9. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n10. Halobetasol Propionate 0.05 % topical Q12H:PRN rash \n11. Mesalamine (Rectal) ___AILY \n12. Mesalamine Enema 4 gm PR QHS \n13. Simvastatin 40 mg PO QPM \n14. HELD- LOPERamide 4 mg PO DAILY This medication was held. Do \nnot restart LOPERamide until speaking with our primary care \nphysician\n\n \n___:\nHome\n \nDischarge Diagnosis:\nPRIMARY\n- Pneumonia\n- Sepsis\n- Clostridium difficile infection\n\nSECONDARY\n- Diffuse large b-cell lymphoma\n- Ulcerative colitis \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 ___. You were admitted for \nfevers and low blood pressure, which required a brief stay in \nthe ICU. You were found to have pneumonia and a gastrointestinal \ninfection call clostridium difficile. You were treated with \nantibiotics which you should continue as below. \n\nAntibiotic course: \n--- levofloxacin for completion of a 5 day course (___)\n--- vancomycin (oral) for completion of a ___fter \ncompletion of levofloxacin (last day ___\n\nPrednisone taper: \n--- ___ - ___ prednisone 30 mg daily\n--- ___ prednisone 20 mg daily\n--- ___ prednisone 15 mg daily\n--- ___ prednisone 10 mg daily\n--- ___ - ___ prednisone 5 mg daily\n--- ___ - ___ prednisone 5 mg ever other day\n\nPlease note, your steroid course may change depending on your \nchemotherapy plan. Please discuss with your oncologist about any \npossible changes to your steroids. \n\nPlease follow up with your physicians as below.\n\nWishing you well,\n\nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "A419", "J189", "C8339", "A047", "K5190", "E871", "E861", "R0902", "D649", "J309", "E785", "Z87891" ]

[ "A419: Sepsis, unspecified organism", "J189: Pneumonia, unspecified organism", "C8339: Diffuse large B-cell lymphoma, extranodal and solid organ sites", "A047: Enterocolitis due to Clostridium difficile", "K5190: Ulcerative colitis, unspecified, without complications", "E871: Hypo-osmolality and hyponatremia", "E861: Hypovolemia", "R0902: Hypoxemia", "D649: Anemia, unspecified", "J309: Allergic rhinitis, unspecified", "E785: Hyperlipidemia, unspecified", "Z87891: Personal history of nicotine dependence" ]

[ "E871", "D649", "E785", "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:\nDouble Vision\n \nMajor Surgical or Invasive Procedure:\n___ - Lumbar Puncture\n___ - Lumbar Puncture\n \nHistory of Present Illness:\nMrs. ___ is ___ year-old lady with a history of high grade \nDLBCL (diagnosed ___, currently on C3D16 R-CHOP s/p C1 of \nprophylactic HD-MTX and ulcerative colitis who is presenting \nwith visual changes and headache. \n\nShe was in a parking lot on her car on the day prior to \nadmission, at which point she noted that the road signs looked \n\"double\" for her. Had her daughter take over and drive home \nwhere it resolved. Otherwise, she was in her usual state of \nhealth when she went to bed last night. On the morning of \nadmission, she awoke reporting double vision (around 0830). Also \nreporting a mild headache, centered behind her right eye. She \ndenies any fevers or chills, neck stiffness, difficulty walking, \nweakness or paresthesias.\n\nShe was recently hospitalized at ___ for fever (negative \ninfectious work-up, treated for 2 days with antibiotics and \nultimately afebrile and discharged off antibiotics). Seen in the \noffice on ___ by Dr ___ for ___ from \nprevious hospitalization, where pt was reporting ongoing shin \npain, which had been present during hospitalization. Per note, \nDr ___ reaction to Neulasta in the setting of \ntapering steroids. Had been taking ibuprofen and naproxen for \nthe past few days with little improvement. \n\nED initial vitals: T 96.3, HR 96, BP 128/79, RR 18,SpO2 100% RA.\nED labs were significant for:\n- CBC: WBC: 10.2*. HGB: 6.9*. Plt Count: 428*. Neuts%: 82*. \n- Chemistry: Na: 138. K: 3.9. Cl: 100. CO2: 25. BUN: 11. Creat: \n0.4. Ca: 8.6. Mg: 2.2. PO4: 4.2. \n- Lactate: 1.4 \n- Imaging: CT head w/o contrast -- no acute intracranial \nabnormality. \n- Patient was given: nothing \n- Consults: neurology, recommended MRI w/ and w/o contrast and \nLP afterwards \n- Decision was made to admit to ___ for ongoing work-up of \ndiplopia \n \nOn arrival to the floor, patient reports ongoing diplopia \nwithout blurry vision. Headache has resolved. She continue to \nhave mild pain in her right shin as well as pins/needles \nsensation in bilateral toes. \n\nPatient denies fevers/chills, night sweats, \ndizziness/lightheadedness, weakness/numbnesss, shortness of \nbreath, cough, hemoptysis, chest pain, palpitations, abdominal \npain, nausea/vomiting, diarrhea, hematemesis, \nhematochezia/melena, dysuria, hematuria, and new rashes.\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY: \n-___: Referred to Dr ___ in our dept for \nprobable malignancy. 30 pound wt loss over the past year and 8 \npound drop over the fall. Developed worsening confusion and \nunsteadiness in early ___ and found to be hypercalcemic (Ca ___. \nAdmitted to ___ where she was given iv fluids, \nCalcitonin and Pamidronate. Low PTH and normal PTHrp. Her CBC \nshowed early myeloid forms and some nuc rbc and her LDH was \nelevated at 656. CT scans of chest, abd, pelvis did not show any \nadenopathy or splenomegaly. There was a 5mm low attenuation \nlesion in the panc head and a 1.3 cm lesion in the right adrenal \ngland. There was a large 8.7x7.7x6.5 mass inseparable from the \nuterus where a fibroid had been noted previously. Subsequent MRI \nshowed diffused dilatation of the panc duct raising concern for \nIPM of the main panc duct and endoscopic ultrasound was \nsuggested as well as a dedicated adrenal washout CT for the \nsmall adrenal lesion. \n-Dr. ___ a BM asp and Bx that day which did not \nshow any abnormal lymphocytes in the aspirate and the \ncytogenetics and FISH were normal. However, the biopsy showed a \nmultifocal infiltrate of malignant lymphocytes with Ki67 of \n50-60%, felt to be an aggressive B cell lymphoma of germinal \ncenter origin. \n-___: Upper endoscopy showed mult gastric ulcers - bx \nshowed lymphoma, cytogenetics showed BCL6, no myc or BCL2 \ntranslocations. \n-___: First cycle Rit/CHOP with split dose Rituxan. \n-___ for febrile neutropenia despite neulasta \nthen ulc colitis flare. Restarted Pred. \n-___: Fever, diarrhea due to C.dif. Rx'd po vanco \nand pneumonia, rx'd Levoflox. \n-___: cycle 2 Rit/CHOP.\n\nPAST MEDICAL HISTORY: \n- Ulcerative Colitis\n- Rhinitis, allergic\n- Eczema\n- Headache, common migraine. *MRI performed ___ due to \ncomplaints of headache, and was unremarkable.\n- Hyperlipidemia\n- Fatty Liver\n- Fibroids\n- Osteoarthritis\n- Adrenal Nodule\n- Pancreatic Cyst\n \nSocial History:\n___\nFamily History:\nPaternal aunt with breast CA. Sister with breast CA in her ___.\n \nPhysical Exam:\n========================\nAdmission Physical Exam:\n========================\nVS: 98.1 PO 110 / 70 94 18 99 RA \nGENERAL: Well-appearing lady, in no distress lying, in bed \ncomfortably.\nHEENT: Anicteric, PERLL, Mucous membranes moist, OP clear.\nCARDIAC: Regular rate and rhythm, normal heart sounds, no \nmurmurs, rubs or gallops.\nLUNG: Appears in no respiratory distress, clear to auscultation \nbilaterally, no crackles, wheezes, or rhonchi.\nABD: Non-distended, normal bowel sounds, soft, non-tender, no \nguarding, no palpable masses, no organomegaly.\nEXT: Warm, well perfused. No lower extremity edema. No erythema \nor tenderness.\nNEURO: A&Ox3, good attention and linear thought. No apparent \npalsy of the III, IV, VI oculomotors, diplopia at baseline, \nconvergence, horizontal and vertical gaze. Absent nystagmus. \nOtherwise CN V,VII-XII intact. Strength full throughout. \nSensation to light touch intact.\nSKIN: No significant rashes.\n\n========================\nAdmission Physical Exam:\n========================\nVS: Temp 98.0, BP 100/60, HR 89, RR 16, O2 sat 100% RA.\nGENERAL: Pleasant lady, in no distress lying, in bed \ncomfortably.\nHEENT: Anicteric, PERLL, OP clear. Right ptosis.\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: Appears in no respiratory distress, clear to auscultation \nbilaterally, no crackles, wheezes, or rhonchi.\nABD: Soft, non-tender, non-distended, normal bowel sounds, no \nhepatomegaly, no splenomegaly.\nEXT: Warm, well perfused, no lower extremity edema, erythema or \ntenderness.\nNEURO: A&Ox3, good attention and linear thought. Right eye \nptosis stable, improved from several days ago. RLE weakness \n4+/5. LLE ___ strength. Both upper\nextremities ___ strength. No other deficits noted.\nSKIN: No significant rashes.\nACCESS: Right chest wall port without erythema.\n \nPertinent Results:\n===============\nAdmission Labs:\n===============\n___ 12:00PM BLOOD WBC-10.2* RBC-2.07* Hgb-6.9* Hct-22.7* \nMCV-110* MCH-33.3* MCHC-30.4* RDW-19.7* RDWSD-78.7* Plt ___\n___ 12:00PM BLOOD Neuts-82* Bands-0 Lymphs-8* Monos-8 Eos-0 \nBaso-1 ___ Myelos-1* NRBC-1* AbsNeut-8.36* \nAbsLymp-0.82* AbsMono-0.82* AbsEos-0.00* AbsBaso-0.10*\n___ 05:46AM BLOOD ___ PTT-31.4 ___\n___ 12:00PM BLOOD Glucose-257* UreaN-11 Creat-0.4 Na-138 \nK-3.9 Cl-100 HCO3-25 AnGap-17\n___ 12:00PM BLOOD Calcium-8.6 Phos-4.2 Mg-2.2\n___ 12:17PM BLOOD Lactate-1.4\n\n==============\nInterval Labs:\n==============\n___ 05:27AM BLOOD %HbA1c-6.9* eAG-151*\n___ 06:27AM BLOOD RheuFac-<10 ___\n\n====================\nMethotrexate Levels:\n====================\n___ 12:29PM BLOOD mthotrx-0.53\n___ 12:07PM BLOOD mthotrx-0.07\n___ 05:37AM BLOOD mthotrx-0.02\n\n===============\nDischarge Labs:\n===============\n___ 05:41AM BLOOD WBC-3.8* RBC-2.74* Hgb-9.0* Hct-29.3* \nMCV-107* MCH-32.8* MCHC-30.7* RDW-15.9* RDWSD-63.3* Plt ___\n___ 05:41AM BLOOD Glucose-124* UreaN-9 Creat-0.5 Na-142 \nK-4.1 Cl-103 HCO3-27 AnGap-16\n___ 05:41AM BLOOD ALT-66* AST-42* AlkPhos-90 TotBili-0.2\n___ 05:41AM BLOOD Calcium-9.1 Phos-5.2* Mg-2.2\n\n============\n___ Studies:\n============\n___ 01:50PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-2* Polys-0 \n___ ___ 01:50PM CEREBROSPINAL FLUID (CSF) TotProt-79* \nGlucose-94\n___ 01:25PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-104* \nPolys-2 ___ Monos-25 Basos-2 ___ Macroph-2 Other-5\n___ 01:25PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-23* Polys-1 \n___ Monos-17 Eos-1 Basos-1 ___ Macroph-1 Other-7\n___ 01:25PM CEREBROSPINAL FLUID (CSF) TotProt-61* \nGlucose-66 LD(LDH)-21\n___ 01:50PM CEREBROSPINAL FLUID (CSF) HIV1 VL-NOT DETECT\n___ EBV PCR- Negative\n___ Borrelia Burg___ Antibody - Pending\n___ Angiotensin 1 Converting Enzyme - 11 (Negative)\n___ CMV PCR- Negative\n___ HSV PCR - Negative\n___ Paraneoplastic Autoantibody Evaluation - Negative\n___ VZV PCR - Negative\n___ Toxoplasma Gondii PCR - Negative\n___ VDRL - Non-Reactive\n\n=============\nMicrobiology:\n=============\n___ Blood Culture - No Growth\n___ Urine Culture - Coag Negative Staph\n___ CSF Culture - No Growth\n___ Quantiferon-TB Gold - Negative\n\n========\nImaging:\n========\nHead CT w/o Contrast ___\nImpression: No acute intracranial abnormality on noncontrast \nhead CT.\n\nMRI Head w/o Contrast ___\nImpression: No evidence for intracranial metastatic disease. 5 \nmm right parietal dural calcification versus completely \ncalcified meningioma is stable.\n\nMRI Orbit w/ and w/o Contrast ___\n1. Thickening and enhancement of the left oculomotor nerve from \nthe interpeduncular cistern to the cavernous sinus. Mild \nenhancement of the right oculomotor nerve near the cavernous \nsinus. Given the patient's clinical history, this may represent \nlipomatous involvement.\n2. No cavernous sinus lesion identified.\n\nCT Head/Neck ___\n1. Dental amalgam streak artifact limits study.\n2. No evidence of acute intracranial hemorrhage.\n3. No evidence ofaneurysm greater than 3 mm, dissection or \nsignificant luminal narrowing.\n4. Left parotid gland oval soft tissue nodule may reflect a \nlymph node but remains incompletely characterized. Ultrasound or \nMRI can be obtained on a nonemergent basis for further \nevaluation.\n\n===================\nCytology/Pathology:\n===================\n___ CSF Cytology - Negative for malignant cells. Lymphocytes \nand monocytes.\n___ CSF Flow Cytometry - Immunophenotypic findings are of \ninvolvement by a small population of kappa light chain \nrestricted B cells. Review of corresponding cytospin preparation \nreveals medium to large atypical lymphoid cells with one to \nseveral prominent nucleoli and dark blue cytoplasm with \nvacuolations. Correlation with clinical, cytogenetic, and other \nancillary findings is recommended.\n___ CSF Cytogenetics - Negative for BCL6 rearragnement.\n \nBrief Hospital Course:\nMs. ___ is ___ lady with a history of high \ngrade DLBCL (diagnosed ___, currently on C3D16 R-CHOP s/p \nC1 of prophylactic HD-MTX and ulcerative colitis who presents \nwith visual changes and headache and found to have lymphomatous \nmeningitis.\n\n# Lymphomatous Meningitis:\n# Diploplia: \n# CN III Palsy: CT head and MRI on admission were overall \nnegative. MRI orbit noted thickening and enhancement of the left \noculomotor nerve. Neuro Oncology were consulted. Third nerve \npalsy and enhancement in the left third nerve are suggestive of \nleptomeningeal involvement by her DLCL. She had two LPs which \nwere sent for many infectious studies which were negative. \nCytology and pathology were concerning for lymphomatous \nmeningitis but final results were pending at time of discharge \nShe was started on Rituxan and HD MTX which she tolerated well \nand methotrexate levels now less than 0.1. She was seen by \nOpthamology with no evidence of intraocular lymphoma, given \ninstruction on partial patching of right eye to help with \ndiplopia. If no improvement in diplopia can ___ with \nOphthalmology at ___ for further evaluation. She will \nplan for Rituxan weekly for ___s readmission for \nmethotrexate every 2 weeks.\n\n# High Grade B-Cell Lymphoma: Currently receiving chemotherapy \nwith Rituximab-CHOP, with last dose of chemotherapy given on \n___. She has been given high dose MTX on ___, with mild \nincrease in LFTs, and then administered R-CHOP on ___. Due for\nnext round of chemo on ___ but now delayed. Systemic \nchemotherapy will be held given need for methotrexate as above. \nShe will also ___ with ___ Oncology department as well \nas Atrius Oncology.\n\n# Ulcerative Colitis: Recent flare in ___, during admission \nthought to be related to first chemotherapy cycle as well as CDI \nat which point was started on prednisone taper. Finished taper \non day of admission.\n\n# Diabetes: Last hemoglobin a1c 7.6% on ___. Patient \nreports never having been diagnosed with diabetes. Likely has \nelevated A1c and hyperglycemia in the setting of prednisone \ntaper.\n\n# Hypperlipidemia: Continued home simvastatin.\n \n# Allergic Rhinitis: Continued fluticasone nasal spray daily.\n\n# Sjogren Syndrome: Continued cyclosporine eye drops.\n\n# Macrocytic Anemia: Likely secondary to malignancy and \nchemotherapy. No evidence of active bleeding.\n\n====================\nTransitional Issues:\n====================\n- Patient will return to ___ on ___ for \nRituximab. Appointment currently being scheduled.\n- Patient will return to ___ on ___ for her next \ncycle of methotrexate.\n- Please ___ pending CSF lyme from ___ and CSF flow \ncytometry from ___.\n- Patient evaluated by Ophthalmology without evidence of ocular \nlymphoma. Patient given instruction on partial patching of right \neye to help with diplopia. If no improvement in diplopia can \n___ with Ophthalmology at ___ for further \nevaluation.\n- Please continue to monitor symptoms of right ptosis, right \nlower extremity weakness, and diplopia.\n- Please ensure ___ with Dr. ___ as well as \n___ with Atirus Oncology.\n- Patient with elevated HbA1c and hyperglycemia likely in the \nsetting of recent steroid taper. Please continue to monitor \nblood sugars and repeat HbA1c as an outpatient.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Headache \n2. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic Q12H \n3. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n4. Simvastatin 40 mg PO QPM\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Headache \n2. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic Q12H \n3. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n4. Simvastatin 40 mg PO QPM\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary Diagnosis:\n- Lymphomatous Meningitis:\n- Diploplia: \n- CN III Palsy\n- High Grade B-Cell Lymphoma\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 at the ___ \n___. You were admitted for evaluation of your double \nvision. While in the hospital you also developed drooping of \nyour right eyelid and right leg weakness. You had lumbar \npunctures and an MRI of your brain/orbits which were concerning \nfor central nervous system involvement by lymphoma (also called \nlymphomatous meningitis).\n\nYou were evaluated by Dr. ___ in ___ Oncology who \nrecommended started chemotherapy with methotrexate and rituximab \nfor treatment of your neurological symptoms. You tolerated the \nchemotherapy without any issues. You will be admitted to the \nhospital every two weeks to receive your methotrexate. Please \nplan on returning to ___ on ___ in the \nmorning. We hope that with treatment your symptoms continue to \nimprove.\n\nYou will also have weekly Rituximab infusions for the next 3 \nweeks. The next infusion is due on ___. This is \ncurrently being scheduled for you at ___. You will \nbe called at home in a day or two to confirm the timing of your \nappointment. The following week (week of ___, you will \nneed to go to ___ on either ___ or ___ \n(___) for your Rituximab. You will then come to \n___ on ___ as above for your methotrexate.\n\nYou were also been by Ophthalmology and found no evidence of \nocular lymphoma. They were also able to provide some advice for \nhelping with the double vision. If your double vision does not \nimprove you can see them in clinic as well for further \nevaluation. \n\nYou will ___ with the ___ Oncology team. You will also \n___ with Dr. ___ who is one of the Oncologists at \n___ for discussion on future chemotherapy plan.\n\nAll the best,\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "G038", "C8339", "H4901", "K760", "K5190", "M3509", "M1990", "E785", "G43909", "Z87891", "E119", "D539" ]

[ "G038: Meningitis due to other specified causes", "C8339: Diffuse large B-cell lymphoma, extranodal and solid organ sites", "H4901: Third [oculomotor] nerve palsy, right eye", "K760: Fatty (change of) liver, not elsewhere classified", "K5190: Ulcerative colitis, unspecified, without complications", "M3509: Sicca syndrome with other organ involvement", "M1990: Unspecified osteoarthritis, unspecified site", "E785: Hyperlipidemia, unspecified", "G43909: Migraine, unspecified, not intractable, without status migrainosus", "Z87891: Personal history of nicotine dependence", "E119: Type 2 diabetes mellitus without complications", "D539: Nutritional anemia, unspecified" ]

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

[]

[ " \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:\nLFT abnormality \n \nMajor Surgical or Invasive Procedure:\nNone \n \nHistory of Present Illness:\nMs. ___ is a ___ woman with a history of \nhigh-grade diffuse large B-cell lymphoma (primary bone marrow \nlymphoma) diagnosed in ___ with noted CNS involvement on \nTEDDI-R who presented to clinic for C5D1 TEDDI-R and was found \nto have elevated LFTs.\n\nShe presented to clinic today for C5D1 TEDDI-R. She received her \nRituxan in clinic. Was planning on admitting tomorrow (D2-5) of \ntherapy with close monitoring of glucose with the high dose of \nDexamethasone required with treatment. However, her labs showed \nelevated LFTs so she was referred for admission for evaluation. \nShe denies any pain or any new symptoms. She denies any new \nmedications or OTC medications. She denies taking Tylenol.\n\nOn arrival to the floor, patient reports feeling well. She has \nno acute complaints. She denies fevers/chills, night sweats, \nheadache, vision changes, dizziness/lightheadedness, \nweakness/numbnesss, shortness of breath, cough, hemoptysis, \nchest pain, palpitations, abdominal pain, nausea/vomiting, \ndiarrhea,\nhematemesis, hematochezia/melena, dysuria, hematuria, and new \nrashes.\n\nREVIEW OF SYSTEMS: A complete 10-point review of systems was \nperformed and was negative unless otherwise noted in the HPI.\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY:\n--___, Cycle 1 Rituxan/CHOP, Cycle 1. Complicated by\nadmission for febrile neutropenia despite receiving Neulasta;\nthen ulcerative colitis flare.\n--___ - ___, Fever with C. difficile infection; treated\nwith oral vancomycin. Also PNA, treated with Levaquin.\n--___, Cycle 2 Rituxan/CHOP\n--___, prophylactic dosing of high-dose methotrexate at\n3.5 g/m2. \n--___, Cycle 3 Rituxan-CHOP. \n--___, Admitted with fever felt related to a viral\nillness. \n--___, PET imaging showed decreased uptake in the left\nparotid gland with resolution of multiple focal FDG avid osseous\nlesions as well as resolution of FDG avidity within the left\nadrenal gland, gastric fundus, right breast and subcutaneous\ntissues.\n--___, Admitted with diplobia, right sided ptosis,\nheadache, and RLE weakness. MRI of the orbit revealed \nthickening\nand enhancement of the left ocular motor nerve from the\ninterpeduncular cistern to the cavernous sinus, as well as mild\nenhancement of the right ocular motor nerve near the cavernous\nsinus. Lumbar puncture was performed which showed involvement by\nCNS lymphoma. \n--___, Rituxan and high-dose methotrexate at 8 gm/m2. \nDischarged to home on ___ \n--___, Rituxan. \n--___, Rituxan. Double vision better but not gone with\ndevelopment of some thigh numbness and leg weakness and back \npain\n--___, Admitted for treatment with high dose\nMethotrexate, Ifosfamide and IT Ara-C(Depocyt). \n--___, Rituxan Neurological symptoms had markedly\nimproved with this treatment.\n--___, 2nd dose of IT Ara-C(Depocyt). \n--___, admitted for planned ___ cycle of treatment but\ndeveloped new headache with vomiting. MRI of the head showed\nsignificant progression of her CNS disease. \n--___, HD Methotrexate @ 4 gm/m2, then 12 gm/m2 on\n___. Discharged on ___. \n--___, Rituxan. Started on Ibrutinib at 140 mg daily.\nIncreased slowly to 420 mg per day as of ___. \n--___, Admitted with increasing fever, somnolence,\nheadache, nausea with concern for CNS progression vs. infection. \n\nNo progression noted on imaging.\n--___, C1D1 of TEDDI-R (Temozolomide, Etoposide, Doxil,\nDexamethasone, Ibrutinib, Rituximab). \n--___, C2D1 of TEDDI-R (Temozolomide, Etoposide, Doxil,\nDexamethasone, Ibrutinib, Rituximab) with IT Cytarabine.\n--___, C3D1 of TEDDI-R (Temozolomide, Etoposide, Doxil,\nDexamethasone, Ibrutinib, Rituximab) with IT Cytarabine\n--___ - ___, Admission with difficulty word finding with\n? seizures vs progression of CNS lesions; started on Keppra and\ncompleted ___ cycle of treatment.\n--___, Admission with worsening difficulty word finding\nwith CT scan noting increased edema. Started on dexamethasone\nand initiated fourth cycle of TEDDI-R.\n--___, C4D1 of TEDDI-R (Temozolomide, Etoposide, Doxil,\nDexamethasone, Ibrutinib) Rituximab and IT Cytarabine held.\nIbrutinib to be continued daily at dose of 560 mg daily.\n--___, C5D1 of TEDDI-R (Temozolomide, Etoposide, Doxil,\nDexamethasone, Ibrutinib) Rituximab and IT Cytarabine held.\nIbrutinib to be continued daily at dose of 560 mg daily.\n\nPAST MEDICAL HISTORY:\n1. Diffuse large B-cell lymphoma(Primary bone marrow lymphoma) \nas\nnoted above with CNS involvement.\n2. Ulcerative colitis, last flare in ___ with fever and\nneutropenia admission. Previously treated with ___ for about \none\nand a half years as well as prednisone during flares.\n3. Sjogren's with dry eyes, uses Restasis. \n4. Osteoarthritis.\n5. Eczema.\n6. Hypercholesterolemia.\n7. Fatty liver.\n8. Diabetes. \n9. Pancreatic cyst\n10. Allergic rhinitis.\n \nSocial History:\n___\nFamily History:\nA paternal aunt with breast cancer. Sister with breast cancer in \nher ___ but died from other medical issues.\n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\nVS: Temp 97.9, BP 110/64, HR 85, RR 16, O2 sat 99% RA.\nGENERAL: Pleasant woman, in no distress, lying in bed\ncomfortably.\nHEENT: Anicteric, PERLL, OP clear.\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: Appears in no respiratory distress, clear to auscultation\nbilaterally, no crackles, wheezes, or rhonchi.\nABD: Soft, non-tender, non-distended, normal bowel sounds, no\nhepatomegaly, no splenomegaly.\nEXT: Warm, well perfused, no lower extremity edema, erythema or\ntenderness.\nNEURO: A&Ox2-3 (knows name, year, and BI but not month), flat\naffect, CN II-XII intact. Strength full throughout. Sensation to\nlight touch intact.\nSKIN: No significant rashes.\n\nDISCHARGE PHYSICAL EXAM: Patient died on ___ at 04:00, refer \nto death note\n\n \nPertinent Results:\nADMISSION LABS:\n___ 12:10PM PLT SMR-NORMAL PLT COUNT-267#\n___ 12:10PM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-1+ \nMACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+ SCHISTOCY-OCCASIONAL \nTEARDROP-OCCASIONAL\n___ 12:10PM NEUTS-51 BANDS-15* LYMPHS-6* MONOS-8 EOS-0 \nBASOS-0 ___ METAS-10* MYELOS-10* NUC RBCS-7* AbsNeut-4.75 \nAbsLymp-0.43* AbsMono-0.58 AbsEos-0.00* AbsBaso-0.00*\n___ 12:10PM WBC-7.2 RBC-3.03* HGB-9.2* HCT-29.4* MCV-97 \nMCH-30.4 MCHC-31.3* RDW-24.6* RDWSD-82.9*\n___ 12:10PM ALBUMIN-3.6 CALCIUM-8.6 PHOSPHATE-3.6 \nMAGNESIUM-1.8 URIC ACID-4.3\n___ 12:10PM ALT(SGPT)-127* AST(SGOT)-69* LD(LDH)-618* ALK \nPHOS-340* TOT BILI-0.4\n___ 12:10PM UREA N-23* CREAT-0.4 SODIUM-138 POTASSIUM-4.1 \nCHLORIDE-103 TOTAL CO2-21* ANION GAP-18\n___ 12:10PM GLUCOSE-179*\n___ 12:00AM ___ PTT-26.1 ___\n___ 12:00AM PLT SMR-NORMAL PLT COUNT-203\n___ 12:00AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+ \nMACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-1+ \nTEARDROP-OCCASIONAL FRAGMENT-OCCASIONAL\n___ 12:00AM NEUTS-51 BANDS-14* LYMPHS-7* MONOS-3* EOS-0 \nBASOS-0 ___ METAS-8* MYELOS-15* PROMYELO-2* NUC RBCS-1* \nAbsNeut-3.32 AbsLymp-0.36* AbsMono-0.15* AbsEos-0.00* \nAbsBaso-0.00*\n___ 12:00AM WBC-5.1 RBC-2.53* HGB-7.6* HCT-24.6* MCV-97 \nMCH-30.0 MCHC-30.9* RDW-24.3* RDWSD-82.9*\n___ 12:00AM CALCIUM-8.1* PHOSPHATE-3.8 MAGNESIUM-1.7\n___ 12:00AM ALT(SGPT)-97* AST(SGOT)-40 LD(LDH)-465* ALK \nPHOS-260* TOT BILI-0.3\n___ 12:00AM GLUCOSE-199* UREA N-19 CREAT-0.3* SODIUM-136 \nPOTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-19* ANION GAP-18\n\nIMAGING:\n\nHEAD MRI ___\n\nIMPRESSION: \n \n1. Multiple bilateral periventricular enhancing lesions \ncorresponding to the known lymphoma have decreased in size with \ndecreased adjacent T2/FLAIR \nhyperintensity. \n2. While no new enhancing lesion is seen, there is mild new \nT2/FLAIR \nhyperintensity in the midline and right genu of the corpus \ncallosum, of \nuncertain significance. \n3. Stable nonspecific peripheral enhancement in the pineal \nregion. \n4. Stable nonenhancing focus in the central pituitary, \ncompatible with a \nRathke's cleft cyst. \n5. Stable 13 mm enhancing left parotid tail nodule, compatible \nwith an \nenlarged lymph node. \n\nRUQ U/S ___\n\nIMPRESSION: No biliary ductal dilatation. 1.2 cm indeterminate \nmass within the dome of the liver, which was seen on the prior \nCT from ___. This could be further evaluated with \nMRI. \n\nMRI HEAD ___\n\nIMPRESSION: \n \n1. Interval progression of multiple supratentorial enhancing \nlesions \ncompatible with the history of lymphoma. \n2. Areas of slow diffusion are again noted in the splenium of \nthe corpus \ncallosum, body of left corpus callosum and left perirectal area, \nalso typical of lymphoma. \n \nEEG ___\n\nIMPRESSION: This is an abnormal video-EEG monitoring session \nbecause of an \nasymmetric background. There is continuous focal slowing with \nlower voltage frequencies as well as an absent posterior \ndominant rhythm over the left hemisphere. These findings are \nindicative of focal cerebral dysfunction, cortical and \nsubcortical, in the left hemisphere, which is likely structural \nin origin. This is consistent with the known focal structural \nlesion in the left hemisphere. There is also mild diffuse \nslowing and slow posterior dominant rhythm over the right \nhemisphere, indicative of more diffuse cerebral dysfunction, \nwhich is nonspecific as to etiology. No epileptiform discharges \nor electrographic seizures are present. Compared to the prior \nday's recording, there is no significant change. \n\nEEG ___\n\nIMPRESSION: This is an abnormal video-EEG monitoring session \nbecause of \nbackground asymmetry, with continuous focal slowing and \nattenuation of faster frequencies over the left hemisphere. \nThese findings are indicative of focal cerebral dysfunction, \ncortical and subcortical, in the left hemisphere, likely \nstructural in origin, and consistent with the known focal \nstructural lesion in the left hemisphere. There is also mild \ndiffuse slowing and slow posterior dominant rhythm over the \nright hemisphere, indicative of more diffuse cerebral \ndysfunction, which is nonspecific as to etiology. No \nepileptiform discharges or electrographic seizures are present. \nCompared to the prior day's recording, there is asymmetry of the \nbackground which is now apparent with cessation of the diffuse \nEMG activity. \n\nMRI L SPINE ___\n\nIMPRESSION: \n \n1. Small focal rounded lesion within the anterior L4 vertebral \nbody as \ndescribed above, that appears more conspicuous in comparison \nwith the prior MRI from ___. Finding is \nnonspecific. Although this may represent an atypical \nhemangioma, possibility of underlying malignancy cannot be \nexcluded. Recommend short-term contrast-enhanced study to \nfurther assess. \n2. No associated retropulsion component or extension into the \nposterior \nelements. No evidence of enhancing soft tissue component or \nenhancement of the cauda equina nerve roots. \n3. No evidence of spinal canal stenosis or neural foraminal \nnarrowing. \n4. Please refer to recent noncontrast lumbar spine MRI performed \nthe same date for additional details. \n\nMRI PELVIS ___\n\nRECOMMENDATION(S): \n1. Asymmetric soft tissue edema in the sciatic notch, tracking \nanterior to the sacrum, and along the sacral plexus is new from \n___. No drainable fluid collection is identified. These \nfindings may represent sequela of recent bone marrow aspiration, \nsuch as hematoma or infection. Recommend neurosurgery \nconsultation for further evaluation of the patient. \n2. Heterogeneously enhancing mass in the endometrial canal \nshould be further evaluated with pelvic ultrasound. \n3. Right adnexal mass with central necrosis appears similar in \nsize to \n___, and may represent a partially necrotic broad \nligament fibroid, however this should be further evaluated with \npelvic ultrasound as well. \n \nMRI THORACIC/LUMBAR ___\n\nIMPRESSION: \n \n1. Please note, evaluation is limited due to motion degradation \nand lack of intravenous contrast. Within the confines of this \nstudy: \n2. No evidence of cord compression or cord edema. \n3. No evidence of spinal canal stenosis or neural foraminal \nnarrowing. \n4. Incompletely characterized and indeterminate right adrenal \nnodule. \n \nBONE MARROW BX ___\nSPECIMEN: BONE MARROW\nCLINICAL HISTORY: Diffuse large B-cell lymphoma with CNS disease\nCYTOGENETICS PROCEDURE: Unstimulated and 3 day \nDSP30/IL2-stimulated cultures for Giemsa-banded chromosome \nanalysis.\nFINDINGS: An apparently normal 46,XX female chromosome \ncomplement was observed in 20 mitotic cells examined in detail. \nChromosome band resolution was 400-450. A karyogram was prepared \non 3 cells\n\nBONE MARROW HEMPATH ___\n\nPATHOLOGIC DIAGNOSIS:\n============= DIAGNOSIS =============\nSPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY\nDIAGNOSIS:\nERYTHROID PREDOMINANT BONE MARROW WITH LEFT-SHIFTED MYELOPOIESIS \nAND MILD\nTRILINEAGE DYSPOIESIS. NO EVIDENCE OF INVOLVEMENT BY THE \nPATIENT'S KNOWN\nDIFFUSE LARGE B-CELL LYMPHOMA. SEE NOTE.\n\nCT A/P ___\n\nIMPRESSION: \n \n1. Mild thickening wall of descending: Colitis should be \nconsidered. \n2. Known Right pelvic mass, likely a fibroid. \n \nMR HEAD ___\n\nIMPRESSION: \n \n1. Masslike left posterior temporal and occipital \nperiventricular white matter FLAIR signal abnormality with \nslowed diffusion crossing midline at the splenium of the corpus \ncallosum appears similar to the prior examination, though with \ndecrease of enhancing nodular components, in keeping with given \nhistory of CNS lymphoma. \n2. Additional involvement of the body of the corpus callosum and \npericallosal white matter appears slightly decreased, with \ndecrease of enhancing component. \n3. Additional involvement of the left frontal periventricular \nwhite matter \nwith extension to the genu of the corpus callosum has also \ndecreased, with \ndecrease of enhancing component. \n4. Otherwise no infarct, hemorrhage, or new enhancing lesion. \n\nHEAD CT ___\n\nIMPRESSION: \n \n1. Unchanged left temporoparietal edema with extension across \nthe midline \nwithin the splenium of the corpus callosum and mild associated \nsulcal \neffacement. \n2. No worsening mass effect or intracranial hemorrhage. \n3. Please note MRI of the brain is more sensitive for the \nevaluation of \nintracranial tumors.\n\nMRI HEAD ___\n\nIMPRESSION: \n \n1. Multiple bilateral periventricular enhancing lesions \ncorresponding to the known lymphoma have decreased in size with \ndecreased adjacent T2/FLAIR \nhyperintensity. \n2. While no new enhancing lesion is seen, there is mild new \nT2/FLAIR \nhyperintensity in the midline and right genu of the corpus \ncallosum, of \nuncertain significance. \n3. Stable nonspecific peripheral enhancement in the pineal \nregion. \n4. Stable nonenhancing focus in the central pituitary, \ncompatible with a \nRathke's cleft cyst. \n5. Stable 13 mm enhancing left parotid tail nodule, compatible \nwith an \nenlarged lymph node. \n\nRUQ U/S ___\n\nIMPRESSION: \n \nNo biliary ductal dilatation. \n \n1.2 cm indeterminate mass within the dome of the liver, which \nwas seen on the prior CT from ___. This could be \nfurther evaluated with MRI. \n\nDISCHARGE LABS: None\n \nBrief Hospital Course:\nASSESSMENT AND PLAN: Ms. ___ is a ___ woman \nwith a history of high-grade diffuse large B-cell lymphoma \n(primary bone marrow lymphoma) diagnosed in ___ with noted \nCNS involvement on TEDDI-R who presented to clinic for C5D1\nTEDDI-R and was found to have elevated LFTs.\n\n ****see previous progress notes for details in her hospital \ncourse****\n\n#High-grade Primary Bone Marrow Lymphoma with CNS Involvement: \nNoted for a high-grade lymphoma felt to be primary bone marrow \nlymphoma with noted CNS disease which has unfortunately \nprogressed through different treatments. She completed 5 cycles \nof TEDDI-R but still had radiographic and clinical evidence of \ndisease progression during this hospital course. Decision was \nmade in conjunction with the family about focusing on comfort \nmeasures on ___. Patient was initiated on a morphine drip for \npain management as well as other medications for anxiety and \nagitation support. She was closely followed by an inpatient \nhospice team. She remained overall comfortable. Her family was \nsupportive throughout her care provision. She died on ___ at \n4am with her husband at the bedside. \n\nACTIVE ISSUES DURING HOSPITAL COURSE:\n\n#Elevated LFTs: No hyperbilirubinemia. ___ be secondary to \nmedication effect (voriconazole) vs. progression of lymphoma. \nRUQ U/S negative for biliary dilatation. Throughout her hospital \ncourse, was intermittently off voriconazole while her liver \nenzymes were elevated but ultimately this was discontinued once \nher goals of care changed to comfort care. \n\n#Diarrhea: attributed to medication effect (ibrutinib) as well \nas possible colitis. \n\n#Anemia: Attributed to malignancy and chemotherapy.\n\n#Type II DM: hyperglycemic to the 200s-400s in the setting of \ndexamethasone with previous TEDDI-R regimens so consulted ___ \nwho helped throughout the course of hospitalization to adjust \nher insulin regimen.\n\n#Hyperlipidemia: Simvastatin on hold. \n\n#Sjogren's Syndrome: Used cyclosporine gtts.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acyclovir 400 mg PO Q8H \n2. Atovaquone Suspension 1500 mg PO DAILY \n3. Artificial Tears ___ DROP BOTH EYES PRN dry eyes \n4. LevETIRAcetam 500 mg PO Q12H \n5. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/insomnia/anxiety \n6. Pyridoxine 100 mg PO DAILY \n7. Voriconazole 200 mg PO Q12H \n8. Dexamethasone 2 mg PO DAILY \n9. ibrutinib 560 mg ORAL DAILY \n10. Pantoprazole 40 mg PO Q24H \n11. butalbital-acetaminophen-caff 50-300-40 mg oral Q8H:PRN \nheadache \n12. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n13. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n14. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n15. MetFORMIN (Glucophage) 500 mg PO BID \n16. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic BID \n17. NPH 10 Units Breakfast\nInsulin SC Sliding Scale using HUM Insulin\n\n \nDischarge Medications:\nNone\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n======================\nLiver enzymes abnormalities \n\nhigh-grade diffuse large B cell lymphoma (with CNS involvement)\n\n \nDischarge Condition:\ndeceased on ___\n\n \nDischarge Instructions:\nNot applicable\n \nFollowup Instructions:\n___\n" ]

[ "C8339", "G936", "G9341", "K521", "R1310", "E871", "R4701", "R740", "M3500", "K6289", "Z66", "Z515", "Z923", "Z87891", "Z9221", "F419", "R451", "T451X5A", "Y92230", "D6481", "K529", "D638", "Z794", "E785", "D72829", "E1165", "R531", "R110", "T380X5A", "Y929" ]

[ "C8339: Diffuse large B-cell lymphoma, extranodal and solid organ sites", "G936: Cerebral edema", "G9341: Metabolic encephalopathy", "K521: Toxic gastroenteritis and colitis", "R1310: Dysphagia, unspecified", "E871: Hypo-osmolality and hyponatremia", "R4701: Aphasia", "R740: Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]", "M3500: Sicca syndrome, unspecified", "K6289: Other specified diseases of anus and rectum", "Z66: Do not resuscitate", "Z515: Encounter for palliative care", "Z923: Personal history of irradiation", "Z87891: Personal history of nicotine dependence", "Z9221: Personal history of antineoplastic chemotherapy", "F419: Anxiety disorder, unspecified", "R451: Restlessness and agitation", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92230: Patient room in hospital as the place of occurrence of the external cause", "D6481: Anemia due to antineoplastic chemotherapy", "K529: Noninfective gastroenteritis and colitis, unspecified", "D638: Anemia in other chronic diseases classified elsewhere", "Z794: Long term (current) use of insulin", "E785: Hyperlipidemia, unspecified", "D72829: Elevated white blood cell count, unspecified", "E1165: Type 2 diabetes mellitus with hyperglycemia", "R531: Weakness", "R110: Nausea", "T380X5A: Adverse effect of glucocorticoids and synthetic analogues, initial encounter", "Y929: Unspecified place or not applicable" ]

[ "E871", "Z66", "Z515", "Z87891", "F419", "Y92230", "Z794", "E785", "E1165", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nmethotrexate / pantoprazole / niacin / doxazosin / lidocaine\n \nAttending: ___.\n \nChief Complaint:\n___\n \nMajor Surgical or Invasive Procedure:\nBronchoscopy ___\nRenal biopsy ___\n\n \nHistory of Present Illness:\nMr ___ is a ___ man with a history of hypertension, \nhyperlipidemia, and rheumatoid arthritis, who presents with lung \nlesions and acute kidney injury.\n\n2 weeks ago, he developed a persistent cough and worsening \nshortness of breath. He had no fevers, nasal congestions, or \nother signs of infection, and no sick contacts. His cough and \ndyspnea got severe, so he presented to his PCP, who ordered a \nCXR. CXR showed a consolidation, but PCP was concerned about \ndegree of dyspnea, so he ordered a CTA chest. This showed no PE, \nbut was concerning for infiltrative process. At this point, his \ndyspnea continued to worsen, and PCP checked labs, which were \nnotable for new Cr 3.4, up from baseline of normal. During this \ntime, the patient had no chest pain, flank pain, dysuria, \nhematuria, or frothy urine. He has had 3 episodes of vomiting, \nbut no diarrhea.\n\nHis PCP instructed him to come to the ED, and was referred to \n___ for urgent Nephrology consultation. \n\n- In the ED, initial vitals were: 98.1 72 200/55 18 97% RA \n- Exam notable for: no CVAT, 1+ pitting edema to knees \nbilaterally \n- Labs notable for: Cr 3.1\n- Imaging was notable for: renal U/S with no hydro\n- Patient was given: \n___ 05:35 IVF NS ___ Started \n___ 09:29 SC Insulin 2 Units ___ \n- Vitals on transfer: 97.9 64 171/97 16 96% RA \n\nUpon arrival to the floor, patient reports feeling well. He does \nnot have headache, and is breathing comfortably at rest. He is \nstill coughing a dry cough. He notes that his legs have gotten \nmore swollen today. Otherwise, no complaints. \n\nROS: Positive per HPI. Remaining 10 point ROS reviewed and \nnegative\n \nPast Medical History:\n- Rheumatoid arthritis \n- HTN\n- HLD\n- TIA (on Plavix)\n- Myocardial infarction ___ viral process, but clean coronaries\n- T2DM on insulin \n\n \nSocial History:\n___\nFamily History:\nNo family history of kidney disease. 1 sister with \nhypothyroidism\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n===========================\nVITAL SIGNS: 97.0 AdultAxillary 201 / 86 L Lying 67 20 96 Ra \nGENERAL: Sitting comfortably in bed, NAD\nHEENT: no scleral icterus, mmm\nNECK: no JVD, supple\nCARDIAC: rrr, ___ systolic murmur at ___\nLUNGS: clear bilaterally with faint expiratory wheezing at \nbases\nABDOMEN: soft, NT/ND, +bs, no suprapubic pain\nEXTREMITIES: warm, 1+ pitting edema to shins bilaterally \nNEUROLOGIC: A&Ox3, CN intact, moving all 4 extremities w/ \npurpose\nSKIN: no rashes or jaundice\nBACK; no CVA tenderness \n\nDISCHARGE PHYSICAL EXAM: \n===========================\nVITAL SIGNS: 98.5 PO 161 / 54L Lying 57 18 97 Ra \nGENERAL: Sitting comfortably in chair, NAD\nHEENT: no scleral icterus, mmm\nNECK: supple\nCARDIAC: rrr, ___ systolic murmur at ___\nLUNGS: CTAB\nABDOMEN: soft, NT/ND, +bs\nEXTREMITIES: warm, trace pitting edema to shins bilaterally \nNEUROLOGIC: A&Ox3, CN intact, moving all 4 extremities w/\npurpose\nSKIN: There are scattered erythematous, non-blanching, ~purpuric\nlesions on the bilateral UEs on forearms and left side of back\n \nPertinent Results:\nADMISSION LABS: \n===========================\n___ 10:50PM BLOOD WBC-4.9 RBC-2.65* Hgb-8.3* Hct-24.6* \nMCV-93 MCH-31.3 MCHC-33.7 RDW-13.0 RDWSD-44.1 Plt ___\n___ 10:50PM BLOOD Neuts-78.2* Lymphs-8.2* Monos-10.6 \nEos-2.2 Baso-0.4 Im ___ AbsNeut-3.83 AbsLymp-0.40* \nAbsMono-0.52 AbsEos-0.11 AbsBaso-0.02\n___ 10:50PM BLOOD ___ PTT-34.9 ___\n___ 10:50PM BLOOD Glucose-228* UreaN-54* Creat-3.1*# Na-138 \nK-4.3 Cl-97 HCO3-25 AnGap-16\n___ 10:50PM BLOOD Calcium-9.6 Phos-5.1* Mg-2.4\n___ 10:50PM BLOOD CRP-59.0*\n\nIMAGING/STUDIES: \n===========================\n___ RENAL U/S:\n1. No hydronephrosis. Both ureteral jets are visualized.\n2. Nonobstructive nephrolithiasis of the left kidney.\n\n___ronchus centric opacities in the right upper lobe and both \nlower lobes\nconcerning for multifocal pneumonia.\nSmall bilateral effusions and mild interstitial edema.\nSmall mediastinal lymph nodes could be reactive.\n\nDISCHARGE LABS:\n===========================\n___ 07:40AM BLOOD WBC-6.6 RBC-2.46* Hgb-7.7* Hct-23.4* \nMCV-95 MCH-31.3 MCHC-32.9 RDW-13.2 RDWSD-45.1 Plt ___\n___ 07:40AM BLOOD ___ PTT-33.1 ___\n___ 07:40AM BLOOD Glucose-120* UreaN-41* Creat-1.8* Na-145 \nK-4.3 Cl-110* HCO3-23 AnGap-12\n___ 07:40AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.2\n\nOTHER PERTINENT LABS\n===========================\n___ 06:38AM BLOOD Hypochr-NORMAL Anisocy-1+* Poiklo-1+* \nMacrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-OCCASIONAL \nOvalocy-1+* Tear Dr-OCCASIONAL\n___ 06:38AM BLOOD Ret Aut-2.2* Abs Ret-0.05\n___ 06:38AM BLOOD ALT-19 AST-20 LD(LDH)-166 AlkPhos-35* \nTotBili-<0.2\n___ 01:20PM BLOOD CK(CPK)-414*\n___ 10:48PM BLOOD CK(CPK)-464*\n___ 06:30AM BLOOD CK-MB-5 cTropnT-0.05*\n___ 01:20PM BLOOD CK-MB-7 cTropnT-0.07*\n___ 10:48PM BLOOD CK-MB-7 cTropnT-0.04*\n___ 05:28AM BLOOD CK-MB-6 cTropnT-0.06*\n___ 06:38AM BLOOD calTIBC-268 Ferritn-68 TRF-206\n___ 06:20AM BLOOD TSH-5.7*\n___ 06:20AM BLOOD Free T4-0.9*\n___ 05:00PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG\n___ 05:00PM BLOOD ANCA-NEGATIVE B\n___ 10:50PM BLOOD CRP-59.0*\n___ 05:00PM BLOOD ___\n___ 06:38AM BLOOD CRP-16.7*\n___ 05:30PM BLOOD PEP-NO SPECIFI\n___ 05:00PM BLOOD C3-164 C4-28\n___ 06:30AM BLOOD HIV Ab-NEG\n___ 05:00PM BLOOD HCV Ab-NEG\n___ 09:35AM BLOOD SM ANTIBODY-Test \n___ 09:35AM BLOOD RO & ___ \n___ 09:35AM BLOOD RNP ANTIBODY-Test \n___ 09:35AM BLOOD ALDOLASE-Test \n___ 06:38AM BLOOD SED RATE-Test \n___ 05:00PM BLOOD ANTI-GBM-Test \n___ 06:12AM BLOOD SED RATE-Test Name \n \nBrief Hospital Course:\nPATIENT SUMMARY\n===============\n___ w/ HTN, HL, RA, DM, TIA presenting after recent episode \nlikely community-acquired pneumonia s/p azithromycin with \nimprovement who presented with persistent cough and dyspnea and \nfound to have bilateral lung opacities and acute kidney injury \nwith nephrotic-range proteinuria.\n\nACTIVE ISSUES \n=============\n#) ACUTE KIDNEY INJURY\nOn admission, patient noted to have acute kidney injury with a \ncreatinine of 3.1 (baseline normal, 0.5). Renal ultrasound \nnormal. Nephrology consulted. Urine sediment showed few \ncellular casts. Urine protein/creatinine ratio 10.3. CRP 59 \nand ESR 119. Other workup remained unrevealing (negative ___ \nand ANCA, normal C3, C4). During admission, creatinine \nimproved. The etiology of the acute kidney injury remained \nunclear. It is possible that the proteinuria is secondary to \ndiabetes, and that he developed acute kidney injury secondary \nto post-streptococcal glomerulonephritis, or pre-renal \nazotemia, and that the cellular casts were related to the \nhypertension. Very low suspicion for pulmonary-renal syndrome. \n Underwent kidney biopsy on ___. The patient was discharge \nwhile awaiting pathology results because it was felt that his \nkidney function had stabilized and he was appearing clinically \nwell without symptoms. Needs outpatient follow up with \nnephrology. \n\n#) PULMONARY INFILTRATES\nPatient was recently diagnosed with community-acquired \npneumonia and completed a course of azithromycin and presented \nwith persistent dyspnea and productive cough. Imaging was \nnotable for nodular pulmonary consolidations with associated \nground-glass opacities. Repeat CT scan showed persistent \nradiographic evidence of multifocal nodular opacities in RUL \nand LLL, which prompted bronchoscopy for further evaluation. \nBAL was only notable for diffusely edematous airways without \nfocal lesions or hemorrhage. BAL cell count showed atypical \ncells but cytology was negative for malignancy. The patient \nsymptomatically improved during admission and did not receive \nantibiotics. The symptoms and infiltrates were thought to be \nrelated to community acquired pneumonia. Patient will need \nrepeat outpatient CT chest to evaluate the infiltrates in ___ \nweeks, and outpatient follow up with pulmonology.\n\n#) HYPERTENSIVE URGENCY: \nDuring admission, patient was found to have hypertensive \nurgency with systolic blood pressure up to 200 but the patient \nremained asymptomatic without evidence of end organ damage. \nPer the patient, he has longstanding hypertension, and rarely \nhad blood pressure readings less than 150. During admission, \nanti-hypertensives were adjusted given the setting of acute \nkidney injury. Lisinopril was held. Received home furosemide, \namlodipine and spironolactone. Metoprolol was transitioned to \nlabetalol for better blood pressure control. Also started on \nhydralazine. There was aggressive blood pressure management to \nreduce the bleeding complication risk of the renal biopsy. \nPatient should have further outpatient workup of resistant \nhypertension, and should have monitoring of blood pressure and \nadjustment of anti-hypertensives as appropriate.\n\n#) CHEST PAIN\nDuring admission, patient reported intermittent pleuritic chest \ndiscomfort. EKG showed stable ST elevations that were \nattributed to repolarization in anterior leads. Cardiac \nenzymes showed only slight elevation of troponin and normal \nCK-MB. Per the patient's report, cardiac catheterization one \nyear previously showed no evidence of CAD. The \ncharacterization of the pain, and the clinical picture was not \nfelt to be consistent with ACS. Could consider further \noutpatient workup with stress test and TTE. \n\n#) ANEMIA\nPatient found to have new hypoproliferative anemia with \nhemoglobin ___. No evidence of bleeding. Iron studies were \nnormal. The etiology remained unclear during admission but \npatient remained hemodynamically stable, with stable hemoglobin \nand did not require a transfusion so it was felt that further \nworkup could be pursued in the outpatient setting. \n\n#) CONCERN FOR MYOSITIS\nNoted during admission patient had evidence of myositis \n(elevated CK, mildly elevated troponin T, and elevated \nCRP/ESR). No associated myalgias or weakness. Differential \nincludes hypothyroidism (TSH elevated and FT4 low, needs repeat \nthyroid studies as outpatient), drug-induced (was on \ngemfibrozil and rosuvastatin (which were both held during \nadmission) or autoimmune. Patient needs further workup as an \noutpatient. \n\nCHRONIC STABLE ISSUES:\n========================\n#) DM: glargine and ISS while inpatient\n#) HLD: held gemfibrozil and rosuvastatin in setting of \npossible myositis\n#) h/o TIA: held clopidogrel in setting of renal biopsy. Needs \nto wait at least until ___ to resume plavix.\n\nTRANSITIONAL ISSUES: \n========================\n#) Monitor labs as an outpatient: CBC, BUN/Cr, CK, troponin. \nNext lab check will be on ___ while seeing PCP.\n#) Continue to hold Plavix for at least one week post-renal \nbiopsy (okay to resume on ___\n#) Needs outpatient follow up with nephrology. Kidney biopsy \npathology pending on discharge\n#) Needs outpatient workup of resistant hypertension. Need to \nfollow up blood pressure, and adjust anti-hypertensives. \nLisinopril was held given ___, but can be resumed as \nappropriate.\n#) Patient needs repeat thyroid studies checked as an \noutpatient\n#) Rosuvastatin and gemfibrozil were held in the setting of \nconcern for myositis. \n#) Patient will need repeat outpatient CT chest to evaluate the \ninfiltrates in ___ weeks, and outpatient follow up with \npulmonology (Dr. ___.\n#) Consider outpatient workup of chest pain, including TTE and \nstress test\n#) Patient needs further workup of hypoproliferative anemia as \nan outpatient\n#) Needs further workup of suspected myositis as an outpatient. \n Monitor for symptom improvement after cessation of gemfibrozil \nand statin. Also recheck CK, troponin as an outpatient. Could \nassess for vitamin D deficiency.\n\n#CONTACT: ___, wife, ___\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Spironolactone 100 mg PO BID \n2. Metoprolol Succinate XL 75 mg PO DAILY \n3. Gemfibrozil 600 mg PO BID \n4. Furosemide 40 mg PO BID \n5. Clopidogrel 75 mg PO DAILY \n6. Rosuvastatin Calcium 40 mg PO QPM \n7. Lisinopril 40 mg PO DAILY \n8. Glargine 30 Units Bedtime\n9. amLODIPine 10 mg PO DAILY \n\n \nDischarge Medications:\n1. HydrALAZINE 25 mg PO Q6H \nRX *hydralazine 25 mg 1 tablet(s) by mouth every six (6) hours \nDisp #*120 Tablet Refills:*0 \n2. Labetalol 300 mg PO TID \nRX *labetalol 300 mg 1 tablet(s) by mouth three times a day Disp \n#*90 Tablet Refills:*0 \n3. amLODIPine 10 mg PO DAILY \n4. Furosemide 40 mg PO BID \n5. Glargine 30 Units Bedtime \n6. Spironolactone 100 mg PO BID \n7. HELD- Clopidogrel 75 mg PO DAILY This medication was held. \nDo not restart Clopidogrel until at least one week after kidney \nbiopsy. Do not resume until after discussing with kidney doctor\n8. HELD- Gemfibrozil 600 mg PO BID This medication was held. Do \nnot restart Gemfibrozil until instructed to resume by your \ndoctor. This medication may have caused muscle inflammation\n9. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do \nnot restart Lisinopril until instructed to resume by your \ndoctor. This medication cannot be restarted right away because \nit can cause kidney injury\n10. HELD- Rosuvastatin Calcium 40 mg PO QPM This medication was \nheld. Do not restart Rosuvastatin Calcium until instructed to \nresume by your doctor. This medication may have caused muscle \ninflammation\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n- Acute kidney injury\n- bilateral pulmonary infiltrates\n\nSECONDARY DIAGNOSES\n- Hypertensive urgency \n- Dyspnea on exertion \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 ___.\n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n- ___ had shortness of breath\n- Your kidney function was getting worse\n\nWHAT HAPPENED WHILE I WAS HERE?\n- ___ saw the kidney doctors and ___ had a kidney biopsy done. \nIt is important for ___ to not take your plavix for at least one \nweek after the kidney biopsy. Do not resume plavix until \ndiscussing with your kidney doctor. \n- ___ saw the lung doctors and have follow up scheduled with the \nlung doctors. ___ will need another CT scan of your lungs in 6 \nto 8 weeks\n\nWHAT SHOULD I DO WHEN I GO HOME?\n- Please call your doctors ___ away ___ return if ___ develop \nblood in your urine or back pain\n- Take all of your medicines as prescribed\n- Go to all of your follow-up appointments, which are listed \nbelow\n- Call your doctor if ___ have any fevers, shortness of breath, \nweight gain >3 lbs in 3 days, leg swelling, or decreased urine\n\nWe wish ___ all the best in the future!\n\nSincerely,\nYour ___ Care Team \n \nFollowup Instructions:\n___\n" ]

[ "R918", "N179", "D619", "N059", "I160", "R0600", "M609", "M069", "R0789", "E119", "E785", "R21", "Z8701", "Z8673", "Z7902", "I252", "Z794", "Z87891" ]

[ "R918: Other nonspecific abnormal finding of lung field", "N179: Acute kidney failure, unspecified", "D619: Aplastic anemia, unspecified", "N059: Unspecified nephritic syndrome with unspecified morphologic changes", "I160: Hypertensive urgency", "R0600: Dyspnea, unspecified", "M609: Myositis, unspecified", "M069: Rheumatoid arthritis, unspecified", "R0789: Other chest pain", "E119: Type 2 diabetes mellitus without complications", "E785: Hyperlipidemia, unspecified", "R21: Rash and other nonspecific skin eruption", "Z8701: Personal history of pneumonia (recurrent)", "Z8673: Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "I252: Old myocardial infarction", "Z794: Long term (current) use of insulin", "Z87891: Personal history of nicotine dependence" ]

[ "N179", "E119", "E785", "Z8673", "Z7902", "I252", "Z794", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nProchlorperazine / Zocor\n \nAttending: ___.\n \nChief Complaint:\nright leg claudication\n \nMajor Surgical or Invasive Procedure:\n___: Gore limb extension in right and left limbs with right \ncommon femoral artery cutdown and right common iliac artery \nthrombectomy.\n\n \nHistory of Present Illness:\n ___ gentleman with a history of percutaneous EVAR in \n___ with bilateral limb extensions in ___ and ___ was found \nto have a chronically occluded right limb of his previously \ncompleted EVAR while undergoing a workup for chronic back and \nlimb pain. As he had significant claudication symptoms, he was \nbrought the OR for thrombectomy and stent to reopen the inflow \nto the right lower extremity\n \nPast Medical History:\nPAST MEDICAL HISTORY: \n CAD- s/p CABG with LIMA to LAD and SVG to PDA in ___ s/p PCI \nto \n PDA in ___ and POBA to SVG-->PDA in ___ \n AAA s/p EVAR ___ with limb extensions ___ and ___. \n Atrial fibrillation s/p PVI ___ \n HTN \n HLD \n BPH \n PMR \n Sarcoid dx on biopsy of LNs -otherwise asymptomatic \n Renal artery stenosis s/p bilat RAS \n PTSD \n OSA on CPAP \n Osteopenia/arthritis \n Anxiety \n\n \nPhysical Exam:\nVitals: 24 HR Data (last updated ___ @ 618)\n Temp: 98.5 (Tm 99.0), BP: 136/72 (135-152/62-76), HR: 101\n(89-126), RR: 18 (___), O2 sat: 97% (92-98), O2 delivery: RA\nGENERAL: NAD, A/O x 3 \nCV: RRR \nPULM: CTA b/l, no respiratory distress \nABD: Soft, mildly TTP in RLQ around incision , nondistended, no\nrebound/guarding \nWOUND: CD&I , non erythematous, non indurated. Staples in place\nEXTREMITIES: [X]no CCE \nPULSES: R: -/-/p/d L: -/-/p/d\n \nPertinent Results:\n___ 04:45AM BLOOD WBC-8.3 RBC-3.50* Hgb-10.7* Hct-32.9* \nMCV-94 MCH-30.6 MCHC-32.5 RDW-14.7 RDWSD-49.9* Plt ___\n___ 04:45AM BLOOD ___ PTT-35.3 ___\n___ 04:45AM BLOOD Glucose-116* UreaN-12 Creat-1.1 Na-141 \nK-4.3 Cl-108 HCO3-19* AnGap-14\n___ 04:45AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.8\n \nBrief Hospital Course:\n___ is a ___ yo M s/p EVAR in ___ with bilateral limb \nextensions (___). While undergoing a workup for chronic \nback and limb pain. He underwent a CT scan which revealed \nchronically occluded right limb of his previously completed \nEVAR. Given his worsening claudication symptoms and pain, the \ndecision was made to proceed to the operating room for right \ngraft thrombectomy with bilateral iliac stents. He tolerated the \nprocedure well, please see the Op note for full details. \n\nFoley and A-line were placed intra-operatively. The next day, he \nwas advanced to a regular diet, foley was removed, and A-line \nwas removed. He was started on Cilostazol, Plavix, home Coumadin \n2.5mg, and hep gtt. Aspirin was discontinued. The same day, he \nhad persistently tachycardia to the 130s and was given \nmetoprolol 5mg, 500cc bolus, and EKG was negative. At he \ncontinued to be in intermittent atrial fibrillation vs sinus \ntach with frequent PACs to 130s cardiology was consulted. They \nfelt the tachycardia likely occurred secondary to infection, \npain, and post-operative stress. Fluid and electrolyes were \nrepleted. Medication regimen was titrated then consolidate to \ninclude metoprolol succinate 200 mg QD + diltiazem ER 240 mg QD \nw/ goal HR is < 110, even if in atrial fibrillation. Followup \nwith his home cardiologist was arranged. \nAs part of the workup for tachycardia he was found to have a \npan-sensitive E. Coli UTI and was initially treated with CTX on \n___ then changed to TMP-SMX DS tablet BID on ___. Course will \nbe completed on ___. \n\n___ saw him and cleared him for suggested rehab. ). On \ndischarge, his pain was well controlled, he was voiding, and had \nnormal bowel movements tolerating a regular diet and ambulatory \nwith assist. \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Acetaminophen 650 mg PO Q6H:PRN pain \n2. Calcium Carbonate 1500 mg PO BID \n3. ClonazePAM 1 mg PO QHS:PRN bed \n4. Clopidogrel 75 mg PO DAILY \n5. Docusate Sodium 100 mg PO BID \n6. DULoxetine 90 mg PO DAILY \n7. Rosuvastatin Calcium 40 mg PO QPM \n8. Zonisamide 100 mg PO DAILY headaches \n9. Sildenafil 25 mg ORAL ONCE:PRN before activity \n10. PredniSONE 5 mg PO DAILY \n11. Vitamin D ___ UNIT PO DAILY \n12. Metoprolol Succinate XL 75 mg PO BID \n13. Pantoprazole 40 mg PO Q12H \n14. Warfarin 2.5 mg PO DAILY16 \n15. Alendronate Sodium 70 mg PO Frequency is Unknown \n16. Diltiazem 15 mg PO TID \n17. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n18. Potassium Chloride 10 mEq PO DAILY \n19. Aspirin 81 mg PO DAILY \n20. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Medications:\n1. Cilostazol 100 mg PO BID \n2. Diltiazem Extended-Release 240 mg PO DAILY \nStart ___ AM \n3. Metoprolol Tartrate 50 mg PO Q6H \nLast dose this 11:59PM. To change to succinate in AM \n4. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - \nSevere \nRX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hours as \nneeded, Disp #*4 Tablet Refills:*0 \n5. Senna 8.6 mg PO BID:PRN constipation \n6. Sulfameth/Trimethoprim DS 1 TAB PO BID \nFor 6 doses. Start ___ AM znc Stop ___ ___ \n7. Alendronate Sodium 70 mg PO QTHUR \n8. Diltiazem 30 mg PO Q6H \nLast dose 11:59PM ___. \n9. DULoxetine 60 mg PO DAILY \nIn AM \n10. DULoxetine 30 mg PO DAILY \nIN ___ \n11. Metoprolol Succinate XL 200 mg PO DAILY \nstart ___ am \n12. Acetaminophen 650 mg PO Q6H:PRN pain \n13. Calcium Carbonate 1500 mg PO BID \n14. ClonazePAM 1 mg PO QHS:PRN bed \n15. Clopidogrel 75 mg PO DAILY \n16. Docusate Sodium 100 mg PO BID \n17. Pantoprazole 40 mg PO Q12H \n18. Potassium Chloride 10 mEq PO DAILY \n19. PredniSONE 5 mg PO DAILY \n20. Rosuvastatin Calcium 40 mg PO QPM \n21. Sildenafil 25 mg ORAL ONCE:PRN before activity \n22. Tamsulosin 0.4 mg PO QHS \n23. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n24. Vitamin D ___ UNIT PO DAILY \n25. Warfarin 2.5 mg PO DAILY16 \nINR check ___. Goal >2.0. IF less than 2 please give lovenox. \n \n26. Zonisamide 100 mg PO DAILY headaches \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \n___ Diagnosis:\nOcclusion of a stent graft with right lower extremity \nclaudication. \nTachycardia\nUnrinary tract infection\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent with assistance.\n\n \nDischarge Instructions:\nIt was a pleasure taking care of you at ___ \n___. You were admitted to the hospital after \nundergoing a right common iliac artery thrombectomy and \nplacement of extensions onto the limbs of your aortic stent \ngraft. To perform this procedure, a incision was made over the \nright groin and a small puncture was made in the left groin. \nYou tolerated the procedure well and are now ready to be \ndischarged from the hospital. Please follow the \nrecommendations below to ensure a speedy and uneventful \nrecovery.\n\nDivision of Vascular and Endovascular Surgery\n\nCIA thrombectomy and Aortic Stent graft extension: \n\nPLEASE NOTE: After endovascular aortic repair (EVAR), it is very \nimportant to have regular appointments (every ___ months) for \nthe rest of your life. These appointments will include a CT \n(“CAT”) scan and/or ultrasound of your graft. If you miss an \nappointment, please call to reschedule. \nWHAT TO EXPECT:\n•Bruising, tenderness, and a sensation of fullness at the groin \npuncture sites (or incisions) is normal and will go away in \none-two weeks\n\nCARE OF THE GROIN PUNCTURE SITES:\n•It is normal to have mild swelling, a small bruise, or small \namounts of drainage at the groin puncture sites. In two weeks, \nyou may feel a small, painless, pea sized knot at the puncture \nsites. This too is normal. Male patients may notice swelling \nin the scrotum. The swelling will get better over one-two \nweeks.\n•Look at the area daily to see if there are any changes. Be \nsure to report signs of infection. These include: increasing \nredness; worsening pain; new or increasing drainage, or drainage \nthat is white, yellow, or green; or fever of 101.5 or more. (If \nyou have taken aspirin, Tylenol, or other fever reducing \nmedicine, wait at least ___ hours after taking it before you \ncheck your temperature in order to get an accurate reading.)\n\nINCISION CARE: \n• Please keep clean, dry and covered. Place dry gauze \nover the incision is drainage is present. \n• Evaluate the incision for sign of infection, to include \nexpanding erythema, separation of your incision, increased \ndrainage, increased pain and foil odor. \n\nFOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or \nincision)\n•If you have sudden, severe bleeding or swelling at either of \nthe groin puncture sites: \n-Lie down, keep leg straight and apply (or have someone apply) \nfirm pressure to area for ___ minutes with a gauze pad or \nclean cloth. \n-Once bleeding has stopped, call your surgeon to report what \nhappened. \n-If bleeding does not stop, call ___ for transfer to closest \nEmergency Room. \n•You may shower 48 hours after surgery. Let the soapy water \nrun over the puncture sites, then rinse and pat dry. Do not rub \nthese sites and do not apply cream, lotion, ointment or powder. \n•Wear loose-fitting pants and clothing as this will be less \nirritating to the groin puncture sites. \n\nMEDICATIONS\n•You have been instructed to stop taking asprin. \n• Please continue Coumadin. \n• You have been provided with prescription for Plavix and \nCiloztazol. These medications will replace aspirin while you \nare taking them. \n•You will be given prescriptions for any new medication started \nduring your hospital stay.\n•Before you go home, your nurse ___ give you information about \nnew medication and will review all the medications you should \ntake at home. Be sure to ask any questions you may have. If \nsomething you normally take or may take is not on the list you \nreceive from the nurse, please ask if it is okay to take it. \nPAIN MANAGEMENT\n•Most patients do not have much pain following this procedure. \n Your puncture sites may be a little sore. This will improve \ndaily. If it is getting worse, please let us know.\n•You will be given instructions about taking pain medicine if \nyou need it.\n\nACTIVITY\n•You must limit activity to protect the puncture sites in your \ngroin. For ONE WEEK:\n-Do not drive\n-Do not swim, take a tub bath or go in a Jacuzzi or hot tub\n-Do not lift, push, pull or carry anything heavier than five \npounds\n-Do not do any exercise or activity that causes you to hold your \nbreath or bear down with your abdominal muscles.\n-Do not resume sexual activity\n•Discuss with your surgeon when you may return to other regular \nactivities, including work. If needed, we will give you a \nletter for your workplace. \n•It is normal to feel weak and tired. This can last six-eight \nweeks, but should get better day by day. You may want to have \nhelp around the house during this time.\n___ push yourself too hard during your recovery. Rest when \nyou feel tired. Gradually return to normal activities over the \nnext month.\n•We encourage you to walk regularly. Walking, especially \noutdoors in good weather is the best exercise for circulation. \nWalk short distances at first, even in the house, then do a \nlittle more each day.\n•It is okay to climb stairs. You may need to climb them slowly \nand pause after every few steps. \n\nDIET\n•It is normal to have a decreased appetite. Your appetite will \nreturn over time.\n•Follow a well balance, heart-healthy diet, with moderate \nrestriction of salt and fat. \n•Eat small, frequent meals with nutritious food options (high \nfiber, lean meats, fruits, and vegetables) to maintain your \nstrength and to help with wound healing.\nBOWEL AND BLADDER FUNCTION\n•You should be able to pass urine without difficulty. Call you \ndoctor if you have any problems urinating, such as burning, \npain, bleeding, going too often, or having trouble urinating or \nstarting the flow of urine. Call if you have a decrease in the \namount of urine. \n•You may experience some constipation after surgery because of \npain medicine and changes in activity. Increasing fluids and \nfiber in your diet and staying active can help. To relief \nconstipation, you may talk a mild laxative. Please take to \nyour pharmacist for advice about what to take. \nSMOKING\n•If you smoke, it is very important that you STOP. Research \nshows smoking makes vascular disease worse. This could increase \nthe chance of a blockage in your new graft. Talk to your \nprimary care physician about ways to quit smoking. \n\n \nFollowup Instructions:\n___\n" ]

[ "T82858A", "Y831", "Y929", "E872", "N390", "B9620", "I714", "I739", "I4891", "I10", "E785", "K219", "I2510", "N400", "G4733", "F4310", "F419", "F329", "M353", "R000", "I491", "R791", "Z23", "Z7901", "Z7902", "Z951", "Z955", "Z86718", "Z85820", "Z87891" ]

[ "T82858A: Stenosis of other vascular prosthetic devices, implants and grafts, 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", "Y929: Unspecified place or not applicable", "E872: Acidosis", "N390: Urinary tract infection, site not specified", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "I714: Abdominal aortic aneurysm, without rupture", "I739: Peripheral vascular disease, unspecified", "I4891: Unspecified atrial fibrillation", "I10: Essential (primary) hypertension", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "G4733: Obstructive sleep apnea (adult) (pediatric)", "F4310: Post-traumatic stress disorder, unspecified", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified", "M353: Polymyalgia rheumatica", "R000: Tachycardia, unspecified", "I491: Atrial premature depolarization", "R791: Abnormal coagulation profile", "Z23: Encounter for immunization", "Z7901: Long term (current) use of anticoagulants", "Z7902: Long term (current) use of antithrombotics/antiplatelets", "Z951: Presence of aortocoronary bypass graft", "Z955: Presence of coronary angioplasty implant and graft", "Z86718: Personal history of other venous thrombosis and embolism", "Z85820: Personal history of malignant melanoma of skin", "Z87891: Personal history of nicotine dependence" ]

[ "Y929", "E872", "N390", "I4891", "I10", "E785", "K219", "I2510", "N400", "G4733", "F419", "F329", "Z7901", "Z7902", "Z951", "Z955", "Z86718", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nSimvastatin / Prochlorperazine / Celexa / Paxil / alendronate \nsodium / Zocor / azithromycin / Isosorbide\n \nAttending: ___.\n \nChief Complaint:\nType IB endoleak\n \nMajor Surgical or Invasive Procedure:\n___ PROCEDURES PERFORMED:\n1. Ultrasound-guided access to the left common femoral\n artery and placement of a ___ sheath.\n2. Abdominal aortogram and pelvic arteriogram.\n3. Left hypogastric coil embolization using 10 mm Interlock\n coils.\n4. Left Common iliac stent graft extension with the proximal\ngraftbeing a 16 x 20 x 9.5 Gore iliac limb\n\n5. Left EIA graft extension\n graft with a 16 x 12 x 12 Gore iliac limb.\n6. Left groin access site closure using a Perclose ProGlide\n device.\n\n \nHistory of Present Illness:\nMr. ___ is a ___ y.o. male who underwent EVAR in ___, right \nlimb extension in ___ for Type I endoleak and additionally \nbilat renal artery stenting who presents for left limb extension \nin the setting of large type 1B endoleak from the left limb. \n \nPast Medical History:\n1. Hypertension. \n2. Hyperlipidemia. \n3. PMR - on prednisone and Celebrex \n4. AAA s/p EVAR ___ - R limb extension ___. Coronary artery disease, status post CABG x3 in ___ with \nsubsequent angioplasty to saphenous vein grafts to the RCA and \nto the PDA in ___, angioplasty x 13. Angioplasty of the \nSVG-PDA and PL branch ___. \n6. OSA on CPAP \n7. PTSD \n8. Anxiety \n9. Sarcoid dx on biopsy of LNs -otherwise asymptomatic \n10. h/o Malaria \n11. Osteopenia/arthritis \n12. renal artery stenosis s/p bilat RAS\n13. sciatica \n\n \nSocial History:\n___\nFamily History:\nFather deceased had AAA and emphysema \nMother deceased from ___ \n\n \nPhysical Exam:\nPhysical ___ and oriented x 3 \nVSS, pt afebrile, normotensive, SpO2 >95% on RA\nResp: Lungs ___\nCV: RRR\nAbd: Soft, non distended, LLQ slightly tender to palp ___, no \nrebound\nExt: Pulses:  Palp fems, pops and DP's\nFeet warm,  well perfused.  No open areas. N edema\n___ groin access site: Dressing clean dry and intact. \nSoft, no hematoma or ecchymosis\n\n \nPertinent Results:\n___ 05:55AM BLOOD WBC-8.6 RBC-3.25* Hgb-10.0*# Hct-31.2* \nMCV-96 MCH-30.8 MCHC-32.1 RDW-13.7 RDWSD-48.1* Plt ___\n___ 05:55AM BLOOD Glucose-98 UreaN-12 Creat-0.9 Na-138 \nK-3.1* (repleted) Cl-100 HCO3-25 AnGap-16\n___ 05:55AM BLOOD Phos-4.5 Mg-1.3*\n\nCTA ___ \nS/P EVAR. Interval retraction/detachment of the distal left \nendograft limb with contrast leak into the aneurysmal sac \nconsistent with type 1B endoleak. The endograft limb retracted \nfrom the ipsilateral common iliac into the distal aortic \naneurysmal sac. The aneurysmal sac increased.\n \nBrief Hospital Course:\nMr. ___ is a ___ y.o. male who underwent EVAR in ___, right \nlimb extension in ___ for Type I endoleak and additionally \nbilat renal artery stenting who presents for left limb extension \nin the setting of large type 1B endoleak from the left limb.\n\nThe patient was brought to the operating room on ___ and \nunderwent extension of EVAR left iliac limb into L EIA and coil \nembolization of left hypogastric. The procedure was without \ncomplications. Please see operative report for procedural \ndetails. He was transferred to the floor in stable condition \nwhere he remained hemodynamically stable. At the time of \ndischarge he is tolerating a regular diet, is independantly \nambulatory, voiding and passing flatus. On the day of discharge \nhe did c/o dizziness that has been ongoing for ___ year and was \nnoted to be mildly orthostatic. He is discharged on atenolol \n25mg once daily, down from his home BID dose and 1 week followup \nhas been made with his PCP. Additionally he was hypokalemic on \nthe day of discharge for which he was repleted and instructed to \nfollow with his PCP. His left groin procedural access site is \nslightly tender to palpation but without ecchymosis, bleeding, \nhematoma, erythema or drainage. At the time of discharge he \ndenies any new abdominal or back pain. He was discharged to home \non POD #1 in stable condition. His PCP was contacted regarding \nwarfarin therapy which had been held pre-operatively. Given >6 \nmonths since last provoked DVT, per PCP this was discontinued. \nFollow-up has been arranged with Dr. ___ in 1 month with \nsurveillance CTA. One week followup to address hypokalemia and \northostasis / beta blockade titration has been arranged with his \nPCP. \n \n \nMedications on Admission:\n1. amlodipine 5 mg tablet (oral) 1 tablet(s) by mouth once a day\n2. atenolol 25 mg tablet (oral)1 tablet(s) by mouth twice a day\n3. clonazepam 1 mg tablet 1 tablet(s) by mouth at bedtime,, and \none prn during the day\n4. duloxetine [Cymbalta] 30 mg capsule,delayed ___ \n(oral) 3 capsule(s) by mouth daily\n5. nitroglycerin 0.4 mg Tablet, Sublingual 1 Tablet(s) \nsublingually for CP, may repeat times 3 every 5 mins\n6. nortriptyline 10 mg capsule (oral) 1 capsule(s) by mouth \nnightly \n7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) 1 Tablet(s) \nby mouth twice a day\n8. prednisone 5 mg tablet (oral) 1 tablet(s) by mouth once a \nday\n9. rosuvastatin [Crestor] 20 mg tablet (oral) 1 tablet(s) by \nmouth once a day\n10. sildenafil [Viagra] 25 mg tablet1 tablet(s) by mouth once \na day as needed for prior to sexual activity\n11. tamsulosin 0.4 mg capsule,extended release 24hr 1 (One) \ncapsule,extended release 24hr(s) by mouth ___\n12. warfarin [Coumadin] 2.5 mg tablet (oral) 1 tablet(s) by \nmouth once a day with 2 tablets on ___\n13. acetaminophen 325 mg Tablet 2 Tablet(s) by mouth as needed \nfor pain, not to exceed 4g daily\n14. aspirin [Adult Low Dose Aspirin] 81 mg tablet,delayed \nrelease (___) (oral) 1 tablet(s) by mouth daily\n15. calcium carbonate 1 (One) Tablet(s) by mouth twice a day\n16. docusate sodium [Colace] 100 mg capsule 1 (One) capsule(s) \nby mouth one/two times a day\n \n \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN pain \n2. Amlodipine 5 mg PO DAILY \n3. Aspirin EC 81 mg PO DAILY \n4. Duloxetine 90 mg PO DAILY \n5. Pantoprazole 40 mg PO Q12H \n6. PredniSONE 5 mg PO DAILY \n7. Rosuvastatin Calcium 20 mg PO QPM \n8. Tamsulosin 0.4 mg PO QHS \n9. Nitroglycerin SL 0.4 mg SL ONCE chest pain Duration: 1 Dose \n1 tab sublingual for chest pain, may repeat every 5 min x3. \n10. Nortriptyline 10 mg PO QHS \n11. Viagra (sildenafil) 25 mg oral once daily for sexual \nactivity \ndo not take with nitrates \n12. Docusate Sodium 100 mg PO BID constipation \n13. Calcium Carbonate 600 mg PO BID \n14. Atenolol 25 mg PO DAILY \n15. clonazepam 1 mg tablet 1 tablet(s) by mouth at bedtime,, \nand one prn during the day\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nType IB endoleak from left iliac limb s/p EVAR ___\n\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 here at ___ \n___. You were admitted to our hospital with \nfor repair of your vascular stent graft endoleak. You tolerated \nthe procedure well and are now ready to be discharged to home. \nPlease follow the recommendations below to ensure a speedy and \nuneventful recovery.\n\nMEDICATIONS:\n• Take Aspirin 81 mg once daily \n* Your warfarin has been discontinued per your primary care \ndoctor\n• You make take Tylenol or prescribed pain medications for any \npost procedure pain or discomfort\n\nWHAT TO EXPECT AT HOME:\nIt is normal to have slight swelling of the legs:\n• Elevate your leg above the level of your heart (use ___ \npillows or a recliner) every ___ hours throughout the day and at \nnight\n• Avoid prolonged periods of standing or sitting without your \nlegs elevated\nIt is normal to feel tired and have a decreased appetite, your \nappetite will return with time \n• Drink plenty of fluids and 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\nACTIVITIES:\n• When you go home, you may walk and go up and down stairs\n• You may shower (let the soapy water run over groin incision, \nrinse and pat dry)\n• Your puncture site may be left uncovered, unless you have \nsmall amounts of drainage from the wound, then place a dry \ndressing or band aid over the area that is draining, as needed\n• No heavy lifting, pushing or pulling (greater than 5 lbs) for \n1 week (to allow groin puncture to heal)\n• After 1 week, you may resume sexual activity\n• After 1 week, gradually increase your activities and distance \nwalked as you can tolerate\n• No driving until you are no longer taking pain medications\n\n \nFollowup Instructions:\n___\n" ]

[ "T82538A", "Y831", "E876", "Z86718", "E785", "R42", "I10", "I2510", "Z951", "G4733", "M353", "D869", "M810", "Z87310", "K219", "K449", "K2270", "I701", "Z85820", "Z87891", "F4310", "F419", "F329" ]

[ "T82538A: Leakage of other cardiac and vascular devices and implants, 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", "E876: Hypokalemia", "Z86718: Personal history of other venous thrombosis and embolism", "E785: Hyperlipidemia, unspecified", "R42: Dizziness and giddiness", "I10: Essential (primary) hypertension", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "G4733: Obstructive sleep apnea (adult) (pediatric)", "M353: Polymyalgia rheumatica", "D869: Sarcoidosis, unspecified", "M810: Age-related osteoporosis without current pathological fracture", "Z87310: Personal history of (healed) osteoporosis fracture", "K219: Gastro-esophageal reflux disease without esophagitis", "K449: Diaphragmatic hernia without obstruction or gangrene", "K2270: Barrett's esophagus without dysplasia", "I701: Atherosclerosis of renal artery", "Z85820: Personal history of malignant melanoma of skin", "Z87891: Personal history of nicotine dependence", "F4310: Post-traumatic stress disorder, unspecified", "F419: Anxiety disorder, unspecified", "F329: Major depressive disorder, single episode, unspecified" ]

[ "Z86718", "E785", "I10", "I2510", "Z951", "G4733", "K219", "Z87891", "F419", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nSimvastatin / Prochlorperazine / Celexa / Paxil / alendronate \nsodium / Zocor / azithromycin / Isosorbide\n \nAttending: ___.\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\nCardiac catheterization (___)\n\n \nHistory of Present Illness:\n___ PMH of CAD s/p CABG x3 with multiple angioplasties (total \n17) to the RCA, PDA, SVG-PDA, and PL branch, AAA s/p EVAR, HTN, \nHL, OSA, who presents with chest pain. He notes that he started \nhaving chest pain earlier this morning. This was after he got up \nthis morning. He says that the pain is in the upper chest, \nradiates to the throat, no shortness of breath. This is exactly \nthe same as his cardiac chest pain in the past. He also started \nnoticing some lightheadedness that was related to position \nstarting yesterday and worsening today. He has had this \nsignificantly since having his last femoral bypass in ___, \nbut he states that for the most part the lightheadedness had \nbeen improving. He denies any other symptoms. He presented to an \nOSH and had negative troponin, normal CXR. He had taken some \nnitro, which he said were old, and did not help his pain. In the \nED he had negative troponin, unremarkable chest xray. He was \ntransferred here, en route he had new significant chest pain \nthat was throughout the chest and into the abdomen. Has never \nhad pain like this before. It lasted for two to three hours and \ndid not improve with nitro or morphine, but did improve with \nAtivan. He does note that he is very anxious. \n In the ED initial vitals were: 98.0 50 148/72 16 95% RA \n EKG: sinus rhythm at 85, TWI in III, AVF, AVR, V1-V3, normal \nintervals, slight ST depression in v2 unchanged \n Labs/studies notable for: WBC 7.4, H/H 12.6/38.9, normal Chem7, \ntrop <0.01 x2 \n Patient was given: Ativan, aspirin, nitro SL x2, IV morphine, \nGI cocktail \n Vitals on transfer: 97.9 85 121/56 14 94% RA \n On the floor, he said his chest pain had resolved but his \nlightheaded symptoms were slightly worse. \n ROS: On review of systems, denies any prior history of stroke, \nTIA, deep venous thrombosis, pulmonary embolism, bleeding at the \ntime of surgery, myalgias, joint pains, cough, hemoptysis, black \nstools or red stools. Denies recent fevers, chills or rigors. \nDenies exertional buttock or calf pain. All of the other review \nof systems were negative. Cardiac review of systems is notable \nfor absence of dyspnea on exertion, paroxysmal nocturnal \ndyspnea, orthopnea, ankle edema, palpitations. \n\n \nPast Medical History:\n1. Hypertension. \n2. Hyperlipidemia. \n3. PMR - on prednisone and Celebrex \n4. AAA s/p EVAR ___ - R limb extension ___. Coronary artery disease, status post CABG x3 in ___ with \nsubsequent angioplasty to saphenous vein grafts to the RCA and \nto the PDA in ___, angioplasty x 13. Angioplasty of the \nSVG-PDA and PL branch ___. \n6. OSA on CPAP \n7. PTSD \n8. Anxiety \n9. Sarcoid dx on biopsy of LNs -otherwise asymptomatic \n10. h/o Malaria \n11. Osteopenia/arthritis \n12. renal artery stenosis s/p bilat RAS\n13. sciatica \n\n \nSocial History:\n___\nFamily History:\nFather deceased had AAA and emphysema \nMother deceased from ___ \n\n \nPhysical Exam:\nADMISSION:\nVS: 97.7 144/83 92 18 93%RA \n-Weight: 87.2kg \nGENERAL: NAD. Oriented x3. Mood, affect appropriate. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa. No xanthelasma. \n\nNECK: Supple with no elevated JVP. \nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. RR, normal S1, S2. No murmurs. Notable sternotomy scar. \nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp \nwere unlabored, no accessory muscle use. No crackles, wheezes or \nrhonchi. \nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: No c/c/e. No femoral bruits. \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \nPULSES: Distal pulses palpable and symmetric \n\nDISCHARGE:\nVS: 98.0 152/86 (110-52/50-80) 78 16 99% CPAP\n-Weight 86.4kg (<-87.2kg) \nI/O: ___ / 80/850\nGENERAL: NAD, resting in bed. Oriented x3. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP clear. \nNECK: Supple with no elevated JVP. \nCARDIAC: large mid-sternal well-healing scar ___ sternotomy. PMI \nlocated in ___ intercostal space, midclavicular line. RRR, \nnormal S1, S2. No murmurs. \nLUNGS: CTAB, No crackles, wheezes or rhonchi. \nABDOMEN: Soft, NTND. (+)LLQ TTP, no rebound/guarding\nEXTREMITIES: WWP, no edema/cyanosis/clubbing \nPULSES: Distal pulses palpable and symmetric 2+\n\n \nPertinent Results:\nADMISSION:\n___ 03:55PM WBC-7.4 RBC-4.13*# HGB-12.6*# HCT-38.9* \nMCV-94 MCH-30.5 MCHC-32.4 RDW-13.7 RDWSD-46.3\n___ 03:55PM GLUCOSE-108* UREA N-18 CREAT-1.1 SODIUM-138 \nPOTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-21* ANION GAP-17\n\nPERTINENT:\n___ 03:55PM BLOOD cTropnT-<0.01\n___ 10:34PM BLOOD cTropnT-<0.01\n___ 06:25AM BLOOD cTropnT-<0.01\n___ 06:40AM BLOOD Cortsol-1.3*\n\nIMAGING:\n-ECG (___): Sinus rhythm. The limb leads are misattached. \nThere is continued evidence for prior inferior wall myocardial \ninfarction. Non-specific anterior and apical ST-T wave \nabnormalities. A repeat tracing of diagnostic quality is \nsuggested. \n-Cardiac cath (___): \nCoronary Anatomy\nDominance: Right\nThe LMCA had no angiographically apparent CAD. the LAD was \nostially occluded. The Cx had serial moderate lesions ranging \nfrom ___ severity. The RCA was known occluded. The SVG to PDA \nwas widely patent with the previously treated segment showing \nonly mild disease at the touchdown. The graft itself had distal \n30% stenosis unchanged from prior.\nImpressions:\n1. Moderate CAD not significantly changed from ___.\nRecommendations\n1. Medical therapy.\n2. Follow-up Dr. ___.\n-TTE (___): The left atrium is elongated. No atrial septal \ndefect is seen by 2D or color Doppler. There is mild symmetric \nleft ventricular hypertrophy with normal cavity size and \nregional/global systolic function (LVEF>55%). There is no \nventricular septal defect. Right ventricular chamber size and \nfree wall motion are normal. The aortic root is mildly dilated \nat the sinus level. The ascending aorta is mildly dilated. The \naortic valve leaflets (3) are mildly thickened but aortic \nstenosis is not present. No aortic regurgitation is seen. The \nmitral valve leaflets are mildly thickened. Mild (1+) mitral \nregurgitation is seen. The pulmonary artery systolic pressure \ncould not be determined. There is no pericardial effusion. \n\nDISCHARGE:\n___ 06:30AM BLOOD WBC-7.6 RBC-4.07* Hgb-12.5* Hct-38.6* \nMCV-95 MCH-30.7 MCHC-32.4 RDW-13.7 RDWSD-46.4* Plt ___\n___ 06:30AM BLOOD ___ PTT-26.5 ___\n___ 06:30AM BLOOD Glucose-89 UreaN-15 Creat-1.1 Na-141 \nK-4.0 Cl-103 HCO3-25 AnGap-17\n___ 06:30AM BLOOD Calcium-9.2 Phos-2.9 Mg-2.___ M PMHx CABG x3 (___) s/p multiple angioplasties (x17), AAA \ns/p EVAR (___), HTN, HLD, OSA, PMR, right hip pain who \npresented with exertional chest pain, lightheadedness c/f \nunstable angina s/p cardiac cath showing and low AM cortisol c/f \nadrenal insufficiency.\n\n#Chest pain: patient presented to OSH due to having increased \nfrequency of episodes of his \"typical chest pain\"; described \njust above the sterum, (+) radiation to throat, occurring \nw/exertion. He received SL nitro with improvement in his pain. \nTrops negative, ECG without evidence of ischemic changes at OSH. \nHe was transferred to ___ for further management. On transfer, \npatient had an episode of severe, diffuse chest pain that did \nnot improve with nitro/morphin; however he received Ativan with \nimprovement, c/f anxiety. Following transfer, his troponins were \ntrended and were negative x3. His ECG was concerning for ?ST \ndepressions in inferior leads; he was started on a heparin gtt \nand continued on asa/statin/metoprolol. He underwent cardiac \ncath on ___ showing stable atherosclerotic disease from \nprevious cath (___), no interventions. Concern for anxiety \ncontributing to his increasing frequency of episodes of chest \npain. He will have close follow up with his Cardiologist and \nPCP. \n \n#Lightheadedness, c/f adrenal insufficiency: on admission \npatient described subacute episodes of lightheadedness, \nattributed to orthostasis vs medication-effect (tamsulosin was \ndiscontinued) as an outpatient. Of note, patient presented on \nprednisone taper at 5mg (down from 10mg the week before). He was \nmonitored on tele without evidence of arrhythmias. Orthostatics \nwere negative. AM cortisol found to be 1.8, consistent with \nadrenal insufficiency. ACTH was sent and was pending at \ndischarge. Given concern for symptomatic adrenal insufficiency, \nhis prednisone dose was increased to 15mg with plan for an \nextended taper; patient will have close follow up with his PCP \nand ___ to determine exact course of taper. \n\n#Right hip pain: chronic issue; pt carries a diagnosis of \nsciatica and polymyalgia rheumatica. In addition, patient \nunderwent work-up for vascular cause of his pain given recent \nEVAR. Also concerning for possible hip fracture?, although pain \ndenied recent falls. His recent CT A/P was reviewed, which was \nnegative for acute pathology. He received Tylenol PRN for his \npain. He was monitored while ambulating in the hallways. He will \nfollow up with Physical Therapy as recommended by his PCP. \n\n#Depression, anxiety: patient was noted to have periods of \nworsening anxiety in hospital, requiring Ativan PRN. He was \ncontinued on home zonisamide, nortriptyline. He should have \ncontinued follow up with PCP/Psychiatry.\n\n#OSA: he was continued on home CPAP.\n\nTRANSITIONAL ISSUES:\n[] ACTH pending at discharge\n[] AM cortisol 1.8 c/w adrenal insuffiency; he was discharged on \nprednisone 15mg with plan to continue long taper over x9 weeks; \nrec close follow up and direction re: taper by Rheumatologist\n[] if ongoing chest pain, c/s initiation of imdur\n[] pt w/severe anxiety in hospital contributing to chest pain; \nrecommend ongoing medication titration/counseling as outpatient \n# CODE: Full \n# CONTACT: ___ (wife) ___ \n \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. PredniSONE 5 mg PO DAILY \n2. Acetaminophen 650 mg PO Q6H:PRN pain \n3. Zonisamide 25 mg PO DAILY \n4. ClonazePAM 1 mg PO QHS:PRN bed \n5. Atenolol 50 mg PO DAILY \n6. Docusate Sodium 100 mg PO BID \n7. Rosuvastatin Calcium 40 mg PO QPM \n8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n9. sildenafil 25 mg oral ONCE:PRN sex \n___. Clopidogrel 75 mg PO DAILY \n11. Pantoprazole 40 mg PO Q12H \n12. Calcium Carbonate 1500 mg PO BID \n13. Aspirin 81 mg PO DAILY \n14. DULoxetine 90 mg PO DAILY \n15. alfuzosin 10 mg oral Q24H \n16. Nortriptyline 10 mg PO QHS \n17. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN pain \n2. Aspirin 81 mg PO DAILY \n3. Calcium Carbonate 1500 mg PO BID \n4. ClonazePAM 1 mg PO QHS:PRN bed \n5. Clopidogrel 75 mg PO DAILY \n6. Docusate Sodium 100 mg PO BID \n7. DULoxetine 90 mg PO DAILY \n8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain \n9. Nortriptyline 10 mg PO QHS \n10. Pantoprazole 40 mg PO Q12H \n11. Rosuvastatin Calcium 40 mg PO QPM \n12. Zonisamide 25 mg PO DAILY \n13. alfuzosin 10 mg oral Q24H \n14. Sildenafil 25 mg ORAL ONCE:PRN before activity \n15. PredniSONE 15 mg PO DAILY \nRX *prednisone 5 mg 3 tablet(s) by mouth daily Disp #*105 Tablet \nRefills:*0\n16. Vitamin D ___ UNIT PO DAILY \n17. Metoprolol Succinate XL 25 mg PO ONCE Duration: 1 Dose \nRX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*6\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES:\n-Chest pain\n-Adrenal insufficiency\n\nSECONDARY DIAGNOSES:\n-Lightheadedness\n-Right hip pain\n-Polymyalagia rheumatic\n-Hypertension\n-Depression\n-Anxiety\n-Obstructive sleep apnea, on CPAP\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___\n\n___ were admitted to ___ due to chest pain. ___ underwent a \ncardiac catheterization on ___ which showed stable plaques in \nyour arteries and did not require intervention. ___ should \ncontinue taking your aspirin, Plavix, and rosuvastatin. We are \nalso concerned that anxiety is contributing to your chest pain; \nplease continue taking your Klonopin as needed. Please follow up \nwith your Cardiologist and Primary Care Doctor. \n\nIn addition, ___ were noted to have a low cortisol level, \nconcerning for adrenal insufficiency. This means that your \nadrenal glands are not producing enough cortisol on their own. \nThis is likely because of being on prednisone. ___ were started \non prednsone 15mg; please follow up with your Rheumatologist for \nfurther direction of your prednisone taper.\n\nThank ___ for letting us be a part of your care!\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "R079", "E2740", "I10", "I25119", "Z87891", "G8929", "M25551", "M353", "F329", "F419", "G4733", "Z951", "Z7952" ]

[ "R079: Chest pain, unspecified", "E2740: Unspecified adrenocortical insufficiency", "I10: Essential (primary) hypertension", "I25119: Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris", "Z87891: Personal history of nicotine dependence", "G8929: Other chronic pain", "M25551: Pain in right hip", "M353: Polymyalgia rheumatica", "F329: Major depressive disorder, single episode, unspecified", "F419: Anxiety disorder, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z951: Presence of aortocoronary bypass graft", "Z7952: Long term (current) use of systemic steroids" ]

[ "I10", "Z87891", "G8929", "F329", "F419", "G4733", "Z951" ]

[]

[ " \nName: ___ ___ No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Allergies/ADRs on File\n \nAttending: ___.\n \nChief Complaint:\nSTEMI\n \nMajor Surgical or Invasive Procedure:\nIABP (placed at ___ \n___: Cardiac catheterization with placement of ___ 2 to \nLAD and Circumflex (at ___)\n\n \nHistory of Present Illness:\n___ w/ PMHx of IDDM, HTN and PVD s/p bypass surgery who presents \nas transfer from ___ with STEMI s/p DEX x2 to LAD \nand LCx and intraprocedural IABP placed for hypotension. \n\nShe reports being in her usual state of health when she \ndeveloped severe substernal chest pain, back pain and arm pain \nwith nausea. she presented to ___, taken to cath lab where \nDES x2 to LAD and LCx with hypotension to ___ s/p IABP \nplacement. Per report developed vomiting immediately after \nantiplatelet load and concern she did not actually receive the \nmedication. She was then transferred to ___ for further \nmanagement.\n\nOn arrival to the CCU she reports significant improvement in her \nchest pain and shortness of breath. She has a sensation of \nnumbness in her abdomen which is not exactly pain and comes and \ngoes. This was one of the symptoms she had at her OSH \npresentation. \n\nShe endorses hx of cardiac disease in multiple family members as \nbelow. She also reports unilateral RLE swelling since a flight \nto ___ a week ago with recent negative ___ (this is the \nleg where bypass was done). MAPs high, norepi drip weaned.\n \nROS: Positive per HPI. Remaining 10 point ROS reviewed and \nnegative\n \n\n \nPast Medical History:\n1. CARDIAC RISK FACTORS \n- Diabetes - yes\n- Hypertension - yes\n- Dyslipidemia - unknown\n2. CARDIAC HISTORY \n- CAD: as above\n- Pump - unkown\n- Rhythm - currently sinus\n3. OTHER PAST MEDICAL HISTORY \n\n \nSocial History:\n___\nFamily History:\nfather - MI in ___\nMother afib/bradycardia age ___\nsister: emergent ___ surgery age ___\n2 nephews with blood clots and heart disease \n\n \nPhysical Exam:\nADMISSION EXAM: \nVS: T 97.8, HR 94, BP 146/78, RR 18, O2 92% 3L\nGENERAL: Well developed, well nourished in NAD. Oriented x3. \nMood, affect appropriate. Lying flat in bed. \nHEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. \nConjunctiva were pink. No pallor or cyanosis of the oral mucosa. \nNECK: Supple. JVP not appreciated ___ body habitus \nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. Regular rate and rhythm. Normal S1, S2. No m/r/g\nLUNGS: No chest wall deformities or tenderness. Respiration is \nunlabored with no accessory muscle use. bibasilar crackles. \nABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No \nsplenomegaly. \nEXTREMITIES: Warm, well perfused. Pulses not palpable. Balloon \npump in place in ___ without hematoma. 1+ edema in RLE. \nSKIN: No significant skin lesions or rashes. \nPULSES: Distal pulses intact\n\nDISCHARGE EXAM: \n\nGENERAL: Well developed, well nourished in NAD. Oriented x3.\nHEENT: PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis \nof the oral mucosa. NECK: Supple. JVP not appreciated ___ body \nhabitus \nCARDIAC: Regular rate and rhythm. Normal S1, S2. No m/r/g\nLUNGS: Respiration is unlabored with no accessory muscle use. \nbibasilar crackles. \nABDOMEN: Soft, non-tender, non-distended. \nEXTREMITIES: Warm, well perfused. \nSKIN: No significant skin lesions or rashes. \nPULSES: Distal pulses intact\n\n \nPertinent Results:\nAdmission labs: \n___ 07:00PM BLOOD WBC-16.1* RBC-4.87 Hgb-13.7 Hct-41.4 \nMCV-85 MCH-28.1 MCHC-33.1 RDW-13.4 RDWSD-41.7 Plt ___\n___ 07:00PM BLOOD Neuts-88.1* Lymphs-8.5* Monos-2.7* \nEos-0.1* Baso-0.1 Im ___ AbsNeut-14.14* AbsLymp-1.37 \nAbsMono-0.44 AbsEos-0.01* AbsBaso-0.02\n___ 07:00PM BLOOD ___ PTT-69.7* ___\n___ 07:00PM BLOOD Glucose-190* UreaN-13 Creat-0.6 Na-137 \nK-3.8 Cl-106 HCO3-22 AnGap-13\n___ 07:00PM BLOOD ALT-85* AST-462* AlkPhos-98 TotBili-0.3\n___ 07:00PM BLOOD CK-MB->600* cTropnT-9.07*\n___ 04:10AM BLOOD CK-MB->600* cTropnT-___*\n___ 07:00PM BLOOD Albumin-3.6 Calcium-8.6 Phos-2.3* Mg-1.8\n___ 07:12PM BLOOD Type-ART pO2-73* pCO2-31* pH-7.46* \ncalTCO2-23 Base XS-0\n___ 07:12PM BLOOD Lactate-1.2\n\nInterval labs: \n\n___ 07:00PM BLOOD CK-MB->600* cTropnT-9.07*\n___ 04:10AM BLOOD CK-MB->600* cTropnT-12.07*\n___ 12:28PM BLOOD CK-MB-261* cTropnT-5.88*\n\nDischarge labs: \n\n___ 07:40AM BLOOD WBC-11.0* RBC-4.21 Hgb-12.1 Hct-37.1 \nMCV-88 MCH-28.7 MCHC-32.6 RDW-13.6 RDWSD-43.7 Plt ___\n___ 08:10AM BLOOD ___\n___ 07:40AM BLOOD Glucose-179* UreaN-14 Creat-0.6 Na-135 \nK-4.3 Cl-101 HCO3-26 AnGap-12\n___ 05:51AM BLOOD ALT-64* AST-128* AlkPhos-82 TotBili-0.5\n___ 07:40AM BLOOD Calcium-8.3* Phos-2.6* Mg-2.0\n\nSTUDIES:\n\nTTE ___\nThe left atrium is elongated. No atrial septal defect is seen by \n2D or color Doppler. There is mild symmetric left ventricular \nhypertrophy. The left ventricular cavity size is normal. There \nis moderate regional left ventricular systolic dysfunction with \nmid to distal anterior/anteroseptal/distal LV/apical \nhypokinesis. No masses or thrombi are seen in the left \nventricle. There is no ventricular septal defect. Right \nventricular chamber size and free wall motion are normal. 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. Mild (1+) mitral \nregurgitation is seen. The tricuspid valve leaflets are mildly \nthickened. There is mild pulmonary artery systolic hypertension. \nThere is no pericardial effusion. \n\n \nBrief Hospital Course:\n___ w/ PMHx of IDDM, HTN and PVD s/p bypass surgery who \npresented as transfer from ___ with STEMI s/p DES \nx2 to LAD and LCx, with intraprocedural intra-aortic balloon \npump placed for hypotension. Her balloon pump was weaned soon \nafter arrival to ___, and she did not require pressors. TTE \nrevealed newly depressed EF ___, with apical akinesis. She \nwas started on lovenox for bridging to Coumadin given her apical \nakinesis, and discharged with a LifeVest given her newly \ndepressed EF. She was also started on aspirin, ticagrelor, and \nmetoprolol. Her home ACE-I was not restarted due to SBPs \n___. She will have outpatient follow-up with her PCP and ___ \ncardiologist.\n\nACUTE ISSUES\n#HFrEF:\n#STEMI: Initial ECG at ___ with STE in V2-V3. \nTaken to cath lab emergently and underwent DES x2 to LAD and \nLCx. Course c/b hypotension with IABP placement, and for this \nreason she was transferred to ___. On arrival to ___ CCU, \nshe was chest pain free, and her ECG demonstrated resolved STEs, \nevolving q waves in V1-V3. She was started on ASA, ticagrelor, \nand atorvastatin. TTE revealed newly depressed EF to ___ with \napical hypokinesis. For this reason, she was started on lovenox \nbridging to Coumadin, and was discharged with a LifeVest. Her \nhome lisinopril 40mg was held at discharge due to systolic BPs \nin ___. She appeared relatively euvolemic at discharge, and so \nwas not started on any diuretics.\n\nCHRONIC ISSUES:\n#IDDM: Continued her home insulin regimen: lantus 30U, Humalog \n10U TID with meals, and Humalog sliding scale.\n#HTN: On amlodipine and lisinopril at home. Both held due to \nhypotension. \n\nTRANSITIONAL ISSUES:\n-Will need f/u TTE in ~1 month (middle of ___ to assess for \nrecovery of EF, need for ICD, need to continue anticoagulation\n-Should have INR checked on ___, stop lovenox once INR >2\n-Pantoprazole started for GI protection while on \nanticoagulation. Consider stopping this once anticoagulation is \nstopped/decreased\n-NEW MEDICATIONS: Aspirin, Ticagrelor, Atorvastatin, Metoprolol, \nLovenox, Warfarin, Pantoprazole\n-HELD MEDICATIONS: Amlodipine, Lisinopril--Given newly reduced \nEF, Lisinopril should be restarted preferentially as tolerated \nby BP\n\nCODE: Full\nCONTACT: ___daughter) ___\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Glargine 30 Units Bedtime\nHumalog 10 Units Breakfast\nHumalog 10 Units Lunch\nHumalog 10 Units Dinner\n2. Lisinopril 40 mg PO DAILY \n3. amLODIPine 5 mg PO DAILY \n4. Vitamin D 4000 UNIT PO DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n2. Atorvastatin 80 mg PO QPM \nRX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0 \n3. Enoxaparin Sodium 80 mg SC BID \nStart: ___, First Dose: Next Routine Administration Time \nRX *enoxaparin 80 mg/0.8 mL 80 U SC twice a day Disp #*28 \nSyringe Refills:*0 \n4. Metoprolol Succinate XL 50 mg PO DAILY \nRX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0 \n5. Pantoprazole 40 mg PO Q24H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*0 \n6. TiCAGRELOR 90 mg PO BID \nRX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day \nDisp #*60 Tablet Refills:*3 \n7. Warfarin 5 mg PO DAILY16 \nRX *warfarin [Coumadin] 2.5 mg 2 tablet(s) by mouth daily Disp \n#*60 Tablet Refills:*0 \n8. Glargine 30 Units Bedtime\nHumalog 10 Units Breakfast\nHumalog 10 Units Lunch\nHumalog 10 Units Dinner \n9. Vitamin D 4000 UNIT PO DAILY \n10. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do \nnot restart amLODIPine until instructed to by your doctors\n11. HELD- Lisinopril 40 mg PO DAILY This medication was held. \nDo not restart Lisinopril until instructed to by your doctors\n\n \n___:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\nST elevation myocardial infarction\n\nSECONDARY DIAGNOSES:\nAcute heart failure with reduced ejection fraction\nInsulin dependent diabetes mellitus\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou came to the hospital because you were having chest pain.\n\nWhile you were in the hospital:\n-You were diagnosed with a heart attack\n-You had a procedure called a cardiac catheterization, and had a \nstent placed in an artery in your heart\n-You were started on some new medications to help protect the \nheart\n\nWhen you leave the hospital:\n \n-It is VERY important to take your aspirin and ticagrelor (also \nknown as Brilinta). You should not miss even 1 dose. \n-These two medications keep the stents in the vessels of the \nheart open and help reduce your risk of having a future heart \nattack. \n-If you stop these medications or miss ___ dose, you risk causing \na blood clot forming in your heart stents, and you may die from \na massive heart attack. \n-You should weigh yourself every day, and call your doctor if \nyour weight goes up by 3 pounds or more \n- Take all of your medications as prescribed (listed below) \n- Follow up with your doctors as listed below \n- Call your doctor if you have new or concerning symptoms or you \ndevelop chest pain, swelling in your legs, abdominal distention, \nor shortness of breath at night. \n\nIt was a pleasure taking care of you.\n\nSincerely,\nYour ___ Cardiology Team\n \nFollowup Instructions:\n___\n" ]

[ "I213", "I5021", "E119", "I739", "I2510", "Z9861", "Z794", "I110" ]

[ "I213: ST elevation (STEMI) myocardial infarction of unspecified site", "I5021: Acute systolic (congestive) heart failure", "E119: Type 2 diabetes mellitus without complications", "I739: Peripheral vascular disease, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z9861: Coronary angioplasty status", "Z794: Long term (current) use of insulin", "I110: Hypertensive heart disease with heart failure" ]

[ "E119", "I2510", "Z794", "I110" ]

[]

[ " \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:\nReason for Consult/CC: rectal pain \n \nMajor Surgical or Invasive Procedure:\nExam Under Anesthesua and ___ placement X2\n\n \nHistory of Present Illness:\nHPI: ___ with recent diagnosis of IBD presents with ___\nabscess and pain. Patient was recently diagnosed with IBD likely\nUC during a work up for anemia and weight loss. He also had\nhemorrhoids banded in ___ of this year, however, due to ongoing\nbleeding he had a sigmoidoscopy which showed multi-focal colitis\nand was given diagnosis of UC although further workup was in\nprogress (MRE). Patient reports that he has ___ bowel movements\nper day. Urgency in the morning. No incontinence. Occasionally\nblood and feels like he has hemorrhoids in that there is \npressure\nwhen he goes to the bathroom. He has also developed an \nincreasing\npain on the left side of his buttocks over the last six weeks. \nIt\nhas been draining a mixture of clear and purulent fluid over the\nlast week and his pain has been increasing. He denies fevers,\nchills, vomiting, nausea. He was seen by PCP who prescribed\ncephalexin but this did not have any effect on drainage or pain. \n\n\n \nPast Medical History:\nPMH: recently diagnosed IBD, beta thalassemia trait, iron \ndeficiency anemia \nPSH: hemorrhoid ligation ___ \n\n \nSocial History:\nmarried\n \nPhysical Exam:\nGeneral: post-op, doing well, arrived to floor\nVSS\nAlert and orientted\nCardio/Pulm: no chest pain or shortness of breath\nAbd: flat, soft\n\n \nPertinent Results:\n___ 07:30PM BLOOD WBC-7.7 RBC-6.24* Hgb-10.1* Hct-35.9* \nMCV-58* MCH-16.2* MCHC-28.1* RDW-19.3* RDWSD-34.8* Plt ___\n___ 07:30PM BLOOD Neuts-73.7* Lymphs-16.1* Monos-8.8 \nEos-0.6* Baso-0.4 Im ___ AbsNeut-5.70 AbsLymp-1.25 \nAbsMono-0.68 AbsEos-0.05 AbsBaso-0.03\n___ 07:30PM BLOOD Glucose-97 UreaN-9 Creat-0.9 Na-137 K-4.5 \nCl-98 HCO3-23 AnGap-16\n\n \n___ M ___ ___BD & PELVIS WITH CONTRAST Study Date of \n___ 10:15 ___ \nIMPRESSION: \n \n \n1. 5.3 x 1.8 cm rim enhancing fluid collection in the left \ngluteal cleft, \ncontiguous with the rectum, concerning for perianal abscess with \nfistulous \nconnection. If clinically warranted, may evaluate further with \nMRI. \n2. Inflammation of the transverse and distal ascending colon \nwith sparing of \nthe descending colon is atypical for ulcerative colitis. \nConsiderations \ninclude local therapy effect of the distal colon versus is \nalternative \ndiagnosis of Crohn's disease. \n\n \nBrief Hospital Course:\nMr. ___ was admitted to the inpatient colorectal service \nwith a perirectal abscess and fistula. On the morning of ___ \nhe was taken to the operating room where the abscess was drained \nand ___ was placed. He was discharged when he arrived back to \nthe inpatient unit. He should follow up with Dr. ___ his \nGI doctor as an outpatient. \n \nMedications on Admission:\nKeflex ___ tid\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild \ndo not take more than 3000mg of Tylenol in 24 hours or drink \nalcohol \n2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \ndo not drink alcohol or drive a car while taking this medication \n\nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*20 Tablet Refills:*0 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nperianal crohn's with abscess and posterior transsphincteric \nfistula \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 inpatient Colorectal Surgery Service \nwith a perirectal abscess ad fisutla and had drainage of \nperirectal abscess and ___ placement. You may return home. \nContinue to avoid constipation, drink water and you may take the \nmedication Colace if needed. Continue to shower daily especially \nafter bowel movements, this is the best way to keep this area \nclean. The ___ is a little rubber band allowing the area and \nabscess to drain. Please leave this in place. Call the office if \nthe ___ falls out.\n\nIf you have any of the following symptoms please call the office \nfor advice ___:\nfever greater than 101.5\nincreasing abdominal distension\nincreasing abdominal pain\nnausea/vomiting\ninability to tolerate food or liquids\nprolonged loose stool\nextended constipation\ninability to urinate\n\nIt is expected that you will have pain after surgery and this \npain will gradually improved over the first week or so you are \nhome. You will especially have pain when changing positions and \nwith movement. You should continue to take 2 Extra Strength \nTylenol (___) for pain every 8 hours around the clock for 7 \ndays. It is ok to stop if you do not need it. Please do not take \nmore than 3000mg of Tylenol in 24 hours or any other medications \nthat contain Tylenol such as cold medication. Do not drink \nalcohol while or Tylenol. If these medications are not \ncontrolling your pain to a point where you can ambulate and \npreform minor tasks, you should take a dose of the narcotic pain \nmedication Oxyocdone. Please take this only if needed for pain. \nDo not take with any other sedating medications or alcohol. Do \nnot drive a car if taking narcotic pain medications.\n\n \nFollowup Instructions:\n___\n" ]

[ "K610", "K5090", "L03317", "R634" ]

[ "K610: Anal abscess", "K5090: Crohn's disease, unspecified, without complications", "L03317: Cellulitis of buttock", "R634: Abnormal weight loss" ]

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[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nStatins-Hmg-Coa Reductase Inhibitors / minocycline\n \nAttending: ___.\n \nChief Complaint:\nCryptococcal meningitis \n \nMajor Surgical or Invasive Procedure:\n- Lumbar puncture x 2\n- RUE PICC line\n- Endotracheal intubtion\n- Indwelling urinary catheter placement\n___ - Exploratory laparotomy w/ temporary abdominal closure \nwith negative pressure wound VAC (ABThera).\n___ - Reopening of recent laparotomy, washout, and closure.\n\n \nHistory of Present Illness:\nThis is a ___ y/o man with a history\nof CAD s/p CABG, HTN, HLD, BPH, cryptococcal meningitis on\nfluconazole who presented to an outside hospital with altered\nmental status and was diagnosed with recurrent cryptococcal\nmeningitis and re-initiated on amphotericin B and flucytosine. \nHe\nwas transferred to ___ for further management for recurrent\ncryptococcal meningitis.\n\nHistory is obtained from chart review, as the ___ is unable\nto provide history secondary to altered mental status. \n\nThe ___ was discharged from ___ on ___ after \na\nprolonged stay for crypotococcal meningitis for which he was\ntreated with induction therapy with amphotericin B and\nflucytosine and then transitioned to oral fluconazole and\ndischarged. Of additional note, there is report that his ___ antibodies were also positive, however ID thought his\npresentation was more consistent with cryptococcal menigitis. \nHIV\nwas negative.\n\nHe reportedly was doing well at home until approximately 2 weeks\nprior to present when he developed fevers, confusion, headache,\nfor which he presented again to ___ on ___.\n\nLumbar puncture was performed that demonstrated positive\ncryptococcal antigen, high protein, and low glucose (no opening\npressure was recorded). Infectious disease was consulted, and he\nfluconazole was discontinued and amphotericin B was restarted on\n___ and flucytosine on ___. MRI brain demonstrated meningeal\nenhancement. Other infectious workup was notable for UTI. The\n___ has a chronic indwelling Foley for urinary retention, \nand\nurinalysis was positive with culture growing E. faecalis for\nwhich he was treated with ampicillin. The ___ Foley was\ndiscontinued, however he failed voiding trials and it was\nreplaced.\n\nA PICC line was placed, but the ___ self-discontinued this.\nHe was placed on mirtazapine and megace for appetite \nstimulation.\nThe ___ was frequently agitated throughout his\nhospitalization and required a 1:1 sitter. Psychiatry was\nconsulted and recommended Ativan for agitation.\n\nOn arrival, the ___ denies any physical complaints. He\nspecifically denies any headache, phono or photophobia, neck\nstiffness, numbness, tingling, or weakness. He denies nausea,\nvomiting, abdominal pain. He cannot recall where he is or why he\nis here. \n\n \nPast Medical History:\nCryptococcal meningitis as above\nCAD s/p CABG (___)\nHTN\nHLD\nBPH \nSpinal stenosis \nS/p right hip replacement\n\n \nSocial History:\n___\nFamily History:\nUnable to obtain from ___. Per chart, no history of GU \nmalignancy. History of early cardiac disease in multiple \nsiblings. Daughter deceased at age ___ from cystic fibrosis.\n\n \nPhysical Exam:\n==========================\nADMISSION PHYSICAL EXAM: \n==========================\n\n VS: 99.3 126/77 95 20 96 Ra \n GENERAL: AOx0, agitated and rambling, in no apparent distress \n HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM \n NECK: Supple, no meningismus \n HEART: RRR, S1/S2, III/VI systolic murmur at RUSB \n LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably \nwithout use of accessory muscles \n ABDOMEN: Nondistended, nontender in all quadrants \n GU: +Foley \n EXTREMITIES: No peripheral edema \n NEURO: AOx0, confused and intermittently agitated \n SKIN: No rashes \n\n==========================\nDISCHARGE PHYSICAL EXAM: \n==========================\nVitals: 98 92 / 62 99 19 99% RA \nGeneral: Elderly male laying in bed. NAD. Cooperative with exam\nand interview.\nHEENT: NCNT, dry mucous membranes, EOMI\nCV: RRR, normal S1,2, no m/r/g\nLungs: CTAB, no wheezes, rales, or rhonchi \nAbdomen: Nondistended, normoactive bowel sounds, nonTTP. Midline\nsurgical scar healing well, clean and dry without signs of\nerythema, induration, or exudate.\nGU: Foley.\nExt: No edema or cyanosis. PICC in LUE, no signs of erythema,\ninduration, or exudate.\nNeuro: AAOx3, cognition improved but ongoing difficulty with \nword\nfinding. Perseverative. Moving all 4 extremities with purpose.\nCNII-XII grossly intact. No focal deficits.\n \nPertinent Results:\nADMISSION LABS:\n===================\n\n___ 09:25AM GLUCOSE-112* UREA N-24* CREAT-1.0 SODIUM-136 \nPOTASSIUM-3.3 CHLORIDE-96 TOTAL CO2-19* ANION GAP-21*\n___ 09:25AM estGFR-Using this\n___ 09:25AM ALT(SGPT)-25 AST(SGOT)-17 LD(LDH)-158 ALK \nPHOS-98 TOT BILI-0.6\n___ 09:25AM ALBUMIN-3.9 CALCIUM-9.6 PHOSPHATE-4.8* \nMAGNESIUM-1.4*\n___ 09:25AM WBC-12.2* RBC-3.62* HGB-11.0* HCT-32.4* \nMCV-90 MCH-30.4 MCHC-34.0 RDW-13.3 RDWSD-43.8\n___ 09:25AM PLT COUNT-275\n___ 09:25AM ___ PTT-27.2 ___\n\n===================\nMICROBIOLOGY:\n=================== \nRPR ___: negative\nSputum Cx ___: sparse growth commensal flora\nUCx ___: no growth\nUCx ___: MSSA\nBCx ___ x2, ___ x2, ___ x2, ___ x2, ___ \nx2- no growth\nPICC tip Cx ___: no growth\n___ Ascitic fluid: no growth\n___ BCX: 2 BCx + for Staph Aureus, 1 positive for Enterococcus \nfaecalis\n___: C.Diff- negative\n\n___ 11:46 am CSF;SPINAL FLUID Source: LP #3. \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 FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n\n___ 11:46 am CSF;SPINAL FLUID Source: LP. \n **FINAL REPORT ___\n CRYPTOCOCCAL ANTIGEN (Final ___: \n ___ credited. Minimum 14 day interval for repeat \ntesting. \n PREVIOUS POSITIVE # 47___ ___ AT A TITER OF \n1:1280. \n TEST CANCELLED, ___ CREDITED. \n\n___ 7:55 am Blood (EBV) ADDED CMVP,EBVP ___. \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___ 7:55 am Blood (CMV AB) ADDED CMVP,EBVP ___. \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 CMV IgM ANTIBODY (Final ___: \n NEGATIVE FOR CMV IgM ANTIBODY BY EIA. \n INTERPRETATION: NO ANTIBODY DETECTED. \n Greatly elevated serum protein with IgG levels ___ mg/dl \nmay cause \n interference with CMV IgM results. \n\n___ 3:48 pm CSF;SPINAL FLUID Source: LP. \n **FINAL REPORT ___\n Enterovirus Culture (Final ___: No Enterovirus \nisolated. \n\n___ 3:48 pm CSF;SPINAL FLUID Source: LP. \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 FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. \n\n___ 3:48 pm CSF;SPINAL FLUID Source: LP. \n **FINAL REPORT ___\n QUANTITATIVE CRYPTOCOCCAL ANTIGEN (Final ___: \n POSITIVE FOR CRYPTOCOCCAL ANTIGEN. \n AT A TITER OF 1:1280. \n (Reference Range-Negative). \n Test performed by Lateral Flow Assay. \n Reported to and read back by ___. ___. (___) @ \n___ ON\n ___. \n\n CRYPTOCOCCAL ANTIGEN (Final ___: \n POSITIVE FOR CRYPTOCOCCAL ANTIGEN. \n (Reference Range-Negative). \n Test performed by Lateral Flow Assay. \n\n___ 3:48 pm CSF;SPINAL FLUID Source: LP. \n **FINAL REPORT ___\n QUANTITATIVE CRYPTOCOCCAL ANTIGEN (Final ___: \n POSITIVE FOR CRYPTOCOCCAL ANTIGEN. \n AT A TITER OF 1:1280. \n (Reference Range-Negative). \n Test performed by Lateral Flow Assay. \n Reported to and read back by ___. ___. (___) @ \n___ ON\n ___. \n\n CRYPTOCOCCAL ANTIGEN (Final ___: \n POSITIVE FOR CRYPTOCOCCAL ANTIGEN. \n (Reference Range-Negative). \n Test performed by Lateral Flow Assay. \n\n___ 7:17 am SEROLOGY/BLOOD\n **FINAL REPORT ___\n CRYPTOCOCCAL ANTIGEN (Final ___: \n POSITIVE FOR CRYPTOCOCCAL ANTIGEN. \n (Reference Range-Negative). \n Test performed by Lateral Flow Assay. \n\n QUANTITATIVE CRYPTOCOCCAL ANTIGEN (Final ___: \n POSITIVE FOR CRYPTOCOCCAL ANTIGEN. \n AT A TITER OF 1>=2560. \n (Reference Range-Negative). \n Test performed by Lateral Flow Assay. \n Reported to and read back by ___ \n(___) @\n 1810 ON ___. \n\n===================\nIMAGING:\n===================\nCT Abdomen and pelvis ___\nIMPRESSION: \n1. No findings to suggest bowel ischemia, no evidence of \nmechanical bowel \nobstruction. Stable dilated fluid-filled colon with segmental \nareas of mild mural stratification, which may be nonspecific; \nhowever, a mild underlying colitis cannot be excluded especially \ngiven history of antibiotic treatment, clinical correlate \nrecommended. Focal segmental wall thickening involving the \ndistal ileum could represent enteritis. \n2. Small hepatic hypodensity in segment 8, although this is too \nsmall to be characterized on this study, this is new compared to \nthe prior CTs and \nattention on follow-up imaging is recommended. \n\nTEE ___:\nNo spontaneous echo contrast or thrombus is seen in the body of \nthe left atrium/left atrial appendage or the body of the right \natrium/right atrial appendage. No atrial septal defect or patent \nforamen ovale is seen by 2D, color Doppler or saline contrast \nwith maneuvers. Overall left ventricular systolic function is \nnormal (LVEF>55%). Right ventricular chamber size and free wall \nmotion are normal. There are simple atheroma in the aortic arch. \nThere are simple atheroma in the descending thoracic aorta. The \naortic valve leaflets (3) appear structurally normal with good \nleaflet excursion and no aortic stenosis. No masses or \nvegetations are seen on the aortic valve. No aortic valve \nabscess is seen. No aortic regurgitation is seen. The mitral \nvalve leaflets are mildly thickened. There is no mitral valve \nprolapse. No mass or vegetation is seen on the mitral valve. No \nmitral valve abscess is seen. Mild (1+) mitral regurgitation is \nseen. There is no abscess of the tricuspid valve. The pulmonary \nartery systolic pressure could not be determined. No \nvegetation/mass is seen on the pulmonic valve. There is no \npericardial effusion. \n\n IMPRESSION: No definite vegetations or pathologic valvular flow \nidentified. No definite cardiac source of embolism identified. \nGrossly normal biventricular systolic function. Mild mitral \nregurgitation. \n\nCTA head/neck ___:\n1. Known right medial occipital lobe infarct, now late \nacute/early subacute. Additional small infarcts as seen on prior \nMRI are not well documented by CT. \n2. No evidence of hemorrhage. \n3. Atherosclerotic disease within the bilateral carotid bulbs \nand proximal \ninternal carotid arteries, with approximately 50% stenosis of \nthe proximal \nright ICA and less than 30% stenosis of the proximal left ICA by \nNASCET \ncriteria. \n4. Multifocal atherosclerotic disease within the bilateral \nvertebral arteries, as above. Findings are most significant \nwithin the proximal left V4 segment where there is severe \ncalcifications, with gross patency of the artery itself. \n5. Mild-to-moderate calcifications of the proximal right V4 \nsegment with mild caliber change distal to this. No evidence of \nintraluminal filling defect or dissection flap. \n\nMR head ___: IMPRESSION: \n1. New, focus of slow diffusion within the right medial \noccipital lobe, with numerous additional punctate areas of slow \ndiffusion within the posterior right parietal lobe, right \noccipital lobe, and bilateral cerebellar hemispheres. Findings \nare concerning for interval infarction, likely secondary to \nvascular involvement of the ___ known meningitis. \n2. Multiple micro hemorrhages are stable from the prior \nexamination. \n3. Increasingly prominent pachymeningeal enhancement, with a \nrelatively stable degree of leptomeningeal enhancement. \nFindings are compatible with known underlying meningitis, likely \nwith the superimposed effect of multiple interval lumbar \npunctures. \n4. Diffuse patchy T2/FLAIR signal abnormalities within the right \nfrontal lobe and bilateral periventricular white matter. These \nfindings are minimally progressed from the prior examination, \nand of uncertain etiology. They may represent areas of active \ninfection, a secondary superinfection, or treatment related \neffects. Additional diagnostic considerations include missed \nprior white matter infarctions secondary to vasculitis in the \nsetting of meningitis \n\nCTA a/p ___: IMPRESSION: \n1. No findings to suggest bowel ischemia, no evidence of \nmechanical bowel \nobstruction. Stable dilated fluid-filled colon with segmental \nareas of mild mural stratification, which may be nonspecific; \nhowever, a mild underlying colitis cannot be excluded especially \ngiven history of antibiotic treatment, clinical correlate \nrecommended. Focal segmental wall thickening involving the \ndistal ileum could represent enteritis. \n2. Small hepatic hypodensity in segment 8, although this is too \nsmall to be characterized on this study, this is new compared to \nthe prior CTs and \nattention on follow-up imaging is recommended. \n\nCTA A/P ___: IMPRESSION: \n-Distal ileal bowel loops with wall thickening and suggestion of \npneumatosis intestinalis, surrounded by mild ascites are highly \nsuspected for bowel necrosis. \n-Although there is no clear evidence of large bowel wall \nischemia, diffuse \ndilatation of the large bowel associated with large quantity of \nfluid and \nair-fluid levels, as well as heterogeneous enhancement of its \nwall-raises the possibility of ischemic colitis. \n-Severe atherosclerotic calcifications of the aorta and major \nbranches with no evidence of clear emboli. \n\nCT ABD & PELVIS WITH CONTRAST Study Date of ___ 4:14 ___ \nIMPRESSION: \n1. No acute intra-abdominal process. \n2. There is marked thickening of the urinary bladder which may \nbe related to \nchronic obstruction, however infection cannot be entirely \nexcluded. \nCorrelation with urinalysis is recommended. \n3. Prominent rectal fecal impaction. Disimpaction is advised. \n4. Additional findings as above. \n\nEEG ___\nIMPRESSION: This is an abnormal continuous ICU EEG monitoring \nstudy because of mild background slowing, consistent with a mild \nencephalopathy which is nonspecific and can be secondary to \nmetabolic/toxic derangements including infection, medication \neffect, or anoxia. There are no pushbutton activations.\nThere are no epileptiform discharges or seizures. Overall, this \nrecording is unchanged from the previous days' recording. \n\nEEG ___\nIMPRESSION: This is an abnormal continuous ICU EEG monitoring \nstudy because of mild background ___ Hz slowing admixed with \nbursts of generalized ___ Hz theta and delta slowing which is \nconsistent with a mild encephalopathy which is nonspecific and \ncan be secondary to metabolic/toxic derangements including \ninfection, medication effect, or anoxia. There are no pushbutton \nactivations. \nThere are no epileptiform discharges or seizures. \n\nEEG ___\nIMPRESSION: This is an abnormal routine EEG due to the presence \nof a slow, \ndisorganized background with intermittent frontally predominant \nrhythmic \nslowing. These findings indicate a moderate diffuse \nencephalopathy, which \nimplies widespread cerebral dysfunction but is nonspecific as to \netiology. \n\n===================\nDISCHARGE LABS:\n===================\n___ 05:39AM BLOOD WBC-18.5* RBC-3.12* Hgb-9.1* Hct-28.4* \nMCV-91 MCH-29.2 MCHC-32.0 RDW-16.4* RDWSD-54.3* Plt ___\n___ 05:39AM BLOOD ___ PTT-42.5* ___\n___ 05:39AM BLOOD Glucose-111* UreaN-15 Creat-0.5 Na-133* \nK-4.5 Cl-100 HCO3-18* AnGap-15\n___ 05:39AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.8\n \nBrief Hospital Course:\n___ SUMMARY:\n================\nMr. ___ is a ___ man with ___ CAD s/p CABG, HTN, \nHLD, BPH and prolonged admission (___) for cryptococcal \nmeningitis s/p 2 week course of amphotericin and PO fluconazole,\nwho re-presented on ___ ___ with worsening AMS \nand elevated cryptococcal antigen titer, subsequently \nre-initiated on amphotericin B and flucytosine, and transferred \nto ___ on ___ for further management given minimal \nimprovement in his mental status.\n\n==============\nACTIVE ISSUES:\n==============\n# Altered mental status\n# Cryptococcal meningoencephalitis\n# Possible ___ had waxing and waning mental status over the course of \nhis hospitalization. Etiology was uncertain, however potential \ncauses included cryptococcal meningitis, possible ___, and new \nCVAs. ___ underwent repeat induction treatment with ambisome \nand flucytosine given concern for recurrent cryptococcal \nmeningoencephalitis. Flucytosine was stopped early given \nlymphopenia, however ___ completed a course of ambisome on \n___ and was transitioned to PO fluconazole. Per ID, will \ncontinue on fluc as maintenance therapy until seen as \noutpatient. Given history and literature review of cryptococcal \nmeningoencephalitis, an ___ phenomenon was also considered \nas a potential etiology for his altered mental status, \nespecially in light of negative CSF cultures. He completed a \ncourse of IV dexamethasone on ___, and it was unclear if his \nprogressive improvement in mental status over that time period \nwas secondary to the steroids or just the natural progression of \nhis disease. Repeat LP was deferred given overall improvement in \nclinical status.\n\nNotably, additional workup notable for AMS included ___ PCR \nnegative, HSV PCR negative, and EEG without seizure activity. \n\n#Bacteremia\n___ blood cultures from ___ grew both MSSA and \nEnterococcus faecalis. He was initially started on vancomycin \nand zosyn before being transition to unasyn on ___ and \ncompleting a 14 day course. ___ remained afebrile after \ninitiation of antibiotics and repeat blood cultures were \nnegative.\n\n#Persistent GI Bleed\nOn ___, ___ had 2 guaiac positive stools and azotemia (BUN \nin the ___ with exam notable for hypotension and peritonitis. \nLactate at that time was 5.2. GI bleed thought to be due to \ndexamethasone without prior GI prophylaxis. CTA of the abdomen \nwas concerning for pneumatosis intestinalis and mesenteric \nischemia. He was taken for an urgent exploratory laparotomy \nwhich showed no evidence of bowel ischemia. He reCeived 5U pRBC \nin the setting of this GI bleed. Gastroenterology was consulted, \nwho suggested deferring colonoscopy given resolution of the \n___ GIB. Since that time, ___ hemoglobin remained \nstable and there was no further concern for GIB. Anticoagulation \nwas restarted on ___ without any signs of recurrent GIB.\n\n#Chest pain\n___ complained of substernal chest pain overnight on ___. \nACS negative. The pain resolved with antacids. Upon further \nquestioning, ___ reported some difficulty swallowing along \nwith the pain, suspected to be secondary to pill esophagitis vs \nGERD. GI was consulted, deferred EGD given elevated INR. ___ \nwas treated symptomatically with \nMaalox/diphenhydramine/lidocaine mouth wash and started on PPI. \nThis can be further evaluated in the outpatient setting if \nsymptoms persist.\n\n#Lymphopenia\nFound to have low B/T cells and low lymphocyte count with a CD4 \ncount of 117 (notably HIV negative x2). Reportedly, CD4 count \nwas ~1100 prior to starting Crypto treatment at OSH, although \nthis could not be confirmed. Extensive work up was unrevealing \nfor etiology, including assessment for viral etiologies, CT \ntorso without signs of malignancy, negative lymphoma panel, and \nnormal immunoglobulin levels. Heme-onc was consulted, who \nsuggested that ___ undergo a more extensive work up in the \noutpatient setting once his acute illness has resolved and he is \noff any potentially immune suppressing medications.\n\n#Electrolyte abnormalities (hypokalemia, hypomagnesemia)\n___ with persistent hypokalemia and hypomagnesemia requiring \ndaily electrolyte repletion. This was presumably multifactorial, \nwith components of GI loses in the setting of intermittent \ndiarrhea, GU loses in the setting of polyuria (see below), \nmedication effect from ambisone, and rapid cell turnover in \nsetting of persistent inflammation. Moreover, concurrent \nadministration of corticosteroids may exacerbate the hypokalemic \neffect of amphotericin. Ultimately, the ___ was discharged \non 400mg PO magnesium oxide daily and 20mg PO vitamin K daily.\n\n# Hyponatremia: noted in middle of hospitalization. Urine osms \nelevated. Thought to be ___ SIADH. Improved with fluid \nrestriction.\n\n#Multiple right sided and posterior ischemic lesions on MRI\n#CVAs\nRepeat brain MRI and CTA on ___ to monitor for improvement was \nconcerning for numerous punctate areas of slow diffusion within \nthe posterior right parietal lobe, right occipital lobe, and \nbilateral cerebellar hemispheres consistent with mini CVAs. TEE \nwithout evidence of endocarditis and posterior circulation \ndistribution is inconsistent with septic emboli. Vasculitis was \nfelt to be unlikely given minimally elevated CRP and normal ESR. \nAtrial fibrillation (new) occurred likely after stroke, and no \nthrombus on TEE. Biopsy of the frontal lobe lesion was declined \nby the ___ wife. Subsequent CTA of the head and neck \nobtained on ___ showed multifocal atherosclerotic disease \nwithin the bilateral vertebral arteries and carotid arteries.\n\n#Atrial fibrillation\nNew diagnosis this stay noticed overnight on ___, likely in \nthe setting of a myriad of complications as detailed elsewhere. \nRate control was deferred given his recent history of sepsis and \nGIB. TSH was notably 7.0. Ultimately, the ___ converted \nspontaneously and remained in NSR for the remainder of his \nhospitalization.\n\n#Chronic PEs\nIncidentally discovered on CT chest on recent CT scan \n(non-occlusive in the main PA). Anticoagulation was held given \nthe recent GIB and CVAs, however was reinitiated on ___. At \ntime of discharge, ___ had warfarin held for a \nsupertherapeutic INR. INR should be monitored every ___ days, \nand restarted on reduced dose of warfarin 1mg daily when INR <3. \n___ should complete a 3 month course of anticoagulation for \nprovoked PE.\n\n#Thrombocytopenia\nPossibly secondary to BM suppression in the setting of acute \nillness/sepsis or medication related (amphotericin, pip/tazo). \nAlthough he had recent heparin exposure, 4T score was 3, low \nprobability. His platelets were monitored and uptrended \nthroughout his hospitalization, ultimately reaching a normal \nlevel.\n\n#BPH\n#Urinary retention\n___ home tamsulosin and finasteride were held \nintermittently throughout his hospitalization in light of \ncomorbid conditions and numerous complications. They were \nultimately restarted near the end of his hospitalization, \nhowever ___ failed voiding trial. Foley catheter was \nreplaced on ___ with plans for the ___ to follow up with \nurology after discharge.\n\n#Pulmonary nodules: Will require repeat scan in ___ months post \ndischarge.\n\n======================\nTRANSITIONAL ISSUES:\n======================\n[ ] Urinary retention: likely secondary to BPH. ___ to \nfollow up with urology on ___.\n[ ] Pulmonary nodules: will need reimaging within ___ months to \nassess for progression\n[ ] Anticoagulation: warfarin 4mg held given supertherapeutic \nINR to 6.1. Check INR q1-2 days, when < 3, restart warfarin 1mg \ndaily, monitor INR, and dose adjust as necessary to keep within \nINR range ___. Plan to complete 3 months of anticoagulation for \nprovoked PE.\n[ ] Electrolyte abnormalities: etiology as above. Discharged on \ndaily magnesium and potassium repletion. Once weekly chem ___ \nwith repletion adjusted accordingly.\n[ ] Lymphopenia: as above, to follow up with allergy/immunology \nfor further assessment as outpatient\n[ ] QTc monitoring: please check prior to giving any \nQT-prolonging medicines, given he will remain on fluc.\n[ ] Creatinine Clearance: if ___ CC decreases, Fluconazole \ndosing may need to be adjusted. Please contact Infectious \nDisease clinic for guidance (___.)\n[ ] Follow up with ___ in ___ weeks.\n[] follow up with urology, has foley in place until that time\n\n# CONTACT: ___ (wife), healthcare proxy\n# CODE STATUS: Full code, confirmed.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete\n1. Aspirin 325 mg PO DAILY \n2. Vitamin D 3000 UNIT PO DAILY \n3. Finasteride 5 mg PO DAILY \n4. Fluconazole 800 mg PO Q24H \n5. LORazepam 0.5 mg PO Q4H:PRN Nausea \n6. Metoprolol Succinate XL 50 mg PO DAILY \n7. Senna 17.2 mg PO QHS \n8. Tamsulosin 0.4 mg PO QHS \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Magnesium Oxide 400 mg PO DAILY \n3. Miconazole Powder 2% 1 Appl TP TID:PRN Rash \n4. Multivitamins W/minerals 1 TAB PO DAILY \n5. Omeprazole 20 mg PO DAILY \n6. Potassium Chloride 20 mEq PO DAILY \n7. Simethicone 40-80 mg PO QID:PRN bloating \n8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \nContinue until you see the infectious disease doctors as ___ \noutpatient. \n9. Aspirin 81 mg PO DAILY \n10. Fluconazole 400 mg PO BID \n11. Finasteride 5 mg PO DAILY \n12. Tamsulosin 0.4 mg PO QHS \n13. Vitamin D 3000 UNIT PO DAILY \n14. HELD- Metoprolol Succinate XL 50 mg PO DAILY This \nmedication was held. Do not restart Metoprolol Succinate XL \nuntil you see your outpatient provider.\n15.Outpatient Lab Work\nICD 10 - I26 (pulmonary embolism)\nDaily INR checks until INR ___, dose adjust warfarin as \nnecessary to maintain within range\nThen INR checks per attending MD.\n___.Outpatient Lab Work\nICD 10 R94.5\nWeekly LFTs while on fluconazole.\nPlease send results to attending MD.\n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary:\n- Cryptococcal neoformans meningoencephalitis c/b ___ \nreaction and right occipital, parietal, and bilateral cerebellar \ninfarctions.\n- Toxic-metabolic encephalopathy\n- Paroxysmal atrial fibrillation\n- Subacute/chronic pulmonary embolism\n- Ischemic gut c/b GIB and acute blood loss anemia.\n- E. faecalis blood stream infection with sepsis (presumed gut \ntranslocation)\n- MSSA UTI and blood stream infection with sepsis \n- Lymphopenia NOS; r/o idiopathic CD4 deficiency\n- Urinary retention\n- Constipation/impaction\n- Severe malnutrition\n\nSecondary:\n- CAD s/p CABG\n- Hypertension\n- BPH\n- Spinal stenosis\n- S/P right THR\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\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\n\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:\nDear Mr. ___,\n \nIt was a pleasure caring for you at the ___ \n___.\n \nWHY WAS I SEEN IN THE HOSPITAL?\n=====================================================\n- You had an infection of the lining that surrounds the brain \nand the spinal cord that was causing you to have an altered \nmental status.\n \nWHAT WAS DONE WHILE I WAS IN THE HOSPITAL?\n===================================================== \n- You were treated with medications that helped resolve your \ninfection. \n- Other types of infections/causes of your altered mental status \nwere tested for.\n- You developed an infection in your blood, which was treated \nwith antibiotics.\n- We were concerned that you had a blockage in the arteries to \nyour intestines, so we had the surgeons look in your belly. \nUltimately, they found nothing wrong.\n- You were found to have a clot in your lungs, for which we \nplaced you on blood thinners.\n- You had a small stroke, which did not leave any permanent \neffects.\n \nWHAT SHOULD I DO WHEN I AM OUT OF THE HOSPITAL? \n=====================================================\n- Follow up with your doctors, as listed below.\n- Take all of your medications as prescribed.\n \nWe wish you the best,\n \nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "B451", "A4101", "A4181", "I2699", "I6340", "G92", "J9601", "K659", "R6521", "E43", "E222", "D684", "I2782", "D62", "I76", "E870", "R188", "T83511A", "N390", "I480", "D893", "E876", "I10", "E8342", "D72810", "E785", "N401", "R338", "Z23", "K5641", "K208", "R918", "I6523", "I672", "I6503", "D638", "Z951", "Z006", "Y846" ]

[ "B451: Cerebral cryptococcosis", "A4101: Sepsis due to Methicillin susceptible Staphylococcus aureus", "A4181: Sepsis due to Enterococcus", "I2699: Other pulmonary embolism without acute cor pulmonale", "I6340: Cerebral infarction due to embolism of unspecified cerebral artery", "G92: Toxic encephalopathy", "J9601: Acute respiratory failure with hypoxia", "K659: Peritonitis, unspecified", "R6521: Severe sepsis with septic shock", "E43: Unspecified severe protein-calorie malnutrition", "E222: Syndrome of inappropriate secretion of antidiuretic hormone", "D684: Acquired coagulation factor deficiency", "I2782: Chronic pulmonary embolism", "D62: Acute posthemorrhagic anemia", "I76: Septic arterial embolism", "E870: Hyperosmolality and hypernatremia", "R188: Other ascites", "T83511A: Infection and inflammatory reaction due to indwelling urethral catheter, initial encounter", "N390: Urinary tract infection, site not specified", "I480: Paroxysmal atrial fibrillation", "D893: Immune reconstitution syndrome", "E876: Hypokalemia", "I10: Essential (primary) hypertension", "E8342: Hypomagnesemia", "D72810: Lymphocytopenia", "E785: Hyperlipidemia, unspecified", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "R338: Other retention of urine", "Z23: Encounter for immunization", "K5641: Fecal impaction", "K208: Other esophagitis", "R918: Other nonspecific abnormal finding of lung field", "I6523: Occlusion and stenosis of bilateral carotid arteries", "I672: Cerebral atherosclerosis", "I6503: Occlusion and stenosis of bilateral vertebral arteries", "D638: Anemia in other chronic diseases classified elsewhere", "Z951: Presence of aortocoronary bypass graft", "Z006: Encounter for examination for normal comparison and control in clinical research program", "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" ]

[ "J9601", "D62", "N390", "I480", "I10", "E785", "Z951" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nsutures / Seasonal Allergies\n \nAttending: ___.\n \nChief Complaint:\nIncisional hernia\n \nMajor Surgical or Invasive Procedure:\n___: Incarcerated incisional hernia repair with mesh.\n\n \nHistory of Present Illness:\nPer Dr. ___ had a subcostal incision for adrenalectomy \ncomplicated by bleeding, which required reexploration. She \ndeveloped a bulging and pain at the incision and had a hernia by \nexam. Consent was reviewed and signed for repair.\n\n \nPast Medical History:\nPAST MEDICAL HISTORY: \nGlaucoma\nIncisional hernia \n\nPAST SURGICAL HISTORY: \nPheochromocytoma s/p R adrenalectomy ___,\nRight breast papilloma sp excision ___\n\n \nSocial History:\nShe widowed and does not work. She used to smoke ___ cigarettes \na day, but quit ___ years ago. She denies alcohol and drug use. \n \nPhysical Exam:\nResident exam ___:\nPhysical Exam:\nGen: [x] NAD, [] AAOx3\nCV: [] RRR, [] murmur\nResp: [x] breaths unlabored, no inc wob \nAbdomen: [x] soft, [] distended, [] tender, [] rebound/guarding\nWound: [x] incisions clean, dry, intact\nExt: [x] warm, [] tender, [] edema\n\n \nPertinent Results:\nLABS:\n___ 06:45AM BLOOD WBC-12.4* RBC-3.74* Hgb-10.0* Hct-32.0* \nMCV-86 MCH-26.7 MCHC-31.3* RDW-14.3 RDWSD-44.8 Plt ___ \nGlucose-129* UreaN-11 Creat-0.6 Na-132* K-4.6 Cl-98 HCO3-25 \nAnGap-9* Calcium-8.2* Phos-2.9 Mg-1.6\n\n___ 06:35AM BLOOD Glucose-102* UreaN-9 Creat-0.8 Na-141 \nK-4.3 Cl-104 \nHCO3-29 AnGap-8*WBC-10.6* RBC-3.93 Hgb-10.6* Hct-34.1 MCV-87 \nMCH-27.0 MCHC-31.1* RDW-14.5 RDWSD-46.0 Plt ___\n \nBrief Hospital Course:\nMs. ___ is a ___ with an incisional hernia who \nunderwent an open incarcerated incisional hernia repair with \nmesh on ___ please see operative note for \ndetails.Pt was extubated, taken to the PACU until stable, then \ntransferred to the ward for observation. \nNeuro: The patient was alert and oriented throughout \nhospitalization; pain was initially managed with a thoracic \nepidural and hydromorphone containing PCA and then transitioned \nto oral pain medications once tolerating a diet. The epidural \nwas managed by the Acute Pain service and removed on POD2.\nCV: The patient remained stable from a cardiovascular \nstandpoint; vital signs were routinely monitored.\nPulmonary: The patient remained stable from a pulmonary \nstandpoint; vital signs were routinely monitored. Good pulmonary \ntoilet, early ambulation and incentive spirometry were \nencouraged throughout hospitalization. \nGI/GU/FEN: The patient was initially kept NPO. Her diet was \nadvanced beginning on POD1 and well tolerated. Patient's intake \nand output were closely monitored; she was discharged to home \nwith a JP drain in place. The patient reported plans to stay \nwith a family member and received teaching for drain management. \n Additionally, an appointment was made for the day after \ndischarge at her PCP's office for a drain check.\nID: The patient's fever curves were closely watched for signs of \ninfection, of which there were none.\nHEME: The patient's blood counts were closely watched for signs \nof bleeding, of which there were none.\nProphylaxis: The patient received subcutaneous heparin and ___ \ndyne boots were used during this stay and was encouraged to get \nup and ambulate as early as possible.\nAt the time of discharge, the patient was doing well, afebrile \nand hemodynamically stable. The patient was tolerating a diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan.\n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfurther investigation.\n1. brimonidine 0.2 % ophthalmic (eye) BID \n2. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever \n3. Timolol Maleate 0.5% 1 DROP BOTH EYES BID \n4. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n5. hydrocortisone-acetic acid ___ % otic (ear) ASDIR \n6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n7. Cetirizine 10 mg PO QHS \n8. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day \nDisp #*10 Capsule Refills:*0 \n2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nRX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours \nDisp #*5 Tablet Refills:*0 \n3. Senna 8.6 mg PO BID \nRX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp \n#*10 Tablet Refills:*0 \n4. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever \nDo not exceed 3000 mg per 24 hour period. \n5. brimonidine 0.2 % ophthalmic (eye) BID \n6. Cetirizine 10 mg PO QHS \n7. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n8. hydrocortisone-acetic acid ___ % otic (ear) ASDIR \n9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n10. Timolol Maleate 0.5% 1 DROP BOTH EYES BID \n11. Vitamin D 1000 UNIT PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\n___: Incisional hernia with atrophy of the oblique \nmusculature.\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\nYou have undergone repair of your abdominal wall hernia, \nrecovered in the hospital and are now preparing for discharge \nwith the following instructions:\n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n*You experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n*You are getting dehydrated due to continued vomiting, diarrhea, \nor other reasons. Signs of dehydration include dry mouth, rapid \nheartbeat, or feeling dizzy or faint when standing.\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n*Your pain in not improving within ___ hours or is not gone \nwithin 24 hours. Call or return immediately if your pain is \ngetting worse or changes location or moving to your chest or \nback.\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon.\n\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\nIncision Care:\n*Please call your doctor or nurse practitioner if you have \nincreased pain, swelling, redness, or drainage from the incision \nsite.\n*Avoid swimming and baths until your follow-up appointment.\n*You may shower, and wash surgical incisions with a mild soap \nand warm water. Gently pat the area dry.\n*If you have staples, they will be removed at your follow-up \nappointment.\n*If you have steri-strips, they will fall off on their own. \nPlease remove any remaining strips ___ days after surgery.\n\n___ 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. Call \nthe 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\n \nFollowup Instructions:\n___\n" ]

[ "K430", "L299", "Z87891" ]

[ "K430: Incisional hernia with obstruction, without gangrene", "L299: Pruritus, unspecified", "Z87891: Personal history of nicotine dependence" ]

[ "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nIodinated Contrast Media - IV Dye / bee venom (honey bee)\n \nAttending: ___\n \nChief Complaint:\nAbdominal Pain, diarrhea, fever\n \nMajor Surgical or Invasive Procedure:\nnone\n \nHistory of Present Illness:\n___ who was recently hospitalized (___) for acute \nappendicitis s/p laparoscopic appendectomy on ___ now \npresenting with worsening abdominal pain. Her hospital course \nwas notable for a Hct drop from 42.1 pre-op to 27.4 on POD1. At \ntime of discharge her Hct had stabilized at 25.4 and her \northostatic\nsymptoms resolved. In the immediate post-discharge period, she \nwas doing well and tolerating a regular diet. Yesterday \nafternoon, she began having worsening generalized abdominal pain \nwith multiple episodes of nonbloody diarrhea. Additionally, she \nhad subjective fevers, nausea, night sweats, and burning on\nurination. She therefore presented to her PCP this morning for \nfurther evaluation and was sent to ___ for further evaluation.\n \nPast Medical History:\nPectus excavatum, acute appendicitis \n\n \nSocial History:\n___\nFamily History:\nNo family history of inflammatory bowel disease, aunt with \npancreatic cancer, mother with HTN, relatives with CAD\n\n \nPhysical Exam:\nAdmission Physical Exam:\nVitals: 100.4 97 138/84 18 100%RA\nGEN: AOx3, 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, laparoscopic incisions well healing,\ndiffuse abdominal tenderness to palpation, + guarding, no\nrebound, no palpable masses\nExt: No ___ edema, ___ warm and well perfused\n\nDischarge Physical Exam:\nVS:99.0, 83, 138/83, 18, 99% RA\nGen: awake, alert, sitting up in bed.\nHEENT: no deformity. PERRL. EOMI. mucus membranes pink, moist. \nneck supple. trachea midline.\nCV: RRR\nPulm: clear to auscultation bilaterally\nAbd: soft, mildly diffusely tender to palpation, mildly \ndistended. \nSkin: multiple laparoscopic sites to abdomen well healed.\nExt: Warm and dry, 2+ ___ pulses. \nNeuro: A&Ox3. Follows commands, moves all extremities equal and \nstrong. \n\n \nPertinent Results:\n___ 02:50PM BLOOD WBC-8.4 RBC-3.25* Hgb-10.4* Hct-31.8*# \nMCV-98 MCH-32.0 MCHC-32.7 RDW-13.8 RDWSD-45.5 Plt ___\n___ 06:15PM BLOOD WBC-9.7 RBC-3.28* Hgb-10.4* Hct-30.2* \nMCV-92 MCH-31.7 MCHC-34.4 RDW-13.4 RDWSD-41.7 Plt ___\n___ 09:40PM BLOOD WBC-9.7 RBC-3.16* Hgb-10.2* Hct-29.4* \nMCV-93 MCH-32.3* MCHC-34.7 RDW-13.5 RDWSD-42.4 Plt ___\n___ 03:47AM BLOOD WBC-7.9 RBC-3.04* Hgb-9.8* Hct-28.7* \nMCV-94 MCH-32.2* MCHC-34.1 RDW-13.4 RDWSD-43.4 Plt ___\n___ 02:50PM BLOOD Neuts-76.9* Lymphs-12.8* Monos-8.1 \nEos-1.2 Baso-0.4 Im ___ AbsNeut-6.50*# AbsLymp-1.08* \nAbsMono-0.68 AbsEos-0.10 AbsBaso-0.03\n___ 02:50PM BLOOD ___ PTT-26.5 ___\n___ 02:50PM BLOOD Glucose-91 UreaN-15 Creat-0.8 Na-138 \nK-3.9 Cl-100 HCO3-24 AnGap-18\n___ 02:58PM BLOOD Lactate-0.9\n\n___ Non-contrast CT abd/pelvis:\nModerate volume hyperdense free fluid in the abdomen/pelvis \nstatus post \nappendectomy is concerning for hemoperitoneum. Findings raise \nconcern for \npostoperative bleeding/vascular injury. Recommend close \nmonitoring of \nhematocrit levels. Please note differential considerations \npotentially \ninclude hemo peritoneum secondary to ruptured ovarian cyst. \n\n___ CXR:\nNo acute cardiopulmonary process.\n \nBrief Hospital Course:\nMrs. ___ is a ___ F admitted to the Acute Care Surgery \nService on ___ with new onset abdominal pain, nausea, and \ndiarrhea. She is status post laparoscopic appendectomy on \n___. Her previous hospital course was notable for \nanaphylaxis to contrast dye and a post operative hematocrit drop \n(42.1 pre-op to 27.4 on POD1) that stabilized at 25 without \nfurther intervention. On readmission her hematocrit was improved \nat 31.8. She had a non-contrast CT scan that showed a right \nlower quadrant fluid collection. She was admitted to the floor \nhemodynamically stable on IV fluids for serial hematocrits, \nabdominal exams, and further evaluation.\n\nOn HD2 her abdominal pain was improved, her hematocrit was \nstable, and she was tolerating a regular diet. She was afebrile \nwith a normal white blood cell count. Stool samples were sent \nfor infectious work up. She noted malodorous vaginal discharge \nand was given diflucan. \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\n \n \nMedications on Admission:\n1. Prenatal Vitamins 1 TAB PO DAILY \n2. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 anaphylaxis Duration: \n1 Dose \n3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \n4. Docusate Sodium 100 mg PO BID \nhold for diarrhea \n5. Acetaminophen 650 mg PO Q6H:PRN pain \n\n \nDischarge Medications:\n1. Prenatal Vitamins 1 TAB PO DAILY \n2. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 anaphylaxis Duration: \n1 Dose \n3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \n4. Docusate Sodium 100 mg PO BID \nhold for diarrhea \n5. Acetaminophen 650 mg PO Q6H:PRN pain \n6. Fluconazole 150 mg PO ONCE Duration: 1 Dose \nRX *fluconazole 150 mg 1 tablet(s) by mouth once Disp #*1 Tablet \nRefills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAbdominal pain, diarrhea, fever\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\n\n___ were admitted to the Acute Care Surgery Service on ___ \nwith abdominal pain. ___ had a CT scan that showed a fluid \ncollection in your pelvis. Your blood counts were checked and \nare stable. Your white blood cell count, a marker of infection, \nis normal. Your abdominal pain was probably caused by irritation \nof the fluid collection or a gastrointestinal infection. \n\n___ are now doing better, tolerating a regular diet, your \nabdominal pain is improved and ___ are ready to be discharged to \nhome.\n\nPlease note the following discharge instructions:\n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n___ experience new chest pain, pressure, squeezing or \ntightness.\n*New or worsening cough, shortness of breath, or wheeze.\n*If ___ are vomiting and cannot keep down fluids or your \nmedications.\n___ 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___ see blood or dark/black material when ___ vomit or have a \nbowel movement.\n___ experience burning when ___ 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___ 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 \n___.\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 ___ follow-up with your \nsurgeon.\n\nAvoid driving or operating heavy machinery while taking pain \nmedications.\n\n \nFollowup Instructions:\n___\n" ]

[ "R1084", "R509", "R197", "Z23" ]

[ "R1084: Generalized abdominal pain", "R509: Fever, unspecified", "R197: Diarrhea, unspecified", "Z23: Encounter for immunization" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nIodinated Contrast Media - IV Dye / bee venom (honey bee)\n \nAttending: ___\n \nChief Complaint:\nabdominal pain\n \nMajor Surgical or Invasive Procedure:\nLaparoscopic Appendectomy \n\n \nHistory of Present Illness:\n___ presenting with 1 day of worsening abdominal pain, nausea, \nvomiting x1. She was in her normal state of health until \nyesterday morning when she started to have ___ generalized \nabdominal pain. The pain subsequently localized to the right \nabdomen this morning. She initially presented to her PCP this \nmorning and underwent an abdominal CT. CT showed acute \nappendicitis and possible appendiceal mucocele. She subsequently \nhad a anaphylactic reaction to IV contrast with difficulty \nbreathing and facial swelling. She was treated with fluids, \nEpiPen, Benadryl, and transferred to ___ for further care.\n \nPast Medical History:\nPectus excavatum\n\n \nSocial History:\n___\nFamily History:\nNo family history of inflammatory bowel disease, aunt with \npancreatic cancer, mother with HTN, relatives with CAD\n\n \nPhysical Exam:\nPhysical Exam on admission:\nVitals: 97.9 70 151/84 16 100%RA\nGEN: AOx3, 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: RLQ tenderness to palpation, soft, no rebound, negative\nRovsing's and psoas signs\nExt: No ___ edema, ___ warm and well perfused\n\nExam on Discharge:\n\n \nPertinent Results:\n___ 06:00AM BLOOD WBC-10.1* RBC-2.98*# Hgb-9.5*# Hct-29.3*# \nMCV-98 MCH-31.9 MCHC-32.4 RDW-12.2 RDWSD-43.9 Plt ___\n___ 01:00PM BLOOD WBC-16.4* RBC-4.48 Hgb-14.4 Hct-42.5 \nMCV-95 MCH-32.1* MCHC-33.9 RDW-11.9 RDWSD-41.3 Plt ___\n___ 01:00PM BLOOD Neuts-80.3* Lymphs-16.4* Monos-2.3* \nEos-0.4* Baso-0.1 Im ___ AbsNeut-13.15* AbsLymp-2.68 \nAbsMono-0.37 AbsEos-0.07 AbsBaso-0.02\n___ 01:00PM BLOOD ___ PTT-23.0* ___\n___ 06:00AM BLOOD Glucose-106* UreaN-13 Creat-0.8 Na-134 \nK-4.5 Cl-102 HCO3-26 AnGap-11\n___ 01:00PM BLOOD Glucose-160* UreaN-15 Creat-0.8 Na-138 \nK-3.2* Cl-103 HCO3-20* AnGap-18\n___ 06:00AM BLOOD Calcium-8.0* Phos-4.1 Mg-1.7\n___ 01:20PM BLOOD Lactate-2.8*\n\n___ OSH CT scan\nMid to distal aspect of the appendix is dilated to 13 mm and \ncontains \nintraluminal hypodensity. The more proximal appendix (the base) \nis collapsed. It is difficult to discern whether maybe subtle \nminimal periappendiceal inflammation. Differential diagnosis \nincludes appendiceal mucocele vs appendicitis. \n\n \nBrief Hospital Course:\nThe patient presented to the emergency department and was \nevaluated by the Acute Care Surgery Team. The patient was found \nto have appendicitis with possible mucocele and was admitted to \nthe Acute Care Surgery Service. The patient was taken to the \noperating room on ___ for a laprascopic appendectomy, which \nthe patient tolerated well. Please see operative report for \ndetails. The patients appendix was sent to pathology for \nassessment of the appendix for a possible mucocele. The patient \nwas taken from the OR to the PACU in stable condition and after \nsatisfactory recovery from anesthesia was transferred to the \nfloor. \n\nThe 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 of pre-natal vitamins were continued throughout this \nhospitalization. The ___ hospital course was remarkable \nfor anaphylaxis secondary to IV iodine contrast prior to her CT \nscan in the Emergency Department. She was treated with an \nEpi-Pen and her symptoms promptly resolved. She continued to \nhave orthostatic hypotension on POD1. Her hct down trended from \n42.1 pre-op to 27.4 by POD1. Her Hct stabilized at 25.4 and her \northostatic symptoms resolved \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, and tolerating a regular diet. The patient \nwill follow up with Dr. ___ in two weeks. A thorough \ndiscussion was had with the patient regarding the diagnosis and \nexpected post-discharge course including reasons to call the \noffice or return to the hospital, and all questions were \nanswered. The patient was also given written instructions \nconcerning precautionary instructions and the appropriate \nfollow-up care. The patient expressed readiness for discharge.\n\n \nMedications on Admission:\n1. Pre-natal Vitamins\n \nDischarge Medications:\n1. Prenatal Vitamins 1 TAB PO DAILY \n2. Acetaminophen 650 mg PO Q6H pain \n3. Docusate Sodium 100 mg PO BID \n4. EPINEPHrine (EpiPEN) 0.3 mg IM X2 PRN Anaphylaxis reaction \nRX *epinephrine HCl (PF) 1 mg/mL (1 mL) 1 Epipen IM prn \nanaphylaxis Disp #*3 Ampule Refills:*0\n5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain \nRX *oxycodone 5 mg 1 tablet(s) by mouth q4hrs Disp #*20 Tablet \nRefills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAppendicitis\nAnaphylaxis secondary to contrast iodine\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDr. ___,\n\n___ were admitted to the Acute Care Surgery Service at BICMD on \n___ with acute appendicitis. ___ were taken to the \noperating room and had your appendix removed laparoscopically. \nSamples of the appendix were sent to pathology. The results of \nthis test will be reviewed with ___ at your follow up \nappointment. ___ tolerated the procedure well and are now being \ndischarged home to continue your recovery with the following \ninstructions. \n\n___ had a CT scan with IV contrast and had an anaphylactic \nreaction to the contrast media. ___ were treated with \nepinephrine. Please update your primary care provider with this \ninformation. ___ should alert future health care providers of \nthis allergy. \n\nACTIVITY: \n \no Do not drive until ___ have stopped taking pain medicine and \nfeel ___ could respond in an emergency. \no ___ may climb stairs. \no ___ may go outside, but avoid traveling long distances until \n___ see your surgeon at your next visit. \no Don't lift more than ___ lbs for 4 weeks. (This is about the \nweight of a briefcase or a bag of groceries.) This applies to \nlifting children, but they may sit on your lap. \no ___ may start some light exercise when ___ feel comfortable. \no ___ will need to stay out of bathtubs or swimming pools for a \ntime while your incision is healing. Ask your doctor when ___ \ncan resume tub baths or swimming. \n \nHOW ___ MAY FEEL: \no ___ may feel weak or \"washed out\" for a couple of weeks. ___ \nmight want to nap often. Simple tasks may exhaust ___. \no ___ may have a sore throat because of a tube that was in your \nthroat during surgery. \no ___ might have trouble concentrating or difficulty sleeping. \n___ might feel somewhat depressed. \no ___ could have a poor appetite for a while. Food may seem \nunappealing. \no All of these feelings and reactions are normal and should go \naway in a short time. If they do not, tell your surgeon. \n \nYOUR INCISION: \no Tomorrow ___ may shower and remove the gauzes over your \nincisions. Under these dressing ___ have small plastic bandages \ncalled steri-strips. Do not remove steri-strips for 2 weeks. \n(These are the thin paper strips that might be on your \nincision.) But if they fall off before that that's okay). \no Your incisions may be slightly red around the stitches. This \nis normal. \no ___ may gently wash away dried material around your incision. \no Avoid direct sun exposure to the incision area. \no Do not use any ointments on the incision unless ___ were told \notherwise. \no ___ may see a small amount of clear or light red fluid \nstaining your dressing or clothes. If the staining is severe, \nplease call your surgeon. \no ___ may shower. As noted above, ask your doctor when ___ may \nresume tub baths or swimming. \n \nYOUR BOWELS: \no Constipation is a common side effect of narcotic pain \nmedications. If needed, ___ may take a stool softener (such as \nColace, one capsule) or gentle laxative (such as milk of \nmagnesia, 1 tbs) twice a day. ___ can get both of these \nmedicines without a prescription. \no If ___ go 48 hours without a bowel movement, or have pain \nmoving the bowels, call your surgeon. \n \nPAIN MANAGEMENT: \no It is normal to feel some discomfort/pain following abdominal \nsurgery. This pain is often described as \"soreness\". \no Your pain should get better day by day. If ___ find the pain \nis getting worse instead of better, please contact your surgeon. \n\no ___ will receive a prescription for pain medicine to take by \nmouth. It is important to take this medicine as directed. o Do \nnot take it more frequently than prescribed. Do not take more \nmedicine at one time than prescribed. \n o Your pain medicine will work better if ___ take it before \nyour pain gets too severe. \n o Talk with your surgeon about how long ___ will need to take \nprescription pain medicine. Please don't take any other pain \nmedicine, including non-prescription pain medicine, unless your \nsurgeon has said its okay. \no If ___ are experiencing no pain, it is okay to skip a dose of \npain medicine. \no Remember to use your \"cough pillow\" for splinting when ___ \ncough or when ___ are doing your deep breathing exercises.\n\nIf ___ experience any of the following, please contact your \nsurgeon: \n - sharp pain or any severe pain that lasts several hours \n - pain that is getting worse over time \n - pain accompanied by fever of more than 101 \n - a drastic change in nature or quality of your pain \n \n MEDICATIONS: \n Take all the medicines ___ were on before the operation just as \n___ did before, unless ___ have been told differently. \n If ___ have any questions about what medicine to take or not to \ntake, please call your surgeon.\n \nFollowup Instructions:\n___\n" ]

[ "K3580", "T886XXA", "T490X5A", "I951", "Q676" ]

[ "K3580: Unspecified acute appendicitis", "T886XXA: Anaphylactic reaction due to adverse effect of correct drug or medicament properly administered, initial encounter", "T490X5A: Adverse effect of local antifungal, anti-infective and anti-inflammatory drugs, initial encounter", "I951: Orthostatic hypotension", "Q676: Pectus excavatum" ]

[]

[]

[ " \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:\nleft leg weakness\n \nMajor Surgical or Invasive Procedure:\nnone##\n\n \nHistory of Present Illness:\nPt is a ___ yr M w/ hx of HTN, HLD, CAD s/p MI and BMP x 3,\nischemic cardiomyopathy, DMII, prior CVA in ___ and ___ w/\nresidual R facial weakness, and CKD and who presents from home\nfor L hemibody weakness. LKW at 2030 on ___ prior to going to\nbed. Overnight, he slept in chair due to knee issues. This\nmorning, upon awakening at 0400 he attempted to go to bathroom\nbut fell down (unclear if sustained head trauma). His wife\nattempted to pick him up but found him to have new LUE/LLE\nweakness. EMS was called and he was urgently transferred to BI \nED\nfor Stroke eval. \n\nOf note, pt was previously evaluated for new onset R facial/arm\nweakness in ___, with administration of tPA which successful\nresolved his deficits. He was post-procedurally evaluated at\n___ w/ MR imaging showing L ACA, MCA, and MCA/PCA watershed\ninfarcts. Found on Echo to have reduced EF w/ LV hypokinesis, he\nwas started on Warfarin (prior to stroke on ASA) d/t presumed\ncardioembolic etiology and later bridged to Aspirin monotherapy.\nPer notation, he subsequently suffered some residual agraphia \nand\nR NLFF. \n\n \nPast Medical History:\nHTN\nCKD\nHLD\nCAD c/b MI in ___, BMS x 3 in ___\nIschemic cardiomyopathy w/ EF of 35% \nAAA\nGrave's Dz\nGlaucoma\nOSA\nProstate CA s/p XRT, hormonal therapy \nPrior CVAs in ___ and ___ (former per ___ records)\nGERD\nDMII\n\n \nSocial History:\nOriginally from ___. Retired ___.\n___: plays the saxophone, clarinet, flute, and\npreviously the ___. Plays with a ___ group in ___\ncalled the \"Old Kids on the Block.\" Teaches at ___. Lives with his wife. Prior\ntobacco use (1ppd, 30 pack years, none in 30+ years). Rare\nalcohol use. Denies illicit drug use.\n\n- Modified ___ Scale:\n[] 0: No symptoms\n[X] 1: No significant disability - able to carry out all usual\nactivities despite some symptoms\n[] 2: Slight disability: able to look after own affairs without\nassistance but unable to carry out all previous activities\n[] 3: Moderate disability: requires some help but able to walk\nunassisted\n[] 4: Moderately severe disability: unable to attend to own\nbodily needs without assistance and unable to walk unassisted\n[] 5: Severe disability: requires constant nursing care and\nattention, bedridden, incontinent\n[] 6: Dead\n\n \nFamily History:\nno hx of stroke or CAD. His mother died at age ___. \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAMINATION\n==============================\nVitals: T: 99.0 HR: 68 BP: 148/57 RR: 16 SaO2: 100% RA\nGeneral: NAD, elderly AA male\nHEENT: NCAT, no oropharyngeal lesions, neck supple\n___: RRR, no M/R/G\nPulmonary: CTAB, no crackles or wheezes\nAbdomen: Soft, NT, ND, +BS, no guarding\nExtremities: Warm, no edema\n\nNeurologic Examination:\n- Mental status: Awake, alert, oriented x 3. Able to relate\nhistory without difficulty. Attentive to examinerSpeech is \nfluent\nwith full sentences, intact repetition to short phrases, and\nintact verbal comprehension. Naming intact. No paraphasias. \nMild\nchronic dysarthria. Normal prosody. No apraxia. No evidence of\nhemineglect. No left-right confusion. Able to follow both \nmidline\nand appendicular commands.\n\n- Cranial Nerves: PERRL 3->2 on L, 3.5->2.5 on R w/ irregular\npupil, brisk. L superior quadrantanopia. EOMI, no nystagmus.\nV1-V3 without deficits to light touch bilaterally. R lower \nfacial\ndrop at rest (chronic), symmetric activation. L eyelid\ndehiscence. Hearing intact to finger rub bilaterally. Palate\nelevation symmetric. SCM/Trapezius strength ___ bilaterally.\nTongue midline.\n\n- Motor: Normal bulk, increased tone in RUE/RLE. No drift. No\ntremor or asterixis.\n [___]\nL 5 5 5 5 5 4+ 2 5 2 1 2 1\nR 5 5 5 5 ___ 5 5 5 5 5 \n*giveway attributed to LBP\n\n- Reflexes: \n [Bic] [Tri] [___] [Quad] [Gastroc]\n L 1 1 1 1 trace\n R 2 2 2 1 trace \n\nPlantar response extensor b/l \n\n- Sensory: No deficits to light touch, pin, or proprioception\nbilaterally. No extinction to DSS.\n\n- Coordination: No dysmetria with finger to nose testing\nbilaterally. Good speed and intact cadence with rapid \nalternating\nmovements.\n\n- Gait: Deferred.\n\nDISCHARGE PHYSICAL EXAM: \n========================\n\nExam:\nMS: alert, oriented to self, ___ hospital, date, can name \ndays of week backwards. able to name current president and \nprevious president.\nCN: EOM incomplete burying of sclera bilaterally on horizontal \ngaze. NO nystagmus. R NLFF, R side smile slow to activate\nMotor: left hand slight pronation with no drift\ndeltoid: L 5 R 5\nbiceps: L 5 R 5\ntricep L 5 R 5\nIP: L 4 R 5\nhamstring: L 4 R 5\nhamstring 5\nquad: L 5 R 5\nTA: L 4 R 5\ngastroc: L 5 R 5\n\nReflexes:\nExtensor plantar response bilaterally\n\n \nPertinent Results:\nADMISSION LABS: \n===============\n___ 02:51PM CK(CPK)-148\n___ 02:51PM CK-MB-3\n___ 02:51PM cTropnT-0.04*\n___ 10:35AM CK(CPK)-152\n___ 10:35AM CK-MB-3\n___ 10:35AM cTropnT-0.03*\n___ 10:05AM URINE HOURS-RANDOM\n___ 10:05AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG \ncocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG\n___ 10:05AM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 10:05AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30* \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-NEG\n___ 10:05AM URINE RBC-10* WBC-2 BACTERIA-NONE YEAST-NONE \nEPI-1\n___ 09:25AM ___ PTT-30.1 ___\n___ 08:45AM ___ TO PTT-UNABLE TO ___ \nTO \n___ 07:54AM CREAT-0.9\n___ 07:54AM estGFR-Using this\n___ 07:48AM GLUCOSE-124* NA+-141 K+-5.9* CL--105 TCO2-23\n___ 07:46AM %HbA1c-6.4* eAG-137*\n___ 07:38AM GLUCOSE-136* UREA N-12 CREAT-1.0 SODIUM-144 \nPOTASSIUM-5.2 CHLORIDE-107 TOTAL CO2-25 ANION GAP-12\n___ 07:38AM estGFR-Using this\n___ 07:38AM ALT(SGPT)-11 AST(SGOT)-25 ALK PHOS-77 TOT \nBILI-0.3\n___ 07:38AM LIPASE-19\n___ 07:38AM cTropnT-0.03*\n___ 07:38AM ALBUMIN-3.9 CALCIUM-9.5 PHOSPHATE-2.4* \nMAGNESIUM-2.0\n___ 07:38AM ___\n___ 07:38AM TSH-2.6\n___ 07:38AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG \ntricyclic-NEG\n___ 07:38AM WBC-8.5 RBC-4.53* HGB-13.0* HCT-40.8 MCV-90 \nMCH-28.7 MCHC-31.9* RDW-14.9 RDWSD-49.1*\n\n___ 07:38AM BLOOD WBC: 8.5 RBC: 4.53* Hgb: 13.0* Hct: 40.8\nMCV: 90 MCH: 28.7 MCHC: 31.9* RDW: 14.9 RDWSD: 49.1* Plt Ct: \n126*\n___ 09:25AM BLOOD ___: 11.1 PTT: 30.1 ___: 1.0 \n___ 07:38AM BLOOD Glucose: 136* UreaN: 12 Creat: 1.0 Na: \n144\nK: 5.2 Cl: 107 HCO3: 25 AnGap: 12 \n___ 07:38AM BLOOD ALT: 11 AST: 25 AlkPhos: 77 TotBili: 0.3 \n___ 07:38AM BLOOD Lipase: 19 \n___ 07:38AM BLOOD cTropnT: 0.03* \n___ 07:38AM BLOOD Albumin: 3.9 Calcium: 9.5 Phos: 2.4* Mg:\n2.0 \n\nIMAGING: \n======== \n \nCTA H&N ___:\n\nCT Head\n1. Encephalomalacia in the left frontoparietal region is\nincreased as compared to CT head ___ and likely\nrepresent sequelae of chronic infarct.\n2. No intracranial hemorrhage or evidence of large acute\nterritorial infarction. Please note that MRI is more sensitive\nfor detection of infarct.\n\nCTA head and neck\n1. No evidence of occlusion significant stenosis, or aneurysm of\nthe anterior circulation, posterior circulation, circle of\n___, bilateral internal carotid arteries, or bilateral\nvertebral arteries.\n2. Moderate atherosclerotic calcifications and mild narrowing of\nthe bilateral right greater than left carotid bifurcations.\nModerate atherosclerotic calcifications in the clinoid and\nsupraclinoid portions of the bilateral internal carotid \narteries.\n3. Multinodular thyroid.\n\nMRI ___\n1. Acute to subacute infarct is seen in the right ACA territory. \n No evidence \nof hemorrhagic conversion. \n2. Encephalomalacia and T2 signal abnormality seen in the left \nMCA territory \nis compatible with old prior infarct \n\n___ TRANSTHORACIC ECHO: Moderate regional left ventricular\nsystolic dysfunction c/w prior inferoposterior MI with adverse\nremodelling. No cardiac source of embolism identified (patient\nrefused lumason, but the apex was not akinetic).\n\nINTERVAL/DISCHARGE LABS: \n========================\n\n___ 02:51PM BLOOD cTropnT-0.04*\n___ 05:25AM BLOOD CK-MB-2 cTropnT-0.05*\n___ 12:13PM BLOOD cTropnT-0.04*\n___ 12:13PM BLOOD D-Dimer-2709*\n___ 05:25AM BLOOD %HbA1c-6.5* eAG-140*\n___ 07:38AM BLOOD ___\n___ 05:25AM BLOOD Triglyc-89 HDL-58 CHOL/HD-2.8 LDLcalc-84\n \nBrief Hospital Course:\nInformation for Outpatient Providers: Mr. ___ is a ___ yr \nmale with prior history of DM2, HLD, HTN, CAD s/p MI with bare \nmetal stents x3, ischemic cardiomyopathy, HFrEF previous 35%, \nand prior acute ischemic infarcts ___ with ?residual \nright sided weakness) who presented with left sided weakness and \nwas found to have a right ACA territory infarct.\n\n#Acute ischemic infarct- Right ACA territory, likely \ncardioembolic\nHe presented with acute onset leg weakness. His exam on \nadmission was notable for left lower extremity weakness \n___ in UMN pattern). CTA without large vessel cutoff. \nMRI showed right ACA infarct and encephalomalacia concerning for \nprior left MCA territory infarct. Stroke risk factors: A1c 6.5, \nLDL 98. D-dimer 2709 (checked given concern for hypercoagulable \nstate). TTE showed EF 20% with\nprior inferior posterior wall motion abnormality. CT Torso was \nwithout malignancy. He was initially continued on aspirin and \nPlavix and his simvastatin was increased to atorvastatin 80 mg \ndaily. Given low EF and history of bilateral infarcts, most \nlikely etiology felt to be cardioembolic. He was started on \nCoumadin 5 mg on ___ and continued on aspirin 81 mg daily given \nbare metal stents. Plavix was discontinued. He will follow-up \nwith ___ neurology as outpatient.\n\n#Type II NSTEMI\nHe had troponins on admission which were .03-> .05-> .04 with \nstable EKG showing left bundle branch block. His CKMB was \nnormal. He was asymptomatic. He was continued on asa/Plavix \ninitially and his simvastatin was switched to atorvastatin 80 mg \ndaily. He did not receive a beta blocker due to heart rates \n50-60s. ___ cardiology was contacted and recommended no \nchange to medications. His plavix was stopped and he was \nultimately continued on aspirin and Coumadin as above.\n\n#History of chronic systolic heart failure (prior EF 35%), \nischemic cardiomyopathy \nHe had no shortness of breath or increased dyspnea on exertion \nor chest pain. He had no evidence of volume overload on exam. He \nhad a TTE as part of his stroke work-up which showed EF ~20% and \nsigns of prior inferior posterior wall infarct. He was continued \non torsemide 20 mg daily. Lisinopril 10 mg was held in the \nsetting of acute stroke and resumed at 5 mg daily after 48 hours \npost acute stroke. He was continued on ASA and Plavix, but then \nPlavix was discontinued in prep for possible PEG. His newly \nreduced EF was discussed with ___ who recommend no acute \nwork-up or changes in his medication management. He was not on a \nbeta blocker prior to admission and this was not started due to \nheart rates 50-60s. Ultimately, he was started on Coumadin 5 mg \ndaily on ___ and continued on aspirin 81 mg daily.\n\n#DM2\n- A1c 6.5\n- Glipizide was held during his hospitalization and he was \nmanaged with sliding scale insulin. Glipizide was resumed on \ndischarge\n\n#Dysphagia\nHe was seen by s/s who recommended NPO initially. He had a video \nswallow on ___ and he was advanced to pureed and thin liquids. \n\nTRANSITIONAL ISSUES: \n====================\n[] Discontinue subq heparin when INR ___ on Coumadin\n[] ensure INR is checked daily and warfarin is dosed accordingly \nto get patient therapeutic \n[] patient has to f/u with his atirus PCP ___ ___ weeks \n\n=\n=\n=\n=\n=\n=\n================================================================\n\nAHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic \nAttack \n1. Dysphagia screening before any PO intake? (x) Yes, confirmed \ndone - () Not confirmed () No. If no, reason why: \n2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not \n(I.e. bleeding risk, hemorrhage, etc.) \n3. Antithrombotic therapy administered by end of hospital day 2? \n(x) Yes - () No. If not, why not? (I.e. bleeding risk, \nhemorrhage, etc.)\n4. LDL documented? (x) Yes (LDL = 98 ) - () 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 (verbally or \nwritten)? (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 \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 10 mg PO DAILY \n2. GlipiZIDE XL 5 mg PO DAILY \n3. Torsemide 40 mg PO DAILY \n4. Aspirin 81 mg PO DAILY \n5. Clopidogrel 75 mg PO DAILY \n6. Simvastatin 40 mg PO QPM \n7. Pantoprazole 40 mg PO Q24H \n8. oxybutynin chloride 5 mg oral DAILY \n9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n10. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \n11. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Atorvastatin 80 mg PO QPM \n3. Cyanocobalamin 1000 mcg PO DAILY \n4. ___ MD to order daily dose PO DAILY16 \n5. Torsemide 20 mg PO DAILY \n6. Aspirin 81 mg PO DAILY \n7. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H \n8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \n9. GlipiZIDE XL 5 mg PO DAILY \n10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n11. Lisinopril 10 mg PO DAILY \n12. oxybutynin chloride 5 mg oral DAILY \n13. Pantoprazole 40 mg PO Q24H \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nacute ischemic stroke\nchronic systolic heart failure\nhypertension\nhyperlipidemia\ndiabetes\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\nYou were hospitalized due to symptoms of weakness resulting from \nan 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 \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 - diabetes\n - high blood pressure\n - high fats in your blood (hyperlipidemia)\n - heart disease\n \n \nWe are changing your medications as follows: \n 1. Take warfarin \n 2. Take aspirin with the warfarin\n \nPlease take your other medications as prescribed. \n \n\nWeigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n\nPlease follow up with Neurology and your primary care physician \nas listed below. \n \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, \n Your ___ Neurology Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I63421", "I21A1", "I130", "I5022", "G8194", "I2510", "I252", "E785", "I255", "E1122", "N189", "Z955", "G4733", "Z8546", "Z923", "Z79890", "R1310", "I69392", "R29705" ]

[ "I63421: Cerebral infarction due to embolism of right anterior cerebral artery", "I21A1: Myocardial infarction type 2", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "I5022: Chronic systolic (congestive) heart failure", "G8194: Hemiplegia, unspecified affecting left nondominant side", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I252: Old myocardial infarction", "E785: Hyperlipidemia, unspecified", "I255: Ischemic cardiomyopathy", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N189: Chronic kidney disease, unspecified", "Z955: Presence of coronary angioplasty implant and graft", "G4733: Obstructive sleep apnea (adult) (pediatric)", "Z8546: Personal history of malignant neoplasm of prostate", "Z923: Personal history of irradiation", "Z79890: Hormone replacement therapy", "R1310: Dysphagia, unspecified", "I69392: Facial weakness following cerebral infarction", "R29705: NIHSS score 5" ]

[ "I130", "I2510", "I252", "E785", "E1122", "N189", "Z955", "G4733" ]

[]

[ " \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:\nleg swelling, cough, dysphagia\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ is a ___ yo M w/ PMHx of HTN, CAD c/b MI s/p BMS \nx3\n___, mixed diastolic/systolic CHF (EF 21% ___, Afib on\ncoumadin, hx of CVA ___, 14 & ___ w/residual R facial weakness &\nL hemiparesis, DMII, OSA, AAA, CKD (b/l Cr 1.0-1.2), prostate ca\ns/p XRT/hormonal rx who presents as a referral from his PCP for\nbilateral leg swelling, melena, and symptoms concerning for\npneumonia found to have CAP with probable HFrEF exacerbation.\n\nPer his wife, chart review and discussion with the patient he\nreports:\n(1) Increased fatigue, lethargy\n(2) Cough, wheezing, dyspnea particularly when laying down\nultimately requiring recliner to sleep last night\n(3) Increased leg swelling (has been missing diuretic doses \nwhile\ntraveling)\n(4) Difficulty swallowing, particularly solid foods, with\nregurgitation. He does at times have difciutly with liquids,\nreportedly choking on water while in waiting room of his PCP\noffice prior to presentation. He has not had difficulty with\npills. Lately his wife has been giving him ensure BID due to\ndifficulty eating. He previously had G-tube after his CVA,\nactually asked his PCP about it. \n(5) For the past 2 weeks he has had black tarry stool, seen in \nUC\nlast week with stable H/H. B/l hgb 12.\n \nPast Medical History:\nHTN\nCKD\nHLD\nCAD c/b MI in ___, BMS x 3 in ___\nIschemic cardiomyopathy w/ EF of 35% \nAAA\nCOPD\nGrave's Dz\nGlaucoma\nOSA\nProstate CA s/p XRT, hormonal therapy \nPrior CVAs in ___ and ___ (former per Atrius records)\nGERD\nDMII\n\n \nSocial History:\n___\nFamily History:\nno hx of stroke or CAD. His mother died at age ___. \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVITALS: BP 112 / 67, HR 90, RR 22, SpO2 99% 2.5 L NC \nGEN: chronically ill appearing, raspy voice\nHEENT: MMM, JVP >10cm\nCV: RRR freq ectopic beat, no mrg\nPULM: diffuse exp wheezing, quiet bibasilar crackles, decr\nbreath sounds in RLL/RML\nGI: Obese/S/ND/NT\nEXT: WWP, 1+ pitting edema reaching to sacrum\n\nDISCHARGE PHYSICAL EXAM:\n=======================\n___ 0518 Temp: 97.5 PO BP: 107/56 L Lying HR: 68 RR: 20 O2\nsat: 94% O2 delivery: Ra \nGEN: elderly gentleman, appears young for his age. In no acute\ndistress, up in chair and conversational\nHEENT: MMM, no upper teeth, JVD at level of mandible with \npatient\nhead at approximately 15 degrees\nCV: irregularly irregular, no mrg\nPULM: no crackles, clear to auscultation. \nGI: Obese, soft, ND, NT\nEXT: WWP, 1+ pitting edema at the ankles bilaterally. \n \nPertinent Results:\nADMISSION LABS\n=============\n___ 06:25PM BLOOD WBC-6.7 RBC-3.63* Hgb-10.6* Hct-34.6* \nMCV-95 MCH-29.2 MCHC-30.6* RDW-15.9* RDWSD-55.6* Plt ___\n___ 06:25PM BLOOD Neuts-77.6* Lymphs-10.3* Monos-10.9 \nEos-0.0* Baso-0.6 Im ___ AbsNeut-5.19 AbsLymp-0.69* \nAbsMono-0.73 AbsEos-0.00* AbsBaso-0.04\n___ 06:25PM BLOOD ___ PTT-42.1* ___\n___ 06:25PM BLOOD Glucose-103* UreaN-18 Creat-1.2 Na-139 \nK-4.4 Cl-103 HCO3-25 AnGap-11\n___ 06:25PM BLOOD ___\n___ 08:37PM BLOOD cTropnT-0.03*\n___ 06:25PM BLOOD Iron-15*\n___ 06:59AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.8\n___ 06:25PM BLOOD calTIBC-231* VitB12-534 Folate->20 \nFerritn-145 TRF-178*\n___ 06:36PM BLOOD Lactate-2.0\n\nDISCHARGE LABS\n==============\n___ 06:19AM BLOOD WBC-6.7 RBC-3.85* Hgb-10.9* Hct-35.5* \nMCV-92 MCH-28.3 MCHC-30.7* RDW-15.2 RDWSD-51.1* Plt ___\n___ 06:19AM BLOOD ___ PTT-35.1 ___\n___ 06:19AM BLOOD Glucose-139* UreaN-18 Creat-1.0 Na-144 \nK-5.0 Cl-100 HCO3-31 AnGap-13\n___ 06:19AM BLOOD Calcium-9.2 Phos-3.5 Mg-1.8\n\nMICRO:\n=====\n___ 8:37 pm BLOOD CULTURE\n **FINAL REPORT ___\n Blood Culture, Routine (Final ___: NO GROWTH.\n\n___ 15:11 Streptococcus pneumoniae Antigen Detection \n Test Result Reference \nRange/Units\nS. PNEUMONIAE ANTIGENS, Not Detected Not Detected\nURINE \n\n___ 3:11 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\nIMAGING\n=======\nCXR ___\nFINDINGS: \nPA and lateral views of the chest provided.\nThere is a focal opacity spanning the entire right lung and left \nlower lobe\nconcerning for aspiration or pneumonia. Small right pleural \neffusion. There is no pneumothorax. There are no signs of \ncongestion or edema. The\ncardiomediastinal silhouette is normal. Imaged osseous \nstructures are intact. No free air below the right hemidiaphragm \nis seen.\nIMPRESSION: \nMultifocal opacities concerning for aspiration or pneumonia.\n\nVIDEO OROPHARYNGEAL SWALLOW ___\nFINDINGS: \nThere was penetration with thin liquids which cleared at the \nheight of the\nswallow. No evidence of gross aspiration. Likely small \npharyngocele noted on the right.\nIMPRESSION:\n1. No evidence of gross aspiration.\n2. Mild penetration with thin liquids which cleared at the \nheight of the swallow.\n\nBARIUM SWALLOW STUDY ___\nFINDINGS: \nThe esophagus was not dilated. There was no stricture within \nthe esophagus. There was no esophageal mass. The esophageal \nmucosa appear normal. There was near complete absence of the \nprimary peristaltic wave, with holdup of contrast in the mid \nesophagus which eventually cleared via secondary and tertiary \ncontractions. The lower esophageal sphincter demonstrated \ndelayed opening, though otherwise opened and closed normally.\nThere was minimal gastroesophageal reflux. There was no hiatal \nhernia.\nNo overt abnormality in the stomach or duodenum on limited \nevaluation.\nIMPRESSION: Moderate esophageal dysmotility with minimal \ngastroesophageal reflux.\n\n \nBrief Hospital Course:\nOutpatient Providers: PATIENT SUMMARY:\n===============\n___ is a ___ yo M w/ PMHx of HTN, CAD c/b MI s/p BMS \nx3 ___, mixed diastolic/systolic CHF (EF 21% ___, Afib on \ncoumadin, hx of CVA ___ w/residual R facial weakness, \nDMII, OSA, AAA, CKD (b/l Cr 1.0-1.2) who presents as a referral \nfrom his PCP for bilateral leg swelling, dysphagia, and dyspnea, \nfound to have acute hypoxic respiratory failure and a HFrEF \nexacerbation. He received a 5d course of CTX/Azithro for \npresumed community acquired pneumonia, and was diuresed daily \nwith IV Lasix. He also reported difficulty swallowing prior to \nadmission, which was evaluated with a video swallow study and a \nbarium swallow study, both of which were normal. He was \ndischarged on 40mg PO Torsemide and with a regular diet. \n\nACUTE ISSUES:\n===========\n# Acute on chronic mixed systolic diastolic heart failure \nEF 21%, volume overloaded on exam, BNP consistent with a heart \nfailure exacerbation. Suspect secondary to occasional \nnon-compliance with torsemide, as well as possible aspiration \nevents. Given overall HD stability, he was diuresed with IV \ndiuresis, with gradual improvement in oxygenation and volume \nexam. Dry weight: 200-203 lbs. Admission weight: 214 lbs.\n\n# Sepsis secondary to aspiration pneumonitis vs pneumonia\n# Acute hypoxic respiratory failure \nFebrile to 101.8 in ED, tachycardic, with new O2 requirement. \nInitially it seemed that he may have aspirated, in the setting \nof progressive dysphagia, possibly from one of his prior \nstrokes. However, video swallow was unconcerning for chronic \naspiration, and his barium swallow showed only delayed \nesophageal emptying with preserved LES function. He was treated \nwith a 5d course CTX/Azithromycin. Despite aggressive treatment \nas above, patient continued to require oxygen with exertion (up \n___ walks). For this reason, he was evaluated and \napproved for home oxygen. \n\n#OSA\nHe has a history of OSA and previously was on CPAP at home which \nhe stopped using because of an issue with cleaning it. He was \ntrialed on CPAP in the hospital and is discharged with \ninstructions on how to contact the original prescriber to \nresolve this issue. \n\n# Dysphagia\nPresented with dysphagia eating solid foods, no trouble with \nliquids. Speech/swallow video study without aspiration, but with \ndelayed clearance of esophageal barium. Trial of regular diet \nwas successful, and patient was discharged on a regular diet. \n\n# Hx of CVA ___ last was cardioembolic to Right ACA \nterritory). \nSuspected ___ cardioemolic strokes in ___. Already optimally \nmedically managed (asa, high dose statin). There was initial \nconcern that a previous stroke was causing the patient's \ndysphagia/aspiration, but in light of normal video study and \nbarium study, this was felt to be much less likely. \n\n# CKD (B/l 1.0-1.2)\nPresented with Cr 1.2, near baseline. Remained at baseline with \nIV diuresis, and home Torsemide was resumed at discharge with \ndose increase to 40 mg daily.\n\nCHRONIC ISSUES:\n==============\n# Acute on Chronic Anemia\n# Iron Deficiency\n# Tarry Stools \nMild acute on chronic anemia setting of supratherapeutic INR. \nLast ___ ___ with multiple polyps, diverticulosis. On \nsupplemental iron outpatient, which we suspect is the cause of \nhis tarry stools. Patient reported dark stools, but Hg stable \nwhile inpatient. \n\n# Paroxysmal Afib on Coumadin (Chads2vasc = 8)\nCurrently in sinus with 1st degree AV block on EKG, mildly \nsupratherapeutic on arrival. INR was monitored, and warfarin \ndosed daily, goal INR ___.\n\n# DMII\n# Hypoglyemia\nPatient w hypoglycemia unawareness on arrival, FSG in ___. \n___ HgA1c was 6.0%. Patient was given a sliding scale of \ninsulin while inpatient. Glipizide was discontinued because of \nhypoglycemia unawareness. \n\n# CAD c/b MI s/p BMS x3 ___\nTrop 0.03 likely iso HF exacerbation. Continued aspirin 81 and \nstatin.\n\n# GERD: Continued PPI\n\n# Glaucoma: Continued eye drops\n\n# Constipation: Continued senna\n\nTRANSITIONAL ISSUES:\n=================\n#INR:\n[] lab check on ___ with ___\n\n#Acute hypoxic respiratory failure:\n[] Home O2 with exertion- effort should be made to wean this off\n[] f/u w PCP and wean as tolerated \n[] Do not smoke or cook near flames while wearing O2 \n[] As patient recovers from HFrEF and CAP, please re-evaluate \nthe need for home O2. \n[] Recommend outpatient pulmonary rehabilitation\n\n#OSA\n[] Would recommend referral to pulmonology for titration of CPAP \nsettings and machine maintenance or replacement as needed.\n\n#Acute on Chronic Heart Failure Exacerbation \n[] Ensure taking new dose torsemide 40mg daily \n[] f/u electrolytes at upcoming appointment with PCP ___\n[] Daily weights, call MD if weight goes up by 3 lbs\n[] Consider ICD placement given low EF of ~20%\n[] Consider outpatient TTE to reevaluate EF \n[] Started on 12.5 mg metoprolol twice daily, f/u HR\n\n#Tarry Stools:\n[] Suspect secondary to iron supplementation, but if persistent, \nor worsening, would consider colonoscopy outpatient (last ___ \nwith a few polyps that were not removed due to anticoagulation)\n\n#DMII\n[]Discontinued glipizide given hypoglycemic unawareness, f/u \nglucose\n\nCODE: full code\nCONTACT: Wife ___ \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \n3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n4. Lisinopril 5 mg PO DAILY \n5. Pantoprazole 40 mg PO Q24H \n6. Torsemide 20 mg PO DAILY \n7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n8. Atorvastatin 80 mg PO QPM \n9. Cyanocobalamin 1000 mcg PO DAILY \n10. Warfarin 7.5 mg PO DAILY16 \n11. GlipiZIDE XL 5 mg PO DAILY \n12. Vitamin D 1000 UNIT PO DAILY \n13. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H \n14. Senna 8.6 mg PO BID \n15. Ferrous Sulfate 325 mg PO EVERY OTHER DAY \n\n \nDischarge Medications:\n1. Metoprolol Tartrate 12.5 mg PO BID \nRX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth \nevery twelve (12) hours Disp #*60 Tablet Refills:*0 \n2. Torsemide 40 mg PO DAILY \nRX *torsemide 20 mg 2 tablet(s) by mouth once daily Disp #*60 \nTablet Refills:*0 \n3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n4. Aspirin 81 mg PO DAILY \n5. Atorvastatin 80 mg PO QPM \n6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H \n7. Cyanocobalamin 1000 mcg PO DAILY \n8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID \n9. Ferrous Sulfate 325 mg PO EVERY OTHER DAY \n10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n11. Lisinopril 5 mg PO DAILY \n12. Pantoprazole 40 mg PO Q24H \n13. Senna 8.6 mg PO BID \n14. Vitamin D 1000 UNIT PO DAILY \n15. Warfarin 7.5 mg PO DAILY16 \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAcute on Chronic Mixed Heart Failure Exacerbation\nAcute Hypoxic Respiratory Failure \nCommunity Acquired Pneumonia \nModerate Esophageal Dysmotility\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (___ \nor cane).\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- You were admitted to the hospital because of difficulty \nswallowing, and because of extra fluid that had built up in your \nbody.\n\nWHAT HAPPENED TO ME IN THE HOSPITAL? \n- Your swallowing was evaluated by our speech/swallow team, as \nwell as by two imaging studies. Your swallowing is normal. No \nfood is going down the wrong pipe into yours lungs. It takes a \nlittle longer for the food to move through your esophagus to \nyour stomach. \n- You received IV diuretics (Lasix) to help remove extra fluid \nfrom your body \n- You were also treated with 5 days of antibiotics for a \npossible pneumonia.\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?\n- Please be careful to chew your food entirely, and take time in \nbetween bites. It is also a good idea to wash down each bite of \nfood with some water. \n- Please take your Torsemide every day as directed. \n- Weigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n- Call the number on your home CPAP machine to reach the person \nwho can help you clean it\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" ]

[ "J189", "I5043", "I130", "J440", "E1122", "N189", "K224", "E11649", "I480", "I2510", "I69392", "G4733", "I714", "I252", "T501X6A", "Y92009", "D509", "K219", "I255", "H409", "K5909", "K635", "R791", "Z7901", "Z9119", "Z955", "Z8546", "Z87891" ]

[ "J189: Pneumonia, unspecified organism", "I5043: Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure", "I130: Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "J440: Chronic obstructive pulmonary disease with (acute) lower respiratory infection", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "N189: Chronic kidney disease, unspecified", "K224: Dyskinesia of esophagus", "E11649: Type 2 diabetes mellitus with hypoglycemia without coma", "I480: Paroxysmal atrial fibrillation", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I69392: Facial weakness following cerebral infarction", "G4733: Obstructive sleep apnea (adult) (pediatric)", "I714: Abdominal aortic aneurysm, without rupture", "I252: Old myocardial infarction", "T501X6A: Underdosing of loop [high-ceiling] diuretics, initial encounter", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause", "D509: Iron deficiency anemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "I255: Ischemic cardiomyopathy", "H409: Unspecified glaucoma", "K5909: Other constipation", "K635: Polyp of colon", "R791: Abnormal coagulation profile", "Z7901: Long term (current) use of anticoagulants", "Z9119: Patient's noncompliance with other medical treatment and regimen", "Z955: Presence of coronary angioplasty implant and graft", "Z8546: Personal history of malignant neoplasm of prostate", "Z87891: Personal history of nicotine dependence" ]

[ "I130", "E1122", "N189", "I480", "I2510", "G4733", "I252", "D509", "K219", "Z7901", "Z955", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nSulfa(Sulfonamide Antibiotics) / atenolol\n \nAttending: ___\n \nChief Complaint:\nFever and confusion\n \nMajor Surgical or Invasive Procedure:\nERCP\n \nHistory of Present Illness:\nCC: fever and confusion\n\nHPI(4): Mr. ___ is a ___ man with a long history of\nhypertension, with bilateral renal artery stenosis, history of\nlacunar stroke ___ years, ?Afib on chronic warfarin, with a\nrecent L4-L5 discectomy at ___ who presented \nwith\nacute onset of confusion, fevers, and chills, found to have GNR\nbacteremia. ___ had his discectomy about one month ago; his\ncourse was complicated by delirium attributed to alprazolam\nwithdrawal. He was discharged to ___, and progressed\nwell, discharging home last ___. His course there was\ncomplicated by diarrhea; a C Diff was sent and vancomycin \nstarted\nwith improvement in the diarrhea, but the PCR was negative. When\nvancomycin was stopped, diarrhea worsened so he was treated\nempirically. After discharging home, he continued to improve --\nwalking at his baseline with a cane and eating well. He \ncontinued\nto be at his normal state of health until ___ at lunch \ntime.\nAt that point he started to complain of feeling hot; by 2 ___ he\nhad a temperature of 102.4, and was completely altered. His\nbrother ___ (who is a retired emergency room ___) took his\nBP and noted he was hypotensive and brought him to ___\nemergency room. ___ denies any localizing symptoms -- no\nabdominal pain, no urinary symptoms, no meningismus, no \nheadache.\n\nIn the ED, TMax 101.8 with SBPs in the ___, oxygen was 88% on \nRA,\nrequiring 4 liters to have spO2 in the mid ___. Out of concern\nfor meningitis he was started on IV acyclovir, IV vancomycin, IV\nampicillin, and IV CefePIME. The ED considered performing a\nlumbar puncture, but deferred in the setting of anticoagulation.\nHis blood cultures came back with both bottles growing GNRs.\n\nOut of concern for a spine infection, ortho spine was consulted,\nand an MRI of his spine was performed. \n\n1. No evidence of epidural collection, cord compression or \nsevere\nspinal canal stenosis. \n2. Postsurgical changes after right L3-L4 hemilaminectomy with\nexpected postsurgical changes. \n3. Small fluid collection in the subcutaneous soft tissues\nsubjacent to the incision site with minimal surrounding\nenhancement most likely represents a \npostoperative seroma. However, an early phlegmon or abscess\nformation is not entirely excluded and clinical correlation is\nsuggested. \n4. Mild multilevel degenerative changes throughout the cervical\nspine partially with mild remodeling of the ventral cord\nsecondary to small disc herniations but without cord signal\nabnormality. \n5. Degenerative changes of the lumbar spine are most pronounced\nat L2-L3 where there is moderate spinal canal stenosis and\ncompression of the traversing L3 nerve roots as well as at L4-L5\nand L5-S1 where there is compression of the exiting nerve roots\nwithin the neuroforamen. \n\nPer ortho, this fluid collection likely represented a seroma and\nnot an infected collection.\n\nA CT abdomen was performed which showed:\n\n1. Mild intrahepatic biliary dilatation. Linear hypodensities\nsurrounding the bile ducts within the right lobe of the liver \nmay\nrepresent the sequela of cholangitis, however there are no \npriors\nfor comparison. No focal fluid collections. \n2. Incidental findings include a large periampullary duodenal\ndiverticulum and severe atherosclerosis. \n\nCT head was performed since:\n\n1. No acute intracranial abnormalities. \n2. Severe chronic microvascular ischemic and age-related\ninvolutional changes. \n\nEKG showed ventricular bigeminy.\n \nPatient was started on a heparin gtt because on INR 1.8 and high\nCHADS2Vasc and then admitted to medicine.\n\nROS: Pertinent positives and negatives as noted in the HPI. All\nother systems were reviewed and are negative. \n\nPAST MEDICAL/SURGICAL HISTORY:\n\n1. HTN\n2. GERD\n3. PMR, previously on prednisone\n4. PVD with claudication\n5. pAF\n6. Anxiety\n7. Carotid stenosis\n8. BPH\n9. CVA\n___. Celiac artery stenosis\n11. CKD\n12. Anemia\n13. AS\n\nSOCIAL HISTORY: ___\nFAMILY HISTORY: Heart disease\n\n \nPast Medical History:\nSee HPI\n \nSocial History:\n___\nFamily History:\nSee HPI\n \nPhysical Exam:\nVITALS: Afebrile and vital signs stable (see eFlowsheet)\nGENERAL: Alert and in no apparent distress\nEYES: Anicteric, pupils equally round\nCV: Heart regular at present, sys m, 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 at\npresent. Bowel sounds present. \nGU: No suprapubic fullness or tenderness to palpation\nMSK: No edema or cyanosis\nSKIN: No rashes or ulcerations noted\nNEURO: Alert, memory deficits, grossly intact. AAOx3 today\nPSYCH: pleasant, appropriate affect\n \nPertinent Results:\n___ 05:45AM BLOOD WBC-7.6 RBC-3.25* Hgb-10.0* Hct-28.9* \nMCV-89 MCH-30.8 MCHC-34.6 RDW-12.9 RDWSD-41.9 Plt ___\n___ 05:45AM BLOOD Neuts-67.9 Lymphs-18.0* Monos-8.6 Eos-3.8 \nBaso-0.8 Im ___ AbsNeut-5.14 AbsLymp-1.36 AbsMono-0.65 \nAbsEos-0.29 AbsBaso-0.06\n___ 05:45AM BLOOD Plt ___\n___ 05:45AM BLOOD ___ PTT-34.8 ___\n___ 05:45AM BLOOD Glucose-90 UreaN-7 Creat-0.6 Na-139 K-3.6 \nCl-105 HCO3-23 AnGap-11\n___ 05:45AM BLOOD ALT-76* AST-34 AlkPhos-472* TotBili-0.3\n___ 05:50AM BLOOD ALT-111* AST-89* AlkPhos-583* TotBili-0.4\n___ 05:45AM BLOOD Albumin-2.9* Calcium-8.3* Mg-1.3*\n \nBrief Hospital Course:\n___ y//o patient who presented w/ sepsis secondary to cholangitis \nassociated with Klebsiella bacteremia.\n\nHe underwent ERCP w/ sludge and stone extraction. Clinically \nimproved. All sepsis parameters have resolved. Bcx +ve for \nKlebsiella pneumoniae >> covered w/ Rocephin and transitioned to \nLevaquin at discharge. LFTs improving. F/u blood Cx negative. \nWill need 5 more days of Abx.\n\nDiarrhea has resolved. Although appetite is poor -- able to \ntolerate diet well. Quite weak -- rehab was discussed. Pt and \nfamily preferred to go home w/ services.\n\nWarfarin was briefly held for ERCP. Resumed now. INR 2.4 today. \nRecc INR check on ___ and f/u w/ PCP. F/u CMP; CBC w/ PCP \nin ___ week\n\nInitially was hypotensive -- req IVF. BP stable now but still \noff HTN meds (on Terazosin for BPH). Recc check BP at home over \nnext week and show log to PCP at next visit.\n\n___ plan d/w patient; his wife and brother. All agree w/ \nthe plan.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Pantoprazole 20 mg PO Q12H \n2. Spironolactone 50 mg PO DAILY \n3. amLODIPine 10 mg PO DAILY \n4. Citalopram 10 mg PO DAILY \n5. Losartan Potassium 50 mg PO DAILY \n6. Chlorthalidone 25 mg PO DAILY \n7. Terazosin 1 mg PO QHS \n8. Warfarin 2.5 mg PO 3X/WEEK (___) \n9. Warfarin 5 mg PO 4X/WEEK (___) \n10. Atorvastatin 80 mg PO QPM \n11. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \n12. Gabapentin 300 mg PO QHS \n13. Vancomycin Oral Liquid ___ mg PO Q6H \n\n \nDischarge Medications:\n1. LevoFLOXacin 750 mg PO Q24H Duration: 5 Days \nRX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth once a \nday Disp #*5 Tablet Refills:*0 \n2. Citalopram 10 mg PO DAILY \n3. Gabapentin 300 mg PO QHS \n4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \n5. Pantoprazole 20 mg PO Q12H \n6. Terazosin 1 mg PO QHS \n7. Warfarin 2.5 mg PO 3X/WEEK (___) \n8. Warfarin 5 mg PO 4X/WEEK (___) \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nSepsis secondary to Cholangitis w/ Klebsiella pneumonia \nbacteremia\n\n \nDischarge Condition:\nStable\nNo distress; Currently AAOx3; Quite frail though\n\n \nDischarge Instructions:\nFollow up w/ PCP in ___ week\nCBC; CMP check w/ PCP in ___ week\nINR check on MON ___ and send results to PCP. Warfarin dose \nadjustment per MD accordingly. Target INR ___\n\nCheck BP twice/day and show records to PCP at next visit\n \nFollowup Instructions:\n___\n" ]

[ "A4159", "G9341", "E43", "K8030", "I69351", "B961", "I480", "I129", "N183", "R197", "Z6825", "E876", "E8342", "F329", "R339", "I739", "E785", "K219", "N400", "Z7901", "R791", "Z87891", "Z95828", "Z98890" ]

[ "A4159: Other Gram-negative sepsis", "G9341: Metabolic encephalopathy", "E43: Unspecified severe protein-calorie malnutrition", "K8030: Calculus of bile duct with cholangitis, unspecified, without obstruction", "I69351: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side", "B961: Klebsiella pneumoniae [K. pneumoniae] as the cause of diseases classified elsewhere", "I480: Paroxysmal atrial fibrillation", "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)", "R197: Diarrhea, unspecified", "Z6825: Body mass index [BMI] 25.0-25.9, adult", "E876: Hypokalemia", "E8342: Hypomagnesemia", "F329: Major depressive disorder, single episode, unspecified", "R339: Retention of urine, unspecified", "I739: Peripheral vascular disease, unspecified", "E785: Hyperlipidemia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "N400: Benign prostatic hyperplasia without lower urinary tract symptoms", "Z7901: Long term (current) use of anticoagulants", "R791: Abnormal coagulation profile", "Z87891: Personal history of nicotine dependence", "Z95828: Presence of other vascular implants and grafts", "Z98890: Other specified postprocedural states" ]

[ "I480", "I129", "F329", "E785", "K219", "N400", "Z7901", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nMidazolam / Demerol / Tegaderm Frame Style / Red Dye / Iodinated \nContrast Media - IV Dye\n \nAttending: ___.\n \nChief Complaint:\nabdominal pain\n \nMajor Surgical or Invasive Procedure:\n___: Subtotal colectomy, rigid sigmoidoscopy, lysis of\nadhesions, ABThera placement.\n\n___: Resection of rectum, left oophorectomy, ileostomy\n\n___: Interventional Radiology paracentesis \n\n___: EGD: 2x clips applied over AVM\n\n___: EGD\n\n___: Interventional Radiology JP drains placed x2\n\n \nHistory of Present Illness:\nMs ___ is a ___ year old lady with history of CAD, MI,\nischemic colitis, pacemaker, bioprostetic AVR ___ years ago and\nTAVR last year, and diverticulosis, who has been having \nabdominal\ndiscomfort mostly in the LLQ for the past ___ months, treated\nintermittently as diverticulitis in ___ and here with\nantibiotic course, last course of which has been two weeks ago\nwhich was completed 3days ago. She states that the overall \ncourse\nhas been worsening but that the antibiotics helped sometimes. \nPatient states that after completion of this last course of \ncipro\nand flagyl 3 days ago, she became progressively and severely\nnauseous with frequent vomiting, had abdominal pain and \ndiarrhea.\n\nthe patient went to ___ initially where her lactate was\nfound to be 2.3, and her WBC was ___ with left shift. \nA CT scan without IV contrast was notable for colonic dilation \nup\nto the level of the sigmoid colon, and a complex cystic mass in\nthe left adnexa. \nThe patient was transferred to ___ for further workup after 1L\nfluid resuscitation and one dose of meropenem. On presentation \nto\n___ her lactate had increased to 5, her pressures were soft \nand\nher mental status was deteriorated. \nSurgery is consulted regarding the need for surgical\nintervention. \nat the time of this consult the patient is still nauseous, and\ncomplains of severe abdominal pain. her last bowel movement had\nbeen the day prior to this presentation, which she describes as\nblack and soft. From a mental status standpoint she was very\ndrowsy, however, she responded appropriately to a few questions\nwhen verbally reoriented. She denies fever, chills, SOB, CP,\npalpitations, lightheadedness. \nCardiac enzymes were negative for acute MI, and cardiology\nservice did not recommend further cardiac output. \n\n \nPast Medical History:\nPast Medical History:\nMI\nCAD\nischemic colitis\ndiverticulosis\n\nPast Surgical History:\ncholecystectomy\nC-section\nopen bioprosthetic AVR ___ years ago\nTAVR one year ago\n \nSocial History:\n___\nFamily History:\nbrother s/p OLT for hep C, passed away\n \nPhysical Exam:\nAdmission Physical Exam:\n\nVitals: HR:70 BP: 95/60 RR:28 Sat: 92%RA T:97.8\nGEN: A&O, NAD\nHEENT: No scleral icterus, mucus membranes moist\nCV: RRR, No M/G/R\nPULM: tachypneic on RA, no use of accessory muscles, no central\ncyanosis\nABD: Soft, TTP diffusely, no rebound/guarding\nExt: No ___ edema, no cyanosis.\n\nDischarge Physical Exam:\n\nVS: T: 98.3 PO BP: 109/71 HR: 70 RR: 18 O2: 100% Ra\nGEN A+Ox3, NAD\nCV: RRR\nPULM: no respiratory distress, breathing comfortably on room air\nABD: soft, non-distended, non-tender to palpation. Surgical \nwound with wet-to-dry dressing. Wound base red overall with \nminimal fibrinous debris in inferior portion of the wound, no \ns/s infection. Right ileostomy with stool in bag.\nExtremity: wwp, no edema b/l \n \nPertinent Results:\nPathology: ___:\n\n1- Ileocecal resection:\n- Partially autolyzed viable small and large intestine; margins \nviable.\n- Tubular adenomas, up to 0.4cm\n- Unremarkable vermiform appendix\n2- Ascending colon, partial colectomy:\n- Diverticular disease; no significant peridiverticular \ninflammation seen.\n- Viable colon with partial autolysis including viable specimen \nmargins\n3- Transverse colon, partial colectomy:\n- Colon with subtotal transmural infarction; margins viable\n4- Ileum, partial resection:\n- Small intestine with mucosal and submucosal ischemia involving \nspecimen margins\n5- Descending colon, partial colectomy:\n- Diverticular disease; with associated stricture, patchy mural \nchronic inflammation, and foreign body\ngiant cell reaction.\n\nLABS:\n\n___ 09:46PM TYPE-ART PO2-139* PCO2-41 PH-7.33* TOTAL \nCO2-23 BASE XS--4\n___ 09:46PM LACTATE-2.0\n___ 09:46PM freeCa-1.08*\n___ 09:39PM GLUCOSE-103* UREA N-33* CREAT-1.5* SODIUM-146 \nPOTASSIUM-4.4 CHLORIDE-112* TOTAL CO2-20* ANION GAP-14\n___ 09:39PM CALCIUM-7.4* PHOSPHATE-4.2 MAGNESIUM-2.6\n___ 09:39PM HGB-10.7* HCT-33.5*\n___ 08:07PM TYPE-ART PO2-174* PCO2-40 PH-7.33* TOTAL \nCO2-22 BASE XS--4\n___ 08:07PM LACTATE-2.1*\n___ 08:07PM freeCa-1.07*\n___ 04:01PM TYPE-ART PO2-178* PCO2-45 PH-7.28* TOTAL \nCO2-22 BASE XS--5\n___ 04:01PM LACTATE-2.6*\n___ 04:01PM freeCa-1.11*\n___ 03:54PM GLUCOSE-110* UREA N-33* CREAT-1.5* SODIUM-146 \nPOTASSIUM-4.6 CHLORIDE-112* TOTAL CO2-19* ANION GAP-15\n___ 03:54PM CALCIUM-7.6* PHOSPHATE-4.8* MAGNESIUM-2.8*\n___ 03:54PM WBC-8.1 RBC-4.14 HGB-11.6 HCT-35.7 MCV-86 \nMCH-28.0 MCHC-32.5 RDW-15.3 RDWSD-48.1*\n___ 03:54PM PLT COUNT-187\n___ 01:34PM TYPE-ART PO2-151* PCO2-45 PH-7.25* TOTAL \nCO2-21 BASE XS--7\n___ 01:34PM LACTATE-2.7*\n___ 11:51AM TYPE-ART PO2-171* PCO2-50* PH-7.20* TOTAL \nCO2-20* BASE XS--8\n___ 11:51AM LACTATE-3.8*\n___ 09:06AM TYPE-ART PO2-450* PCO2-44 PH-7.24* TOTAL \nCO2-20* BASE XS--8\n___ 08:50AM GLUCOSE-92 UREA N-35* CREAT-1.4* SODIUM-145 \nPOTASSIUM-3.4* CHLORIDE-109* TOTAL CO2-18* ANION GAP-18\n___ 08:50AM CALCIUM-8.5 PHOSPHATE-5.1* MAGNESIUM-1.6\n___ 08:50AM CEA-10.6*\n___ 08:50AM WBC-11.4* RBC-4.22 HGB-11.9 HCT-36.5 MCV-87 \nMCH-28.2 MCHC-32.6 RDW-15.1 RDWSD-47.7*\n___ 08:50AM PLT COUNT-221\n___ 08:50AM ___ PTT-32.8 ___\n___ 07:54AM TYPE-ART PO2-318* PCO2-48* PH-7.20* TOTAL \nCO2-20* BASE XS--9 INTUBATED-INTUBATED VENT-CONTROLLED\n___ 07:54AM GLUCOSE-78 LACTATE-5.4* NA+-138 K+-3.4 \nCL--110*\n___ 07:54AM HGB-10.3* calcHCT-31\n___ 07:54AM freeCa-1.22\n___ 06:14AM TYPE-ART O2-80 PO2-272* PCO2-50* PH-7.09* \nTOTAL CO2-16* BASE XS--14 AADO2-244 REQ O2-49 \nINTUBATED-INTUBATED VENT-CONTROLLED\n___ 06:14AM GLUCOSE-102 LACTATE-4.4* NA+-137 K+-3.7 \nCL--113*\n___ 06:14AM HGB-12.0 calcHCT-36 O2 SAT-98\n___ 06:14AM freeCa-1.12\n___ 01:58AM ___ PO2-50* PCO2-26* PH-7.23* TOTAL \nCO2-11* BASE XS--15\n___ 01:58AM LACTATE-6.1* K+-3.6\n___ 01:58AM O2 SAT-77\n___ 12:08AM LACTATE-5.0*\n___ 11:53PM GLUCOSE-158* UREA N-35* CREAT-1.6* SODIUM-136 \nPOTASSIUM-7.0* CHLORIDE-116* TOTAL CO2-9* ANION GAP-11\n___ 11:53PM ALT(SGPT)-9 AST(SGOT)-52* ALK PHOS-81 TOT \nBILI-0.5\n___ 11:53PM LIPASE-17\n___ 11:53PM cTropnT-<0.01\n___ 11:53PM CK-MB-2\n___ 11:53PM ALBUMIN-3.2*\n___ 11:53PM WBC-29.1* RBC-5.54* HGB-15.3 HCT-47.6* MCV-86 \nMCH-27.6 MCHC-32.1 RDW-15.2 RDWSD-47.3*\n___ 11:53PM NEUTS-82* BANDS-13* LYMPHS-3* MONOS-2* EOS-0 \nBASOS-0 ___ MYELOS-0 AbsNeut-27.65* AbsLymp-0.87* \nAbsMono-0.58 AbsEos-0.00* AbsBaso-0.00*\n___ 11:53PM HYPOCHROM-NORMAL ANISOCYT-NORMAL \nPOIKILOCY-1+* MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL \nBURR-1+* ELLIPTOCY-OCCASIONAL\n___ 11:53PM PLT SMR-NORMAL PLT COUNT-321\n___ 11:53PM ___ PTT-29.0 ___\n\nMicrobiology:\n\n___ 9:30 am PERITONEAL FLUID PERITONEAL FLUID. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n\n FLUID CULTURE (Final ___: \n Reported to and read back by ___ (___) AT \n3:15 ___\n ___. \n ENTEROCOCCUS SP.. SPARSE GROWTH. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ENTEROCOCCUS SP.\n | \nAMPICILLIN------------ =>32 R\nLINEZOLID------------- 2 S\nPENICILLIN G---------- =>64 R\nVANCOMYCIN------------ =>32 R\n\n ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.\n\n___ 11:55 am PERITONEAL FLUID PERITONEAL FLUID LLQ. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n This is a concentrated smear made by cytospin method, \nplease refer to\n hematology for a quantitative white blood cell count.. \n\n FLUID CULTURE (Final ___: NO GROWTH. \n\n ANAEROBIC CULTURE (Final ___: NO GROWTH. \n\n___ 11:40 am ABSCESS\n ABCESS DRAINAGE RUQ PER HANDWRITTEN ON SYRINGE. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n\n FLUID CULTURE (Final ___: NO GROWTH. \n\n ANAEROBIC CULTURE (Final ___: NO GROWTH. \n\n___ 11:40 am URINE Source: ___. \n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n ESCHERICHIA COLI. >100,000 CFU/mL. \n Cefazolin interpretative criteria are based on a dosage \nregimen of\n 2g every 8h. \n\n SENSITIVITIES: MIC expressed in \nMCG/ML\n \n_________________________________________________________\n ESCHERICHIA COLI\n | \nAMPICILLIN------------ =>32 R\nAMPICILLIN/SULBACTAM-- 16 I\nCEFAZOLIN------------- <=4 S\nCEFEPIME-------------- <=1 S\nCEFTAZIDIME----------- <=1 S\nCEFTRIAXONE----------- <=1 S\nCIPROFLOXACIN--------- =>4 R\nGENTAMICIN------------ <=1 S\nMEROPENEM-------------<=0.25 S\nNITROFURANTOIN-------- <=16 S\nPIPERACILLIN/TAZO----- 8 S\nTOBRAMYCIN------------ <=1 S\nTRIMETHOPRIM/SULFA---- =>16 R\n\n \nBrief Hospital Course:\n**Rehab stay expected to be less than 30 days.**\n\nMs ___ was admitted to the ACS service after emergent \nsubtotal colectomy for necrotic cecum and obstructing sigmoid \nmass. She underwent her initial surgery and was admitted to the \nTrauma ICU for resuscitation, intubated and sedated with an open \nabdomen. She was taken back to the operating room the following \nday for resection of the remainder of her sigmoid colon as well \nas her left ovary and fallopian tube. An ileostomy was created. \n She was treated with 4 days of zosyn postoperatively. \nShe was readmitted to the trauma ICU postoperatively for \nmonitoring. Her hospital course, by systems, is as follows:\n\nNeuro: The patient was initially sedated and intubated \npostoperatively. After she was extubated, she was acutely \ndelirious for two days, after which her mental status improved. \nAfter transfer to the floor, she was intermittently delirious \nand geriatrics was consulted for any medical recommendations to \nreduce delirium. \n\nCV: The patient was initially requiring vasopressors \npostoperatively but they were soon weaned; vital signs were \nroutinely monitored. Cardiology was consulted for a 30 minute \nepisode of tachycardia (underlying rhythm consistent with RV \npacing). Pacemaker was interrogated and was normal. Cardiology \nalso assisted with anticoagulation recommendations and \nrecommended stopping Plavix. \n\nPulmonary: The patient was extubated on POD #1 from her second \noperation and was weaned successfully to room air. Good \npulmonary toilet, early ambulation and incentive spirometry were \nencouraged throughout hospitalization. \n\nGI/GU/FEN: The patient was initially kept NPO with a \n___ tube in place for decompression. Postoperatively, \nthe NGT was dc'ed once she had good ostomy output. She received \nanti-diarrheal medication as she initially had high ostomy \noutput. Once her output was controlled, the antidiarrheal \nmedication was discontinued. Her diet was advanced sequentially \nto a Regular diet. The patient had episodes of nausea and \nemesis and had a CT scan which showed a large volume of ascites \nwhich was removed via paracentesis. She had an episode of \nhematemesis and underwent EGD which was normal. The patient \nreceived medication, such as reglan, erythromycin and Marinol, \nto stimulate her appetite. She had a dobhoff feeding tube \nplaced and tube feeds were initiated, however, she self-removed \nthe dobhoff and refused any enteral access. POs were encouraged \nand nutritional supplements were provided. All appetite \nstimulants were later stopped, as the patient felt that all the \nmedication she was receiving may be contributing to her nausea. \n\nID: peritoneal fluid collection grew enterococcus sp and she \nreceived a course of linezolid which finished. She also grew \ne.coli from her urine culture and she received ceftazedime which \nfinished. The patient later had two JP drains placed by \nInterventional Radiology for simple fluid seen within the \nabdomen. These JP drains were later removed. \n\nHEME: The patient's blood counts were closely watched for signs \nof bleeding and she required intermittent blood transfusions to \nmaintain adequate hematocrit/hemoglobin.\n\nProphylaxis: The patient received subcutaneous heparin and ___ \ndyne boots were used during this stay and was encouraged to get \nup and ambulate as early as possible.\n\nWound Care: The patient had her scheduled bedside wound vac \nchanges which she tolerated well. \n\nAt the time of discharge, the patient was doing well, afebrile \nand hemodynamically stable. The patient was tolerating a diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. LORazepam 0.5 mg PO BID:PRN anxiety \n2. Levothyroxine Sodium 100 mcg PO DAILY \n3. Anastrozole 1 mg PO DAILY \n4. Metoprolol Succinate XL 50 mg PO DAILY \n5. Aspirin 325 mg PO DAILY \n6. Lisinopril 5 mg PO DAILY \n7. Clopidogrel 75 mg PO DAILY \n8. Atorvastatin 80 mg PO QPM \n9. Citalopram 20 mg PO DAILY \n\n \nDischarge Medications:\n1. Heparin 5000 UNIT SC BID \n2. Metoprolol Tartrate 25 mg PO BID \n3. Miconazole Powder 2% 1 Appl TP QID:PRN excoration perineum \n\n4. Pantoprazole 40 mg PO Q24H \n5. Aspirin 81 mg PO DAILY \n6. LORazepam 0.25 mg PO BID:PRN sleep/anxiety \nRX *lorazepam 0.5 mg 0.5 (One half) mg by mouth twice a day Disp \n#*5 Tablet Refills:*0 \n7. Anastrozole 1 mg PO DAILY \n8. Atorvastatin 80 mg PO QPM \n9. Citalopram 20 mg PO DAILY \n10. Levothyroxine Sodium 100 mcg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nLarge bowel obstruction with ischemic colon, with malignant \nversus diverticular sigmoid stricture \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the hospital with an obstruction of your \ncolon and decreased blood flow to your bowel. You were taken to \nthe operating room and underwent removal of the colon, rectum, \nand the left ovary and a diverting ileostomy was created. \nFollowing surgery, you had an infected intra-abdominal fluid \ncollection as well as a urinary tract infection and you \ncompleted a course of antibiotic therapy. You had a wound vac \nsponge dressing placed to help close your surgical wound. You \nnow have return of bowel function and are tolerating a regular \ndiet. It is important to keep eating a nutritious, high-calorie \ndiet while at rehab to regain your strength and promote healing. \n You are now ready to be discharged to rehab to continue your \nrecovery. Please note the following discharge instructions:\n\nWeigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\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\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\nGeneral 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*If the drain is connected to a collection container, please \nnote color, consistency, and amount of fluid in the drain. Call \nthe doctor, ___, or ___ nurse if the amount \nincreases significantly or changes in character. Be sure to \nempty the drain frequently. Record the output, if instructed to \ndo so.\n*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\n \nFollowup Instructions:\n___\n" ]

[ "A419", "K55041", "R6521", "K31811", "K5720", "N390", "E872", "F05", "K559", "D62", "B9620", "Z950", "I10", "E039", "I2510" ]

[ "A419: Sepsis, unspecified organism", "K55041: Focal (segmental) acute infarction of large intestine", "R6521: Severe sepsis with septic shock", "K31811: Angiodysplasia of stomach and duodenum with bleeding", "K5720: Diverticulitis of large intestine with perforation and abscess without bleeding", "N390: Urinary tract infection, site not specified", "E872: Acidosis", "F05: Delirium due to known physiological condition", "K559: Vascular disorder of intestine, unspecified", "D62: Acute posthemorrhagic anemia", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "Z950: Presence of cardiac pacemaker", "I10: Essential (primary) hypertension", "E039: Hypothyroidism, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris" ]

[ "N390", "E872", "D62", "I10", "E039", "I2510" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nMidazolam / Demerol / Tegaderm Frame Style / Red Dye / Iodinated \nContrast Media - IV Dye\n \nAttending: ___.\n \nChief Complaint:\nShock, severe aortic stenosis\n\n \nMajor Surgical or Invasive Procedure:\nTAVR procedure ___\n\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with a history of aortic stenosis \ns/p bioprosthetic AVR ___ years ago, hypertension, invasive \nductal carcinoma, hypothyroidism, and RLL nodules c/f malignancy \nwho is transferred from ___ in shock and respiratory \nfailure.\n\nPer discharge summary and family, for the past ___ months, Ms. \n___ was experiencing worsening dyspnea on exertion. On the \nmorning of admission, she suddenly developed acute respiratory \ndistress. She called her daughter who found her to be clutching \nher chest and feeling very short of breath. EMS was called and \nfound the patient at home in significant respiratory distress, \ncyanotic, mottled, awake but speaking in ___ word sentences with \noxygen saturation in the ___ on room air. Sats improved on a \nnonrebreather mask and she was taken by ambulance to \n___.\n\nUpon arrival to the ___, patient was intubated for \nairway protection in the setting of worsening respiratory \ndistress. Soon after intubation, patient vomited and thought to \nhave aspirated. Reportedly, she was able to be ventilated \nreasonably well on mechanical ventilation. Labs were significant \nfor a WBC=19.0 and H/H of 16.1/48. BUN was 19 with a Cr=1.6 from \nbaseline of 0.9. Troponin was initially 2.19 then 2.24 then \n1.95. She was started on phenylephrine in the ED and transferred \nto the ICU for further management. Heparin infusion was started \nfor ACS. \n\nIn the ICU patient reportedly continued to vomit around ETT. OGT \nwas placed to wall suction and she was put on standing Reglan. \nShe was thought to have melena initially and PPI bolus and drip \nwas initiated and then discontinued when the stool turned to \nliquid brown. Antibiotics given included vancomycin (ED), Zosyn \n(ED), IV metronidazole (empiric C. diff), levofloxacin (ICU for \nCAP), and ceftriaxone (ICU for CAP). TSH was sent and returned \nat 17.23, at which point levothyroxine was switched to IV for \npresumed malabsorption. C-diff was reportedly negative at time \nof transfer.\n\nWhile in the ICU, pressor requirements increased and she was \ntransitioned from phenylephrine to norepinephrine. Stress dose \nsteroids with solumedrol 80mg q.8H were initiated given \nhypotension and possible undiagnosed COPD.\n\nUrgent echo performed on ___ has formal read pending but \nreportedly showed increased \"aortic insufficiency of moderate to \nsevere with a peak gradient greater than 100.\" Cardiology at \n___ recommended urgent transfer to ___. \n\nAt the time of transfer, patient was net positive 3098cc. \nTransfer summary notes that the prior team was unable to diurese \npatient due to her being hypotensive and in cardiogenic shock. \n\nOf note, patient had been undergoing workup for planned TAVR at \n___. Per ___ records, patient apparently \ninitially scheduled for TAVR on ___, but rescheduled to ___ \ndue to another emergent case. Had labs drawn on ___, which \nshowed WBC=11.6, H/H=15.8/48.2, Plt=156.\n\nOn arrival to the CCU, she continued to be hypotensive requiring \nhigh doses of norepinephrine. She was given IV fluids.\n \nREVIEW OF SYSTEMS: \nNegative except as indicated per HPI.\n\n \nPast Medical History:\n1. CARDIAC RISK FACTORS \n- Hypertension \n- Hyperlipidemia \n2. CARDIAC HISTORY \n- Aortic stenosis (I/s/o bicuspid AV) s/p bovine aortic valve \nreplacement in ___, planned TAVR in ___.\n- Diastolic CHF, class III \n- CABG with SAVR ___ ___)\n- Complete heart block s/p pacemaker ___\n3. OTHER PAST MEDICAL HISTORY \n- Possible COPD, no formal diagnosis\n- Aortic aneurysm, 4.5-cm, stable\n- Sigmoid ischemia diagnosed on colonoscopy ___\n- Invasive ductal carcinoma, right breast, stage 1, ER/PR \npositive, HER2 negative, s/p lumpectomy, sentinel node biopsy, \npartial radiation and radioactive seed placement. Maintained on \nArimidex since ___.\n- RLL speculated pulmonary nodule suspicious for low-grade \nbronchoalveolar carcinoma, mild FGD avidity on PET scan. \nFollowed clinically with serial CT scans q.3 months. Biopsy \ndeferred for now.\n- Hx of Iron deficiency anemia\n- Hx of B12 deficiency\n- Hypothyroidism\n- Sebaceous cyst excision\n\n \nSocial History:\n___\nFamily History:\nbrother s/p OLT for hep C, passed away\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n============================\nVS: T 99.7F HR 91 BP 140/59 RR 21 O2 97% on 50% FiO2 \nGENERAL: Elderly female. Intubated and sedated.\nHEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI. \nConjunctiva were pink. No pallor or cyanosis of the oral mucosa. \nNo xanthelasma. \nNECK: Supple. JVP of 7-9 cm. \nCARDIAC: Regular rate and rhythm. Normal S1, S2. ___ Systolic \nmurmur at USB.\nLUNGS: No chest wall deformities or tenderness. Bilateral breath \nsounds on the mechanical ventilator. No obvious crackles, \nwheezes or rhonchi but obscured by mechanical vent.\nABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No \nsplenomegaly. Flexiseal in place. Foley in place.\nEXTREMITIES: Upper extremities warm, well perfused. Lower \nextremities cool. 1+ pitting edema in b/L ___. No clubbing, \ncyanosis, or peripheral edema. \nSKIN: No significant skin lesions or rashes. \nPULSES: Distal pulses palpable and symmetric. ___ 1+ b/L.\n\nDISCHARGE PHYSICAL EXAM\n===========================\n\nPHYSICAL EXAMINATION: \n EKG: NA\n VS: Temp: 98.4, heart rate: 60, respiratory rate: 18, BP: 121-\n163/61-70, O2 sat 95% on room air. \n GENERAL: comfortable, sitting up in bed, conversing with family\nat bedside, laughing \n NECK: Supple. JVP not elevated\n CARDIAC: Regular rate and rhythm. Normal S1, S2. ___ Systolic\nmurmur at right USB. \n LUNGS: No chest wall deformities or tenderness. Bilateral \nbreath\nsounds. Clear anteriorly.\n ABDOMEN: Soft, tender diffusely. No hepatomegaly. No\nsplenomegaly. Foley in place. \n EXTREMITIES: Upper extremities warm, well perfused. No \nclubbing,\ncyanosis, or peripheral edema. Right and left groin site with\nDSD, no hematoma or significant ecchymosis\n SKIN: Mid back lesion with DSD and brown drainage. Area is\nmildly raised with a firm border and no apparent drainage at\npresent\n PULSES: Distal pulses palpable and symmetric. ___ 1+ b/L. \n\n \nPertinent Results:\nADMISSION/PERTINENT LABS\n===============================\n___ 08:06PM BLOOD WBC-13.9* RBC-5.39* Hgb-15.7 Hct-48.8*# \nMCV-91 MCH-29.1 MCHC-32.2 RDW-15.9* RDWSD-52.3* Plt ___\n___ 08:06PM BLOOD ___ PTT-45.6* ___\n___ 08:06PM BLOOD Glucose-208* UreaN-27* Creat-1.3* Na-137 \nK-4.2 Cl-107 HCO3-15* AnGap-19\n___ 08:06PM BLOOD ALT-33 AST-43* LD(LDH)-391* CK(CPK)-215* \nAlkPhos-59 TotBili-0.7\n___ 08:06PM BLOOD CK-MB-18* MB Indx-8.4* cTropnT-0.24*\n___ 03:16AM BLOOD CK-MB-12* MB Indx-7.3* cTropnT-0.18*\n___ 08:06PM BLOOD Albumin-3.6 Calcium-8.2* Phos-3.3 Mg-2.7*\n___ 05:58AM BLOOD Cortsol-12.9\n___ 05:58AM BLOOD TSH-2.2\n___ 08:34PM BLOOD ___ pO2-49* pCO2-43 pH-7.20* \ncalTCO2-18* Base XS--10\n___ 03:11PM BLOOD ___ pO2-41* pCO2-40 pH-7.26* \ncalTCO2-19* Base XS--8\n___ 04:53PM BLOOD ___ Temp-36.1 pO2-52* pCO2-31* \npH-7.45 calTCO2-22 Base XS-0\n___ 08:34PM BLOOD Lactate-3.0*\n___ 09:17PM BLOOD Lactate-2.4*\n___ 03:27AM BLOOD Lactate-1.9\n\nIMAGING/STUDIES:\n========================\n+ CARDIAC CATH ___:\nRight dominant.\nTandem mild to moderate stenosis in the RCA.\n - Proximal RCA lesion, 30% stenosed\n - Mid-RCA lesion, 30% stenosed\n - Distal RCA lesion, 50% stenosed\nModerate proximal LAD stenosis, FFR of this lesion was negative.\n - Proximal LAD to Mid-LAD lesion, 60% stenosed. Pressure \nwire/FFR was performed on the lesion. FFR:0.9.\n - Distal LAD lesion 40% stenosed\n\nOther TAVR workup:\n+ ABI ___: Bilateral inflow, femoral popliteal and moderate \ninfragenicular disease. Follow up CTA may be performed as \nclinically indicated.\n\n+ CTA abdomen/pelvis ___: Moderate atherosclerotic \ncalcifications are present. Small focal aneurysm of distal \nabdominal aorta 2.2 x2.4 cm. Celiac and SMA patent without \nstenosis. Renal arteries patent without stenosis.\n\n+ CAROTID DUPLEX ULTRASOUND (___): No evidence of \nhemodynamically significant carotid artery stenosis. Extensive \ncalcified carotid plaque formation bilaterally.\n\nTTE (___):\nThe left atrial volume index is moderately increased. The \nestimated right atrial pressure is at least 15 mmHg. There is \nmild symmetric left ventricular hypertrophy with normal cavity \nsize. There is mild regional left ventricular systolic \ndysfunction with hypokinesis of the mid to distal septum and \nanterior wall as well as apex. Some of the spetal motion may be \ndue to an IVCD. The remaining segments contract normally (LVEF = \n40 %). Tissue Doppler imaging suggests an increased left \nventricular filling pressure (PCWP>18mmHg). There is no \nventricular septal defect. Right ventricular chamber size and \nfree wall motion are normal. The diameters of aorta at the \nsinus, ascending and arch levels are normal. A bioprosthetic \naortic valve prosthesis is present. The transaortic gradient is \nhigher than expected for this type of prosthesis. At least mild \nto moderate (___) aortic regurgitation is seen. [Due to \nacoustic shadowing, the severity of aortic regurgitation may be \nsignificantly UNDERestimated.] The mitral valve leaflets are \nmildly thickened. There is no mitral valve prolapse. Mild to \nmoderate (___) mitral regurgitation is seen. [Due to acoustic \nshadowing, the severity of mitral regurgitation may be \nsignificantly UNDERestimated.] Mild to moderate [___] tricuspid \nregurgitation is seen. There is moderate pulmonary artery \nsystolic hypertension. The end-diastolic pulmonic regurgitation \nvelocity is increased suggesting pulmonary artery diastolic \nhypertension. There is no pericardial effusion. \n\n IMPRESSION: Severe bioprosthetic aortic valve stenosis. Mild to \nmoderate regional left ventricualr systolic dysfunction c/w CAD \n(mid LAD territory). At least mild to moderate aortic and mitral \nregurgitation. At least moderate pulmonary hypertension with \nincreased right and left atrial filling pressures. \n\n \nBrief Hospital Course:\n___ with Hx of severe AS s/p Bioprosthetic AVR, hypertension, \npossible COPD presented to ___ with respiratory failure \nand shock and is now transferred for further management \nincluding possible emergent TAVR.\n\n# CORONARIES: 60% ___ distal LAD 40%; Distal RCA 50%\n# PUMP: LVEF approx. 40% by report, echo pending\n# RHYTHM: Paced, bigeminy \n\n# Shock:\nPatient presented in shock likely mixed shock with primary \nelement of sepsis (likely PNA with bandemia, high CvO2, response \nto IV fluids). She was given broad spectrum antibiotics with \nvancomycin, cefepime, flagyl, azithromycin and was on \nnorepinephrine. She was give fluid boluses with response to her \npressures and was able to be weaned off pressors. Stress dose \nsteroids were not continued. Antibiotic course was completed and \nBP/HR stable at time of discharge. \n\n# Pneumonia:\nMultifactorial in the setting of pneumonia, aspiration, and \npulmonary venous congestion. RLL infiltrate with surrounding \npleural effusion, known RLL nodules and possible malignancy. \nPatient was started on broad spectrum abx and narrowed to \nceftriaxone/azithromycin to treat CAP for 7 day course \n(___). She was extubated successfully on ___. Her course \nwas complicated by episodes of flash pulmonary edema in setting \nof agitation and severe aortic stenosis requiring Lasix 40mg IV \nboluses. Inc WBC, Low BP and O2 sat and cough all resolved at \ntime of discharge. \n\n# Severe Aortic Stenosis:\nReportedly worsening AS after bioprosthetic valve replacement in \n___. Currently undergoing workup for TAVR at ___, \nwhich was completed here at ___. Patient was not a candidate \nfor SAVR and underwent TAVR on ___. Post TAVR ECHO showed good \nvlalve positioning and improved gradients. Pt states she feels \nless DOE by discharge. \n\n# NSTEMI: \nElevated troponin and lateral ST depressions concerning for \nischemia. Likely demand in the setting of sepsis and severe AS. \nTroponins peaked, and she was on heparin gtt temporarily. She \nwas continued on aspirin 81mg and atorvastatin 80mg. Beta \nblocker was restarted at dec dose on discharge. \n\n# Complete heart block s/p PPM:\nPacer in place since AVR. Intermittently V-pacing at 100 bpm.\n\n# Hx of Diastolic CHF: Euvolemic. D/c'ed on low dose furosemide \nand lisinopril. Weight stable. \n\n#Toxic Metabolic Encephalopathy\nIn setting of infection and hospital delirium, which improved. \nOT felt she had improving delirium but was safe to go home with \n24 supervision by family. She will not drive until after her F/U \nappts in 1 month. \n\n# Hypothyroidism:\nTSH at OSH reportedly >17, which was blamed on limited GI \nabsorption in the setting of critical illness. TSH here wnl\n\n# Hypertension:\n- Held antihypertensives given soft BPs\n\n# Hyperlipidemia:\n- continued atorvastatin\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Anastrozole 1 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. LORazepam 0.5 mg PO BID \n4. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose \ninhalation BID \n5. Gabapentin 100 mg PO BID \n6. Escitalopram Oxalate 20 mg PO DAILY \n7. Atorvastatin 80 mg PO QPM \n8. Metoprolol Tartrate 25 mg PO BID \n9. Levothyroxine Sodium 100 mcg PO 3X/WEEK (___) \n10. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, SOB \n\n \nDischarge Medications:\n1. Clopidogrel 75 mg PO DAILY \n2. Furosemide 20 mg PO DAILY \n3. Lisinopril 2.5 mg PO DAILY \n4. Metoprolol Succinate XL 50 mg PO DAILY \n5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, SOB \n6. Anastrozole 1 mg PO DAILY \n7. Aspirin 81 mg PO DAILY \n8. Atorvastatin 80 mg PO QPM \n9. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose \ninhalation BID \n10. Escitalopram Oxalate 20 mg PO DAILY \n11. Gabapentin 100 mg PO BID \n12. Levothyroxine Sodium 100 mcg PO 3X/WEEK (___) \n13. LORazepam 0.5 mg PO BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nCommunity acquired pneumonia\nAcute respiratory failure\nAcute on chronic systolic heart failure\nNon ST elevation myocardial infarction\nHypothyroid\nSevere AS\nToxic Metabolic Encephalopathy\nCardiogenic shock\nDiarrhea\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n.\n VS: Temp: 98.4, heart rate: 60, respiratory rate: 18, BP: 121-\n163/61-70, O2 sat 95% on room air. \n GENERAL: comfortable, sitting up in chair\n NECK: Supple. JVP not elevated\n CARDIAC: Regular rate and rhythm. Normal S1, S2. ___ Systolic\nmurmur at right USB. \n LUNGS: No chest wall deformities or tenderness. Bilateral \nbreath\nsounds. Clear anteriorly.\n ABDOMEN: Soft, tender diffusely. No hepatomegaly. No\nsplenomegaly. \n EXTREMITIES: Upper extremities warm, well perfused. No \nclubbing,\ncyanosis, or peripheral edema. Right and left groin site with\nDSD, no hematoma or significant ecchymosis\n SKIN: Mid back lesion with DSD and brown drainage. Area is\nmildly raised with a firm border and no apparent drainage at\npresent\n PULSES: Distal pulses palpable and symmetric. ___ 1+ b/L. \n\nECHO POST TAVR:\n 1. Unchanged bi-ventricular systolic function, EF 40%\n 2. There is a tri-leaflet prosthetic valve in aortic position.\nWell seated and stable with good leaflet excursion. There is\ntrace ___ AI and trace valvular AI with minimal\ntrans-aortic gradient\n 3. Severity of MR is unchanged \n ASSESSMENT AND PLAN: ___ with Hx of severe AS s/p Bioprosthetic\nAVR, hypertension, possible COPD presented to ___ with\nrespiratory failure and shock and is now transferred for further\nmanagement including possible emergent TAVR \n # CORONARIES: 60% ___ distal LAD 40%; Distal RCA 50% \n\n # PUMP: LVEF approx. ___ on ___\n \n # CAP Pneumonia: Presented intubated from OSH, now extubated.\nMultifactorial in the setting of pneumonia, aspiration, and\npulmonary venous congestion with fluid overload. RLL infiltrate\nwith surrounding pleural effusion, known RLL nodules likely\nmalignancy. Course complicated by episodes of flash pulmonary\nedema \n - Seven-day course of ceftriaxone, azithromycin (day 1: ___\nend ___ finished \n - furosemide 20 mg daily \n\n # Severe Aortic Stenosis: Status post a 23-mm \n___\nvalve in ___. No complications\n- post echo with improved gradients and well seated valve. \n- Continue aspirin and Plavix\n- 1 month follow-up per structural heart team \n\n # Sebaceous cyst: Has sebaceous cyst on back. Partially \nresected\nlast year by general surgeon. Procedure complicated by a \n'pinched\nnerve' and patient preferred not to have any further \nintervention\nunless absolutely necessary. Looks non-infected, nontender.\nCulture neg. Brown scant discharge \n - Trend clinically \n\n #Acute on chronic systolic CHF: Appears euvolemic at present\n EF of 40-45%. On no home diuretics.\n - furosemide 20 mg daily to start\n- metoprolol succinate and lisinopril\n \n # NSTEMI: Elevated troponin and lateral ST depressions\nconcerning for ischemia. Likely demand in the setting of sepsis\nand severe AS. Troponins have peaked, was on heparin gtt\ntemporarily. No further chest pain. \n - Aspirin 81mg daily \n - Atorvastatin 80mg Daily \n - metoprolol changed to succinate \n - Lisinopril 2.5 mg daily\n\n # Complete heart block s/p PPM: Pacer in place since AVR.\nIntermittently V-pacing at 100 bpm. \n - continue on telemetry \n \n # Hypothyroidism: TSH at OSH reportedly >17, which was blamed \non\nlimited GI absorption in the setting of critical illness. TSH\nhere wnl \n - cont home synthroid \n\n # Hypertension: \n - Hold antihypertensives given soft BPs\n \n # Hyperlipidemia: \n - continue atorvastatin \n\nRESOLVED:\n # Shock:Likely mixed shock with primary element of sepsis\n(likely PNA with bandemia, high CvO2, response to IV fluids) and\npossible contributing cardiogenic shock I/s/o severe aortic\nstenosis requiring levophed \n - abx course finished\n\n #Toxic Metabolic Encephalopathy: In setting of infection and\nhospital delirium now improved and AAOx3. Pt is still mildly \nconfused. OT evaluated pt and felt she was safe to go home with \n24 hour supervision. No driving for 1 month until after f/u. \n - delirium precautions \n\n #Diarrhea \n KUB without obstruction. Patient with chronic diarrhea \n - Simethicone \n \n\n \nDischarge Instructions:\nYou had an TAVR to fix severe aortic valve disease after being \ntransferred from ___ with a severe shock syndrome, \nheart failure and pneumonia. The procedure went well and you now \nare at an ideal weight and fluid status. \nWeigh yourself every morning, call Dr ___ weight goes up \nmore than 3 lbs. \n\nContinue all your current medications with the following \nchanges:\n1. Change metoprolol succinate to 50 mg daily\n2. Start lisinopril 2.5 mg daily\n3. Start taking furosemide to prevent the fluid from backing up \nagain\n4. STart taking clopidogrel to prevent a blood clot on the \nvalve. \n\n \nActivity restrictions and care of the groin are included in your \ndischarge instructions.\n\nYou have been given an updated list of current medications.\n\n Do not stop taking aspirin and clopidogrel or miss any doses \nunless Dr. ___ it is OK to do so. \n\n \nIt has been a pleasure to have participated in your care. If you \nhave any questions that are related to your recovery from your \nprocedure or are experiencing any symptoms that are concerning \nto you, please call the ___ HeartLine at ___ to speak \nto a cardiologist or cardiac nurse practitioner.\n \nFollowup Instructions:\n___\n" ]

[ "T82857A", "R570", "I214", "J9601", "I5023", "R6521", "A419", "J189", "G92", "I110", "C3431", "I350", "F17210", "D509", "E039", "E785", "I2510", "Z006", "E538", "J449", "Z853", "Z781", "Z950", "Z951", "Y838", "Y929", "Z905", "Z85828", "K529", "L723" ]

[ "T82857A: Stenosis of other cardiac prosthetic devices, implants and grafts, initial encounter", "R570: Cardiogenic shock", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "J9601: Acute respiratory failure with hypoxia", "I5023: Acute on chronic systolic (congestive) heart failure", "R6521: Severe sepsis with septic shock", "A419: Sepsis, unspecified organism", "J189: Pneumonia, unspecified organism", "G92: Toxic encephalopathy", "I110: Hypertensive heart disease with heart failure", "C3431: Malignant neoplasm of lower lobe, right bronchus or lung", "I350: Nonrheumatic aortic (valve) stenosis", "F17210: Nicotine dependence, cigarettes, uncomplicated", "D509: Iron deficiency anemia, unspecified", "E039: Hypothyroidism, unspecified", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z006: Encounter for examination for normal comparison and control in clinical research program", "E538: Deficiency of other specified B group vitamins", "J449: Chronic obstructive pulmonary disease, unspecified", "Z853: Personal history of malignant neoplasm of breast", "Z781: Physical restraint status", "Z950: Presence of cardiac pacemaker", "Z951: Presence of aortocoronary bypass graft", "Y838: Other surgical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure", "Y929: Unspecified place or not applicable", "Z905: Acquired absence of kidney", "Z85828: Personal history of other malignant neoplasm of skin", "K529: Noninfective gastroenteritis and colitis, unspecified", "L723: Sebaceous cyst" ]

[ "J9601", "I110", "F17210", "D509", "E039", "E785", "I2510", "J449", "Z951", "Y929" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nMidazolam / Demerol / Tegaderm Frame Style / Red Dye / Iodinated \nContrast Media - IV Dye\n \nAttending: ___.\n \nChief Complaint:\nSeptic shock\n \nMajor Surgical or Invasive Procedure:\nCentral venous catheter placement on ___\n\n \nHistory of Present Illness:\nMs. ___ is a ___ woman with multiple cardiovascular \ncomorbidities including several ischemic/embolic events (to the \ncolon and to bilateral legs), s/p CABG, s/p pacemaker placement \nfor complete heart block, s/p AVR then a TAVR, who initially \npresented to an OSH complaining of nausea and vomiting, fever \nand chills. At OSH she had temp of 100.8, SBP ___, WBC 19, CXR \nwith possible PNA. She was treated with azithromycin, cefepime, \nacetaminophen, and 4L NS prior to transfer to the ___ ED.\n\nHistory is notable for a recent ___ admission for \nEnterococcus faecalis pneumonia/bacteremia, during which her TEE \nwas negative, VAD was removed, PICC was placed, and she was \ntreated with a 6-week course of IV antibiotics.\n \nPast Medical History:\nNotable for:\n- colonic ischemia s/p subtotal colectomy and ileostomy\n- CAD s/p CABG\n- CHB s/p pacemaker\n- AVR\n- subsequent TAVR\n- peripheral artery disease s/p embolectomy\n- Enterococcus faecalis bacteremia in ___\n- HTN/HLD\n- C section\n- cholecystectomy\n- recurrent diverticulitis\n- Invasive ductal carcinoma s/p lumpectoy, SNLB, radiation, \nanastrozole\n- RLL speculated pulmonary nodule suspicious for BAC\n- hyoothyroidism\n- anxiety\n \nSocial History:\n___\nFamily History:\nBrother s/p OLT for hep C, passed away\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\nVS: HR 81, BP 151/66, RR 24, O2 88% RA \nGENERAL: Alert and pleasantly conversant. Shivering. \nHEENT: NCAT. Dry mucus membranes. \nCARDIAC: Regular rate and rhythm. Normal S1 and S2. ___ SEM best\nheard at RUSB \nLUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or\nrales. Normal work of breathing. \nABDOMEN: Normal bowels sounds, non distended, non-tender to\npalpation. Ostomy bag with thin green liquid. \nEXTREMITIES: No edema. Radial pulses palpable. PICC line in \nright\narm without drainage. Some erythema from bandage surrounding the\nPICC. \nNEUROLOGIC: Moving all extremities spontaneously. AOx3.\n\nDISCHARGE PHYSICAL EXAM\n\nGENERAL: Alert, in NAD, eating pudding with her sister\nEYES: ___, pupils equally round\nPSYCH: pleasant, appropriate affect\nRemainder of exam deferred given CMO\n \nPertinent Results:\nADMISSION LABS\n___ 09:53PM WBC-15.8* RBC-3.02* HGB-9.0* HCT-28.6* MCV-95 \nMCH-29.8 MCHC-31.5* RDW-16.8* RDWSD-57.5*\n___ 09:53PM NEUTS-93.8* LYMPHS-2.5* MONOS-2.5* EOS-0.0* \nBASOS-0.1 IM ___ AbsNeut-14.84* AbsLymp-0.39* AbsMono-0.40 \nAbsEos-0.00* AbsBaso-0.02\n___ 09:53PM ___ PTT-26.4 ___\n___ 09:53PM GLUCOSE-80 UREA N-23* CREAT-2.1* SODIUM-142 \nPOTASSIUM-4.0 CHLORIDE-122* TOTAL CO2-8* ANION GAP-12\n___ 09:53PM ALBUMIN-2.7* CALCIUM-7.1* PHOSPHATE-2.2* \nMAGNESIUM-0.9*\n___ 09:53PM ALT(SGPT)-8 AST(SGOT)-21 ALK PHOS-48\n___:53PM LIPASE-9\n___ 09:55PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 09:55PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30* \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-NEG\n___ 09:55PM URINE RBC-9* WBC-5 BACTERIA-NONE YEAST-NONE \nEPI-0\n___ 10:04PM LACTATE-1.4 CREAT-2.0*\n\nPERTINENT LABS\n\nMICRO\n\nDISCHARGE LABS\n\nIMAGING/STUDIES\n\nCXR ___- PICC line in expected position and unchanged. Early \npulmonary edema suspected, with patchy airspace opacities of the \nlung bases, could represent alveolar edema, or superimposed \ninfection. \n\nCT A/P ___- 1. Post subtotal colectomy and proctectomy, with \nright lower quadrant diverting ileostomy with a small amount of \nascites. No acute intra-abdominal process. \n2. Small bilateral pleural effusion, with bibasal atelectasis \nand superimposed aspiration/pneumonia in the RLL.\n\nNCHCT ___- 1. Right occipital parietal subacute infarction \nwithout edema. \n2. MR may be helpful for further characterization to investigate \nthe \npossibility of infection as well as any evidence for mycotic \naneurysm. \n3. Evidence of chronic infarct in the right frontal lobe. \n\nTTE ___- There is normal regional and global left ventricular \nsystolic function. The visually estimated left ventricular \nejection fraction is >=55%. There is no resting left ventricular \noutflow tract gradient. Normal\nright ventricular cavity size with normal free wall motion. An \naortic valve bioprosthesis is present. The prosthesis is well \nseated with leaflets not well seen. There is no aortic \nregurgitation. The mitral valve leaflets are mildly thickened \nwith no mitral valve prolapse. There is mild to moderate [___] \nmitral regurgitation. The pulmonic valve leaflets are not well \nseen. The tricuspid valve is not well seen. There is mild to \nmoderate [___] tricuspid regurgitation. The estimated pulmonary \nartery systolic pressure is normal. There is no pericardial \neffusion.\n\nIMPRESSION: Focused study.Suboptimal image quality. Overall LV \nsystolic function. Bioprosthetic AVR is present, gradients not \nobtained on this focused study. Thickening around aortic valve \nshort axis and aorto-mitral continuity appears similar to prior \nstudy, however image quality is poor. Mild to moderate mitral \nregurgitation. Mild to moderate tricuspid regurgitation. \nCompared with the prior TTE (images reviewed) of ___, \nthere is no obvious change, but the suboptimal image quality of \nthe studies precludes definitive comparison.\n\n___ 05:50AM BLOOD WBC: 23.3* RBC: 3.49* Hgb: 10.1* Hct:\n31.6* MCV: 91 MCH: 28.9 MCHC: 32.0 RDW: 16.6* RDWSD: 55.2* Plt\nCt: 86* \n___ 01:07AM BLOOD WBC: 10.1* RBC: 3.49* Hgb: 10.1* Hct:\n31.4* MCV: 90 MCH: 28.9 MCHC: 32.2 RDW: 16.6* RDWSD: 55.0* Plt\nCt: 93* \n___ 03:02AM BLOOD WBC: 15.2* RBC: 3.35* Hgb: 9.8* Hct: \n29.5*\nMCV: 88 MCH: 29.3 MCHC: 33.2 RDW: 16.4* RDWSD: 53.1* Plt Ct: \n123*\n___ 01:07AM BLOOD Glucose: 124* UreaN: 22* Creat: 1.5* Na:\n134* K: 3.5 Cl: 106 HCO3: 16* AnGap: 12 \n___ 03:02AM BLOOD Glucose: 112* UreaN: 24* Creat: 1.7* Na:\n138 K: 4.2 Cl: 110* HCO3: 13* AnGap: 15 \n___ 03:42PM BLOOD Trep Ab: NEG \n\n___ Blood culture: +GPC\n___ Blood culture: MRSA ___ Blood culture: MRSA ___ Blood culture: MRSA ___ Blood culture: MRSA ___\n SENSITIVITIES: MIC expressed in MCG/ML \n_________________________________________________________\n STAPH AUREUS COAG +\n | \nCLINDAMYCIN----------- =>8 R\nERYTHROMYCIN---------- =>8 R\nGENTAMICIN------------ <=0.5 S\nLEVOFLOXACIN---------- =>8 R\nOXACILLIN------------- =>4 R\nRIFAMPIN-------------- <=0.5 S\nTRIMETHOPRIM/SULFA---- <=0.5 S\nVANCOMYCIN------------ 1 S\n\nOther micro:\n___ Legionella urine Ag: negative\n___ Urine culture: No growth final\n___ Stool culture: Campylobacter negative, otherwise pending\n\nCultures from prior admissions:\n___ Blood culture - enterococcus faecalis\n E faecalis \n M.I.C. Inter \n ------ ----- \n Ampicillin <=2 S \n Beta Lactamase - \n Ciprofloxacin <=0.5 S \n Daptomycin 0.5 S \n Erythromycin 2 I \n Gentamicin Syn S \n Levofloxacin 1 S \n Minocycline <=0.5 S \n Norfloxacin 4 S \n Penicillin 2 S \n Streptomycin ___ S \n\n___ CT Head:\n1. Right occipital parietal subacute infarction without edema. \n2. Evidence of chronic infarct in the right frontal lobe. \n\nUpper extremity ultrasound ___- No evidence of deep venous \nthrombosis in the left lower extremity veins.\n \nBrief Hospital Course:\nSUMMARY STATEMENT\nMs. ___ is a ___ with multiple cardiovascular \ncomorbidities(pacemaker, aortic valve replacement, peripheral \nartery disease), initially presenting with altered mental status \nand hypotension, found to have high-grade MRSA bacteremia with \npresumed bacterial endocarditis and imaging findings of a \nsub-acute brain infarct\nconcerning for a septic embolus.\n\nACUTE ISSUES\n# Septic shock\nPt presented to ___ ED in shock briefly requiring levophed. \nEtiology of shock most likely secondary to MRSA sepsis and \nhypovolemia. MAP was maintained >60 initially with levophed, \nthen with fluid resuscitation. Serial blood cultures grew MRSA. \nChest x-ray had scant opacities that could not rule out \npneumonia. Given source control, her PICC line was removed. \nFamily refused pacemaker extraction. \n\nPt found to fulfill Duke Criteria for endocarditis: 1) MRSA+ \nblood cultures, 2) fever, 3) history of aortic valve \nreplacement, 4) imaging evidence of endocarditis complications \n(subacute infarct in brain). Infectious Disease team was \nconsulted, and recommended a 6 week course of vancomycin + \ngentamycin, with rifampin to follow. TTE demonstrated normal \ncardiac function but was unable to visualize aortic valve. TEE \nwas deferred as it was not consistent with patient's goals of \ncare.\n\n# Endocarditis\nDefinitive treatment for endocarditis is cardiac surgery. Workup \nof surgery would necessitate (among other things) 1) extraction \nof pacemaker, 2) TEE. Family was consulted and determined that \nsurgery and other invasive interventions are not within their \ngoals of care. Therefore, we decided to treat pt's endocarditis \nwith antibiosis alone.\n\n# Brain infarct\nGiven persistent altered mental status including inattentiveness \nand echolalia, a head CT without contrast was performed, \nrevealing a left-sided subacute infarct in the parietal and \noccipital region consistent with an embolic event. No edema was \nnoted, though an MRI/MRA would be required to further determine \netiology of stroke. Family refused MRI/MRA as they determined it \nwas not within goals of care. \n\nThere was a question of whether pt's home antithrombotic regimen \n(plavix + apixaban) would be appropriate. Ultimately given pt's \ndeclining platelet count and risk of hemorrhagic transformation \nof septic emboli, anticoagulation regimen was held.\n\n# Altered mental status\nConsidered most likely delirium given waxing and waning course, \nthough probably complicated by worsening vascular dementia. \n\n# ___ on CKD\nMost consistent with a pre-renal etiology given patient's \npresenting hypovolemia. Creatinine trending to normal after \nfluid resuscitation.\n\n#CMO\nAfter thorough discussion with\nthe patient and her HCP/daughter ___, plan was not to pursue a\nTEE or any surgical interventional for source control and to\nreturn home with hospice on ___ (when her daughter is off from\nwork)\n\nTRANSITIONAL ISSUES\n[] Palliation with home hospice\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Escitalopram Oxalate 20 mg PO DAILY \n2. Clopidogrel 75 mg PO DAILY \n3. Anastrozole 1 mg PO DAILY \n4. Cyanocobalamin 500 mcg PO DAILY \n5. FoLIC Acid 1 mg PO BID \n6. Levothyroxine Sodium 100 mcg PO DAILY \n7. Multivitamins 1 TAB PO DAILY \n8. Vitamin D 1000 UNIT PO DAILY \n9. loperamide-simethicone ___ mg oral TID \n10. Octreotide Acetate 50 mcg SC Q8H \n11. TraZODone 25 mg PO QHS \n12. Atorvastatin 80 mg PO QPM \n13. Apixaban 2.5 mg PO BID \n14. OLANZapine 5 mg PO QHS:PRN agitation \n15. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain - \nModerate \n16. sodium chloride 0.9 % intravenous 3X/WEEK \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q4H:PRN mild pain,tactile fever \n2. Lidocaine 5% Ointment 1 Appl TP ONCE Duration: 1 Dose \n3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \n4. Phenazopyridine 100 mg PO TID Duration: 3 Days \n5. Levothyroxine Sodium 100 mcg PO DAILY \n6. TraZODone 25 mg PO QHS \n\n \nDischarge Disposition:\nHome with Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPersistent MRSA bacteremia likely ___ infective endocarditis\n\n \nDischarge Condition:\nMental Status: Confused - sometimes.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Bedbound.\n\n \nDischarge Instructions:\nFor any discomfort at home, please consult your hospice nurse. \nWe want to honor your wishes to have you return home and stay \nhome.\n \nFollowup Instructions:\n___\n" ]

[ "T826XXA", "A4102", "I330", "R6521", "I6349", "J189", "N179", "I76", "E872", "F05", "T827XXA", "E785", "I2510", "Y848", "Z953", "E039", "Z66", "F419", "E8342", "F17210", "Z9049", "Z85038", "F0150", "I739", "Z515", "I129", "N189", "E861", "C50919", "Z932" ]

[ "T826XXA: Infection and inflammatory reaction due to cardiac valve prosthesis, initial encounter", "A4102: Sepsis due to Methicillin resistant Staphylococcus aureus", "I330: Acute and subacute infective endocarditis", "R6521: Severe sepsis with septic shock", "I6349: Cerebral infarction due to embolism of other cerebral artery", "J189: Pneumonia, unspecified organism", "N179: Acute kidney failure, unspecified", "I76: Septic arterial embolism", "E872: Acidosis", "F05: Delirium due to known physiological condition", "T827XXA: Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter", "E785: Hyperlipidemia, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "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", "Z953: Presence of xenogenic heart valve", "E039: Hypothyroidism, unspecified", "Z66: Do not resuscitate", "F419: Anxiety disorder, unspecified", "E8342: Hypomagnesemia", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z9049: Acquired absence of other specified parts of digestive tract", "Z85038: Personal history of other malignant neoplasm of large intestine", "F0150: Vascular dementia without behavioral disturbance", "I739: Peripheral vascular disease, unspecified", "Z515: Encounter for palliative care", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "N189: Chronic kidney disease, unspecified", "E861: Hypovolemia", "C50919: Malignant neoplasm of unspecified site of unspecified female breast", "Z932: Ileostomy status" ]

[ "N179", "E872", "E785", "I2510", "E039", "Z66", "F419", "F17210", "Z515", "I129", "N189" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nMidazolam / Demerol / Tegaderm Frame Style / Red Dye / Iodinated \nContrast Media - IV Dye\n \nAttending: ___.\n \nChief Complaint:\nleft foot pain\n \nMajor Surgical or Invasive Procedure:\nLLE angiogram. ___\nL CFA and profunda thrombectomy, Patch angioplasty. ___\n\n \nHistory of Present Illness:\n___ with CAD s/p CABG, complete heart block s/p pacemaker \nplacement, AVR and then TAVR for restenosis of aortic valve, \nlong-standing smoker and ___ year history of worsening \nclaudication (L>R, cannot walk 1 block without stopping), rest \npain in L foot at times requiring her to hang her left leg off \nthe edge of the bed now presents from a rehab facility with 3 \ndays of worsening constant L foot pain. She is still able to \nmove her foot and toes, but her foot hurts quite a bit when it \ntouches anything, rendering her non-ambulatory at this time. \nDenies fevers or chills. No CP or SOB on current presentation. \nHas never had such severe pain in her left foot before. No \npreceding palpitations or feelings that her heart was racing or \nbeating in a strange manner. She presented to ___ where \nan ultrasound apparently showed chronic occlusive disease of the \nbilateral SFA's and a more acute-appearing inflow occlusion of \nher left iliac artery, prompting her transfer to ___ for \nfurther workup. Of note, she was hospitalized for nearly 2 weeks \n(late ___ to ___ for enterococcus pneumonia and sepsis \nthat ultimately infected a portacath she had in place and \nrequired its removal, and the plan was for her to complete a 6 \nweek course of unasyn and gentamicin from the time of her \ndischarge ___, she still has in-situ hardward including a \npacemaker and AVR) and to get repeat imaging of her chest at \nthat time as well. \n \nPast Medical History:\nPast Medical History:\nMI\nCAD\nischemic colitis\ndiverticulosis\n\nPast Surgical History:\ncholecystectomy\nC-section\nopen bioprosthetic AVR ___ years ago\nTAVR one year ago\n \nSocial History:\n___\nFamily History:\nbrother s/p OLT for hep C, passed away\n \nPhysical Exam:\nVitals: 24 HR Data (last updated ___ @ 1115)\n Temp: 98.3 (Tm 99.0), BP: 133/61 (95-173/48-65), HR: 59\n(59-78), RR: 18 (___), O2 sat: 98% (94-98), O2 delivery: Ra,\nWt: 112.5 lb/51.03 kg\nGEN: no acute distress, resting in bed\nCV: warm and well-perfused\nPULM: breathing comfortably on RA\nABD: Soft, nondistended, ileostomy bag in place with mild \nleakage\ntowards staple line\nWound: medial left thigh staples and JP drain site with no\ndischarge or erythema\nExt: wwp\nNeuro: motor and sensation intact in bilateral ___\nPulse exam: R: //p/p L: //p/p\n \nPertinent Results:\n___ 05:16AM BLOOD WBC-7.9 RBC-2.94* Hgb-8.3* Hct-27.0* \nMCV-92 MCH-28.2 MCHC-30.7* RDW-16.1* RDWSD-54.6* Plt ___\n___ 05:16AM BLOOD PTT-61.2*\n___ 05:16AM BLOOD Glucose-87 UreaN-17 Creat-2.1* Na-140 \nK-4.4 Cl-106 HCO3-18* AnGap-16\n___ 01:20AM BLOOD CK(CPK)-24*\n___ 06:05AM BLOOD ALT-<5 AST-8 LD(LDH)-122 AlkPhos-61 \nTotBili-0.2 DirBili-<0.2 IndBili-0.2\n___ 05:16AM BLOOD Calcium-8.7 Phos-4.6* Mg-1.4*\n\nAorta US (___):\nThe aorta measures 2.9 cm in the proximal portion, 2.4 cm in mid \nportion and 2.9 cm in the distal abdominal aorta. There is \nsevere calcified atherosclerotic plaque. Wall-to-wall color flow \nis seen within the aorta with appropriate arterial waveforms. \nThe right common iliac artery measures 1.4 cm and the left \ncommon iliac artery measures 1.1 cm. The right kidney measures \n10.4 cm and the left kidney measures 10.0 cm. Limited views of \nthe kidneys are unremarkable without hydronephrosis. \n\nIMPRESSION: Stable fusiform abdominal aortic ectasia measuring \nup to 2.9 cm, as above, with normal arterial flow. \n\nTTE (___):\nThe left atrial volume index is moderately increased. The right \natrium is mildly enlarged. The estimated right atrial pressure \nis >15mmHg. There is normal left ventricular wall thickness with \na normal cavity size. There is normal regional and global left \nventricular systolic function. The visually estimated left \nventricular ejection fraction is 70%. There is no resting left \nventricular outflow tract gradient. Normal right ventricular \ncavity size with normal free wall motion. The aortic sinus \ndiameter is normal for gender with normal ascending aorta \ndiameter for gender. There are complex (>4mm, non-mobile) aortic \natheroma in the aortic root. There are complex (>4mm, \nnon-mobile) atheroma in the ascending aorta. The aortic arch \ndiameter is normal with a normal descending aorta diameter. \nThere are complex (>4mm, non-mobile) atheroma in the aortic arch \nwith complex (>4mm, non-mobile) atheroma in the descending aorta \nto from the incisors. An aortic valve bioprosthesis is present. \nThe prosthesis is well seated with normal gradient. There is no \naortic regurgitation. The mitral valve leaflets are mildly \nthickened 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 \nmoderate [2+] tricuspid regurgitation. Due to acoustic \nshadowing, the severity of tricuspid regurgitation may be \nUNDERestimated. There is mild pulmonary artery systolic \nhypertension. There is no pericardial effusion. \n\nIMPRESSION: severe calcified atheroma present along the entire \nvisible course of aorta Compared with the prior TTE (images not \navailable for review) of ___, the findings are similar.\n \nBrief Hospital Course:\n___ CAD s/p CABG, pacer, AVR then TAVR, smoker, CKD3, ___ years \nworsening claudication, rest pain in L foot, p/w acute on \nchronic left leg ischemia. She was placed on a heparin gtt and \nreceived LLE angiogram showing occlusion of the distal common \nfemoral, proximal profunda, and long segment SFA occlusion from \nthe origin. Post-op she was noted to have worsening leg weakness \nconcerning for acute limb ischemia and taken for femoral \nembolectomy and patch angioplasty. She had prevena and drain \nplaced over her left thigh incision, removed throughout \nhospitalization prior to discharge. Post-operatively improved \nthough required 1U pRBC POD2 for downtrending hgb to 6.5, \nappropriate bump. Cardiology/vascular medicine/EP was consulted \nfor further embolic work up and anticoagulation management given \nprior GIB with clopidogrel stopped. She had negative TTE and no \nafib on pacemaker. Her aspirin was replaced with clopidogrel and \nheparin gtt was transitioned to apixaban 2.5 bid (renally dosed) \nat discharge. She will require CTA chest for r/o aortic arch \nthrombus when her renal function returns to baseline. She will \nneed apixaban dosage adjusted if Cr improves <1.5 as it is \ncurrently renally dosed at 2.5 mg bid.\n\nHer hospital course was c/b ___ on admission, high ileostomy \noutput, and delirium. Renal was consulted for ___ and noted \nmuddy brown casts in the urine consistent with ATN, likely from \nprior sepsis episode. They thought it was unlikely to be solely \nfrom gentamicin and renal function would return to baseline over \nweeks without intervention. ID was consulted for her IV \nantibiotic course from ___ and ampicillin/gentamicin was \nswitched to ampicillin/ceftriaxone for possible contribution to \n___. Per ID, OPAT at ___ was made aware of the change \nand no antibiotic duration changes were necessary. General \nsurgery was consulted for high ileostomy output, loperamide was \ntitrated and psyllium wafers started for goal output ___. \nGeriatrics was consulted for delirium as she self d/ced \nlines/drains such as her prevena and ileostomy bag overnight. \nShe was started on trazadone 25 qhs, her olanzapine was \ndecreased to daily with additional qhs PRN dose. \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Metoprolol Tartrate 12.5 mg PO BID \n2. Acetaminophen 1000 mg PO TID:PRN Pain - Mild/Fever \n3. Aspirin 325 mg PO DAILY \n4. Escitalopram Oxalate 20 mg PO DAILY \n5. Levothyroxine Sodium 100 mcg PO DAILY \n6. loperamide-simethicone ___ mg oral TID \n7. Multivitamins 1 TAB PO DAILY \n8. Lactobacillus acidophilus 100 mmu oral DAILY \n9. FoLIC Acid 1 mg PO BID \n10. Vitamin D 1000 UNIT PO DAILY \n11. Cyanocobalamin 500 mcg PO DAILY \n12. Nicotine Patch 14 mg/day TD DAILY \n13. Octreotide Acetate 50 mcg SC Q8H \n14. OLANZapine 2.5 mg PO BID \n15. Gentamicin 40 mg IV Q24H \n16. Ampicillin 2 g IV Q8H \n17. Anastrozole 1 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nAcute on chronic limb ischemia, left lower extremity.\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:\nIt was a pleasure taking care of you at ___ \n___. You were admitted to the hospital after surgery \non your leg for a bloot clot. This surgery was done to improve \nblood flow to your leg and you tolerated the procedure well. You \nwere evaluated by the heart doctors who recommended starting a \nblood thinner to help reduce risk of further clots. You were \nseen by the kidney doctors because your ___ function was \nworse than before, they suspected it was a temporary injury that \nwould recover with time. Your IV antibiotics were switched from \nampicillin/gentamicin to ampicillin/ceftriaxone by \nrecommendations by the infectious disease doctors, they have \ncontacted your outpatient infectious disease doctor.\n\nPlease follow the recommendations below to ensure a speedy and \nuneventful recovery.\n\nVascular Leg Surgery Discharge Instructions\n\nWhat to except:\n\n•It is normal feel tired for ___ weeks after your surgery\n•It is normal to have leg swelling. Keep your leg elevated as \nmuch as possible. This will decrease the swelling. \n•Your leg will feel tired and sore. This usually passes \nwithin a few weeks.\n•Your incision will be sore, slightly raised, and pink. Any \ndrainage should decrease or stop with in the first 2 weeks. \n•If you are home, you will likely receive a visit from a \nVisiting Nurse ___. Members of your health care team will \ndiscuss this with you before you go home. \n\nMedications:\n•Before 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\n•It is very important that you take Aspirin every day! You \nshould never stop this medication before checking with your \nsurgeon\n\nPain Management:\n•It is normal to feel some discomfort/pain following surgery. \nThis pain is often described as “soreness”. \n•You may take Tylenol (acetaminophen ) as needed for pain. \nYou will also receive a prescription for stronger pain medicine, \n if the Tylenol doesn’t work, take prescription medicine. \n•Narcotic pain medication can be very constipating, please also \ntake a stool softner such as Colace. If constipation becomes a \nproblem, your pharmacist can suggest additional over the counter \nmedications. \n•Your pain medicine will work better if you take it before your \npain gets to severe. \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\n\nActivity:\n•Do not drive until your surgeon says it is okay. In general, \ndriving is not allowed until\n-the staples in your leg have been taken out\n-your leg feels strong\n-you have stopped taking pain medication and feel you could \nrespond in an emergency\n•Walking is good because it helps your muscles get stronger and \nimproves blood flow. Start with short walks. If you can, go a \nlittle further each time, letting comfort be your guide. \n•Try not to go up and downstairs too much in the first weeks. \nUse stairs only once or twice a day until your incision is fully \nhealed and you are back to your usual strength.\n•Avoid things that may constrict blood flow or put pressure on \nyour incision, such as tight shoes, socks or knee highs.\n•Do not take a tub bath or swim until your staples are removed \nand your wound is healed. \n•When you sit, keep your leg elevated to reduce swelling.\n•If swelling in your leg is getting worse, lie down with your \nleg up on a pillows. If your swelling continues, please call \nyour surgeon. You may be instructed to use special elastic \nbandages or stockings.\n•Try not to sit in the same position for a long while. For \nexample, ___ go on a long car ride. \n•You may go outside. But avoid traveling long distances until \nyou see your surgeon at your next visit. \n•You may resume sexual activity after your incisions are well \nhealed.\n\nYour incision\n\n•Your incision may be slightly red around the stitches or \nstaples. This is normal.\n•It is normal to have a small amount of clear or light red \nfluid coming from your incision.\nThis will decrease and stop in a few days. If it does not stop, \nor if you have a lot of fluid coming out., please call your \nsurgeon.\n•You may shower 48 hours after your surgery. Do not let the \nshower spray right on the incision, Let the soapy water run \nover the incision, then rinse. Gently pat the area dry. Do not \nscrub the incision, Do not apply ointment or lotions to the \nincision.\n•You do not need to cover the incision if there is no drainage, \n If there is a small amount of drainage, put a small sterile \ngauze or Bandaid over the incison.\n•It is normal to feel a firm ridge along the incision, This \nwill go away as your wound heals. \n•Avoid direct sun exposure to the incision area for 6 months. \nThis will help keep the scar from becoming discolored.\n•Over ___ months, your incision will fade and become less \nprominent.\n\nDiet and Bowels\n•It is normal to have a decreased appetite. Your appetite will \nreturn over time. Follow a well-balanced, health healthy diet, \nwithout too much salt and fat. \n•Prescription pain medicine might make you constipated. If \nneeded, you may take a stool softener (such as Colace) or gentle \nlaxative (ask your pharmacist for recommendations).\nDrinking more fluid may also help.\n•If you go 48 hours without a bowel movement, or having pain \nmoving your bowels, call your primary care physician.\n \nFollowup Instructions:\n___\n" ]

[ "I70212", "J156", "I330", "N170", "I130", "I5032", "R7881", "I743", "Z952", "N183", "E039", "I2510", "Z951", "Z9049", "F17210", "Z932", "Z853", "R410", "B952", "Z45018", "Z7901" ]

[ "I70212: Atherosclerosis of native arteries of extremities with intermittent claudication, left leg", "J156: Pneumonia due to other Gram-negative bacteria", "I330: Acute and subacute infective endocarditis", "N170: Acute kidney failure with tubular necrosis", "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", "R7881: Bacteremia", "I743: Embolism and thrombosis of arteries of the lower extremities", "Z952: Presence of prosthetic heart valve", "N183: Chronic kidney disease, stage 3 (moderate)", "E039: Hypothyroidism, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z951: Presence of aortocoronary bypass graft", "Z9049: Acquired absence of other specified parts of digestive tract", "F17210: Nicotine dependence, cigarettes, uncomplicated", "Z932: Ileostomy status", "Z853: Personal history of malignant neoplasm of breast", "R410: Disorientation, unspecified", "B952: Enterococcus as the cause of diseases classified elsewhere", "Z45018: Encounter for adjustment and management of other part of cardiac pacemaker", "Z7901: Long term (current) use of anticoagulants" ]

[ "I130", "I5032", "E039", "I2510", "Z951", "F17210", "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:\nConstipation with poor oral intake, lack of appetite, and \ngeneralized weakness after falls\n \nMajor Surgical or Invasive Procedure:\nManual disimpaction\n\n \nHistory of Present Illness:\n___ M with CKD (baseline Cr of 4), MGUS, and depression \npresents\nwith constipation, lack of appetite, and generalized weakness.\nHis primary complain is the constipation, which has been going \non\nfor ~3wks. He has taken lactulose often and miralax the past few\ndays. He did have a normal, somewhat loose, stool a day or two\nago. His reduced appetite has been going on for about the same\ntime, though he is still eating food and denies any abdominal\npain, nausea, or vomiting. He endorses 30lb unintentional weight\nloss over the past year. He has felt generalized weakness and\nfatigue for the past couple days. He reports a trip and fall \nover\nsome boxes ___ days ago, he hit his knee and has an abrasion but\ndenies hitting his head. He denies any visual changes, HA,\ndizziness or light-headedness, focal weakness, or altered\nsensation. He denies any fevers or chills, night sweats, CP, \nSOB,\npalpitations, urinary symptoms, blood in urine or stool, back\npain, or leg swelling.\n\nIn the ED, initial VS were 98.1 60 141/57 16 98% RA.\nLabs notable for CBC with WBC 8.1, H/H of 9.7/30.4, Plt 142. BMP\nwith BUN 79, Cr 4.4. Troponin 0.04\nCT scan showed large stool ball in the rectum causing massive\nrectal distension with imaging findings concerning for stercoral\nproctitis. Disimpaction was recommending\nDisimpaction was attempted but unsuccessful, due to ___\nlike stool not able to break up. Reportedly, the surgical team\ncame and subsequently disimpacted the patient.\nEKG showed Mobitz type I second degree heart block, which was\nconsistent with prior. \nHe received IVF, eye drops, and ___isacodyl. \n\nUpon arrival to the floor, the patient tells the story as\nfollows. He reports that he has had significant constipation, as\ndescribed above. He reports that he has had a decreased \nappetite,\nearly satiety, and perhaps he does not drink enough fluids. He\ndenies dysphagia or odynophagia. He reports frequently feeling\ncold, but denies fevers or chills. He otherwise reaffirms the\nstatements above. He denies nausea, vomiting, abdominal pain,\nbloody bowel movements. He does not know very much about his\nmedical history but asks us to contact the ___ and ___.\nHe is unsure of his medications. He has had a colonoscopy \nbefore,\nbut he is unsure where. \n\n \nPast Medical History:\n- depression with prior suicide attempts \n - MGUS, IgG-L \n - CKD stage 5 (baseline creatinine ~4.0) \n - DMII c/b retinopathy and neuropathy \n - HTN \n - HLD \n - glaucoma \n - anemia of chronic disease \n \nSocial History:\n___\nFamily History:\nmother: drank heavily. Uncle with depression and alcoholic. \nAnother unlce that is described as \"inexpressive; couldn't come \nout of his shell.\"\n\n \nPhysical Exam:\nVITALS: \n___ 0736 Temp: 98.5 PO BP: 179/69 L Lying HR: 53 RR: 20 O2 \nsat: 98% O2 delivery: Ra \n___ 0922 BP: 155/68 L Sitting \n\nEXAMINATION:\nGENERAL: Alert and in no apparent distress, sitting in bed.\nEYES: Anicteric, pupils equally round\nENT: Ears and nose without visible erythema, masses, or trauma. \nOropharynx without visible lesion, erythema or exudate. Moist \noral mucosa. \nCV: Heart regular rate and rhythm. No murmur. Radial and DP \npulses present. \nRESP: Lungs clear to auscultation with good air movement \nbilaterally. Nonlabored breathing. \nGI: Abdomen is soft, non-distended, minimal diffuse tenderness \nwithout rebound or guarding. Bowel sounds present. \nMSK: Neck supple, moves all extremities, strength decreased on \nright upper extremity (patient reports chronic due to nerve \ndamage in that arm). Otherwise, grossly full strength \nthroughout.\nSKIN: A few abrasions noted on bilateral shins\nNEURO: Alert, oriented, face symmetric with mild left eye \nptosis, gaze conjugate with EOMI, left pupil irregular shape, \nspeech fluent, moves all limbs. \nPSYCH: Patient anxious, but pleasant\n\n \nPertinent Results:\n___ 04:40PM BLOOD WBC-8.1 RBC-2.93* Hgb-9.7* Hct-30.4* \nMCV-104* MCH-33.1* MCHC-31.9* RDW-13.7 RDWSD-51.6* Plt ___\n___ 07:20AM BLOOD WBC-9.4 RBC-2.92* Hgb-9.8* Hct-29.5* \nMCV-101* MCH-33.6* MCHC-33.2 RDW-13.4 RDWSD-50.0* Plt ___\n___ 04:46PM BLOOD ___ PTT-31.2 ___\n___ 07:20AM BLOOD Glucose-89 UreaN-63* Creat-3.6* Na-144 \nK-3.8 Cl-115* HCO3-17* AnGap-12\n___ 04:40PM BLOOD Glucose-232* UreaN-79* Creat-4.4* Na-143 \nK-4.1 Cl-108 HCO3-20* AnGap-15\n___ 06:50AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.0\n___ 07:20AM BLOOD Mg-1.9\n___ 04:40PM BLOOD CK-MB-3 cTropnT-0.04*\n___ 07:30AM BLOOD cTropnT-0.05*\n___ 04:40PM BLOOD Lipase-288*\n___ 04:40PM BLOOD ALT-10 AST-12 LD(LDH)-205 CK(CPK)-49 \nAlkPhos-51 TotBili-0.2\n___:40PM BLOOD Hapto-56\n___ 04:40PM BLOOD TSH-3.0\n___ 09:56AM BLOOD %HbA1c-6.0 eAG-126\n\nCT A/P\n1. Large stool ball in the rectum causing massive rectal \ndistension with imaging findings concerning for stercoral \nproctitis. Disimpaction is recommended. \n2. Moderate amount of fecal loading throughout the remainder of \nthe colon. \n3. Findings concerning for small airways disease within the lung \nbases, potentially secondary to aspiration given the presence of \na small hiatal hernia. \n4. Nonspecific haziness of the mesenteric fat, can be seen with \nmesenteric panniculitis. \n5. Extensive atherosclerotic calcifications and coronary artery \ncalcifications. \n\nEKG shows bradycardia, prolonged PR interval, poor baseline, \nwith 2:1 dropped beats.\n\n \nBrief Hospital Course:\n___ years-old male with CKD 5 (baseline Cr of 4), MGUS, diabetes \nand depression who presents with weeks of constipation, lack of \nappetite, and generalized weakness with falls and was found to \nhave sterocoral proctitis and large stool burden. \n\n# Sterocoral proctitis and severe constipation\nConstipation is likely secondary to poor oral intake and/or \ndehydration. Patient has a history of constipation and may not \nbe taking bowel regimen regularly at home. Patient underwent \nsuccessfully disimpaction by the surgical team in the emergency \ndepartment and was subsequently given IV fluid hydration and \nscheduled bowel regimen, including one enema. Patient tolerated \noral intake. Nutrition advised adding Ensure clear BID for \nsupplement. TSH was within normal limits, so unclear chronic \ntriggers of constipation. \n\n# Weight loss. Likely due to decreasing oral intake. Unclear \ntrigger for reduced appetite and early satiety. CT A/P without \nobvious evidence of malignancy. Patient reports prior \ncolonoscopy, although he is not sure when. Ensure patient is up \nto date on his age appropriate cancer screening. Consider \noutpatient gastroenterology follow up after PCP visit at ___ \n___. Again, TSH normal. Dietary supplement provided. \n\n# Acute on CKD stage ___ complicated by metabolic acidosis and \nhypernatremia/hyperchloremia. Prerenal azotemia treated with IV \nfluids. Patient encouraged to take his home medications from \nnephrologist, but he would often refuse (sevelamer, sodium \nbicarbonate, calcium-D supplements). Encourage adequate oral \nintake. Holding furosemide given ___ and dehydration. \n\n# Anemia: No signs or symptoms of active bleeding. Likely \nchronic in the setting of MGUS and CKD. Continue to trend \nintermittently as an outpatient. \n\n# Thrombocytopenia: Admission Platelets of 142. Possibly in the \nsetting of MGUS versus acute illness. Haptoglobin and LDH \nobtained without evidence of hemolysis. Follow as outpatient \nwith hematologist. \n\n# Second Degree Heart Block Mobitz Type I: Unclear etiology, \nseen on prior admission, but not likely due to ischemia, \nmedication effects, or amyloid. This has been evaluated on a \nprevious admission. No significant arrhythmia on telemetry \nmonitoring. \n\n# Elevated troponin: Mildly elevated on admission and likely \nrepresents demand in the setting of acute illness and poor \nclearance from renal disease. EKG without evidence of ischemia. \nOutpatient follow up as indicated. \n\n# Glaucoma: Continues on home eye drops (Dorzolamide, \nBrimonidine, timolol, lantanoprost, artificial tears). \n\n# Diabetes mellitus. Stable as represented by Hemoglobin A1c 6.0 \n(though with poor intake this may falsely represent variable BS \nof high and low values). Monitor on corrective insulin sliding \nscale at home if possible. Holding Glipizide. \n\n# Essential hypertension. On amlodipine and Lasix. Hold Lasix \ngiven volume depletion. Home daily weights and communication \nwith outpatient provider if weight gain or leg swelling to \nresume medication as indicated. \n\n# Weakness and falls. Patient approaching recent baseline per \nPhysical therapy assessments. They recommend home with services \n(patient already with significant services, but will aim to \nmaximize services to prevent readmission and quality of care). \n\nHospital course, assessments, and discharge plans discussed with \npatient who agrees to discharge. Discharge summary to be sent to \nPCP at ___.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. sevelamer CARBONATE 800 mg PO TID W/MEALS \n2. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID \n3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H \n4. Furosemide 10 mg PO DAILY \n5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n6. Acyclovir 400 mg PO DAILY \n7. amLODIPine 10 mg PO DAILY \n8. Calcitriol 0.25 mcg PO DAILY \n9. Artificial Tears GEL 1% ___ DROP BOTH EYES Q6H \n10. Vitamin D 1000 UNIT PO DAILY \n11. Ferrous Sulfate 325 mg PO BID \n12. GlipiZIDE 5 mg PO DAILY \n13. Lactulose 30 mL PO BID Constipation \n14. Sodium Bicarbonate 1300 mg PO TID \n15. Timolol Maleate 0.5% 1 DROP BOTH EYES TID \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever \n2. Docusate Sodium 100 mg PO BID \n3. Psyllium Powder 1 PKT PO BID \n4. Senna 17.2 mg PO BID \n5. Artificial Tears GEL 1% ___ DROP BOTH EYES Q6H:PRN PRN \n6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES TID \n7. Lactulose 30 mL PO DAILY \n8. amLODIPine 10 mg PO DAILY \n9. Calcitriol 0.25 mcg PO DAILY \n10. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID \n11. Ferrous Sulfate 325 mg PO BID \n12. GlipiZIDE 5 mg PO DAILY (HOLD)\n13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n14. sevelamer CARBONATE 800 mg PO TID W/MEALS \n15. Sodium Bicarbonate 1300 mg PO TID \n16. Timolol Maleate 0.5% 1 DROP BOTH EYES TID \n17. Vitamin D 1000 UNIT PO DAILY \n18. HELD- Acyclovir 400 mg PO DAILY This medication was held. \nDo not restart Acyclovir until instructed by outpatient provider\n19. HELD- Furosemide 10 mg PO DAILY This medication was held. \nDo not restart Furosemide until instructed by outpatient \nprovider\n\n \n___:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\n# Sterocoral proctitis\n# Severe Constipation\n# Poor oral intake and dehydration\n# Weight loss\n# Acute on CKD stage ___, prerenal azotemia on CKD\n# Anemia\n# Thrombocytopenia\n# Second Degree Heart Block Mobitz Type I\n# Elevated troponin (demand in setting of fall and dehydration \nwith poor renal clearance)\n# Glaucoma\n# Diabetes mellitus\n# Essential hypertension\n# Weakness and Falls\n\n \nDischarge Condition:\nMental Status: Clear and coherent, but anxious.\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 with severe constipation and failure to thrive \nin the setting of poor intake. You have chronic intermittent \nconstipation that should be controlled with scheduled and as \nneeded bowel regimen (lactulose, miralax, senna). Please follow \nwith your PCP. \n\nWeigh yourself every morning, call MD if weight goes up more \nthan 3 lbs (we are holding your Lasix as this may cause further \ndehydration). \n\nIt was a pleasure meeting you,\n\nYour ___ care team\n\n \nFollowup Instructions:\n___\n" ]

[ "K6289", "K5909", "N179", "E860", "I120", "N185", "E872", "E870", "E878", "D6959", "E1122", "E1142", "E11319", "I441", "D472", "D631", "H409", "E785", "R7989", "R531", "R634", "F329", "Z6822", "Z7984", "Z87891", "Z915", "Z9181" ]

[ "K6289: Other specified diseases of anus and rectum", "K5909: Other constipation", "N179: Acute kidney failure, unspecified", "E860: Dehydration", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N185: Chronic kidney disease, stage 5", "E872: Acidosis", "E870: Hyperosmolality and hypernatremia", "E878: Other disorders of electrolyte and fluid balance, not elsewhere classified", "D6959: Other secondary thrombocytopenia", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "I441: Atrioventricular block, second degree", "D472: Monoclonal gammopathy", "D631: Anemia in chronic kidney disease", "H409: Unspecified glaucoma", "E785: Hyperlipidemia, unspecified", "R7989: Other specified abnormal findings of blood chemistry", "R531: Weakness", "R634: Abnormal weight loss", "F329: Major depressive disorder, single episode, unspecified", "Z6822: Body mass index [BMI] 22.0-22.9, adult", "Z7984: Long term (current) use of oral hypoglycemic drugs", "Z87891: Personal history of nicotine dependence", "Z915: Personal history of self-harm", "Z9181: History of falling" ]

[ "N179", "E872", "E1122", "E785", "F329", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\ndyspnea on exertion\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ y/o male with a past medical history of \nCKD stage 5, MGUS, DM2 and glaucoma who presented to the ED with \nDOE. \n\nPatient reports that for the past 4 days he has had increasing \nSOB when walking and improves with rest. At baseline walks \napproximately 30 minutes per day, but now gets SOB with walking \n50-60 feet. He denies fevers, chills, lower extremity swelling. \nDuring episodes of dyspnea, denies chest pain, dizziness, \npalpitations, nausea, diaphoresis. Sleeps propped up in easy \nchair for years, denies new/worsening orthopnea. \n\nPatient recently had short URI ~3 weeks prior. \n\nIn the ED, initial vital signs were: T 97.4, HR 66, BP 166/84 RR \n20, 100% RA. \n- Labs were notable for: WBC 11.4, Hb 10.4, PLT 167, HCO3 21, \nBUN 57, Cr 3.9 (baseline around 4), glucose 226. Coags were wnl. \nTrop 0.14 (CK MB added on). BNP >11,000\n- Imaging: CXR Patchy basilar opacity could be due to \natelectasis, aspiration, and/or pneumonia. Cardiac silhouette is \ntop-normal to mildly enlarged. Mediastinal contours are \nunremarkable \n- EKG showed mobitz ___ I \n\nUpon arrival to the floor, patient feels well, without any \nsymptoms at rest. \n\n \nPast Medical History:\n- depression with prior suicide attempts \n - MGUS, IgG-L \n - CKD stage 5 (baseline creatinine ~4.0) \n - DMII c/b retinopathy and neuropathy \n - HTN \n - HLD \n - glaucoma \n - anemia of chronic disease \n \nSocial History:\n___\nFamily History:\nmother: drank heavily. Uncle with depression and alcoholic. \nAnother unlce that is described as \"inexpressive; couldn't come \nout of his shell.\"\n\n \nPhysical Exam:\nPHYSICAL EXAM ON ADMISSION\n===========================\nVITALS: T 97.8, BP 186/91, HR 73, RR 22, SPO2 98RA \nGENERAL: Pleasant, well-appearing, in no apparent distress. \nHEENT - normocephalic, atraumatic, no conjunctival pallor or \nscleral icterus, PERRLA, EOMI, OP clear. \nNECK: Supple, no LAD, no thyromegaly, JVP 7cm \nCARDIAC: irregularly irregular rhythm with occasional dropped \nbeat, normal S1/S2, no murmurs rubs or gallops. \nPULMONARY: Babasilar rales. No wheezing or rhonchi. \nABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, \nno organomegaly. \nEXTREMITIES: Warm, well-perfused, no cyanosis. 1+ pitting to mid \nshins \nSKIN: Without rash. \nNEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, \nwith strength ___ throughout. \n\nPHYSICAL EXAM ON DISCHARGE\n===========================\nVITALS: T 98.0, BP 124-194/59-82, HR 35-80, RR ___, SPO2 97RA \n\nI/O: 84.6<-85.0<-87.9; ___\nGENERAL: Pleasant, well-appearing, in no apparent distress. \nHEENT - normocephalic, atraumatic, no conjunctival pallor or \nscleral icterus, PERRLA, EOMI, OP clear. \nNECK: Supple, no LAD, no thyromegaly, JVP flat \nCARDIAC: irregularly irregular rhythm with occasional dropped \nbeat, normal S1/S2, no murmurs rubs or gallops. \nPULMONARY: Babasilar rales. No wheezing or rhonchi. \nABDOMEN: Normal bowel sounds, soft, non-tender, non-distended, \nno organomegaly. \nEXTREMITIES: Warm, well-perfused, no cyanosis. 2+ pitting edema \non left lower extremity to above the ankle. no edema on right. \nSKIN: Without rash. Some venous stasis findings bilaterally on \nlower extremities L worse than right.\nNEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation, \nwith strength ___ throughout.\n \nPertinent Results:\nLABS ON ADMISSION\n==================\n___ 09:35PM BLOOD WBC-11.4* RBC-3.35* Hgb-10.4* Hct-32.5* \nMCV-97# MCH-31.0 MCHC-32.0 RDW-13.7 RDWSD-48.1* Plt ___\n___ 09:35PM BLOOD Neuts-82.7* Lymphs-7.6* Monos-6.1 Eos-2.3 \nBaso-0.5 Im ___ AbsNeut-9.41* AbsLymp-0.87* AbsMono-0.69 \nAbsEos-0.26 AbsBaso-0.06\n___ 09:35PM BLOOD ___ PTT-30.2 ___\n___ 09:35PM BLOOD Glucose-226* UreaN-57* Creat-3.9*# Na-138 \nK-4.6 Cl-103 HCO3-21* AnGap-19\n___ 09:35PM BLOOD cTropnT-0.14*\n___ 09:35PM BLOOD CK-MB-5 ___\n___ 09:35PM BLOOD Calcium-9.9 Phos-3.8 Mg-2.1\n___ 09:35PM BLOOD TSH-5.3*\n___ 06:34AM BLOOD FreeKap-57.4* ___ Fr K/L-2.19*\n\nLABS ON DISCHARGE\n==================\n___ 07:20AM BLOOD WBC-10.4* RBC-4.19* Hgb-12.6* Hct-40.0 \nMCV-96 MCH-30.1 MCHC-31.5* RDW-13.9 RDWSD-47.3* Plt ___\n___ 07:23AM BLOOD ___ PTT-33.0 ___\n___ 12:40PM BLOOD Glucose-185* UreaN-66* Creat-4.2* Na-136 \nK-4.4 Cl-99 HCO3-24 AnGap-17\n___ 06:34AM BLOOD CK-MB-8 cTropnT-0.24*\n___ 12:40PM BLOOD Calcium-9.5 Phos-4.5 Mg-2.0\n___ 07:23AM BLOOD IgG-1531 IgM-61\n\nIMAGING\n========\nECG ___\nSinus bradycardia with premature atrial contractions. Right \nbundle-branch \nblock with left anterior fascicular block. Left ventricular \nhypertrophy with secondary repolarization abnormalities. \nCompared to the previous tracing the findings are similar. \n\nCXR ___\nIMPRESSION: \nPatchy basilar opacity could be due to atelectasis, aspiration, \nand/or \npneumonia. \n\nECHO ___\nThe left atrial volume index is severely increased. There is \nmild symmetric left ventricular hypertrophy with normal cavity \nsize and regional/global systolic function (LVEF>55%). There is \nno ventricular septal defect. Right ventricle is not well seen. \nThe aortic valve leaflets (?#) appear structurally normal with \ngood leaflet excursion. There is no aortic valve stenosis. Trace \naortic regurgitation is seen. The mitral valve leaflets are \nmildly thickened. There is no mitral valve prolapse. Mild to \nmoderate (___) mitral regurgitation is seen. The pulmonary \nartery systolic pressure could not be determined. There is an \nanterior space which most likely represents a prominent fat pad. \n\n\nIMPRESSION: Biatrial enlargement. Normal biventricular function \nand cavity size. Mild symmetric left ventricular hypertrophy. \nMild to moderate mitral regurgitation. \n\n \nBrief Hospital Course:\n___ y/o male with a past medical history of CKD stage 5, MGUS, \nDM2 and glaucoma who presented to the ED with DOE and found to \nhave HFpEF, and Mobitz Type I. \n\n#Heart failure with preserved ejection fraction:\nLikely DOE secondary to new onset heart failure. Patient \npresented with ___ days of exertional dyspnea. Initial \nevaluation notable for hypertension and EKG that showed Mobitz \ntype 1 second degree heart block. Also, pt presented with BNP \n>11,000 with crackles on exam, lower extremity edema and \nelevated JVP all c/w HF. Etiology of HF unclear, but may be due \nto chronic HTN and DMII. Ischemic CM less likely, as patient has \nno history of CAD although he does have risk factors with \nadvanced CKD and diabetes. Trop elevated in setting of stage V \nCKD, but MB was flat. ECHO done and showed: Biatrial \nenlargement, normal biventricular function and cavity size. Mild \nsymmetric left ventricular hypertrophy. Mild to moderate mitral \nregurgitation and what could be early grade I diastolic heart \nfailure. BP control initiated with captopril(switched to \nlisinopril on discharge) and diuresis was done with IV diuretics \nand then he was transitioned to PO Lasix. \n\n#Second Degree Heart Block Mobitz Type I: Unclear etiology, but \nnot likely due to ischemia, medication effects, or amyloid. \nThyroid disease is a possibility as TSH slightly elevated, but \nthere are no other associated symptoms that suggest thyroid \ndisease. ECHO does not support a diagnosis of amyloid, and he is \nnot taking any medications that would cause bradycardia or an \natypical rhythm. TSH should be rechecked at outpatient \nappointment.\n\n#Hypertension: \nBP elevated to 180s on arrival to floor; patient denies \nheadache, chest pain, dyspnea at rest. New diagnosis per \npatient. Review of ___ records show SBP 100-180. In ___ he \nhad documented blood pressures on discharges of SBP 170-180. \nStarted on short acting ACEi and discharged on lisnopril.\n\n# ___: Cr up from admission 3.9 to 4.6, and 4.2 on discharge \nthough very minimal if any difference in real GFR, thus \ndischarged on lasix 20mg PO and lisinopril 10mg QD, for heart \nfailure and HTN, respectively. \n\n#Diabetes mellitus \n Hgb A1C 6.7 in ___. Continued glipizide.\n\n#Glaucoma: \n Continued home eye drops \n\nTRANSITIONAL ISSUES\n===================\n\n[ ] Patient needs a referral for a ___ cardiologist for new onset \nheart failure and monitoring of second degree heart block, type \nI\n\n[]Patient was diuresed as inpatient, and subsequently had a rise \nin BUN/Cr. His baseline is around 4.0 and ___ in setting of over \ndiuresis bumped to 4.6-which translates to a minimal change in \nhis GFR. He will be discharged on 20mg dose of Lasix, and 10mg \nlisinopril. \n\n[]patient will have Chem 10 checked by ___ on ___ while on \nnew PO Lasix dose and lisinopril for ?___ and/or hyperkalemia. \n___ will check and send labs to ___'s office.\n\n[]NaHCO3 which was probably previously prescribed for CKD \ndiscontinued given new onset heart failure. Adjust as needed.\n\n[ ] DW: 84.6kg\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. GlipiZIDE 2.5 mg PO BID \n2. Sodium Bicarbonate 1300 mg PO TID \n3. Calcitriol 0.25 mcg PO DAILY \n4. calcium carbonate-vitamin D3 250-125 mg-unit oral BID \n5. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID \n6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H \n7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n\n \nDischarge Medications:\n1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H \n2. Calcitriol 0.25 mcg PO DAILY \n3. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID \n4. GlipiZIDE 2.5 mg PO BID \n5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n6. Furosemide 20 mg PO DAILY \nRX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n7. Lisinopril 10 mg PO DAILY \nRX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n==================\nHeart failure with preserved ejection fraction\nHypertension\nsecond degree heart block mobitz Type I\n\nSECONDARY DIAGNOSIS\n===================\nDiabetes mellitus type II\nGlaucoma\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 ___ for \nshortness of breath. You were found to have high blood pressures \nand new onset heart failure. This means that your heart does not \nrelax normally. This can lead to fluid accumulation in your body \nand this can cause you to become short of breath. \n\nWhile you were here, we also noted that you had an abnormal \nheart rhythm. This should be monitored, but at this time, it was \ndetermined you do not need a pacemaker. \n\nPlease ensure that you follow up with your primary care \nphysician who can follow your kidney function and your blood \npressures on your new medications. \n\nPlease take your new blood pressure medication, lisinopril, as \ndirected and please take your fluid pill, Lasix, so you do not \naccumulate more fluid in your body. \n\nIt was a pleasure taking part in your care!\nYour ___ Team\n\nIt will be important to weigh yourself every morning, and call \nyour physician if your weight increases more than 3 lbs.\n \nFollowup Instructions:\n___\n" ]

[ "I5033", "I120", "N179", "I441", "E119", "N185", "D472", "D638", "H409", "I340", "Z87891", "F1021" ]

[ "I5033: Acute on chronic diastolic (congestive) heart failure", "I120: Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease", "N179: Acute kidney failure, unspecified", "I441: Atrioventricular block, second degree", "E119: Type 2 diabetes mellitus without complications", "N185: Chronic kidney disease, stage 5", "D472: Monoclonal gammopathy", "D638: Anemia in other chronic diseases classified elsewhere", "H409: Unspecified glaucoma", "I340: Nonrheumatic mitral (valve) insufficiency", "Z87891: Personal history of nicotine dependence", "F1021: Alcohol dependence, in remission" ]

[ "N179", "E119", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nACE Inhibitors\n \nAttending: ___\n \nChief Complaint:\nChest pain\n \nMajor Surgical or Invasive Procedure:\nPlacement of DES in SVG-OM1.\n\n \nHistory of Present Illness:\n___ M with ___ significant for CAD (s/p CABG in ___ and ___, s/p \npost cardiac cath in ___ at ___ showing patent SVG-PDA, \npatent LIMA-LAD, and 100 % occluded SVG-OM1), ___, HTN, HLD, DM \nand Stage III CKD who presents from CHA with chest pain and \nworsening DOE.\n\nHe presented to ___ on ___ with crushing \nchest pressure. Troponin I was negative X1. However, given \nconcern for unstable angina, the patient was given nitroglycerin \nand ASA with resolution of chest pain.\n\nHe was started on heparin gtt and transferred to ___ ED. \n\nTroponin I was negative X3. Around 1500 on ___, pt developed \nrecurrent chest pain while ambulating to toilet. ECG showed \ndeepened lateral ST depressions. He was given additional SL \nnitroglycerin with resolution of pain. However, he continued to \nhave intermittent CP with minimal exertion that was relieved \nwith SL nitro. he was started on a nitro drip as well as heparin \ngtt. \n\n \nPast Medical History:\n(s/p CABG in ___ and ___, s/p post cardiac cath in ___ at \n___ showing patent SVG-PDA, patent LIMA-LAD, and 100 % occluded \nSVG-OM1)\nHTN\nHLD\nDM\nCKD\nGERD\nB12 deficiency\n \nSocial History:\n___\nFamily History:\ndeferred\n \nPhysical Exam:\nADMISSION EXAM:\nVitals: 98.5 BP 167/72 HR 76 RR 20 99 % RA\nGeneral: Alert, oriented, no acute distress\nHEENT: sclera anicteric, MMM, oropharynx clear, EOMI, PERRL\nNeck: Supple. JVP not elevated, no LAD\nCV: Regular rate an rhythm, normal S1 and S2, no murmurs, rubs, \ngallops,\nLungs: CTAB, no wheezes, rale, rhonci\nAbdomen: Soft, non tender, obese abdomen but more distended per \npatient, bowel sounds present, no organomegaly, no rebound or \nguarding\nGU: no foley\nExt: Warm, well perfused, 2+ pulses, no clubbing, prescence of \n1+ edema. L arm with radial band.\n\nDISCHARGE EXAM:\nDECEASED \n \nPertinent Results:\nADMISSION LABS\n===============================\n\n___ 12:45AM BLOOD WBC-6.3 RBC-2.63* Hgb-8.8* Hct-26.9* \nMCV-102* MCH-33.5* MCHC-32.7 RDW-13.2 RDWSD-49.3* Plt ___\n___ 12:45AM BLOOD ___ PTT-132.8* ___\n___ 12:45AM BLOOD ALT-35 AST-24 CK(CPK)-109 AlkPhos-75 \nTotBili-0.3\n___ 12:45AM BLOOD cTropnT-<0.01\n___ 06:00AM BLOOD Calcium-9.1 Phos-2.8 Mg-2.2\n\ntroponins\n\n___ 12:45AM BLOOD cTropnT-<0.01\n___ 07:20AM BLOOD cTropnT-<0.01\n___ 08:45PM BLOOD cTropnT-0.01\n___ 12:44AM BLOOD CK-MB-6 cTropnT-.26*\n___ 12:40PM BLOOD cTropnT-0.25*\n___ 12:36AM BLOOD cTropnT-0.24*\n___ 06:55AM BLOOD cTropnT-0.27*\n___ 07:40AM BLOOD CK-MB-3 cTropnT-0.17*\n___ 07:59AM BLOOD CK-MB-7 cTropnT-0.29*\n___ 03:55PM BLOOD CK-MB-28* MB Indx-4.6 cTropnT-3.31*\n\nCATH REPORTS\n\nCATH ___\n\nCoronary Anatomy\nCoronary anatomy:\nRight dominant\nLeft main known to be occluded.\nRCA: Proximal 100% occlusion.\nLIMA to LAD: LIMA is patent. Apical LAD is occluded. LAD \nbackfills and fills true LCx.\nSVG to OM: Patent. There is an anatomotic 50% stenosis.\nSVG to the PDA: Patent. The retro limb of the PDA has a 60% hazy \nstenosis.\nImpressions:\nStable CAD. No clear culprit lesion.\n\nCATH ___\n\nCoronary Anatomy\nDominance: Right\nInjection of the SVG-OM showed a moderate hazy lesion in the \ngraft just before the distal anastomosis\nwith flow into a diffusely diseased small distal vesseel\nInterventional Details\nUsing a ___ Fr AL 1 guide, the lesion in the SVG-OM was crossed \nwith a Prowater wire and directly stented\nwith a 3.5x16 Premier at 12 atm with no residual, normal flow.\nIntra-procedural Complications: None\nImpressions:\nSuccessful DES of SVG-OM\nRecommendations\nContinue aspirin uninterruped indefinitely, clopidogrel ___ year\n\nRADIOLOGY\n\nCXR ___\n\nFINDINGS: \n \nFrontal and lateral chest radiographs demonstrate intact sternal \nwires and \nclips along the left mediastinum. The heart is top-normal in \nsize. Opacity \nprojecting over the lower lungs on lateral view may correspond \nto either \nretrocardiac opacity or right infrahilar opacity. There are \nbilateral small \npleural effusions and possible mild heart failure. No pleural \neffusion or \npneumothorax is appreciated. The visualized upper abdomen is \nunremarkable. \n \nIMPRESSION: \n \n \n1. Opacity projecting over the lower lung on lateral view may \ncorrespond \neither retrocardiac or right infrahilar opacity. \n2. Bilateral small pleural effusions and possible mild heart \nfailure. \n \nRECOMMENDATION(S): Oblique views may be helpful in further \nevaluation of \nlower lung opacity seen on lateral view. \n \nNOTIFICATION: The above recommendation was communicated via \ntelephone by Dr. \n___ to Dr. ___ at ___ on ___, \napproximately 1 hour after attending review. \n\n \nBrief Hospital Course:\n___ y/o male with past medical history significant for CAD (s/p \nCABG in ___ and ___, DM, HTN, HLD who presented with with \nworsening CP, DOE, for past month.Of note, patient last had \ncoronary angiography on ___ which showed severe multivessel \nCAD, and two out of three bypass grafts still widely patent. \nPatient presented to ___, and given chest \npain and history of CAD was transferred to ___ on ___ and \nplaced on heparin drip and nitroglycerin drip. \n\nPatient had coronary angiography on ___ which found no \nculprit lesion, no intervention done. On ___, patient had \ndynamic EKG changes, with a troponin bump; patient had repeat \ncoronary angiography on ___ at this time an intervenable \nlesion was found and he had a DES placed in the SVG-OM graft. \nPatient was due to be discharged the following day; however \npatient had ___ (cr 2.0 from 1.5) following procedure on \n___ and was kept in house. Despite being medically cleared \non ___ patient was not discharged due to inability to obtain \ntaxi voucher, and on ___ patient reported severe abdominal \npain. He was found to be grossly distended, without bowel sounds \nand no passing of flatus or bowel movements for 12 hrs, so he \nwas kept NPO and started on IVF for empiric management of ileus. \nHe had abdominal versus chest pain as well am of ___, and had \nrepeat EKG which showed no changes compared to prior. His \ntroponins were trended on ___ as well given slight rise (0.27 \nfrom 0.17). In pm of ___, patient was noted to be \nunconscious and pulseless after watching football on television \nand code was called. During code pm troponin check returned \n(which was drawn while patient was watching game) and troponin \nreturned at 3.31 (from am 0.27). \n\nPatient was sent to cath lab for intervention for likely acute \nMI, and acute IABP placement. During procedure, patient had \nwaning pulses and drop in BP. Despite interventions with \nattempted IABP, patient became pulseless. No lung or heart \nsounds were auscultated, no pulse was palpable and patient had \nno brainstem reflexes, and time of death was called. ___ \nfamily was notified regarding death on their arrival to the \nhospital. HCP ___, wife) declined autopsy. Medical \nExaminer was notified regarding case (POD # 3 from ___ coronary \nangiography with stent to SVG-OM1) and case was declined. \nAdmitting was notified, and message was left for Dr. ___, \n___ PCP. \n\nBRIEF HOSPITAL ISSUE BY PROBLEM:\n# CAD: As above, patient had significant history of CAD s/p two \nCABG in ___ and ___. He had cath on ___ with no intervention \nand cath on ___ with DES to SVG-OM placed. He was kept on \natorvastatin, aspirin, clopidogrel, metoprolol xl 200, \nnifidepine and ranolazine. On ___ patient suffered code event as \nabove, attributable to likely acute MI and subsequently passed. \n# Chronic systolic heart failure: Patient with LVEF of 58% on \nechocardiogram performed ___ at ___. His home furosemide \nwas initially held after ___ above and was deu to be restarted \nta half dose; and home ___ was held. \n# ___ - ? pre-renal, s/p fluid support ___. Patient had Cr jump \nto ___ from ___ s/p cath ___, attributed to dye load. His \nhome losartan was stopped. \n# GI symptoms: Patient complaining of burping and reflux, \nsymptoms worse when lying down after dinner, may account for \nsome of the apparent cardiac symptoms. ___ on ___, patient \nhad worsening constipation, painful in upper quadrants, despite \nmultiple laxatives, enema. Patient reports no longer passing gas \nas of ___ am. His abdominal distension and pain was attributed \nto possible SBO vs ileus and patient was started on maintenance \nIVF on ___ prior to code event above. \n# Diabetes: Continued ISS. Patient confirmed takes 88 units \nlantus in morning, 20 in evening. This was continued in house. \n \n\n \nMedications on Admission:\npatient expired\n \nDischarge Medications:\npatient expired\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\npatient expired\n \nDischarge Condition:\npatient expired\n \nDischarge Instructions:\npatient expired\n \nFollowup Instructions:\n___\n" ]

[ "I25110", "I214", "I5032", "N179", "I25710", "I469", "Z006", "E875", "I129", "N183", "K5900", "E669", "Z6833", "E1121", "E11319", "Z794", "J449", "J45909", "E1165", "I2582" ]

[ "I25110: Atherosclerotic heart disease of native coronary artery with unstable angina pectoris", "I214: Non-ST elevation (NSTEMI) myocardial infarction", "I5032: Chronic diastolic (congestive) heart failure", "N179: Acute kidney failure, unspecified", "I25710: Atherosclerosis of autologous vein coronary artery bypass graft(s) with unstable angina pectoris", "I469: Cardiac arrest, cause unspecified", "Z006: Encounter for examination for normal comparison and control in clinical research program", "E875: Hyperkalemia", "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)", "K5900: Constipation, unspecified", "E669: Obesity, unspecified", "Z6833: Body mass index [BMI] 33.0-33.9, adult", "E1121: Type 2 diabetes mellitus with diabetic nephropathy", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "Z794: Long term (current) use of insulin", "J449: Chronic obstructive pulmonary disease, unspecified", "J45909: Unspecified asthma, uncomplicated", "E1165: Type 2 diabetes mellitus with hyperglycemia", "I2582: Chronic total occlusion of coronary artery" ]

[ "I5032", "N179", "I129", "K5900", "E669", "Z794", "J449", "J45909", "E1165" ]

[]

[ " \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:\nParaesophageal hernia\n___ ulcers\n \nMajor Surgical or Invasive Procedure:\n___ - Laparaoscopic paraesophageal hernia repair, Nissun \nfundoplication\n___ - Hiatal hernia repair with absorbable mesh for slipped \nposterior wrap\n\n \nHistory of Present Illness:\n___ M paraesophageal hernia s/p primary repair hiatal hernia with \nNissen fundoplication c/b slipped posterior wrap s/p hiatal \nhernia repair with absorbable mesh\n \nPast Medical History:\nDepression, gastroesophageal reflux, paraesophageal hernia (with \n___ ulcer).\n \nSocial History:\n___\nFamily History:\nMother with coronary artery disease status post\nCABG, also had a hiatal hernia. He has two aunts with hiatal\nhernias and one cousin with hiatal hernia.\n \nPhysical Exam:\nAdmission physical exam is documented in the pre-operative \nanesthesia record.\n\nDischarge Physical Exam:\nVitals: T 98.1, BP 102/70, HR 84, RR 18, SpO2 99% on RA \nGen: AOx3, NAD\nCV: RRR, normal s1/s2\nPulm: CTAB\nAbd: Soft, nontender, nondistended. Normoactive bowel sounds. \nIncisions intact.\nExt: WWP\n \nPertinent Results:\nLabs immediately post-operatively (day of ICU transfer after \nsurgery):\n\n___ 11:23PM TYPE-ART PO2-92 PCO2-48* PH-7.37 TOTAL CO2-29 \nBASE XS-1\n___ 11:23PM LACTATE-2.6*\n___ 09:44PM WBC-12.7* RBC-4.27* HGB-12.0* HCT-36.9* \nMCV-86 MCH-28.1 MCHC-32.5 RDW-13.6 RDWSD-43.0\n___ 09:44PM PLT COUNT-226\n___ 08:00PM TYPE-ART PO2-133* PCO2-52* PH-7.31* TOTAL \nCO2-27 BASE XS-0\n___ 08:00PM LACTATE-3.4*\n___ 08:00PM freeCa-1.10*\n___ 06:00PM TYPE-ART PO2-107* PCO2-53* PH-7.25* TOTAL \nCO2-24 BASE XS--4\n___ 05:12PM GLUCOSE-200* UREA N-16 CREAT-1.1 SODIUM-140 \nPOTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-23 ANION GAP-18\n___ 05:12PM estGFR-Using this\n___ 05:12PM CALCIUM-8.4 PHOSPHATE-6.1* MAGNESIUM-1.7\n___ 05:12PM WBC-16.0* RBC-4.82 HGB-13.6* HCT-41.5 MCV-86 \nMCH-28.2 MCHC-32.8 RDW-13.5 RDWSD-42.7\n___ 05:12PM NEUTS-85.8* LYMPHS-7.5* MONOS-5.9 EOS-0.1* \nBASOS-0.3 IM ___ AbsNeut-13.75* AbsLymp-1.20 AbsMono-0.94* \nAbsEos-0.02* AbsBaso-0.05\n___ 05:12PM PLT COUNT-264\n___ 05:12PM ___ PTT-24.4* ___\n___ 05:07PM TYPE-ART PO2-168* PCO2-63* PH-7.25* TOTAL \nCO2-29 BASE XS-0\n___ 05:07PM GLUCOSE-195* LACTATE-1.8\n___ 05:07PM freeCa-1.12\n___ 04:18PM TYPE-ART PO2-90 PCO2-66* PH-7.21* TOTAL \nCO2-28 BASE XS--3 INTUBATED-INTUBATED VENT-CONTROLLED\n___ 04:18PM GLUCOSE-200* LACTATE-1.3 NA+-137 K+-4.4 \nCL--105\n___ 04:18PM HGB-14.6 calcHCT-44\n___ 04:18PM freeCa-1.11*\n\nMost recent CXR prior to discharge, s/p NGT placement (___):\nFINDINGS: \n\nThe bilateral diaphragms are not fully visualized on this study. \nThere is no \nvisible gastric distention, which represents an interval \nimprovement from \nprior abdominal radiographs dated ___. \nThere is an enteric tube with its tip and side-port in the \nstomach. \nThere are no abnormally dilated loops of large or small bowel. \nResidual PO \ncontrast from prior upper GI series is seen primarily in the \nnon-distended \ncolon and rectum. \nSupine assessment limits detection for free air; there is no \ngross \npneumoperitoneum. \nOsseous structures are unremarkable. \n\nIMPRESSION: \n\n1. Enteric tube with its tip and side-port in the stomach. \n2. No visualized gastric distention, which represents an \ninterval improvement \ncompared to prior abdominal radiographs dated ___. \n3. Nonspecific bowel gas pattern without evidence of \nobstruction. \n\n___ Abdomen XR (prior to NG placement:\nFINDINGS: \n\nAs previously demonstrated, the stomach is distended with air \nwithin air-fluid \nlevel, unchanged compared to the prior radiograph. Impression \nupon the fundus \nof the stomach is consistent with ___ wrap. Contrast is noted \nwithin the \nnondilated colon from prior upper GI study. Nonobstructive bowel \ngas pattern. \n\nLeft pleural effusion is again noted. Parenchymal opacity in the \nretrocardiac \nregion with silhouetting of the hemidiaphragm is consistent with \n\natelectasis/consolidation. \n\nOsseous structures are unremarkable. \n\nIMPRESSION: \n\n1. Distension of the stomach with air-fluid level, unchanged. \n2. Small right pleural effusion with retrocardiac \nconsolidation/atelectasis, \nbetter evaluated on the recent chest radiograph. \n\n \nBrief Hospital Course:\nMr. ___ was admitted to the bariatric surgery service under \nDr. ___ on ___ after a laparoscopic paraesophageal \nhernia repair and ___ fundoplication procedure, complicated \nby slipped posterior wrap necessitating a hiatal hernia repair \nwith absorbable mesh. His hospital course was complicated, and \nin brief (details below by system): intra-operatively, the \npatient became hypoxic into the high ___. When the abdomen was \ndeflated, the hypoxia improved but that patient still required \n100% FiO2. A post-op XR revealed a small L pneumothorax, with a \nrepeat CXR showing an opacity in the right lower lobe concerning \nfor aspiration. He was started on empiric antibiotic coverage \nand a CT scan to rule out pneumothorax was negative. However, \nthis CT also revealed slippage of the posterior wrap of the \n___ fundoplication which required subsequent repair with \nabsorbable mesh. He tolerated this procedure well but had \nabdominal distension postoperatively. After initially refusing \nNGT placement, he had one placed on ___ which successfully \ndecompressed the stomach. He was kept NPO, then slowly advanced \nto sips of clear liquid when able, though the NGT remained in \nplace. During this time, he was also started on TPN for \nnutrition (day 1 on ___. He tolerated this well. After \nmonitoring his NGT output closely, his NGT was removed on \n___, and he was allowed to advance as tolerated to a \nregular diet, which he tolerated well. He continued to receive \nTPN during this time.\n\nIn detail by system:\nNeuro: The patient's pain was well controlled with IV narcotic \npain medications while NPO. He was advanced to PO pain \nmedications when tolerating a regular diet and he did well on \nthis regimen. By day of discharge, he was reporting no pain and \nhe was told to use over the counter Tylenol as needed for pain \ncontrol. His home venlafaxine was restarted when tolerating oral \nintake. Of note, the patient did report substantial anxiety \nduring his stay; he was given lorazepam for anxiety which \ncontrolled this well.\n\nCV: The patient was diuresed several times during his inpatient \nstay for poor oxygenation (described in detail in Pulm section \nbelow). With this exception, the patient otherwise remained \nstable from a cardiovascular standpoint; vital signs were \nroutinely monitored. \n\nPulmonary: The patient was initially transferred from the OR to \nthe ICU due to hypoxia during the surgery. A CXR performed in \nthe ICU demonstrated concern for a small left sided PTX. A \nsubsequent CXR also demonstrated concern for a possible right \nlower lobe consolidation, for which he was empirically started \non antibiotics. He underwent bedside bronchoscopy on ___ which \nshowed a minimal amount of secretion in the right middle and \nlower lobe main bronchus. Bronchoalveolar lavage was done and \nwas negative for growth. His oxygenation improved and on ___ \nhe was extubated, though her remained on 70% face tent (satting \n95). He was slowly weaned as tolerated from this to nasal \ncannula 5L, and subsequently iven 60 mg of IV Lasix after which \nhis respiratory status further improved. However, given his \ncontinued need for supplemental oxygen, a CTA PE was performed \non ___ which demonstrated no evidence of pulmonary embolism. \nHowever, he was noted to have bilateral pleural effusions as \nwell as left lower lobe atelectasis and evidence of a slipped \nposterior wrap from the fundoplication (in detail under GI \nsection). He was further diuresed with Lasix and pulmonology was \nconsulted for careful diuresis. He subsequently improved and was \nweaned to room air. By day of discharge, he was stable on room \nair without any issue.\n\nGI/GU/FEN: As noted above, the patient underwent a laparoscopic \nparaesophageal hernia repair on ___. During the procedure, the \npatient developed hypoxia and needed to be transferred to the \nICU (detailed in Pulm above). A subsequent CT on ___ for \npulmonary workup demonstrated a slipped posterior wrap, and he \nwas taken back to the OR on ___ for repair and placement of an \nabsorbable mesh. The procedure went well. However, although \ninitially tolerating clears after this surgery, the patient \ndeveloped increasing abdominal distension following this \nprocedure thought to be due to temporary vagal nerve dysfunction \nfollowing the surgery, and he was made NPO and started on TPN \n(discussed further shortly). He had an NGT placed on ___ \n(after initially refusing) which decompressed the stomach well. \nThis was kept in place until ___, and he tolerated NGT \nremoval well and began a regular diet on ___. In terms of GU, \nno issues were noted, though the patient did require diuresis \nseveral times for pulmonary issues listed above. As far as \nnutrition, he patient was placed on intravenous fluids while \nNPO. He was started on TPN on ___ and was seen by nutrition \ndaily due to his long NPO status. He tolerated this well and his \nTPN was continued as an outpatient for which services were \narranged by case management. He resumed a regular diet on ___ \nas noted above once his NGT was removed. He tolerated this well.\n\nID: The patient was started on empiric antibiotics for intial \nconcern of RLL consolidation potentially representing aspiration \npneumonia. His fever curves were closely monitored and these \nantibiotics were discontinued after no growth was noted on \nbronchoalveolar lavage and no further symptoms. \n\nHEME: The patient's blood counts were closely watched for signs \nof bleeding, of which there were none. \n\nProphylaxis: The patient received subcutaneous heparin and ___ \ndyne boots were used during this stay and was encouraged \nambulate. At the time of discharge, the patient was doing well, \nafebrile and hemodynamically stable. The patient was tolerating \na diet, ambulating, voiding without assistance, and pain was \nwell controlled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan. \n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Omeprazole 40 mg PO DAILY \n2. Sucralfate 1 gm PO BID \n3. Venlafaxine XR 150 mg PO DAILY \n\n \nDischarge Medications:\n1. Omeprazole 40 mg PO DAILY \n2. Sucralfate 1 gm PO BID \n3. Venlafaxine XR 150 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nparaesophageal hernia \n___ ulcers \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 ___ on ___ for an elective \nlaparoscopic paraesophageal hernia repair and Nissen \nfundoplication. This repair required a revision surgery on ___ \nfor a slipped posterior wrap. \n\nYour hospital course was complicated by an ICU admission and \nrespiratory distress - you were treated appropriately for this \nand your oxygen saturation was closely monitored until you were \nstable on room air. Full details are described in your discharge \nsummary. You also had a hospital course complicated by gastric \ndistension following the revision repair on ___. We treated \nyou with placement of an NGT as we had discussed at the bedside \nand removed the tube once this distension was adequately \ntreated. You tolerated a regular diet following this and were \nstable from this perspective as well on day of discharge. You \ncan continue a regular diet at home.\n\nYou are now preparing for discharge to home with the following \ninstructions:\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. Please do not take NSAIDs \nincluding, but not limited to, Advil, ibuprofen, Aleve, Motrin, \nas these medications can cause gastrointestinal ulcer formation. \nYou must avoid alcohol and tobacco products as well.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. \n\n \nFollowup Instructions:\n___\n" ]

[ "K440", "J690", "J952", "J90", "E872", "J9811", "K9189", "F05", "K279", "R0902", "Z87891", "Y838", "Y92239", "F419", "R140" ]

[ "K440: Diaphragmatic hernia with obstruction, without gangrene", "J690: Pneumonitis due to inhalation of food and vomit", "J952: Acute pulmonary insufficiency following nonthoracic surgery", "J90: Pleural effusion, not elsewhere classified", "E872: Acidosis", "J9811: Atelectasis", "K9189: Other postprocedural complications and disorders of digestive system", "F05: Delirium due to known physiological condition", "K279: Peptic ulcer, site unspecified, unspecified as acute or chronic, without hemorrhage or perforation", "R0902: Hypoxemia", "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", "F419: Anxiety disorder, unspecified", "R140: Abdominal distension (gaseous)" ]

[ "E872", "Z87891", "F419" ]

[]

[ " \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 \n \nMajor Surgical or Invasive Procedure:\n___: Laparoscopic appendectomy\n\n \nHistory of Present Illness:\nMr. ___ is a ___ with unknown bleeding disorder \npresenting with abdominal pain. He was in his normal state of \nhealth until 2 days ago when he initially developed \nperiumbilical abdominal pain. The pain has since migrated to his \nright lower quadrant. He also notes decreased appetite. He \ninitially went to an outside hospital where CT scan was positive \nfor acute appendicitis. Patient noted that he has had a history \nof unknown bleeding disorder for which he was unable to undergo \na tonsillectomy as a child. Given concerns for bleeding, patient \nwas transferred to ___ for further care. He denies history of \ninflammatory bowel disease, fevers, vomiting, or diarrhea. \n\n \nPast Medical History:\nPMH:\nbleeding disorder, hypertension\n\nPSH:\nnone\n\n \nSocial History:\n___\nFamily History:\nNo family history of IBD. Hx of HTN, diabetes\n\n \nPhysical Exam:\nAdmission Physical Exam:\n\nVitals: 97.7 70 146/85 18 98%RA\nGEN: AOx3, 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, obese, right lower quadrant tenderness to palpation,\nno rebound or guarding, negative psoas/rovsings' sign\nExt: No ___ edema, ___ warm and well perfused\n\nDischarge Physical Exam:\nVS: T: 97.6, BP: 144/99, HR: 81, RR: 16, O2: 99% RA\nGeneral: A+Ox3, NAD\nCV: RRR\nPULM: CTA b/l\nABD: lap sites x 4, steristrips in place, surgical incision \nsites well-approximated. Soft, non-distended, mildly tender at \nincisional sites\nExtremities: no edema\n\n \nPertinent Results:\n___ 11:05PM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 11:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 \nGLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG\n___ 11:05PM URINE RBC-0 WBC-3 BACTERIA-NONE YEAST-NONE \nEPI-0\n___ 11:05PM URINE MUCOUS-OCC\n___ 10:20PM GLUCOSE-90 UREA N-9 CREAT-0.9 SODIUM-139 \nPOTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-29 ANION GAP-13\n___ 10:20PM CALCIUM-9.5 PHOSPHATE-3.8 MAGNESIUM-2.0\n___ 10:20PM WBC-11.3* RBC-4.66 HGB-13.2* HCT-39.2* MCV-84 \nMCH-28.3 MCHC-33.7 RDW-13.0 RDWSD-39.5\n___ 10:20PM PLT COUNT-251\n___ 10:20PM ___ PTT-37.8* ___\n___ 04:50AM GLUCOSE-90 UREA N-10 CREAT-0.9 SODIUM-140 \nPOTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-26 ANION GAP-14\n___ 04:50AM WBC-11.8* RBC-4.44* HGB-12.3* HCT-37.6* \nMCV-85 MCH-27.7 MCHC-32.7 RDW-13.1 RDWSD-40.4\n___ 04:50AM NEUTS-65.2 ___ MONOS-6.9 EOS-3.0 \nBASOS-0.3 IM ___ AbsNeut-7.71* AbsLymp-2.86 AbsMono-0.81* \nAbsEos-0.35 AbsBaso-0.04\n___ 04:50AM PLT COUNT-233\n___ 04:50AM ___ PTT-31.9 ___\n\nImaging:\n\nCT Abd/pelvis \nFinidngs: appendix is enlarged at 1.2 cm in caliber with\nperiappendiceal inflammation, consistent with acute \nappendicitis.\nNo pneumoperitoneum or abscess. \n \nBrief Hospital Course:\nMr. ___ is a ___ year-old male who presented to ___ on \n___ with complaints of abdominal pain. On imaging, he was \nfound to have acute appendicitis. He was admitted to the Acute \nCare Surgery team for further medical management. \n\nOn ___, the patient underwent laparoscopic appendectomy, \nwhich went well without complication (reader referred to the \nOperative Note for details). He had an abdominal JP drain \nplaced. After a brief, uneventful stay in the PACU, the patient \narrived on the floor on IV fluids, and IV pain medicine for pain \ncontrol. The patient was hemodynamically stable.\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. He was discharged with ___ services to \nmonitor his JP drain output. He was discharged with an Acute \nCare Surgery follow-up appointment. \n\n \nMedications on Admission:\nVerapamil 40', lisinopril 12.5'\n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN pain \n2. Docusate Sodium 100 mg PO BID \nplease hold for loose stool \n3. Verapamil 40 mg PO Q24H \n4. Lisinopril 12.5 mg PO DAILY \n5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain \ndo NOT drink alcohol or drive while taking this medication \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAcute appendicitis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to the hospital and were diagnosed with acute \nappendicitis, an inflammation of your appendix. You were \nadmitted to the Acute Care Surgery team for further medical \nmanagement. You were taken to the operating room and had your \nappendix removed laparoscopically. A drain was left in place. \n\nYou are now tolerating a regular diet and your pain is better \ncontrolled. You are now medically cleared to be discharged home \nto continue your recover. Please note the following discharge \ninstructions:\n\nPlease follow up in the Acute Care Surgery clinic at the \nappointment listed below.\n \nACTIVITY:\n \no Do not drive until you have stopped taking pain medicine and \nfeel you could respond in an emergency.\no You may climb stairs. \no You may go outside, but avoid traveling long distances until \nyou see your surgeon at your next visit.\no Don't lift more than ___ lbs for 4 weeks. (This is about \nthe weight of a briefcase or a bag of groceries.) This applies \nto lifting children, but they may sit on your lap.\no You may start some light exercise when you feel comfortable.\no You will need to stay out of bathtubs or swimming pools for a \ntime while your incision is healing. Ask your doctor when you \ncan resume tub baths or swimming.\n \nHOW YOU MAY FEEL: \no You may feel weak or \"washed out\" for a couple of weeks. You \nmight want to nap often. Simple tasks may exhaust you.\no You may have a sore throat because of a tube that was in your \nthroat during surgery.\no You might have trouble concentrating or difficulty sleeping. \nYou might feel somewhat depressed.\no You could have a poor appetite for a while. Food may seem \nunappealing.\no All of these feelings and reactions are normal and should go \naway in a short time. If they do not, tell your surgeon.\n \nYOUR INCISION:\no Tomorrow you may shower and remove the gauzes over your \nincisions. Under these dressing you have small plastic bandages \ncalled steri-strips. Do not remove steri-strips for 2 weeks. \n(These are the thin paper strips that might be on your \nincision.) But if they fall off before that that's okay).\no Your incisions may be slightly red around the stitches. This \nis normal.\no You may gently wash away dried material around your incision.\no Avoid direct sun exposure to the incision area.\no Do not use any ointments on the incision unless you were told \notherwise.\no You may see a small amount of clear or light red fluid \nstaining your dressing or clothes. If the staining is severe, \nplease call your surgeon.\no You may shower. As noted above, ask your doctor when you may \nresume tub baths or swimming.\n \nYOUR BOWELS:\no Constipation is a common side effect of narcotic pain \nmedications. If needed, you may take a stool softener (such as \nColace, one capsule) or gentle laxative (such as milk of \nmagnesia, 1 tbs) twice a day. You can get both of these \nmedicines without a prescription.\no If you go 48 hours without a bowel movement, or have pain \nmoving the bowels, call your surgeon. \n \nPAIN MANAGEMENT:\no It is normal to feel some discomfort/pain following abdominal \nsurgery. This pain is often described as \"soreness\". \no Your pain should get better day by day. If you find the pain \nis getting worse instead of better, please contact your surgeon.\no You will receive a prescription for pain medicine to take by \nmouth. It is important to take this medicine as directed. o Do \nnot take it more frequently than prescribed. Do not take more \nmedicine at one time than prescribed.\no Your pain medicine will work better if you take it before your \npain gets too severe.\no Talk with your surgeon about how long you will need to take \nprescription pain medicine. Please don't take any other pain \nmedicine, including non-prescription pain medicine, unless your \nsurgeon has said its okay.\no If you are experiencing no pain, it is okay to skip a dose of \npain medicine.\no Remember to use your \"cough pillow\" for splinting when you \ncough or when you are doing your deep breathing exercises.\nIf you experience any of the following, please contact your \nsurgeon:\n- sharp pain or any severe pain that lasts several hours\n- pain that is getting worse over time\n- pain accompanied by fever of more than 101\n- a drastic change in nature or quality of your pain\n \nMEDICATIONS:\nTake all the medicines you were on before the operation just as \nyou did before, unless you have been told differently.\nIf you have any questions about what medicine to take or not to \ntake, please call your surgeon.\n\n \nFollowup Instructions:\n___\n" ]

[ "K3580", "I10", "Z87891", "Z23" ]

[ "K3580: Unspecified acute appendicitis", "I10: Essential (primary) hypertension", "Z87891: Personal history of nicotine dependence", "Z23: Encounter for immunization" ]

[ "I10", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: ORTHOPAEDICS\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nLeft foot Calcaneal fracture, Right ankle fracture\n \nMajor Surgical or Invasive Procedure:\nORIF Right pilon fracture\nsplinting of left calcaneus fracture\n\n \nHistory of Present Illness:\n___ y/o M climbing up a ladder around midnight and foot got \ncaught fell off landing on feet L ankle pain with displaced \ncalcaneous fx. Pt states he fell from about ___ feet. Pt was \ntransferred from ___ where he was worked up and has head CT, \nspine imaging ruled out for any fractures. He states that he is\nin significant pain in he left foot and is also endorsing R foot \npain. Pt denies any N/V/F/C/SOB/CP. He states the last time he \nhad anything to eat was yesterday afternoon.\n\n \nPast Medical History:\nnone\n \nSocial History:\n___\nFamily History:\nNC\n \nPhysical Exam:\nPhysical Exam on admission:\nGen: A+Ox3, NAD\nAVSS\nCV: RRR\nResp: No respiratory distress\nAbd: Soft, NT, ND\n\nFocused left lower extremity exam:\nIn splint, overwrapped with fiberglass. Exposed toes wwp, \nwiggling toes. SILT to exposed toes.\n\nFocused right lower extremity exam: \n - ___ fire\n - Sensation intact to light touch in \nSPN/DPN/Tibial/saphenous/Sural distributions\n - 1+ ___ pulses, foot warm and well perfused\\\n- RLE in air cast boot.\n\n \nPertinent Results:\n___ 06:25AM GLUCOSE-112* UREA N-13 CREAT-0.8 SODIUM-136 \nPOTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-21* ANION GAP-17\n___ 06:25AM estGFR-Using this\n___ 06:25AM CALCIUM-9.0 PHOSPHATE-3.1 MAGNESIUM-1.8\n___ 06:25AM WBC-13.3* RBC-4.64 HGB-13.6* HCT-40.2 MCV-87 \nMCH-29.3 MCHC-33.8 RDW-12.5 RDWSD-39.4\n___ 06:25AM PLT COUNT-179\n___ 06:25AM NEUTS-76.1* LYMPHS-16.2* MONOS-6.4 EOS-0.2* \nBASOS-0.5 IM ___ AbsNeut-10.08* AbsLymp-2.15 AbsMono-0.85* \nAbsEos-0.03* AbsBaso-0.06\n___ 06:25AM ___ PTT-23.4* ___\n\nPertinent Imaging:\n\nLeft foot CT ___ and impacted fracture of the \ncalcaneus with intra-articular extension to all three \narticulations of the talocalcaneal joint. There is associated \nsoft tissue swelling overlying the fracture. \n\nRight foot/ankle Xrays (___): 1. Depressed, \nintra-articular fracture of the anterior/medial aspect of the \ndistal tibia. 2. No evidence of fracture in the foot. \n\n \nBrief Hospital Course:\nThe patient was transferred from an OSH following a 10 foot fall \nfor a left foot calcaneal fracture. He was admitted to the \npodiatric surgery service for pain control. After initial \nevaluation it was determined that his injuries would be best \nserved on the orthopaedic service so his care was transferred. \n\nThe patient presented to the emergency department and was \nevaluated by the orthopedic surgery team. The patient was found \nto have a left calcaneus fracture and a right ankle fracture and \nwas admitted to the orthopedic surgery service. The patient was \ntaken to the operating room on ___ for ORIF of the right \nankle and splinting of the left calcaneus, which the patient \ntolerated well. For full details of the procedure please see the \nseparately dictated operative report. The patient was taken from \nthe OR to the PACU in stable condition and after satisfactory \nrecovery from anesthesia was transferred to the floor. The \npatient was initially given IV fluids and IV pain medications, \nand progressed to a regular diet and oral medications by POD#1. \nThe patient was given ___ antibiotics and \nanticoagulation per routine. The patient's home medications were \ncontinued throughout this hospitalization. The patient worked \nwith ___ who determined that discharge to home was appropriate. \nThe ___ hospital course was otherwise unremarkable.\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 \nNWB in the LLE and WBAT in an air cast boot in the RLE, and will \nbe discharged on lovenox for DVT prophylaxis. The patient will \nfollow up with Dr. ___ routine. A thorough discussion \nwas had 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\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. This patient is not taking any preadmission medications\n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO BID:PRN Constipation \nRX *docusate sodium 100 mg 1 capsule(s) by mouth twice per day \nDisp #*30 Capsule Refills:*0\n2. Enoxaparin Sodium 40 mg SC QPM Duration: 4 Weeks \nStart: ___, First Dose: Next Routine Administration Time \nRX *enoxaparin 40 mg/0.4 mL 1 syringe sc every evening Disp #*28 \nSyringe Refills:*0\n3. Gabapentin 300 mg PO DAILY \nRX *gabapentin 300 mg 1 capsule(s) by mouth once per day Disp \n#*30 Capsule Refills:*1\n4. Nicotine Patch 14 mg TD DAILY \nRX *nicotine 14 mg/24 hour apply to skin once every 24h Disp \n#*30 Patch Refills:*1\n5. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain \nplease wean as your pain improves \nRX *oxycodone 5 mg ___ tablet(s) by mouth every three hours Disp \n#*80 Tablet Refills:*0\n6. Senna 8.6 mg PO BID:PRN Constipation \nRX *sennosides [senna] 8.6 mg 1 capsule by mouth twice per day \nDisp #*30 Capsule Refills:*0\n7. Acetaminophen 650 mg PO Q6H:PRN pain \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nLeft foot calcaneal fracture, Right Ankle Fracture\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 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- NWB LLE in splint, WBAT RLE in ACB\n\nMEDICATIONS:\n- Please take all medications as prescribed by your physicians \nat discharge.\n- Continue all home medications unless specifically instructed \nto stop by your surgeon.\n- Do not drink alcohol, drive a motor vehicle, or operate \nmachinery while taking narcotic pain relievers.\n- Narcotic pain relievers can cause constipation, so you should \ndrink eight 8oz glasses of water daily and take a stool softener \n(colace) to prevent this side effect.\n\nANTICOAGULATION:\n- Please take Lovenox 40mg 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- No dressing is needed if wound continues to be non-draining.\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\nINSTRUCTIONS FROM SOCIAL WORK\n\nSW addressed several resource needs for this very low income\npatient without health insurance.\n\nHealth Insurance:\nAlong with pt today we called RI Medicaid. After 60 mins hold\ntime ___ worked with a representative to activate pt's insurance. \n\nPt was able to be activated and enrolled in Neighborhood Health\nPlan of ___. The rep noted that he will not be active in the\nsystem for ___ days, and will have to wait ___ weeks for his\ncard. Until that time ___ weeks), the only way he can have\naccess to ___ medical care is in an emergency using\nhis social security number for ID.\n\nThis insurance plan will pay for past medical bills incurred\nsince ___, including this hospital ___ if pt submits it \nto\nthem.\n\nPrimary Care:\nWe spoke about the pt's need for primary care. ___ recommends\nsetting pt up with PCP at the following ___ clinic,\nnoting with intake there that he has/will have Neighborhood\nHealth Plan:\n\n___ at ___.\n___, ___\nPhone: ___\nFax: ___\n\nThis clinic is accepting new patients but is booking into the \nend\nof ___. They can offer the pt a sliding scale if his\ninsurance is not active by then. Pt feels that this clinic is\nclose enough to his home that he should not have difficulty\ngetting there.\n\nDurable medical equipment:\nPt was given contact information for the ___ in ___ who has free durable medical equipment, as well as\ngetatstuff.com, where individuals who have unused medical\nequipment can post it online. Most of the equipment is free, \nbut\npt would need to pick it up from the individual. Pt did not \nwish\nfor additional SW assistance to identify and organize the\nprocurement of equipment.\n\nA/P\nAlthough pt now has health insurance, he will not be able to\naccess it for some weeks. Any discharge meds will need to be\nunder free care; please communicate with nurse case management\nfor any medication needs upon discharge. He will also have to\nprocure a walker and/or wheelchair. He has the ability to do\nthis and does not wish for further SW assistance for this. A\nlocal sliding-scale PCP office has been identified if pt needs\nfollow-up. \n \nFollowup Instructions:\n___\n" ]

[ "S92065A", "F17210", "S8254XA", "W11XXXA", "Z23", "Y93E5", "Y9289" ]

[ "S92065A: Nondisplaced intraarticular fracture of left calcaneus, initial encounter for closed fracture", "F17210: Nicotine dependence, cigarettes, uncomplicated", "S8254XA: Nondisplaced fracture of medial malleolus of right tibia, initial encounter for closed fracture", "W11XXXA: Fall on and from ladder, initial encounter", "Z23: Encounter for immunization", "Y93E5: Activity, floor mopping and cleaning", "Y9289: Other specified places as the place of occurrence of the external cause" ]

[ "F17210" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: OBSTETRICS/GYNECOLOGY\n \nAllergies: \ncodeine\n \nAttending: ___\n \nChief Complaint:\npelvic organ prolapse\n \nMajor Surgical or Invasive Procedure:\nRobotic Assisted-Sacrocolpopexy, Cystoscopy\n\n \nHistory of Present Illness:\nMs. ___ is a lovely ___ P2 presenting with worsening \nsensation of vaginal bulge since ___. She reports first \nbeing bothered by this sensation in ___ of this year after \nundergoing a colonoscopy, with post-procedural course \ncomplicated by a course of diverticulitis. She now feels a \nconstant sensation of vaginal bulge and pressure that interferes \nwith her life. \n\nShe does not report urinary leakage spontaneously or with \nactivity. She voids every ___ hours during the day and does not \nneed to get up at night to void. She never experiences urinary \nurgency, and never has episodes of urge incontinence. \n\nShe does feel it is often hard for her to empty her bladder \ncompletely, and feels like her stream is not very strong. She \nreports sometimes having to sit on the toilet twice within a few \nminutes to completely empty her bladder. \n\nShe has tried ___ exercises, but has not tried any other form \nof treatment.\n\nShe denies recurrent UTIs, a history of bladder/renal stones, \nhematuria, dysuria, pain or pressure with voiding, feeling of \nincomplete emptying, straining to void. Her urine stream is \nnormal, intermittent, hesitant, slow. She does not splint to\nurinate and/or defecate.\n\nShe does not have issues with constipation or diarrhea. She \ndenies fecal incontinence. She is married but is not sexually \nactive.\n \nPast Medical History:\nPAST MEDICAL HISTORY:\n- Vestibular migraines\n- Orthostatic intolerance\n- Diverticulitis\n\nPAST SURGICAL HISTORY\n- Tubal ligation ___\n- Total abdominal hysterectomy for symptomatic fibroids (ovaries\nnot removed) ___ \n\nPAST OBSTETRICAL HISTORY: G2P2\n- History of 2 spontaneous vaginal deliveries and one \nmiscarriage. Largest baby delivered vaginally 7.2 pounds. No \nhistory of forceps or vacuum-assisted delivery.\n\nPAST GYNECOLOGIC HISTORY\nLast period in ___ at time of hysterectomy. Previously had \nregular but heavy periods. No history of STIs.\n \nSocial History:\n___\nFamily History:\nSignificant for father and grandfather with colon cancer and \nmother with ovarian cancer and high blood pressure.\n\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, incision \nc/d/i\nExt: no TTP\n \nPertinent Results:\n___ 06:23AM BLOOD WBC-12.5* RBC-4.44 Hgb-12.4 Hct-39.5 \nMCV-89 MCH-27.9 MCHC-31.4* RDW-12.5 RDWSD-40.8 Plt ___\n___ 06:23AM BLOOD Glucose-91 UreaN-16 Creat-0.7 Na-139 \nK-4.8 Cl-104 HCO3-26 AnGap-14\n___ 06:23AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.8\n \nBrief Hospital Course:\nOn ___, Ms. ___ was admitted to the gynecology service \nafter undergoing robotic-assisted sacrocolpopexy and cystoscopy. \nPlease see the operative report for full details.\n\nHer post-operative course was uncomplicated. Immediately \npost-op, her pain was controlled with IV dilaudid and toradol. \nOvernight on POD#0, she was noted to have low urine output. She \nwas given a 500cc bolus and her UOP improved. A CBC was drawn in \nthe AM of POD#1 which revealed a hct of 39.5, stable from 41.0 \nat baseline. She also complained of chest tightness. An EKG was \ndone that revealed sinus tachycardia. She also reported a \nsignificant history of GERD. Her symptoms resolve with \nranitidine. On post-operative day 1, her urine output was \nadequate so her foley was removed and she passed a trial of \nvoid. Her diet was advanced without difficulty and she was \ntransitioned to PO oxycodone, ibuprofen, and acetaminophen.\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 \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Ranitidine 75 mg PO DAILY \n2. Pravastatin 20 mg PO QPM \n3. Aspirin 81 mg PO DAILY \n4. Loratadine 10 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild \nRX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours \nDisp #*50 Tablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp \n#*60 Tablet Refills:*0 \n3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild \nRX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp \n#*40 Tablet Refills:*0 \n4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe \nRX *oxycodone 5 mg ___ tablet(s) by mouth every ___ hours Disp \n#*30 Tablet Refills:*0 \n5. Aspirin 81 mg PO DAILY \n6. Loratadine 10 mg PO DAILY \n7. Pravastatin 20 mg PO QPM \n8. Ranitidine 75 mg PO DAILY \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 - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the gynecology service after your \nprocedure. You have recovered well and the team believes you are \nready to be discharged home. Please call Dr. ___ office with \nany questions or concerns. Please follow the instructions below.\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* Nothing in the vagina (no tampons, no douching, no sex) for 6 \nweeks.\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* If you have steri-strips, leave them on. They will fall off on \ntheir own or be removed during your followup visit.\n\nTo reach medical records to get the records from this \nhospitalization sent to your doctor at home, call ___.\n \nFollowup Instructions:\n___\n" ]

[ "N8110", "R000", "K219", "J309", "M479", "M8580", "N736", "G43809", "Z87891" ]

[ "N8110: Cystocele, unspecified", "R000: Tachycardia, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "J309: Allergic rhinitis, unspecified", "M479: Spondylosis, unspecified", "M8580: Other specified disorders of bone density and structure, unspecified site", "N736: Female pelvic peritoneal adhesions (postinfective)", "G43809: Other migraine, not intractable, without status migrainosus", "Z87891: Personal history of nicotine dependence" ]

[ "K219", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: NEUROLOGY\n \nAllergies: \naspirin / phenylephrine / doxylamine\n \nAttending: ___.\n \nChief Complaint:\n Altered mental status\n \nMajor Surgical or Invasive Procedure:\n___ G-tube placement by ___\n___ EGD with attempted G-tube placement by GI\n\n \nHistory of Present Illness:\n___ year-old right-handed woman with primary central nervous \nsystem lymphoma in the left basal ganglia (C5D1 Bevacizumab, \npemetrexed and rituximab) who presents from ___ clinic via \nED for altered mental status. \n\nThe NeuroOnc team was asked to evaluate Mrs. ___ on ___ \n9\ntreatment area for change in mental status. Husband reports\nprogressively more lethargic since the last visit (over past 3 \nweeks). She also has had decrease in appetite and energy level, \nas well as worsening symptoms of aspiration. She was able to \ntake a few bites. She has steady weight drop. She is requiring \nmax assistance with care. Her husband is her sole caretaker. \nHusband brought urine from home. Today, she endorsed abdominal \npain for the first time to her husband. Over the past three \nweeks, she has been increasingly incontinent--she used to let \nher husband know when she needed to use the restroom. \n\nAt baseline, she is able to state her full name and social \nsecurity number. She speaks in ~2 word sentences, and often \nverbalizes incomplete thoughts. She is, however, able to attend \nto stimuli, follow instructions, and communicate her needs to \nher husband. She is not able to transfer or ambulate.\n\nOn initial evaluation in clinic, Mrs. ___ was not oriented \nto person, place or time. She was only able to follow simple \ndirection with repeated prompts. She was given 250 cc NS & \nbecame more alert, but remained disoriented. She was referred to \nED for further eval. \n\nIn the ED, initial vitals: 96.1 81 144/107 16 99% RA \n- Labs were notable for: \nWBC 6.6, K 3.1, lactate 1.0, UA with large leuks, many bacteria, \nTSH 2.5, free T4 1.4\n- Imaging: \nECG Sinus rhythm @ 74 bpm. Possible old inferior wall myocardial \ninfarction. QTc 483. Similar to prior.\nCT HEAD: IMPRESSION: No acute intracranial hemorrhage. Chronic \nchanges. No midline shift. \nCXR: No acute process\n- Patient was given: 1 gm IV CTX\n\nOf note, clinic note on ___ notable for decreased PO intake, \ndifficulty swallowing, waxing/waning mental status. \n \nOn arrival to the floor, per report of patient's husband, she \nlooks much better than earlier today. She is speaking more, and \nresponding appropriately to questions. He notes that when she \nhas presented in the past with a new mass, she has been \nsignificantly more confused than she is today.\n\nREVIEW OF SYSTEMS: \nA complete 10-point review of systems was performed and was \nnegative unless otherwise noted in the HPI. \n \nPast Medical History:\n \nPAST ONCOLOGIC HISTORY: \nShe is s/p:\n1. Non-diagnostic brain biopsy on ___ by Dr. ___ at ___ \n2. Brain biopsy on ___ by Dr. ___ CNS lymphoma\n3. High-dose methotrexate started on ___, \n4. Rituximab + high-dose methotrexate for progression\n5. WBXRT ___ - ___ to 3,600 cGy for progression \n6. Admission ___ for UTI \n7. Admission ___ for DVT and PE \n8. Admission ___ for purulent discharge Portacath\n9. Adm x 2 in ___ for septic shock\n10. Monthly Temozolomide started ___ to ___.\n11. Adm ___ for confusion related to cold medication\n12. Rituximab started ___\n13. SRS to right parieto-occipital lesion ___ to 1600 cGy\n14. Metronomic TMZ ___. SRS to left periventricular lesion ___ to 2200 cGy\n16. Port placed ___\n17. Bevacizumab, pemetrexed and rituximab started ___\n18. SRS to right frontal lesion ___ to ___ cGy\n \nPAST MEDICAL HISTORY: DVT, s/p IVC filter, HTN COPD, \nhypercholesterolemia, oophorectomy. Renal calculi lithotripsy \n___.\n\n \nSocial History:\n___\nFamily History:\nHer father with diabetes and status post coronary artery stent \nplacement. Her mother history of CVA. Sister is healthy. She \nhas 2 children but her daughter has cognitive impairment.\nNo family history of GU malignancies.\n\n \nPhysical Exam:\nADMISSION EXAM:\nVitals: 97.3, 159 / ___ 99 Ra \nGENERAL: Chronically ill appearing, awake, NAD \nHEENT: Dry MM. No scleral icterus. EOMI. \nNECK: Supple, no JVD, no LAD\nLUNGS: CTAB, decreased at bases \nCV: RRR, no r/m/g \nABD: Soft, non-distended, NABS, mildly tender in suprapubic area \n\nEXT: Extremities contracted ___, trace ___ edema \nSKIN: Warm, dry, no visible rash \nNEURO: AO x 1. CNII-XII grossly intact. Alert, following \ncommands. \nACCESS: Port non-tender, no erythema \n\nDISCHARGE EXAM:\nVS: 97.2 162/88 67 18 100 \nGENERAL: Chronically ill appearing, sleeping, but easily\narousable, NAD \nHEENT: Dry MM. No scleral icterus. EOMI. \nNECK: Supple, no JVD, no LAD\nLUNGS: CTAB, decreased at bases \nCV: RRR, no r/m/g \nABD: Soft, non-distended, NABS, non-tender. PEG tube in place in\nR abdomen, dressing c/d/i\nEXT: Extremities contracted ___, trace ___ edema. Increased muscle\ntone throughout. \nSKIN: Warm, dry, no visible rash. \nNEURO: Alert, cannot assess orientation. CNII-XII grossly \nintact.\nAlert, following commands. \nACCESS: Port non-tender, no erythema \n\n \nPertinent Results:\nADMISSION LABS:\n\n___ 11:59AM BLOOD WBC-6.6 RBC-3.70* Hgb-12.0 Hct-38.6 \nMCV-104* MCH-32.4* MCHC-31.1* RDW-16.7* RDWSD-63.3* Plt ___\n___ 11:59AM BLOOD Neuts-85* Bands-0 Lymphs-4* Monos-10 \nEos-1 Baso-0 ___ Myelos-0 AbsNeut-5.61 AbsLymp-0.26* \nAbsMono-0.66 AbsEos-0.07 AbsBaso-0.00*\n___ 11:59AM BLOOD WBC-6.6 Lymph-4* Abs ___ CD3%-88 Abs \nCD3-232* CD4%-53 Abs CD4-140* CD8%-33 Abs CD8-87* CD4/CD8-1.60\n___ 11:59AM BLOOD CD3 %-90.10 CD3Abs-237.86 ___ 11:59AM BLOOD UreaN-11 Creat-0.7 Na-140 K-3.1* Cl-99 \nHCO3-28 AnGap-16\n___ 11:59AM BLOOD ALT-11 AST-17 LD(LDH)-291* AlkPhos-69 \nTotBili-0.6\n___ 11:59AM BLOOD TotProt-5.6* Calcium-9.0 Phos-2.9 Mg-1.9\n___ 11:59AM BLOOD TSH-2.5\n___ 11:59AM BLOOD Free T4-1.4\n___ 11:59AM BLOOD PEP-HYPOGAMMAG b2micro-3.2* IgG-353* \nIgA-72 IgM-15* IFE-NO MONOCLO\n___ 02:02PM BLOOD Lactate-1.0\n___ 11:30AM URINE Color-Yellow Appear-Cloudy Sp ___\n___ 11:30AM URINE Blood-SM Nitrite-NEG Protein-100 \nGlucose-NEG Ketone-10 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-LG\n___ 11:30AM URINE RBC-19* WBC->182* Bacteri-MANY Yeast-NONE \nEpi-0\n___ 11:30AM URINE CaOxalX-MOD\n\nMICROBIOLOGY: \n___ URINE CULTURE (Final ___: \n KLEBSIELLA OXYTOCA. >100,000 CFU/mL. \n___ BLOOD CULTURE: NEGATIVE, FINAL\n\nDISCHARGE LABS: \n___ 05:33AM BLOOD WBC-5.5 RBC-3.14* Hgb-10.1* Hct-32.6* \nMCV-104* MCH-32.2* MCHC-31.0* RDW-16.3* RDWSD-62.4* Plt ___\n___ 05:00AM BLOOD Glucose-105* UreaN-8 Creat-0.4 Na-138 \nK-4.0 Cl-103 HCO3-27 AnGap-12\n___ 05:00AM BLOOD Calcium-8.9 Phos-2.4* Mg-2.0\n\nIMAGING:\n___ CXR: No acute cardiopulmonary process. \n___ CT HEAD: No acute intracranial hemorrhage. Chronic \nchanges including prominence of the ventricular system, ex vacuo \ndilatation of the left frontal horn with left frontal lobe \nencephalomalacia, and confluent bilateral periventricular and \nsubcortical white matter hypodensity, similar in distribution \ncompared to prior MRI. If concern for acute ischemia, MRI would \nbe more sensitive. No midline shift. \n\n \nBrief Hospital Course:\n___ year-old right-handed woman with primary central nervous \nsystem lymphoma in the left basal ganglia (C5D1 Bevacizumab, \npemetrexed and rituximab) who presents with altered mental \nstatus, possibly due to UTI. Mental status improved with IV \nceftriaxone & IVF. She was treated for 7 days. She was evaluated \nfor dysphagia and recommended to be NPO. As such, G-tube was \nplaced for medications/nutrition. Repeat video swallow after \nimprovement of mental status showed continued aspiration with \nall liquids/solids. This, and the risk of aspiration, even \nrespiratory arrest, with any food/liquid by mouth was explained \nto patient and her husband, who expressed understanding. Once \ncontinuous tube feeds were tolerated, she was switched to bolus \nfeeds, which she tolerated prior to discharge. \n\n#UTI\n#Subacute toxic metabolic encephalopathy: Likely multifactorial, \nfrom UTI, dehydration related to poor PO, lastly, CNS lymphoma \nmay also contributing. Calcium, TSH WNL. NCHCT with no active \nbleeding. Treated with IVF and 7 day course of ceftriaxone with \nimprovement in her mental status to baseline. \n\n#Primary CNS lymphoma: Day of admission would have been C5D1 of \nBevacizumab, pemetrexed and rituximab. She has history of \nseizure as well. Repeat brain MRI showed stable to improved \ndisease. She was continued on her home keppra and \nmethylphenidate. Dexamethasone was increased to 4mg daily.\n\n#Swallowing dysfunction: Seen by S&S after resolution of \nencephalopathy, who recommended strict NPO. Underwent PEG tube \nplacement with ___ on ___.\n\nCHRONIC: \n#Depression: Continued citalopram (held while NPO)\n#Constipation: Continued home bowel regimen with lactulose, \nhusband brought in home linzess (which is NF).\n#Hypokalemia: Chronic hypokalemia, ?due to bowel regimen. \n#HLD: Continued atorvastatin \n#Misc: Continued home folate \n\n#Full code, confirmed\n#HCP/Contact: Husband, ______)\n\nTRANSITIONAL ISSUES:\n===================\n-Pt persistently hypokalemic; Needs to continue repletion\n-MRI brain showed no progression/improvement of previous \nabnormal findings\n-Dexamethasone increased to 4 mg qd\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lactulose 15 mL PO Q8H:PRN constipation \n2. Linzess (linaclotide) 290 mcg oral DAILY \n3. Levothyroxine Sodium 75 mcg PO DAILY \n4. FoLIC Acid 1 mg PO DAILY \n5. Citalopram 20 mg PO DAILY \n6. Atorvastatin 10 mg PO QPM \n7. potassium chloride 20 mEq/15 mL oral BID \n8. LevETIRAcetam 500 mg PO BID \n9. MethylPHENIDATE (Ritalin) 10 mg PO BID \n10. Dexamethasone 0.5 mg PO DAILY \n\n \nDischarge Medications:\n1. Docusate Sodium 100 mg PO QHS \nRX *docusate sodium 50 mg/5 mL ___ mL Gtube at bedtime \nRefills:*0 \n2. Senna 8.6 mg PO QHS \nRX *sennosides [senna] 8.8 mg/5 mL ___ mL by mouth at bedtime \nRefills:*0 \n3. Vitamin D 800 UNIT PO DAILY \nRX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth \nonce a day Disp #*60 Tablet Refills:*0 \n4. Dexamethasone 4 mg PO DAILY \nRX *dexamethasone 4 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*0 \n5. MethylPHENIDATE (Ritalin) 10 mg PO Q9AM \n6. Atorvastatin 10 mg PO QPM \n7. Citalopram 20 mg PO DAILY \n8. FoLIC Acid 1 mg PO DAILY \n9. Lactulose 15 mL PO Q8H:PRN constipation \n10. LevETIRAcetam 500 mg PO BID \n11. Levothyroxine Sodium 75 mcg PO DAILY \n12. Linzess (linaclotide) 290 mcg oral DAILY \n13. potassium chloride 20 mEq/15 mL oral BID \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___ Diagnosis:\nPRIMARY: \nUrinary tract infection, complicated\nDysphagia\n\nSECONDARY: \nCNS lymphoma\n\n \nDischarge Condition:\nActivity Status: Out of Bed with assistance to chair or \nwheelchair.\nLevel of Consciousness: Lethargic but arousable.\nMental Status: Confused - sometimes.\n\n \nDischarge Instructions:\nDear ___,\n\n___ was a pleasure taking care of you at the ___ \n___. \n\nYou were admitted for confusion, dehydration. \n\nWe found that you had a urinary tract infection and gave you \nantibiotics and fluids. \n\nYour mental status improved. \n\nGiven you difficulty swallowing food/pills, a G-tube was placed \nto help give you nutrition and your medications. \n\nWe evaluated your swallowing with a special video test and it \nappears unsafe for you to have any medications or food, \nincluding ice chips by mouth. We explained this to you and your \nhusband. \n\nWe wish you all the best,\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "N390", "G92", "C8589", "G8191", "R1310", "G9389", "R627", "E559", "E860", "E876", "F329", "K5900", "E785", "B9689", "R32", "J449", "I10", "I252", "Z9221", "Z923", "Z86718" ]

[ "N390: Urinary tract infection, site not specified", "G92: Toxic encephalopathy", "C8589: Other specified types of non-Hodgkin lymphoma, extranodal and solid organ sites", "G8191: Hemiplegia, unspecified affecting right dominant side", "R1310: Dysphagia, unspecified", "G9389: Other specified disorders of brain", "R627: Adult failure to thrive", "E559: Vitamin D deficiency, unspecified", "E860: Dehydration", "E876: Hypokalemia", "F329: Major depressive disorder, single episode, unspecified", "K5900: Constipation, unspecified", "E785: Hyperlipidemia, unspecified", "B9689: Other specified bacterial agents as the cause of diseases classified elsewhere", "R32: Unspecified urinary incontinence", "J449: Chronic obstructive pulmonary disease, unspecified", "I10: Essential (primary) hypertension", "I252: Old myocardial infarction", "Z9221: Personal history of antineoplastic chemotherapy", "Z923: Personal history of irradiation", "Z86718: Personal history of other venous thrombosis and embolism" ]

[ "N390", "F329", "K5900", "E785", "J449", "I10", "I252", "Z86718" ]

[]

[ " \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:\nchest pain\n \nMajor Surgical or Invasive Procedure:\nLEFT HEART CATHETERIZATION WITH CORONARY ANGIOGRAM\n\n \nHistory of Present Illness:\n___ male with history of hypertension, hyperlipidemia,\ntype 2 diabetes who presented to the ___ with 2\nepisodes of non-exertional chest discomfort over the preceding \n24\nhours with positive stress test at ___. \n\nPatient states that starting one day prior to admission around 3\nAM he had an episode of midsternal chest pain that awoke him \nfrom\nsleep and that lasted approximately 30 minutes and self resolved\nand he had a repeat episode around 2:30 ___ on ___ after which\nshe presented to the ___ emergency department. Reportedly\npatient had negative troponin and nonspecific T-wave \nflattening's\non EKG but his stress test showed ST depressions for which he \nwas\ntransferred to ___ for cardiology eval. \n\nPatient notes pain was subcentral, nonradiating, ___. Denies\nshortness of breath, no nausea, vomiting or diaphoresis. He also\nhad left arm tingling at that time. Pain in the afternoon \nstarted\nwhile he was working, lasted approximately 15 minutes. This pain\nwas less severe, ___ and was intermittent. \n He presented to the ___ at the advice of his primary\nphysician. \n\n In ___ emergency room, chest x-ray showed no acut\ncardiopulmonary disease. Lab results showed normal renal\nfunction, negative troponins x2. He has had no further \nrecurrence\nof chestpain. He was arranged for an exercise tolerance test\nwhich was done this AM and is as follows: \n He completed 10 minutes 30 seconds of ___ protocol,\nrepresenting an average exercise tolerance for age. Blood\npressure 142/82, increased to 172/82. Heart rate increased from\n80 up to 168. He had no chest pain during the test. However, he \ndid have 2-3 mm of downsloping ST depressions in the\ninferolateral leads and 1 mm of elevation in AVR. Changes \nstarted\nat 3 minutes of exercise and resolved by 8 minutes of recovery.\nTransferred to ___ for possible cath. \n\n In the ___ ED initial vitals were: 98.5 76 144/89 18 99% RA.\nEKG at rest did not show any ST changes. Labs were notable for\nBMP WNL, CBC WNL, Ca, Phos WNL, TropT < 0.01. Patient received\nASA 324mg x1. \n Vitals on transfer: 98.7 75 145/90 20 97% RA \n\n On the floor patient reports above history. Denies current CP,\nSOB, palpitations. No new complaints. \n\n \nPast Medical History:\n 1. CARDIAC RISK FACTORS \n - Diabetes type II \n - Hypertension \n - Dyslipidemia \n 2. CARDIAC HISTORY \n - CABG: None \n - PERCUTANEOUS CORONARY INTERVENTIONS: None \n - PACING/ICD: None \n 3. OTHER PAST MEDICAL HISTORY: none \n \nSocial History:\n___\nFamily History:\nFAMILY HISTORY: \nMaternal grandfather had an MI. Mother had a stroke.\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n========================\nVS: 98.1 124/82 85 16 95%RA \nGENERAL: WDWN middle aged male 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: JVP 8cm \nCARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. No\nthrills, lifts. \nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp\nwere unlabored, no accessory muscle use. No crackles, wheezes or\nrhonchi. \nABDOMEN: Soft, NTND. No HSM or tenderness. \nEXTREMITIES: No c/c/e. No femoral bruits. \nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \nPULSES: Distal pulses palpable and symmetric \n\nDISCHARGE PHYSICAL EXAM:\n========================\nVITALS: 98.4 PO 123/71 R Lying HR 82 RR 16 O2 95 RA \nI/Os: 240 cc/ n/a\nWEIGHT: 92.5 kg\nWEIGHT ON ADMISSION: 93.1 kg\n\nPHYSICAL EXAM: \nGENERAL: WDWN middle aged male in NAD. Oriented x3. Mood, affect\nappropriate.\nHEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no \npallor or cyanosis of the oral mucosa. No xanthelasma. \nNECK: JVP < 10 cm at 90 deg \nCARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. No\nthrills, lifts. \nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp\nwere unlabored, no accessory muscle use. No crackles, wheezes or\nrhonchi. \nABDOMEN: Soft, NTND. \nEXTREMITIES: No c/c/e. R wrist puncture site well healed, no \nbleeding, 2+ radial pulse.\nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \nPULSES: Distal pulses palpable and symmetric \n \nPertinent Results:\nADMISSION LABS:\n___ 04:00PM BLOOD WBC-8.9 RBC-5.05 Hgb-14.9 Hct-44.5 MCV-88 \nMCH-29.5 MCHC-33.5 RDW-11.5 RDWSD-37.2 Plt ___\n___ 04:00PM BLOOD Neuts-44.8 ___ Monos-7.0 Eos-2.3 \nBaso-0.5 Im ___ AbsNeut-3.98 AbsLymp-3.97* AbsMono-0.62 \nAbsEos-0.20 AbsBaso-0.04\n___ 08:00AM BLOOD ___ PTT-29.6 ___\n___ 04:00PM BLOOD Glucose-114* UreaN-17 Creat-1.0 Na-140 \nK-5.0 Cl-101 HCO3-24 AnGap-15\n___ 04:00PM BLOOD cTropnT-<0.01\n___ 08:00AM BLOOD CK-MB-2 cTropnT-<0.01\n___ 04:00PM BLOOD Calcium-9.6 Phos-3.7\n\nDISCHARGE LABS:\n___ 08:10AM BLOOD WBC-7.7 RBC-5.15 Hgb-15.1 Hct-45.3 MCV-88 \nMCH-29.3 MCHC-33.3 RDW-11.4 RDWSD-36.6 Plt ___\n___ 08:10AM BLOOD Glucose-146* UreaN-18 Creat-1.1 Na-139 \nK-4.5 Cl-98 HCO3-25 AnGap-16\n___ 08:10AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.0\n\nIMAGING RESULTS:\n___ CORONARY ANGIOGRAM:\nDominance: Right\n* Left Main Coronary Artery\nThe LMCA is normal.\n* Left Anterior Descending\nThe LAD is normal\n* Circumflex\nThe Circumflex is normal.\n* Right Coronary Artery\nThe RCA has mild luminal irregularities.\n\n \nBrief Hospital Course:\n___ w/ PMH HTN, HLD, DM2 who presented to ___ \nfollowing\n2 episodes non-exertional chest pain found to have 2-3 mm of\ndownsloping ST depressions in the inferolateral leads and 1 mm \nof\nelevation in AVR on stress test, transferred ___ on ___ for \ncardiac catheterization, which found no occlusions requiring \nintervention. He was discharged on optimal medical management.\n\n#UNSTABLE ANGINA\n#ST DEPRESSIONS ON EKG: Initially presented as unstable angina. \nAt an outside hospital he had 2-3 mm of downsloping ST \ndepressions in the inferolateral leads and 1 mm of elevation in \nAVR on stress test. Trops negative at both the outside hospital \nand here at ___, EKG at rest negative. During his hospital \ncourse he had ___ brief (<5 min) episodes of mild chest \ndiscomfort, which resolved. He underwent coronary angiography \nwhich was only remarkable for mild RCA luminal irregularities \nbut otherwise, no hemodynamically significant CAD. He should \ncontinue his aspirin 81 daily, atorvastatin 40 mg (prev on \nsimvastatin), metoprolol succinate 50 mg daily, and sublingual \nnitro as needed if chest pain recurs. Given his age and no \nintervention, he does not require cardiology follow up at this \ntime; If in the future he requires cardiology follow up, he can \nsee ___, MD who was his cardiologist during this \nadmission. \n\n#HTN \n- irbesartan 150mg\n\n#DMII \n- hold metformin \n- HISS \n\nTRANSITIONAL ISSUES:\n[ ] Patient was started on Aspirin 81mg, Atorvastatin 40mg, \nMetoprolol 50mg XL, and as needed sublingual nitro.\n[ ] Check blood pressure and heart rates to ensure appropriate \nmetoprolol dose. \n[ ] Check LFTs as outpatient given switch to atorvastatin this \nadmission.\n\n# CODE STATUS: Full\n# CONTACT: ___ (wife) home: ___ cell: \n___\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. irbesartan 150 mg oral QHS \n2. Simvastatin 20 mg PO QHS \n3. MetFORMIN (Glucophage) 500 mg PO BID \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n2. Atorvastatin 40 mg PO QPM \nRX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30 \nTablet Refills:*0 \n3. Metoprolol Succinate XL 50 mg PO DAILY \nRX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp \n#*30 Tablet Refills:*0 \n4. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain \nRX *nitroglycerin 0.3 mg 1 tablet(s) sublingually q5min PRN Disp \n#*1 Packet Refills:*0 \n5. irbesartan 150 mg oral QHS \n6. MetFORMIN (Glucophage) 500 mg PO BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n=================\nSTABLE ANGINA\n\nSECONDARY DIAGNOSIS\n===================\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 Mr ___,\n\nIt was a pleasure taking care of you at the ___ \n___! \n\nWhy was I admitted to the hospital? \n-You were admitted because you had chest pain that brought you \nto the hospital. You were then transferred to ___ \n___ for further work up.\n\nWhat happened while I was in the hospital? \n-You had a \"stress test\", to test your heart, and the doctors \nthought there might be a blockage in part of your heart\n-You had a procedure performed here where heart doctors took \npictures of your heart using special dyes, but they did not see \nanything that required fixing.\n-You were switched onto new medications that would be helpful \nfor your heart's health.\n\nWhat should I do after leaving the hospital? \n- Please take your medications as listed in discharge summary \nand follow up with your primary care doctor.\n\nThank you for allowing us to be involved in your care, we wish \nyou all the best! \n\n Your ___ Healthcare Team \n\n \nFollowup Instructions:\n___\n" ]

[ "I25118", "I10", "R9439", "R9431", "E785", "E119" ]

[ "I25118: Atherosclerotic heart disease of native coronary artery with other forms of angina pectoris", "I10: Essential (primary) hypertension", "R9439: Abnormal result of other cardiovascular function study", "R9431: Abnormal electrocardiogram [ECG] [EKG]", "E785: Hyperlipidemia, unspecified", "E119: Type 2 diabetes mellitus without complications" ]

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

[]

[ " \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:\nPancreatic mass\n \nMajor Surgical or Invasive Procedure:\n \n\n___:\n1. Diagnostic laparoscopy.\n2. Pylorus preserving pancreaticoduodenectomy.\n3. Pedicle omental flap for protection of pancreatic \nanastomosis.\n4. Placement of gold fiducials for possible CyberKnife.\n\n \nHistory of Present Illness:\nMrs. ___ was in her usual state of good health when she \npresented approximately 3 weeks ago with itching, then shortly \nthereafter her daughter noted scleral icterus and jaundice. She \nwent to urgent care at ___ ___, was sent to ___, where \nshe had a CT scan. By report, intra/extrahepatic biliary ductal \ndilatation as well pancreatic duct dilatation, no discrete mass. \n Small cysts in pancreatic head (dilated ducts vs. cysts), \nbenign appearing cysts in liver. Initially patient scheduled for \nMRCP, but in the interval presented to ___ with \nabdominal pain and underwent ERCP late at night, where Dr. ___ \n___ according to the patient found a small mass \"at the \nend of the bile duct\". Biopsies were \"abnormal\" but not frankly \ndiagnostic of cancer per the patient. (Referral from ___ \n___\nreferences pancreatic cancer). A plastic stent was placed. She \nis currently feeling well, less itchy, notices less icterus and \njaundice. Abdominal pain has also receded. Reasonable appetite \nnow (after eating less during the whole episode), reports a \nmodest weight loss, now stable.\n\n \nPast Medical History:\nAtrial fibrillation\n \nSocial History:\n___\nFamily History:\nNon contributory\n \nPhysical Exam:\nPrior to Discharge:\nVS: 98.8, 98, 114/71, 18, 92% RA\nGEN: Pleasant with NAD\nCV: RRR, no m/r/g\nPULM: CTAB\nABD: Midline incision open to air with sreri strips and c/d/I. \nRLQ JP drain to bulb suction with minimal amount of murky fluid, \nsite with drain sponge and c/d/I. \nEXTR: Warm, no c/c/e\n \nPertinent Results:\n___ 04:39AM BLOOD WBC-9.8 RBC-2.95* Hgb-8.9* Hct-26.9* \nMCV-91 MCH-30.2 MCHC-33.1 RDW-15.4 RDWSD-51.6* Plt ___\n___ 05:12AM BLOOD Glucose-88 UreaN-15 Creat-0.6 Na-138 \nK-4.0 Cl-101 HCO3-27 AnGap-14\n___ 07:50PM OTHER BODY FLUID ___\n\nPATHOLOGY: Pancreatic ductal adenocarcinoma\n \nBrief Hospital Course:\nMs. ___ was admitted to ___ \n___ on ___ after undergoing a pylorus-preserving \nwhipple. For details of the procedure, please refer to the \noperative report. Post-operatively, she did well. She required a \ntransfusion of 1 unit PRBC in the PACU for a hematocrit of 23.4. \nOn POD #1, her NG remained in place due to intermittent nausea \nand she was kept NPO. Her pain was controlled with an epidural. \nShe received PR aspirin. She had mild heartburn, and her \nprotonix was changed to BID. On POD #2, her NG tube was removed, \nand she was started on sips. She had mild nausea, and had an \nepisode of 50cc bilious emesis. She was given Zofran, and Reglan \nand Ativan were added to her regimen to help control her nausea. \nOn POD #3, her nausea improved and she did not have additional \nepisodes of vomiting. She continued to tolerate sips of clear \nliquids. She had several episodes of tachycardia, for which she \nwas monitored on continuous telemetry. She was restarted on her \nhome rate-controlling medications, and her heartrate was \nthereafter well controlled. She continued to receive daily \naspirin PR. On POD #4, she was advanced to a clear liquid diet. \nLovenox was started, and she was given Coumadin 5 mg. On POD #5, \nshe was advanced to a low fat regular diet, which she tolerated \nwell. Her epidural was removed, and she was transitioned to oral \npain medication with good effect. JP amylase was sent in the \nevening of POD# 5; patient was discharged home with JP in place \nas amylase level was high. The patient was evaluated by physical \ntherapy and was recommended to discharge in rehabilitation. At \nthe time of discharge on ___, the patient was doing well, \nafebrile with stable vital signs. The patient was tolerating a \nregular diet, ambulating with rolling walker, and pain was well \ncontrolled. Staples were removed, and steri-strips placed. The \npatient received discharge teaching and follow-up instructions \nwith understanding verbalized and agreement with the discharge \nplan.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB \n2. budesonide 90 mcg/actuation inhalation QAM \n3. Cetirizine 10 mg PO DAILY:PRN allergies \n4. Diltiazem Extended-Release 120 mg PO DAILY \n5. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies \n6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n7. Lorazepam 0.5 mg PO Q4H:PRN anxiety \n8. Metoprolol Succinate XL 50 mg PO DAILY \n9. Pantoprazole 40 mg PO Q24H \n10. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY \n11. Tiotropium Bromide 1 CAP IH DAILY \n12. ___ MD to order daily dose PO DAILY16 \n13. Calcium Carbonate 500 mg PO DAILY \n14. Vitamin D ___ UNIT PO DAILY \n15. Multivitamins 1 TAB PO DAILY \n\n \nDischarge Medications:\n1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB \n2. Calcium Carbonate 500 mg PO DAILY \n3. Cetirizine 10 mg PO DAILY:PRN allergies \n4. Diltiazem Extended-Release 120 mg PO DAILY \n5. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies \n6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n7. Lorazepam 0.5 mg PO Q4H:PRN anxiety \n8. Metoprolol Succinate XL 50 mg PO DAILY \n9. Multivitamins 1 TAB PO DAILY \n10. Pantoprazole 40 mg PO Q24H \n11. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY \n12. Tiotropium Bromide 1 CAP IH DAILY \n13. ___ MD to order daily dose PO DAILY16 \n14. Acetaminophen 650 mg PO Q6H:PRN pain \n15. Aspirin 81 mg PO DAILY \n16. Docusate Sodium 100 mg PO BID \n17. Metoclopramide 10 mg PO QIDACHS \nlast day ___ \n18. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*80 Tablet Refills:*0\n19. Budesonide 90 mcg/actuation INHALATION QAM \n20. Vitamin D ___ UNIT PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPancreatic ductal adenocarcinoma\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 surgery service at ___ for surgical \nresection of your pancreatic mass. You have done well in the \npost operative period and are now safe to return home to \ncomplete your recovery with the following instructions:\n.\nPlease resume all regular home medications , unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon, who will instruct you further regarding activity \nrestrictions.\nAvoid driving or operating heavy machinery while taking pain \nmedications.\nPlease follow-up with your surgeon and Primary Care Provider \n(PCP) as advised.\n.\nIncision Care:\n*Please 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.\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\n \nFollowup Instructions:\n___\n" ]

[ "C253", "D62", "K7689", "I4891", "I129", "K219", "Z7901", "N183", "J449", "F419", "E119", "E780", "M810", "Z23", "Z87891" ]

[ "C253: Malignant neoplasm of pancreatic duct", "D62: Acute posthemorrhagic anemia", "K7689: Other specified diseases of liver", "I4891: Unspecified atrial fibrillation", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "K219: Gastro-esophageal reflux disease without esophagitis", "Z7901: Long term (current) use of anticoagulants", "N183: Chronic kidney disease, stage 3 (moderate)", "J449: Chronic obstructive pulmonary disease, unspecified", "F419: Anxiety disorder, unspecified", "E119: Type 2 diabetes mellitus without complications", "E780: Pure hypercholesterolemia", "M810: Age-related osteoporosis without current pathological fracture", "Z23: Encounter for immunization", "Z87891: Personal history of nicotine dependence" ]

[ "D62", "I4891", "I129", "K219", "Z7901", "J449", "F419", "E119", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nWellbutrin / cyclobenzaprine\n \nAttending: ___.\n \nChief Complaint:\nsyncope\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ yo female with a history of pancreatic cancer admitted after \na\nsyncopal epsisode. The patient got up this morning and felt \n\"off\"\nkind of lightheaded. She went downstairs and as she was making\nbreakfast had a syncopal episode. Her husband immediately \nentered\nthe room after they heard he fall and state she was awake and\nalert within seconds to minutes. She denies any associated\npalpitations or shortness of breath. She has had three prior\nepisodes of syncope, the last was in ___. Those were all\nassociated with prolonged standing in the heat. She recently has\nbeen having about one episode of diarrhea a day thought to be\nrelated to her recent radiation and chemotherapy treatment. She\nhas had moderate PO intake but does know that she hasn't been\ndrinking as much as she should. The last medications she had\ntaken prior to the event was an Ativan about four hours prior.\nShe denies any recent fevers, shortness of breath, nausea, or\npain. She denies any dysuria. She might have had some urinary\nfrequency and urgency but says not much.\n\nREVIEW OF SYSTEMS:\n- All reviewed and negative except as noted in the HPI.\n\n \nPast Medical History:\nPAST ONCOLOGIC HISTORY (per OMR):\nMs. ___ is a ___ yo woman who was in her her usual state of\ngood health when she presented late ___ with itching for 3\nweeks. . Shortly following her daughter noted scleral icterus \nand\njaundice. She went to urgent care at ___ ___, was sent to\n___, whereshe had a CT scan. This showed intra/extrahepatic\nbiliary ductal dilatation as well pancduct dilatation, no\ndescrete mass. Small cysts in pancreatic head (dilated ducts \nvs.\ncysts), benign appearing cysts in liver. Initially patient was\nscheduled for MRCP.On ___, she presented to ___ with abdominal pain, underwent ERCP late at night, \nwhere\nDr. ___ who according to the patient found a small\nmass \"at the end of the bile duct\", biopsies were \"abnormal\" but\nnot frankly diagnostic of cancer per the patient. A plastic\nstent was placed. Shewas seen by Dr. ___ at ___. CT\nscan ___ showed ___ upper lobe 2mm nodules, as well as a\n2cm mass in the distal common bile duct. CA ___ was 471.\nShe was evaluated by Dr. ___ proceeding with Whipple\nsurgery ___. Pathology showed a pT3N1 adenocarcinoma \n___\nlymphnodes positive) with positive margins.\nShe was seen in follow-up by her ___ who recommended\ntreatment with cyberknife, feducials have already been placed \nand\nreferral to Oncology. \nShe most recently finished radiation and capcitabine on ___.\n\nPAST MEDICAL HISTORY:\n1. Pancreatic adenocarcinoma.\n2. Atrial fibrillation, on anticoagulation.\n3. Prior laparoscopic cholecystectomy.\n4. Chronic kidney disease.\n5. Hypercholesterolemia.\n6. Osteoarthritis.\n7. Vitamin D deficiency.\n8. Cerebrovascular disease.\n9. Glaucoma\n10. COPD\n11. GERD\n12. Allergic Rhinitis\n\n \nSocial History:\n___\nFamily History:\nThe patient has 14 siblings, one brother died of\ncancer in his ___. No other cancers noted. She has five\nchildren that are healthy.\n\n \nPhysical Exam:\nDISCHARGE EXAM:\nGeneral: NAD\nVITAL SIGNS: 98.5 138/78 107 18 95%RA \nHEENT: MMM\nCV: RR, NL S1S2 no S3S4 MRG\nPULM: CTAB\nABD: Soft, NTND, no masses or hepatosplenomegaly\nLIMBS: warm, well perfused, No edema\nNEURO: Alert and oriented, ___, EOMI, face symmetric, moves all \next against resistance, sensation intact to light touch\n\n \nPertinent Results:\nADMISSION LABS:\nWBC: 4.2. RBC: 2.82*. HGB: 8.4*. HCT: 25.7*. MCV: 91. RDW: \n24.8*.\nPlt Count: 159. \nNeuts%: 78.0*. Lymphs: 2.1*. MONOS: 18.0*. Eos: 0.9*. BASOS: \n0.5.\n\n___: 22.3*. INR: 2.0*. PTT: 31.2. \nNa: 136. K: 3.6. Cl: 102. CO2: 24. BUN: 10. Creat: 0.5. Ca: \n8.3*.\nMg: 1.1*. PO4: 2.6*.\nAlb: 2.8*. AST: 33. ALT: 13. Alk Phos: 51. Total Bili: 0.5. Alb:\n2.8*. \n\nDISCHARGE LABS:\n___ 05:58AM BLOOD WBC-4.4 RBC-2.91* Hgb-8.8* Hct-27.3* \nMCV-94 MCH-30.2 MCHC-32.2 RDW-25.6* RDWSD-88.4* Plt ___\n___ 05:58AM BLOOD Glucose-94 UreaN-5* Creat-0.5 Na-135 \nK-4.0 Cl-103 HCO3-26 AnGap-10\n___ 05:58AM BLOOD Calcium-7.8* Phos-3.1 Mg-1.6\n\nIMAGING:\nHead and C-spine CT: \n1. No acute intracranial process. \n2. Paranasal sinus disease as described above. \n3. Moderate chronic small vessel ischemic changes. \nC-Spine CT: \n1. No evidence of fracture or malalignment of the cervical \nspine.\n2. Moderate degenerative changes at C5-C6 causing mild neural\nforaminal stenosis and spinal canal stenosis with likely\nencroachment on the spinal cord.\n \nCXR: No acute cardiopulmonary abnormality.\n\n \nBrief Hospital Course:\n___ yo female with a history of Afib and pancreatic cancer \nundergoing chemotherapy and recently completed radiation who is \nadmitted after a syncopal epsisode.\n\n# Syncope\n- Most likely related to dehydration from diarrhea. VS notable \nfor HR rise >20 supine to standing suggesting orthostasis. \nCardiac monitoring was negative for arrhythmia. No cardiac echo \nwas obtained as etiology was felt to be due to dehydration. She \nrequired several days of IVF hydration as diarrhea persisted. At \ntime of discharge patient able to maintain hydration off IVF and \nVS stable\n\n#Diarrhea - likely secondary to chemotherapy may also have had \ncomponent of radiation enteritis, ab imaging not obtained as \nunlikely to have changed management, pt did not have fever or \nsigns of bowel obstruction. C.diff testing was negative. \nShe was treated with IVF hydration as above and combination of \nImodium and lomotil.\nAlso increase pancreatic enzymes from 2 caps to 3 caps w/ meals. \n Diarrhea gradually improved. at time of discharge she cont to \nhave frequent but very small volume and soft stools, is \ntolerating regular bland diet.\n\n#UTI - noted to have mild dysuria, mild pyuria and +nitrite on \nUA, urine culture +Ecoli. completed 5 days ceftriaxone\n\n# Vaginal Candidiasis - pt received Fluconazole PO x1. Symptoms \nnow resolved.\n\n#Pancreatic Cancer - patient followed by Dr ___ \noncology. She finished 1 cycle capcitabine and completed XRT on \n___. Plans to start gemzar in 3 weeks.\nShe will f/u in ___ clinic on ___\n\n# Atrial Fibrillation - remained in NSR no arrhythmia noted \nduring her stay.\n- Continued home warfarin (is on low dose as became \nsupratherapeutic after starting capecitabine), INR at goal, \naspirin, and metoprolol. She will continue home INR monitoring \nby ___\n\nGlaucoma\n- Continue home timolol and latanoprost.\n\nCOPD\n- Continue home budesonide, triotropium, and albuterol.\n\nGERD\n- Continue home protonix.\n\nAllergic Rhinitis\n- Continue home fluticasone and cetirizine PRN.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB \n2. Calcium Carbonate 500 mg PO DAILY \n3. Cetirizine 10 mg PO DAILY:PRN allergies \n4. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies \n5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n6. Lorazepam 0.5 mg PO Q4H:PRN anxiety \n7. Metoprolol Succinate XL 50 mg PO DAILY \n8. Multivitamins 1 TAB PO DAILY \n9. Pantoprazole 40 mg PO Q24H \n10. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY \n11. Tiotropium Bromide 1 CAP IH DAILY \n12. Aspirin 81 mg PO DAILY \n13. Metoclopramide 10 mg PO QIDACHS \n14. Budesonide 90 mcg/actuation INHALATION QAM \n15. Warfarin 0.5 mg PO DAILY16 \n16. Potassium Chloride 20 mEq PO DAILY \n17. Vitamin D 1000 UNIT PO DAILY \n18. Creon 12 2 CAP PO TID W/MEALS \n19. LOPERamide 2 mg PO BID:PRN Diarrhea \n\n \nDischarge Medications:\n1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB \n2. Aspirin 81 mg PO DAILY \n3. Budesonide 90 mcg/actuation INHALATION QAM \n4. Calcium Carbonate 500 mg PO DAILY \n5. Cetirizine 10 mg PO DAILY:PRN allergies \n6. Creon 12 3 CAP PO TID W/MEALS \n7. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies \n8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n9. LOPERamide 2 mg PO QID:PRN Diarrhea \nTake only after having loose stool or diarrhea.\ndo NOT take more than 4 times a day. \nRX *loperamide 2 mg 1 tablet by mouth QID prn Disp #*30 Capsule \nRefills:*1\n10. Lorazepam 0.5 mg PO Q4H:PRN anxiety \n11. Metoclopramide 10 mg PO QIDACHS \n12. Metoprolol Succinate XL 50 mg PO DAILY \n13. Multivitamins 1 TAB PO DAILY \n14. Pantoprazole 40 mg PO Q24H \n15. Potassium Chloride 20 mEq PO DAILY \n16. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY \n17. Tiotropium Bromide 1 CAP IH DAILY \n18. Vitamin D 1000 UNIT PO DAILY \n19. Warfarin 0.5 mg PO DAILY16 \n20. Diphenoxylate-Atropine 2 TAB PO Q6H:PRN Diarrhea \ntake only after having loose stool or diarrhea. can be \nalternated w/ immodium up to 4 times per day \nRX *diphenoxylate-atropine 2.5 mg-0.025 mg 2 tablet(s) by mouth \nQID prn Disp #*30 Tablet Refills:*1\n21. Opium Tincture (morphine 10 mg/mL) 3 mg PO Q6H:PRN diarrhea \nuse third \nRX *opium tincture 10 mg/mL (morphine) 3 mg by mouth QID prn \nRefills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \n___:\nSyncope\nOrthostasis\nDiarrhea\nPancreatic cancer\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___ it was a pleasure caring for you during your \nstay at ___. You were admitted after having syncope (passing \nout) and this was thought to be due to dehydration from \ndiarrhea. You were also evaluated for heart failure or \narrhythmia and testing was negative. You were treated with IV \nfluids, bowel rest and anti-diarrheal medications. The diarrhea \nis due to chemotherapy and radiation, testing for infection \nincluding C difficile was negative. Your symptoms are slowly \nimproving. Please continue anti-diarrheal medications ONLY as \nneeded, see medication instructions. \n \nFollowup Instructions:\n___\n" ]

[ "K521", "N390", "T66XXXA", "I4891", "C259", "E559", "J449", "B373", "E780", "E860", "B9620", "T451X5A", "Y92239", "Z7901", "N189", "M1990", "H409", "K219", "J309", "Z87891" ]

[ "K521: Toxic gastroenteritis and colitis", "N390: Urinary tract infection, site not specified", "T66XXXA: Radiation sickness, unspecified, initial encounter", "I4891: Unspecified atrial fibrillation", "C259: Malignant neoplasm of pancreas, unspecified", "E559: Vitamin D deficiency, unspecified", "J449: Chronic obstructive pulmonary disease, unspecified", "B373: Candidiasis of vulva and vagina", "E780: Pure hypercholesterolemia", "E860: Dehydration", "B9620: Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y92239: Unspecified place in hospital as the place of occurrence of the external cause", "Z7901: Long term (current) use of anticoagulants", "N189: Chronic kidney disease, unspecified", "M1990: Unspecified osteoarthritis, unspecified site", "H409: Unspecified glaucoma", "K219: Gastro-esophageal reflux disease without esophagitis", "J309: Allergic rhinitis, unspecified", "Z87891: Personal history of nicotine dependence" ]

[ "N390", "I4891", "J449", "Z7901", "N189", "K219", "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 \n___ Complaint:\nChills, fever, worsening cough \n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMr. ___ is a ___ male with history of DLBCL on\nR-CHOP, ESRD on HD (MWF), diastolic heart failure, and newly\ndiagnosed atrial fibrillation (on rate control, not on\nanticoagulation ___ recent GI bleed) who presents with fever \nduring HD session early in the day.\n\nHe was doing HD today ___ and alternate SAT). Patient notes \nthat during HD he began shaking uncontrollably. States \"the \nfluid was colder than my body and I told them not to keep giving \nit to me but they did!\" Notes a fever there of unknown \ntemperature but \"they kept putting warm packs on me so naturally \nI had a fever!\" \n\nBegan shaking uncontrollably. Incredibly uncomfortable with \nchills. Fever there of unknown temp. His feet were throbbing and \naching. As soon as HD stopped (continued to finish of session), \nhe began feeling much better. Then steadily got worse, and was \nasking for extra blankets. Cough is at baseline. \n\n \nPast Medical History:\n-heart failure w/preserved EF\n-ESRD\n-DM2\n-htn\n-obesity\n-OSA on CPAP \n-Seasonal allergy. \n-History of pneumonia in ___ leading to ESRD in setting of \nlong-standing DM2\n-CAD\n-diffuse large B cell lymphoma\n\nPAST ONCOLOGIC HISTORY:\n- ___ by Dr ___ management of his newly\ndiagnosed B cell diffuse large cell lymphoma, dx'd by a core\nbiopsy 5 d ago of a large pelvic mass. He noted RLE swelling in\nearly ___. LENIs were negative for clot but did show an\nenlarged groin node. The picture was felt to be from a prior\ncellulitis of his foot and he was followed. His swelling\ncontinued and repeat LENIs in early ___ showed suggestion of \nan\nobstruction higher up and he underwent a CT of his abdomen and\npelvis that showed a large pelvic mass with splenomegaly and\nmediastinal and portacaval adenopathy and lytic lesions in the\nright pubic symphysis and inferior pubic ramus. A subsequent \nPET\nscan delineated those areas as well as moderate disease in his\nchest. He underwent a core bx in ___ last week which showed B \ncell\ndiffuse large cell lymphoma, germinal center origin (better\nprognosis) with a high proliferative index of 80-90%.\nCytogenetics showed bcl 6 rearrangement but no worrisome\nmutations. Interestingly, his LDH is normal. He continues to \nhave\nRLE edema but denies any abdominal pain or pelvic pain. His wt \nis\nstable. He denies any fevers, night sweats or pruritis. He has\nmultiple medical problems with DM since adolescence and has been\non dialysis for the past ___ years. He denies any cardiac disease\nbut did have mild dysfunction on a cardiac PET test a year ago.\nHe is complaining of left elbow pain, having fallen at dialysis\nseveral days ago, striking his left elbow and leg. Xrays at the\n___ were negative. Sent home without a sling or any advice. Exam\nshowed obesity, 3 fb splenomegaly, pain, swelling left elbow and\n2+ RLE edema Labs: Hct 32, LDH- 171, protein elec-normal. Hep\nserologies normal. \nA: Stage IIIA large cell lymphoma. High intermediate risk given\nage, performance status and multiple sites of disease with CR\nestimated at 56%, ___ year OS of 37%. Recommended Rit/CHOP chemo.\n- ___: Started chemo with Rit/CHOP. Split dose Rituxan with \n50\nmg/m2 given on day 1. The rest to be given day 6. Under mistaken\nimpression that he was to take his prednisone indefinitely so\nstayed on it until subsequent GI bleed.\n- ___/: Rituxan given.\n- ___: Hosp FH for acute GI bleed. Upper endoscopy showed\nduodenal ulcers. Missed chemo ___ due to miscommunication.\n- ___: Hosp ___ for ___ cellulitis LLE and epistaxis. Also\nhad paroxysmal atrial fib. \n- ___: Cycle 2 Rit/CHOP given. Neulasta given on day 2.\nTreatment delayed 2 wks due to gi bleed and LLE cellulitis.\n- ___: CT showed near resolution of soft tissue masses in \nright iliopsoas and obturator internus muscles, persistence of \nsplenomegaly and bone lytic lesions \n- ___: Resumed chemo with rituxin and bendamustine\n- ___: Received day 2 of rituxin and bendamustine\n\n \nSocial History:\n___\nFamily History:\nHe denies any family history of kidney disease. His father with \ndiabetes ___ and hypertension died at age ___ due to heart \nattack. His mother with diabetes ___ is in her ___. \n\n \nPhysical Exam:\n========================\nADMISSION PHYSICAL EXAM\n========================\n\nVITALS: T 99.6 HR 105 BP 90/51 RR 24 SpO2 94% 5L NC\nGENERAL: Alert, oriented, no acute distress. Lying flat in bed \nwith no dyspnea.\nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: Supple, unable to assess JVP given neck size, no LAD \nLUNGS: Crackles in the lung bases bilaterally but L>R \nCV: Irregularly irregular, 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. 2+ pitting edema to knees \nbilaterally \nSKIN: Unstagable ulcer on right heal, 3-4cm wound on right calf \nwithout erythema or induration.\nNEURO: CNII-XII grossly intact. No focal deficits. Moving all 4 \nextremities\n\n========================\nDISCHARGE PHYSICAL EXAM\n========================\nVS: T98.1 BP121/67 HR98 RR20 99%RA \nGENERAL: Pleasant man, very talkative, NAD, lying in bed \ncomfortably receiving HD.\nHEENT: Anicteric sclerae, OP clear.\nCARDIAC: RRR, normal s1/s2, no m/r/g.\nLUNG: Bibasilar crackles similar to prior, no wheezes or \nrhonchi.\nABD: Soft, non-tender, non-distended, normal bowel sounds.\nEXT: Warm, well perfused, LEs 2+ pitting edema past knees\nNEURO: grossly intact\nSKIN: Unstagable ulcer on right heal, 3-4cm wound on right calf \nwithout erythema or induration, front of left leg diffusely \nerythematous, multiple small linear breaks in the skin of the \nlegs with overlying crust. L leg erythema continues to recede \nfrom ___ markings. \n\n \nPertinent Results:\nADMISSION LABS:\n=================\n___ 07:02PM WBC-11.3* RBC-2.95* HGB-8.8* HCT-28.9* MCV-98 \nMCH-29.8 MCHC-30.4* RDW-22.7* RDWSD-81.5*\n___ 07:02PM NEUTS-83* BANDS-3 LYMPHS-6* MONOS-5 EOS-3 \nBASOS-0 ___ MYELOS-0 NUC RBCS-2* AbsNeut-9.72* \nAbsLymp-0.68* AbsMono-0.57 AbsEos-0.34 AbsBaso-0.00*\n___ 07:02PM GLUCOSE-112* UREA N-24* CREAT-3.5*# \nSODIUM-137 POTASSIUM-3.8 CHLORIDE-90* TOTAL CO2-31 ANION GAP-16\n___ 07:02PM ALT(SGPT)-21 AST(SGOT)-23 CK(CPK)-63 ALK \nPHOS-176* TOT BILI-1.0\n___ 08:57PM ___ PO2-54* PCO2-40 PH-7.54* TOTAL \nCO2-35* BASE XS-10\n___ 08:57PM LACTATE-1.6\n___ 07:42PM LACTATE-2.5*\n___ 07:40PM ___ PO2-34* PCO2-45 PH-7.52* TOTAL \nCO2-38* BASE XS-11\n\nDISCHARGE LABS:\n================\n___ 07:15AM BLOOD WBC-8.6 RBC-2.46* Hgb-7.5* Hct-24.2* \nMCV-98 MCH-30.5 MCHC-31.0* RDW-22.7* RDWSD-82.2* Plt Ct-73*\n___ 07:15AM BLOOD Neuts-85.1* Lymphs-6.2* Monos-4.6* \nEos-2.6 Baso-0.4 Im ___ AbsNeut-7.30* AbsLymp-0.53* \nAbsMono-0.39 AbsEos-0.22 AbsBaso-0.03\n___ 07:15AM BLOOD Glucose-230* UreaN-28* Creat-4.1* Na-136 \nK-4.6 Cl-92* HCO3-28 AnGap-16\n___ 07:15AM BLOOD Glucose-267* UreaN-42* Creat-5.1* Na-132* \nK-4.8 Cl-89* HCO3-28 AnGap-15\n___ 07:15AM BLOOD Calcium-8.0* Phos-2.1* Mg-2.0\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___ 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\n___ 6:30 pm SPUTUM Source: Expectorated. \n\n **FINAL REPORT ___\n\n GRAM STAIN (Final ___: \n <10 PMNs and >10 epithelial cells/100X field. \n Gram stain indicates extensive contamination with upper \nrespiratory\n secretions. Bacterial culture results are invalid. \n PLEASE SUBMIT ANOTHER SPECIMEN. \n\n___ MRSA SCREEN MRSA SCREEN-FINAL negative\n___ BLOOD CULTURE Blood Culture, Routine-FINAL \nnegative\n___ BLOOD CULTURE Blood Culture, Routine-FINAL \nnegative\n\nIMAGING:\n==========\n___ CXR:\nIMPRESSION: \nPulmonary vascular congestion without definite focal \nconsolidation. \n\n___ TTE:\nThere is moderate symmetric left ventricular hypertrophy. The \nleft ventricular cavity size is normal. There is mild to \nmoderate global left ventricular hypokinesis (LVEF = 35 %). No \nmasses or thrombi are seen in the left ventricle. There is no \nventricular septal defect. The right ventricular cavity is \nmoderately dilated with mild global free wall hypokinesis. The \naortic valve leaflets (3) are mildly thickened. No masses or \nvegetations are seen on the aortic valve. There is no aortic \nvalve stenosis. No aortic regurgitation is seen. The mitral \nvalve appears structurally normal with trivial mitral \nregurgitation. No mass or vegetation is seen on the mitral \nvalve. Trivial mitral regurgitation is seen. There is moderate \npulmonary artery systolic hypertension. No vegetation/mass is \nseen on the pulmonic valve. There is no pericardial effusion. \n\nCompared with the prior study (images reviewed) of ___, no \nclear change. \n \nBrief Hospital Course:\nMr. ___ is a ___ male with history of DLBCL on \nR-CHOP, ESRD on HD (MWF, ___, systolic/diastolic heart \nfailure LVEF 35%, and newly diagnosed atrial fibrillation (on \nrate control, not on anticoagulation ___ recent GI bleed) who \npresented with new hypoxia and fever, concerning for pneumonia, \nultimately found to have beta-hemolytic gp G strep bacteremia, \nlikely ___ skin source.\n\n===ACUTE ISSUES===\n\n#Sepsis ___ LLE Cellulitis: \n#Streptococcal bacteremia:\nPt presented to HD, had fevers/chills, BP ___, BCx obtained \n___ at HD ultimately grew Beta-hemolytic gp G Strep. No further \npositive cultures. Initially presumed respiratory source (see \nbelow) however ultimately narrowed to cefepime with HD for 14d \ncourse (___). He was noted to have erythema, swelling, \nseveral linear skin breaks, and warmth on the LLE c/f \ncellulitis, improving with antibiotics. D/c on cefepime with HD, \nper the following schedule: Weeks of MWFSa: 2g/HD. Weeks of MWF: \n2g/MW, 3g/F. ID f/u scheduled ___.\n\n#AF w/ RVR: Mr. ___ has history of paroxysmal AF, however is \nnot on AC due to recent GI bleed from duodenal ulcers. Required \nesmolol gtt in ICU, was quickly weaned off and transitioned to \nmetoprolol tartrate with no further episodes, transitioned to \nhome succinate upon discharge.\n\n#Acute Hypoxic Respiratory Failure: \nOn BiPAP in ED due to respiratory distress, transitioned to NC \nquickly upon arrival to ICU. VBG showing metabolic alkalosis. \nStarted on Vancomycin and Cefepime for presumed HCAP, which was \nnarrowed to cefepime upon improvement in his volume status via \nHD and greater suspicion that the cause of his sepsis was due to \ncellulitis. \n\n#Open Wound RLE\n#Chronic venous stasis changes:\n#Unstagable ulcer on right heel: On exam, his RLE wound did not \nappear infected. Wound consult obtained, continued current \nmanagement.\n\n# DLBCL: Stage IIIA large cell lymphoma. High-intermediate risk \ngiven age, performance status and multiple sites of disease. \nDuring recent admission patient transitioned to\nrituxan/bendamustine and received doses on ___ and ___. Has \noutpatient onc appointment ___/, planned for chemo.\n\n===CHRONIC ISSUES===\n\n#Systolic and Diastolic Heart Failure: Recent TTE that showed \ndecreased EF concerning for doxorubicin-induced cardiomyopathy. \nECHO obtained to assess for bacterial vegetation. None noted. \nLVF remains 35%. \n\n#End Stage Renal Disease on Hemodialysis: \n#Hypophosphatemia:\nReceived dialysis per his usual schedule MWF,QO-Sa. Phos level \nnoted to be low, sevelamer and calcium carbonate were held. \nPlease trend levels at HD.\n\n#T2DM: Continued home regimen of lantus 20 u with breakfast, 15u \nqHS. Started a Humalog SS. \n\n# Anemia: Likely multifactorial. Likely due to malignancy, \nchemotherapy, and ESRD. Not on epo presumed due to malignancy. \nRemained hemodynamically stable. Required no blood transfusions.\n\n# Thrombocytopenia: Likely secondary to chemotherapy. Discharge \nplt 73, no signs of bleeding during hospitalization.\n\n# CAD: Continue home metoprolol and atorvastatin\n\n# Hypertension: Continued home metoprolol (briefly on esmolol as \nabove) and irbesartan\n\n# Gout: Continued home allopurinol\n\n===TRANSITIONAL ISSUES===\n#Antibiotics course (14 days, ___: Cefepime following HD. \nIf patient is on a week where he dialyzes MWFSa, then dose 2g \nfollowing each session. If patient is on a week where he \ndialyzes only MWF, then dose 2g following the MW sessions and 3g \nfollowing the F session.\n\n#Hypophosphatemia: sevelamer and calcium carbonate were held on \ndischarge. Discharge phos 2.1. Please trend at HD.\n\n#Amenic/thrombocytopenic during hospitalization, please obtain \nCBC within 1 week of discharge. Discharge Hb 7.5, plt 73.\n\n#Follow-up for resolution of LLE cellulitis, improving on \ndischarge.\n\n#Continue wound care for RLE open wound: adaptic to wound gel \nand dry gauze daily.\n\nCODE: Full Code (confirmed)\nCOMMUNICATION: Patient\nEMERGENCY CONTACT HCP: ___ (sister/HCP) ___\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Glargine 20 Units Breakfast Glargine 15 Units Bedtime Insulin \nSC Sliding Scale using HUM Insulin\n2. Allopurinol ___ mg PO EVERY OTHER DAY \n3. Atorvastatin 80 mg PO QPM \n4. Loratadine 10 mg PO DAILY:PRN allergies \n5. sevelamer CARBONATE 2400 mg PO TID W/MEALS \n6. irbesartan 300 mg oral DAILY \n7. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n8. Calcium Carbonate 1250 mg PO TID W/MEALS with each meal \n9. Cinacalcet 60 mg PO 5X/WEEK (___) \n10. Benzonatate 100 mg PO TID \n11. Pantoprazole 40 mg PO Q24H \n12. Metoprolol Succinate XL 50 mg PO DAILY \n\n \nDischarge Medications:\n1. CefePIME 2 g IV M, W AFTER HD \n2g ___ and ___ after HD \n2. CefePIME 2 g IV F, SAT AFTER HD ON WEEKS GETTING ___ HD \n\n___ on weeks with ___ HD \n3. CefePIME 3 g IV F WEEKS NOT GETTING ___ HD \n___ after HD on weeks not getting ___ HD \n4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n5. Allopurinol ___ mg PO EVERY OTHER DAY \n6. Atorvastatin 80 mg PO QPM \n7. Benzonatate 100 mg PO TID \n8. Cinacalcet 60 mg PO 5X/WEEK (___) \n9. Glargine 20 Units Breakfast\nGlargine 15 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n10. irbesartan 300 mg oral DAILY \n11. Loratadine 10 mg PO DAILY:PRN allergies \n12. Metoprolol Succinate XL 50 mg PO DAILY \n13. Pantoprazole 40 mg PO Q24H \n14. HELD- Calcium Carbonate 1250 mg PO TID W/MEALS with each \nmeal This medication was held. Do not restart Calcium Carbonate \nuntil cleared by your dialysis doctor\n15. HELD- sevelamer CARBONATE 2400 mg PO TID W/MEALS This \nmedication was held bc phosphate levels were too low. Do not \nrestart sevelamer CARBONATE until cleared by dialysis. \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nSepsis\nBacteremia\nAcute Hypoxic Respiratory Failure\nAtrial Fibrillation with Rapid Ventricular Response\nCellulitis\nOpen Wound on Right Lower Extremity\nSystolic and Diastolic Heart Failure\nEnd Stage Renal Disease on Hemodialysis \nDiffuse Large B Cell Lymphoma\nAnemia\nThrombocytopenia\nCoronary Artery Disease\nType II Diabetes\nHypertension\nGout\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___, \nIt was a pleasure to take care of you during your stay here at \n___. \n\nYou came to the hospital because of fever and shaking during \ndialysis. You went to the intensive care unit because we were \nworried that you had a serious infection and also because your \nheart was beating very quickly from Atrial Fibrillation. You \nthen came to the oncology floor where we continued to treat your \nblood infection.\n\nYou most likely got your blood infection from a skin infection \nin your leg, which we are treating. You are now doing much \nbetter and we have not detected any bacteria in your blood for \nmany days. \n\nYou are safe to return to ___ to continue your \nantibiotics, which will be given to you after your dialysis. We \nhope you continue to feel better. \n\nPlease see below for your follow-up appointments and changes in \nyour medicines.\n\nSincerely, \n___ Oncology Team \n \nFollowup Instructions:\n___\n" ]

[ "A408", "J9601", "I132", "E873", "C8338", "N186", "D6959", "L03116", "I5042", "L97419", "I4891", "E1122", "Z992", "D630", "D631", "D6481", "T451X5A", "Y929", "I2510", "M109", "Z794", "E669", "Z6836", "G4733", "I878", "E11621", "E8339", "S81801A", "X58XXXA" ]

[ "A408: Other streptococcal sepsis", "J9601: Acute respiratory failure with hypoxia", "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "E873: Alkalosis", "C8338: Diffuse large B-cell lymphoma, lymph nodes of multiple sites", "N186: End stage renal disease", "D6959: Other secondary thrombocytopenia", "L03116: Cellulitis of left lower limb", "I5042: Chronic combined systolic (congestive) and diastolic (congestive) heart failure", "L97419: Non-pressure chronic ulcer of right heel and midfoot with unspecified severity", "I4891: Unspecified atrial fibrillation", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "Z992: Dependence on renal dialysis", "D630: Anemia in neoplastic disease", "D631: Anemia in chronic kidney disease", "D6481: Anemia due to antineoplastic chemotherapy", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Y929: Unspecified place or not applicable", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "M109: Gout, unspecified", "Z794: Long term (current) use of insulin", "E669: Obesity, unspecified", "Z6836: Body mass index [BMI] 36.0-36.9, adult", "G4733: Obstructive sleep apnea (adult) (pediatric)", "I878: Other specified disorders of veins", "E11621: Type 2 diabetes mellitus with foot ulcer", "E8339: Other disorders of phosphorus metabolism", "S81801A: Unspecified open wound, right lower leg, initial encounter", "X58XXXA: Exposure to other specified factors, initial encounter" ]

[ "J9601", "I4891", "E1122", "Y929", "I2510", "M109", "Z794", "E669", "G4733" ]

[]

[ " \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:\nDizziness, headche\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ y/o M with PMHx of DLBCL, HFrEF, atrial fibrillation, ESRD on\nHD MWF, DM2, recurrent lower extremity ulcerations and\ncellulitis, who presents to the ED with dizziness. He reports\nbeing in his usual state of health up until yesterday afternoon,\nwhen he noted the onset of a significant nose-bleed that\npersisted for hours. When the nose-bleed stopped, he reports\nfeeling tired and went to take a nap. When he awoke to watch the\ngame, he reports feeling lightheaded, dizzy, noted headache\nonset, muscle aches (at the base of his neck and between the\nshoulder blades), weakness, mild photophobia, and phonophobia.\nAfter some time passed, he reported persistence of the dizziness\nand asked his sister to call an ambulance.\n\nIn the ED, initial VS were: T 96.6 HR 110 BP 90/55 RR 16 O2Sat\n97% RA \nLabs significant for H/H 11.8/34.3 (higher than recent \nbaseline),\nplatelets 97 (baseline), WBC 3.7, MB: 5 Trop-T: 0.38 (baseline\n~0.3), lactate:2.3\nImaging showed: \nCT Head: No acute intracranial process. \nCXR: Mild pulmonary vascular congestion, similar to prior. No\nfocal consolidation.\nEKG: HR 132, PR 124, Afib with RVR with borderline STE in aVR,\nTWI in aVL\nPatient received: no medications \nNo consults were placed.\n\nTransfer VS were: T 98 BP 93/52 RR 18 O2sat 97% RA \n\nOn arrival to the floor, patient reports that his headache,\nlightheadedness and dizziness have improved. He reports feeling\n'much better.' He denies chest discomfort, palpitations, SOB,\nrecent fevers, visual changes, sore throat, cough, recent sick\ncontacts, abdominal pain, nausea, vomiting, diarrhea, blood I \nhis\nstools, dysuria, joint pains. He notes intermittent aches at the\nbase of neck and reports a 40 lb weight loss over the past 6\nmonths (in the setting of DLBCL). He reports receiving a flu \nshot\nthis year. He usually gets dialysis on MWF and reports that they\ntook off an extra 2 kg at his last dialysis session. \n \nREVIEW OF SYSTEMS: \n10 point ROS reviewed and negative except as per HPI \n \nPast Medical History:\n-DLBCL\n-ATRIAL FIBRILLATION\n-HFrEF\n-ESRD\n-DM2\n-HTN\n-obesity\n-CAD\n-Recurrent lower extremity cellulitis and ulcerations\n \nSocial History:\n___\nFamily History:\nHe denies any family history of kidney disease. Reports a\ngrandfather with cancer. Mother with DM. Father with 'heart\nproblems'\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \n======================\nVS: 97.6PO 109 / 64 97 20 94 Ra \nGENERAL: NAD \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM \nNECK: supple\nHEART: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly \nEXTREMITIES: AV fistula in left arm. No cyanosis, clubbing, or\nedema. Ulcerations on bilateral feet without erythema,\ntenderness, or swelling. \nPULSES: 2+ DP pulses bilaterally \nNEURO: A&Ox3, ___ strength in all extremities, sensation grossly\nintact \n\nDISCHARGE PHYSICAL EXAM\n======================\nVS: Reviewed in POE, positive orthostatics noted \nGENERAL: NAD \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM \nNECK: supple\nHEART: Harsh crescendo systolic murmur, S1/S2 \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly \nEXTREMITIES: AV fistula in left arm positive thrill/bruit. No\ncyanosis, clubbing, or edema. Ulcerations on bilateral feet\nwithout erythema, tenderness, or swelling. \nPULSES: 2+ DP pulses bilaterally \nNEURO: A&Ox3, ___ strength in all extremities, sensation grossly\nintact \n \nPertinent Results:\nADMISSION LABS\n=============\n___ 12:50AM BLOOD WBC-3.7*# RBC-3.31* Hgb-11.8* Hct-34.3* \nMCV-104* MCH-35.6* MCHC-34.4 RDW-17.1* RDWSD-64.0* Plt Ct-97*\n___ 12:50AM BLOOD Neuts-61.2 ___ Monos-9.6 Eos-4.6 \nBaso-0.5 Im ___ AbsNeut-2.24# AbsLymp-0.87* AbsMono-0.35 \nAbsEos-0.17 AbsBaso-0.02\n___ 12:50AM BLOOD Glucose-249* UreaN-41* Creat-5.9* Na-137 \nK-4.2 Cl-91* HCO3-28 AnGap-18\n___ 12:50AM BLOOD Calcium-9.4 Phos-4.5 Mg-1.7\n___ 12:57AM BLOOD Lactate-2.3*\n\nINTERIM LABS\n===========\n___ 12:50AM BLOOD CK-MB-5\n___ 12:50AM BLOOD cTropnT-0.38*\n___ 10:00AM BLOOD CK-MB-4 cTropnT-0.47*\n___ 05:10PM BLOOD CK-MB-4 cTropnT-0.44*\n___ 12:50AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG\n___ 12:50AM BLOOD HCV Ab-NEG\n\nMICROBIOLOGY\n============\n___ 12:50 am BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n\n___ 10:00 am BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n\n___ 5:10 pm BLOOD CULTURE 2 OF 2. \n\n Blood Culture, Routine (Pending): \n\nIMAGING\n=======\nCXR (___): Mild pulmonary vascular congestion, similar to \nprior. No focal consolidation.\n\nNCHCT (___): 1. Study is moderately degraded by motion.\n2. Within limits of study, no definite evidence of acute \nintracranial\nhemorrhage.\n3. Please note MRI of the brain is more sensitive for the \ndetection of acute infarct.\n4. Paranasal sinus disease, as described.\n5. Atrophy, probable small vessel ischemic changes, and \natherosclerotic\nvascular disease as described.\n\nDISCHARGE LABS\n=============\n___ 08:10AM BLOOD WBC-3.8* RBC-3.27* Hgb-11.6* Hct-35.0* \nMCV-107* MCH-35.5* MCHC-33.1 RDW-17.3* RDWSD-68.6* Plt ___\n___ 01:30PM BLOOD ___ PTT-35.1 ___\n___ 01:30PM BLOOD Glucose-172* UreaN-28* Creat-5.2* Na-138 \nK-5.2* Cl-94* HCO3-29 AnGap-15\n___ 08:10AM BLOOD Calcium-9.7 Phos-5.0* Mg-2.___ y/o M with complicated PMHx including DLBCL, HFrEF (EF 35%), \nESRD on HD MWF, DM2, HTN, recurrent skin and soft tissue \ninfection who presents to the ED after large epistaxis with \nsubsequent headache and dizziness, found to be hypotensive and \nin Afib. \n\n#Hypotension\n#Dizziness. Patient presented following large volume epistaxis \nand with subsequent headache, dizziness, and muscle aches, found \nin the ED to be hypotensive to 90/50s. Upon arrival to the \nfloor, patient reported complete resolution of headache and \ndizziness, and reported mild lingering of his muscle aches. \nPatient has long and complex history of recurrent leg ulcers and \ncellulitis for which he is on suppressive therapy with \nLevofloxacin. However examination of lower extremity \nulcerations was not concerning for super-infection and patient \nhas been without leukocytosis or fever. Patient did report that \nat his HD session on the day before his presentation, an \nadditional 2 kg of fluid was removed and it is possible that \nfluid shifts could have contributed to the patient's \npresentation, though unlikely. Orthostatics were positive the \nnext morning but patient was asymptomatic with movements and \nwith ambulation. Blood and urine culture pending at time of \ndischarge but overall clinical suspicion for infection was low. \nHe was educated on nose bleed prevention and will continue with \nhis home nasal saline spray and will f/u with ENT. He was \neducated on orthostatic precautions and will continue to wear \nhis compression stockings. \n\n#Atrial fibrillation. Patient in Afib with HRs ranging from \n98-130s per the ED dash. No intervention was pursued in the ED \nand upon arrival to the floor, patient with HRs < 100. Home \nMetoprolol was fractionated on arrival to the floor. Per prior \nOMR notes, patient is not currently on anticoagulation given GI \nbleed history. He was discharged on home medications. \n\n#NSTEMI, type 2. MB 5, Troponin 0.38 on initial ED presentation. \nEKG consistent with atrial fibrillation without evidence of \nischemic changes. Troponins and MB were trended until peaked. \nBaseline troponins recently ~0.30 and patient without chest \npain; troponins were likely elevated in setting of his ESRD and \ndemand ischemia in the setting of Afib with RVR while in the ED\n\n#ESRD on HD. On ___ and every other ___. Continued \nCinacalcet, Sevelemer. Had UF on ___ and due to mild \nhyperkalemia had a short HD run on ___.\n\nCHRONIC AND STABLE ISSUES\n=========================\n#Hx of recurrent ___ cellulitis. Followed by ___ ID as an \noutpatient and on Levofloxacin for suppressive therapy. Has home \nvisiting nurse who comes once per week \n\n#DLBCL. Received C2 Bendamustin on ___. C3 delayed due to \nthrombocytopenia and subsequently ___ recurrent ___ cellulitis. \nPort placement has been reportedly delayed due to infection and \nthrombocytopenia. Per Atrius notes by oncologist Dr. ___ \n(___), most recent PET scan is much improved and additional \nchemotherapy will be held off as he has had much toxicity and is \ncurrently doing well. He will follow-up with Dr. ___ on \n___. Allopurinol was continued\n \n#Anemia. Has longstanding anemia (baseline ___ per recent ___ \nOMR); however in last checks since ___ Hgb/Hct \n___. H/H improved from last check end of ___.\n\n#Thrombocytopenia. Chronic with baseline in 80-90s\n\n#DM2. On glargine 20 U QAM and 20 U QPM, HISS as an outpatient\n\n#HTN. Home irbesartan 300 mg daily was held as he was \nnormotensive. On discharge it was continued. \n\nTRANSITIONAL ISSUES\n==================\n[ ] Has follow-up with ID on ___ regarding history of \nrecurrent lower extremity cellulitis for which he is on \nLevofloxacin q48H\n[ ] Per prior OMR notes, patient is not currently on \nanticoagulation given history of GI bleeding. This matter \nshould continued to be addressed during future discussions. \nCHADSVASC 3\n[ ] Patient reports 40 lb weight loss over the past six months \nin the setting of his lymphoma diagnosis. Reports having extra \nfluid removed during HD sessions to match his weight. Would \ncontinue to monitor for symptoms of hypovolemia after HD \nsessions\n[ ] Per Atrius notes by oncologist Dr. ___ (___), most \nrecent PET scan is much improved and additional chemotherapy \nwill be held off as he has had much toxicity and is currently \ndoing well. He will follow-up with Dr. ___ on ___\n[ ] Recommend outpatient ENT follow up given recurrent \nepistaxis\n[ ] Recommend outpatient evaluation for orthostatic hypotension \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n2. Allopurinol ___ mg PO 3X/WEEK (___) \n3. Atorvastatin 80 mg PO QPM \n4. Calcium Carbonate 1000 mg PO TID W/MEALS with each meal \n5. Cinacalcet 60 mg PO 5X/WEEK (___) \n6. irbesartan 300 mg oral DAILY \n7. Metoprolol Succinate XL 50 mg PO DAILY \n8. Pantoprazole 40 mg PO Q24H \n9. Glargine 20 Units Breakfast\nGlargine 20 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n10. Loratadine 10 mg PO DAILY \n11. Pegfilgrastim Onpro (On Body Injector) Dose is Unknown SC \nPER ONCOLOGIST \n12. Levofloxacin 250 mg PO Q48H \n\n \nDischarge Medications:\n1. Glargine 20 Units Breakfast\nGlargine 20 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n3. Allopurinol ___ mg PO 3X/WEEK (___) \n4. Atorvastatin 80 mg PO QPM \n5. Calcium Carbonate 1000 mg PO TID W/MEALS with each meal \n6. Cinacalcet 60 mg PO 5X/WEEK (___) \n7. irbesartan 300 mg oral DAILY \n8. Levofloxacin 250 mg PO Q48H \n9. Loratadine 10 mg PO DAILY \n10. Metoprolol Succinate XL 50 mg PO DAILY \n11. Pantoprazole 40 mg PO Q24H \n12. HELD- Pegfilgrastim Onpro (On Body Injector) Dose is \nUnknown SC PER ONCOLOGIST This medication was held. Do not \nrestart Pegfilgrastim Onpro (On Body Injector) until you see \nyour oncologist\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES\n=================\nHYPOTENSION\nATRIAL FIBRILLATION WITH RAPID VENTRICULAR RATES\nDIZZINESS\nTROPONINEMIA \nEPISTAXIS \n\nSECONDARY DIAGNOSES\n===================\nDLBCL\nESRD ON HD \nANEMIA\nTHROMBOCYTOPENIA\nRECURRENT LOWER EXTREMITY CELLULITIS\nDM II\nHYPERTENSION\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 ___ after you came in with dizziness and \na headache. Your blood pressure was found to be low and your \nheart rate was found to be fast in the ED. When you arrived to \nthe Medicine floor, your blood pressure and heart rate had \nreturned to normal. You reported resolution of your dizziness, \nheadache, and other symptoms when you arrived to the Medicine \nfloor. You received a dialysis session and we restarted some of \nyour home medications.\n\nIt is very important that you attend your follow-up appointments \nlisted below. \n\nContinue to wear your compression stockings and get up slowly \nfrom lying down to sitting to standing positions given your \northostatic hypotension. \n\nContinue to use your nasal saline nose spray and nose bleed \nprevention strategies as you are already doing. \n\nIt was a pleasure taking care of you. We wish you the best!\n\nYour ___ Team\n\nWeigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n \nFollowup Instructions:\n___\n" ]

[ "I959", "I4891", "R42", "R7989", "R040", "C8330", "E1122", "I132", "I5022", "N186", "D649", "D696", "L03116", "E875", "Z792", "Z794", "E669", "I2510", "Z6834", "L03115" ]

[ "I959: Hypotension, unspecified", "I4891: Unspecified atrial fibrillation", "R42: Dizziness and giddiness", "R7989: Other specified abnormal findings of blood chemistry", "R040: Epistaxis", "C8330: Diffuse large B-cell lymphoma, unspecified site", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "I5022: Chronic systolic (congestive) heart failure", "N186: End stage renal disease", "D649: Anemia, unspecified", "D696: Thrombocytopenia, unspecified", "L03116: Cellulitis of left lower limb", "E875: Hyperkalemia", "Z792: Long term (current) use of antibiotics", "Z794: Long term (current) use of insulin", "E669: Obesity, unspecified", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z6834: Body mass index [BMI] 34.0-34.9, adult", "L03115: Cellulitis of right lower limb" ]

[ "I4891", "E1122", "D649", "D696", "Z794", "E669", "I2510" ]

[]

[ " \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:\nLeg Redness and Wounds\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\n___ yo male with a history of DLBCL and ESRD on HD who is \nadmitted\nwith cellulitis of his leg. The patient has had chronic wounds \non\nhis feet but he notice two new wound two days ago and one new\nwound today and increased redness and edema of his left leg\nespecially. He was evaluated by home care and referred to the \nED.\nThe patient denies any fevers. He denies any increased pain in\nhis feet or legs but he does have neuropathy and decreased\nsensation. He states the new wounds bilstered and the opened and\ndrained. He otherwise denies any shortness of breath, nausea,\npain, diarrhea, or dysuria. He did miss his dialysis today. Of\nnote the patient was recently admitted from ___ for\ncellulitis and bacteremia and then resumed treatment for\ncellulitis with cefepime as an outpatient in ___ which he\nreports stopped about three weeks ago. The last ID note\nrecommends treatment with oral penicillin or amoxicillin after \nIV\nantibiotics and follow up in their clinic but he reports neither\nof these happened.\n \nPast Medical History:\n-heart failure w/preserved EF\n-ESRD\n-DM2\n-htn\n-obesity\n-OSA on CPAP \n-Seasonal allergy. \n-History of pneumonia in ___ leading to ESRD in setting of \nlong-standing DM2\n-CAD\n-diffuse large B cell lymphoma\n\nPAST ONCOLOGIC HISTORY:\n- ___ by Dr ___ management of his newly\ndiagnosed B cell diffuse large cell lymphoma, dx'd by a core\nbiopsy 5 d ago of a large pelvic mass. He noted RLE swelling in\nearly ___. LENIs were negative for clot but did show an\nenlarged groin node. The picture was felt to be from a prior\ncellulitis of his foot and he was followed. His swelling\ncontinued and repeat LENIs in early ___ showed suggestion of \nan\nobstruction higher up and he underwent a CT of his abdomen and\npelvis that showed a large pelvic mass with splenomegaly and\nmediastinal and portacaval adenopathy and lytic lesions in the\nright pubic symphysis and inferior pubic ramus. A subsequent \nPET\nscan delineated those areas as well as moderate disease in his\nchest. He underwent a core bx in ___ last week which showed B \ncell\ndiffuse large cell lymphoma, germinal center origin (better\nprognosis) with a high proliferative index of 80-90%.\nCytogenetics showed bcl 6 rearrangement but no worrisome\nmutations. Interestingly, his LDH is normal. He continues to \nhave\nRLE edema but denies any abdominal pain or pelvic pain. His wt \nis\nstable. He denies any fevers, night sweats or pruritis. He has\nmultiple medical problems with DM since adolescence and has been\non dialysis for the past ___ years. He denies any cardiac disease\nbut did have mild dysfunction on a cardiac PET test a year ago.\nHe is complaining of left elbow pain, having fallen at dialysis\nseveral days ago, striking his left elbow and leg. Xrays at the\n___ were negative. Sent home without a sling or any advice. Exam\nshowed obesity, 3 fb splenomegaly, pain, swelling left elbow and\n2+ RLE edema Labs: Hct 32, LDH- 171, protein elec-normal. Hep\nserologies normal. \nA: Stage IIIA large cell lymphoma. High intermediate risk given\nage, performance status and multiple sites of disease with CR\nestimated at 56%, ___ year OS of 37%. Recommended Rit/CHOP chemo.\n- ___: Started chemo with Rit/CHOP. Split dose Rituxan with \n50\nmg/m2 given on day 1. The rest to be given day 6. Under mistaken\nimpression that he was to take his prednisone indefinitely so\nstayed on it until subsequent GI bleed.\n- ___/: Rituxan given.\n- ___: Hosp FH for acute GI bleed. Upper endoscopy showed\nduodenal ulcers. Missed chemo ___ due to miscommunication.\n- ___: Hosp ___ for ___ cellulitis LLE and epistaxis. Also\nhad paroxysmal atrial fib. \n- ___: Cycle 2 Rit/CHOP given. Neulasta given on day 2.\nTreatment delayed 2 wks due to gi bleed and LLE cellulitis.\n- ___: CT showed near resolution of soft tissue masses in \nright iliopsoas and obturator internus muscles, persistence of \nsplenomegaly and bone lytic lesions \n- ___: Resumed chemo with rituxin and bendamustine\n- ___: Received day 2 of rituxin and bendamustine\n\n \nSocial History:\n___\nFamily History:\nHe denies any family history of kidney disease. His father with \ndiabetes ___ and hypertension died at age ___ due to heart \nattack. His mother with diabetes ___ is in her ___. \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n==================\nGeneral: NAD\nVITAL SIGNS: T 97.7 BP 162/82 HR 72 RR 18 O2 98%RA\nHEENT: MMM, no OP lesions\nCV: RR, NL S1S2\nPULM: CTAB\nABD: Soft, NTND, no masses or hepatosplenomegaly\nLIMBS/SKIN: Multiple excoriates on upper and lower extremities.\nRight foot with black heal wound and anterior open wound. Left\nleg with redness and edema from the foot up to the mid lower \nleg.\nLeft foot with black heel wound, multiple anterior foot wound,\none of which has partial blister and is oozing clear fluid.\nSKIN: No rashes or skin breakdown\nNEURO: Alert and oriented, no focal deficits.\n\nDISCHARGE PHYSICAL EXAM:\n==================\nVS: 97.5 138/72 75 ___ RA\nGEN: lying comfortably in bed, NAD, A/Ox3 \nHEENT: sclerae anicteric, moist mucous membranes, no OP lesions,\nEOMI\nCARD: RRR, no murmurs, rubs or gallops\nPULM: clear to auscultation bilaterally, no rhonchi or rales\nABDM: obese, non-distended, normoactive bowel sounds, soft,\nno tenderness to palpation\nEXTR: Multiple skin tears on LLE, bilateral lower extremity\nerythema which is improving based off marking of rash on initial\npresentation, lower extremity dressings to mid-shin bilaterally,\nno crepitus or tenderness to palpation of bilateral lower\nextremities, Severe onychomycoses of the toenails\nLYMPH: no cervical lymphadenopathy \nNEURO: A/Ox3, CN II-XII grossly intact \nPSYCH: non-anxious, normal affect \nACCESS: Left upper extremity fistula.\n\n \nPertinent Results:\nADMISSION LABS\n===========\n___ 02:25PM BLOOD WBC-6.6 RBC-3.24*# Hgb-11.0*# Hct-35.0*# \nMCV-108*# MCH-34.0*# MCHC-31.4* RDW-17.3* RDWSD-69.9* Plt Ct-86*\n___ 02:25PM BLOOD Neuts-66.4 ___ Monos-8.2 Eos-5.2 \nBaso-0.6 Im ___ AbsNeut-4.36 AbsLymp-1.27 AbsMono-0.54 \nAbsEos-0.34 AbsBaso-0.04\n___ 02:25PM BLOOD Plt Ct-86*\n___ 02:25PM BLOOD Glucose-125* UreaN-54* Creat-6.0* Na-138 \nK-5.4* Cl-92* HCO3-30 AnGap-16\n___ 06:58AM BLOOD ALT-11 AST-15 AlkPhos-126 TotBili-0.7\n___ 06:58AM BLOOD Calcium-8.9 Phos-5.2* Mg-1.8\n\nIMAGING\n======\n___ B/L LOWER EXTREMITY DUPLEX\nNo evidence of deep venous thrombosis in the right or left lower \nextremity\nveins.\n\n___ CXR\nThere is pulmonary vascular congestion without evidence of \npulmonary edema. \nMild left basilar atelectasis. There is no pleural effusion or \npneumothorax\nidentified. The size of the cardiac silhouette is enlarged but \nunchanged.\n\n___ ABI PVR:\nABIs were not obtained due to vessel noncompressibility. Mild \noutflow disease in the territory of the right anterior tibial \nartery. \n\nMICROBIOLOGY\n==========\n___ BLOOD CULTURE ___ WOUND CULTURE\n___ MRSA SWAB\n\nDISCHARGE LABS\n===========\n___ 07:40AM BLOOD WBC-5.2 RBC-3.06* Hgb-10.4* Hct-31.9* \nMCV-104* MCH-34.0* MCHC-32.6 RDW-16.3* RDWSD-62.4* Plt Ct-89*\n___ 07:40AM BLOOD Glucose-184* UreaN-70* Creat-6.6*# Na-138 \nK-4.9 Cl-94* HCO3-22 AnGap-22*\n___ 07:40AM BLOOD Calcium-8.8 Phos-5.1* Mg-1.8\n___ 07:40AM BLOOD Vanco-14.0\n \nBrief Hospital Course:\nMr. ___ is a ___ yo male with a history of DLBCL and ESRD on HD \nwho is admitted with cellulitis of both legs. On admission, he \nwas again started on cefepime and vancomycin and ID was \nconsulted, who agreed with the treatment regimen. A wound \nculture was done and grew MSSA, so he was narrowed to Cefazolin \nmonotherapy post HD. Wound care was consulted who recommended \nelevation of legs and daily dressing changes. He had also missed \nhis dialysis session, so underwent HD on ___, and ___. \nHe also had thrombocytopenia, which was stable throughout \nhospitalization. At time of discharge, his cellulitis had \nimproved and he was ambulating with a walker.\n\nACTIVE ISSUES\n=========\n#Cellulitis\nHe had previously been admitted in ___ for a similar complaint, \nat which time was found to be bacteremic with strep. He was \ntreated with post-dialysis vancomycin and cefepime and was lost \nto follow-up with ID as an outpatient for suppressive therapy. \nWas started on vanc and cefepime while in house and was dosed \npost dialysis. ID was consulted who followed with the patient \nand arranged outpatient follow-up with patient. Wound care was \nconsulted and provided recommendations. Lower extremities \nduplexes were done, which showed no signs of DVT. ID recommended \ncefazolin monotherapy post-HD. Wound recommended elevation of \nlegs and daily dressing changes. He was discharged with a two \nweek course of Cefazolin to be dosed post-HD. \n\n#DLBCL\nReceived C2 Bendamustin on ___. C3 delayed due to \nthrombocytopenia. Currently scheduled for ___. Port placement \nhas been delayed due to infection and thrombocytopenia. Dr. \n___ was notified of the patient's admission. He was \ncontinued on his home doses of continued on home allopurinol and \nativan,\n\n#ESRD on HD\nOn HD MWF and every other ___. Missed his ___ \nscheduled HD when in the ER, so nephrology was consulted and \npatient was dialyzed on ___. He was continued on his home \nsensipar and tums and resumed his home schedule while in house. \nAntibiotics were dosed with dialysis. Patient is scheduled to \nhave HD on ___, which is the ___ after his discharge. \n\nTRANSITIONAL ISSUES:\n=============================\n- Patient was narrowed to Cefazolin IV therapy for his \ncellulitis. Give post-HD (2g on M/W/S, and 3g on ___ \n- He was started on Amlodipine 5mg daily for hypertension. \nPlease follow up BP as outpatient\n- He should continue on ___ HD with HD every other ___ \n(scheduled for this ___\n- He has follow up with his oncologist tomorrow (___). \nOncologist will review staging CT torso at that visit \n\n___. Relationship: Sister Phone: ___ (home) \nCODE: FULL \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n2. Allopurinol ___ mg PO 3X/WEEK (___) \n3. Atorvastatin 80 mg PO QPM \n4. Benzonatate 100 mg PO TID \n5. Cinacalcet 60 mg PO 5X/WEEK (___) \n6. irbesartan 300 mg oral DAILY \n7. Pantoprazole 40 mg PO Q24H \n8. Metoprolol Succinate XL 50 mg PO DAILY \n9. Calcium Carbonate 1500 mg PO TID W/MEALS with each meal \n10. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n11. Loratadine 10 mg PO DAILY \n12. Docusate Sodium 100 mg PO BID:PRN Constipation \n13. Gabapentin 100 mg PO BID \n14. LORazepam 0.5 mg PO Q6H:PRN Nausea, Anxiety \n15. Glargine 20 Units Breakfast\nGlargine 20 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n\n \nDischarge Medications:\n1. amLODIPine 5 mg PO DAILY \nRX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*0 \n2. CeFAZolin 1 g IV POST HD (FR) Duration: 1 Dose \non ___ post HD \nRX *cefazolin in dextrose (iso-os) 1 gram/50 mL 1 g IV Once, \npost HD Disp #*1 Intravenous Bag Refills:*0 \n3. CeFAZolin 2 g IV POST HD (SA) Duration: 1 Dose \non ___ POST HD \nRX *cefazolin in dextrose (iso-os) 2 gram/100 mL 2 g IV once \nDisp #*1 Intravenous Bag Refills:*0 \n4. CeFAZolin 2 g IV POST HD (MO,WE) Duration: 2 Doses \ngive post HD on ___ and ___ \nRX *cefazolin in dextrose (iso-os) 2 gram/100 mL 2 g IV POST HD \nDisp #*2 Intravenous Bag Refills:*0 \n5. CeFAZolin 3 g IV POST HD (FR) Duration: 1 Dose \ngive on ___ post HD \nRX *cefazolin in dextrose (iso-os) 1 gram/50 mL 3 g IV post HD \nDisp #*3 Intravenous Bag Refills:*0 \n6. Loratadine 10 mg PO EVERY OTHER DAY \n7. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n8. Allopurinol ___ mg PO 3X/WEEK (___) \n9. Atorvastatin 80 mg PO QPM \n10. Benzonatate 100 mg PO TID \n11. Calcium Carbonate 1500 mg PO TID W/MEALS with each meal \n12. Cinacalcet 60 mg PO 5X/WEEK (___) \n13. Docusate Sodium 100 mg PO BID:PRN Constipation \n14. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n15. Gabapentin 100 mg PO BID \n16. Glargine 20 Units Breakfast\nGlargine 20 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n17. irbesartan 300 mg oral DAILY \n18. LORazepam 0.5 mg PO Q6H:PRN Nausea, Anxiety \n19. Metoprolol Succinate XL 50 mg PO DAILY \n20. Pantoprazole 40 mg PO Q24H \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n- lower extremity cellulitis\n\nSECONDARY DIAGNOSES\n- diffuse large B cell lymphoma\n- end stage renal disease\n- chronic stable diastolic heart failure\n- type 2 diabetes ___\n- hypertension \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were admitted to the hospital because you had new wounds on \nyour legs and had skin infections in both legs.\n\nWhile you were here, you were treated with IV antibiotics and \nwere seen by a wound care nurse who helped to dress your legs. \nYou were also seen by physicians who specialize in infectious \ndisease and were scheduled to follow-up with them as an \noutpatient. You resumed you dialysis sessions and were in stable \ncondition when you were discharged.\n\nIt is important when you leave the hospital to take your \nmedications as prescribed and attend all your follow-up \nappointments as below. If you has worsening swelling or redness \nin your legs, make sure to call your doctor. If you have fevers \nor chills, go to the ER immediately for further evaluation.\n\nAlso, weigh yourself every morning, call MD if weight goes up \nmore than 3 lbs.\n\nIt was a pleasure caring for you, and we wish you the best of \nluck!\n\nYour ___ Care Team\n \nFollowup Instructions:\n___\n" ]

[ "L03116", "N186", "I132", "C8336", "E1122", "I4891", "K279", "B351", "I5032", "B9561", "L03115", "E669", "Z6836", "E1142", "J309", "G4733", "I2510", "Z807", "Z794", "Z992" ]

[ "L03116: Cellulitis of left lower limb", "N186: End stage renal disease", "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "C8336: Diffuse large B-cell lymphoma, intrapelvic lymph nodes", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I4891: Unspecified atrial fibrillation", "K279: Peptic ulcer, site unspecified, unspecified as acute or chronic, without hemorrhage or perforation", "B351: Tinea unguium", "I5032: Chronic diastolic (congestive) heart failure", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere", "L03115: Cellulitis of right lower limb", "E669: Obesity, unspecified", "Z6836: Body mass index [BMI] 36.0-36.9, adult", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "J309: Allergic rhinitis, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "Z807: Family history of other malignant neoplasms of lymphoid, hematopoietic and related tissues", "Z794: Long term (current) use of insulin", "Z992: Dependence on renal dialysis" ]

[ "E1122", "I4891", "I5032", "E669", "G4733", "I2510", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nL ___ Metatarsal Osteomyelitis \n \nMajor Surgical or Invasive Procedure:\n___: Left foot ___ metatarsal head resection, excision of \nbase of ___ proximal phalanx\n\n \nHistory of Present Illness:\n___ y/o M with PMHx of DLBCL, HFrEF, atrial fibrillation, ESRD on \nHD MWF, DM2, recurrent lower extremity ulcerations and \ncellulitis, who presents with complaint of foot ulcer now found\nto have L ___ Metatarsal Osteomyelitis and admitted per podiatry \nfor ongoing antibiotic therapy and surgical planning.\n\nPer patient, was seen by outpatient podiatrist this AM who noted \na foot XRAY from 1 wk ago with evidence of osteomyelitis of the \nL ___ metatarsal bone. Given clinical concern for spread of\ninfection and need for surgical planning, patient was sent to ED \nfor further evaluation and planned admission for ongoing \nantibiotic therapy. Of note, patient was notified about\nosteomyelitis 1 week ago at time of foot XRAY, but was unwilling \nto go to the hospital at this time. \n\nOn arrival ___ the ED, patient was HDS with initial vitals 98.0 \n84 143/80 16 98% RA. Denied fevers or chills or other systemic \ncomplains. Also denied sensation of pain, but has baseline\nneuropathy. Exam notable for pale-appearing and overweight \nelderly gentleman, with quarter-size open ulceration over \nlateral aspect of the L foot along the plantar surface. Small \narea of\nexudative tissue noted at ulcer site, and ED provider able to \nprobe bone but with no obvious cellulitis surrounding \nulceration. Otherwise CTAB, NTND and soft abdomen, and with \ndopplerable DP pulse of the L foot. Labs significant for CRP \n12.4, WBC 5, Lactate 1.9. Imaging showing no significant change \ncompared to most recent prior, but with concern for \nosteomyelitis of the L\n___ metatarsal. Patient given Levofloxacin 750mg, Insulin 8 \nUnits. Vitals prior to transfer: 97.8 82 129/79 16 96% RA. \n\nCurrently, patient stable on floor and continuing to deny \nfevers, chills, or pain ___ L foot (c/w known underlying \nneuropathy). Amenable to continued treatment with antibiotics, \nand looking\nforward to definitive surgical management. \n \nPast Medical History:\n- Diastolic Heart Failure \n- ESRD on HD (MWF) \n- Type II Diabetes complicated by Diabetic Rentinopathy and \nPeripheral Neuropathy \n- Hypertension \n- Obesity \n- OSA not on CPAP \n- CAD \n- Atrial Fibrillation \n- GI Bleed ___ Multiple Duodenal Ulcers ___ ___ \n- Hyperlipidemia \n- Erectile Dysfunction \n- Colonic Adenoma \n- Hyperparathyroidism \n- Coagulopathy\n \nSocial History:\n___\nFamily History:\nFather with diabetes and hypertension died at age ___ due to \nMI. Mother with diabetes ___ is ___ her ___. Maternal \ngrandfather possibly died of lymphoma age ___. \n \nPhysical Exam:\nADMISSION PHYSICAL EXAM: \nVS: 97.6PO 153 / 96R Sitting 76 18 97 RA \nGEN: Alert, lying ___ bed, no acute distress \nHEENT: Moist MM, anicteric sclerae, no conjunctival pallor \nNECK: Supple without LAD \nPULM: Generally CTA b/l without wheeze or rhonchi \nCOR: RRR (+)S1/S2 with harsh systolic ejection murmur, likely\nfrom fistula \nABD: Soft, non-tender, non-distended \nEXTREM: There is moderate peripheral edema noted to the\nleft lower extremity. 2cm by 2cm ulceration on lateral aspect \nof\nfifth metatarsal head. Fibrinous wound bed with minimal\nsurrounding erythema. T\nNEURO: CN II-XII grossly intact, motor function grossly normal \n\nPHYSICAL EXAM: \nVITALS: 98.1 PO___ R Lying___\nGEN: Alert, sitting up on the edge of the bed, no acute \ndistress, energetic and pleasant. \nHEENT: Moist MM, anicteric sclerae, no conjunctival pallor \nNECK: Supple without LAD \nPULM: CTA b/l without wheeze, rales, rhonchi \nCOR: RRR (+)S1/S2 with harsh systolic ejection murmur\nABD: Soft, non-tender, non-distended \nEXTREM: Left foot is bandaged, post-operatively, with wound vac. \nwarm and well perfused. \nNEURO: CN II-XII grossly intact, motor function grossly normal \n \nPertinent Results:\nADMISSION LABS:\n============\n___ 10:36AM BLOOD WBC-5.0 RBC-3.67* Hgb-12.3* Hct-37.4* \nMCV-102* MCH-33.5* MCHC-32.9 RDW-18.0* RDWSD-67.5* Plt Ct-90*\n___ 10:36AM BLOOD Neuts-76.0* Lymphs-11.0* Monos-9.4 \nEos-2.8 Baso-0.6 Im ___ AbsNeut-3.78 AbsLymp-0.55* \nAbsMono-0.47 AbsEos-0.14 AbsBaso-0.03\n___ 10:36AM BLOOD ___ PTT-34.7 ___\n___ 10:36AM BLOOD Glucose-403* UreaN-41* Creat-4.9*# \nNa-130* K-7.1* Cl-90* HCO3-25 AnGap-15\n___ 01:12PM BLOOD Glucose-377* UreaN-44* Creat-5.2* Na-131* \nK-7.6* Cl-88* HCO3-22 AnGap-21*\n___ 03:41PM BLOOD Glucose-330* UreaN-45* Creat-5.1* Na-134* \nK-5.9* Cl-89* HCO3-28 AnGap-17\n___ 01:12PM BLOOD Calcium-9.3 Phos-4.7* Mg-1.9\n___ 05:55AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG\n___ 10:36AM BLOOD CRP-12.4*\n___ 05:55AM BLOOD HCV Ab-NEG\n___ 03:39PM BLOOD ___ pO2-37* pCO2-47* pH-7.42 \ncalTCO2-32* Base XS-4\n___ 10:44AM BLOOD Lactate-1.9 K-6.0*\n___ SED RATE BY MODIFIED - TEST NOT PERFORMED \n___ 06:15AM BLOOD CRP-61.4*\n\nDISCHARGE LABS:\n============\n___ 07:05AM BLOOD WBC-4.7 RBC-3.14* Hgb-10.6* Hct-31.4* \nMCV-100* MCH-33.8* MCHC-33.8 RDW-17.3* RDWSD-63.1* Plt Ct-90*\n___ 07:05AM BLOOD Glucose-126* UreaN-65* Creat-8.0*# \nNa-133* K-4.8 Cl-89* HCO3-27 AnGap-17\n___ 07:05AM BLOOD Calcium-8.5 Phos-6.4* Mg-1.8\n\nMICROBIOLOGY:\n===========\n___ BLOOD CX X2: NGTD\n\n___ 8:00 am TISSUE ___ METATARSAL HEAD,LEFT. \n\n GRAM STAIN (Final ___: \n 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). \n 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. \n ___ PAIRS. \n SMEAR REVIEWED; RESULTS CONFIRMED. \n\n TISSUE (Preliminary): \n STAPH AUREUS COAG +. SPARSE GROWTH. \n Susceptibility testing performed on culture # ___ \n___. \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\nTime Taken Not Noted ___ Date/Time: ___ 9:28 am\n TISSUE ___ TOE,LEFT FOOT. \n\n GRAM STAIN (Final ___: \n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). \n 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. \n ___ PAIRS. \n SMEAR REVIEWED; RESULTS CONFIRMED. \n\n TISSUE (Preliminary): \n STAPH AUREUS COAG +. SPARSE GROWTH. \n This isolate is presumed to be resistant to clindamycin \nbased on\n the detection of inducible resistance . \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\n SENSITIVITIES: MIC expressed ___ \nMCG/ML\n \n_________________________________________________________\n STAPH AUREUS COAG +\n | \nCLINDAMYCIN----------- R\nERYTHROMYCIN---------- =>8 R\nGENTAMICIN------------ <=0.5 S\nLEVOFLOXACIN---------- =>8 R\nOXACILLIN------------- =>4 R\nRIFAMPIN-------------- <=0.5 S\nTETRACYCLINE---------- <=1 S\nTRIMETHOPRIM/SULFA---- <=0.5 S\nVANCOMYCIN------------ <=0.5 S\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\nIMAGING:\n========\nFOOT AP,LAT & OBL LEFTStudy Date of ___ \n1. No significant change compared to most recent prior. Large \nerosion of the head of the fifth metatarsal and smaller erosion \nat the lateral base of the proximal phalanx of the fifth toe is \nconcerning for osteomyelitis ___ the setting of infection.\n \n2. Previously described fracture of the base of the fifth \nmetatarsal is unchanged compared to most recent prior.\n \nBrief Hospital Course:\n___ M with PmHx notable for T2DM (c/b multiple poorly healing \nfoot ulcers), HTN, and ESRD, who presents with complaint of foot \nulcer, found to have L ___ Metatarsal MSSA Osteomyelitis, now \ns/p debridement and L ___ metatarsal head resection.\n\nACTIVE ISSUES: \n================\n#L ___ Metatarsal Osteomyelitis\nPatient with T2DM c/b neuropathy and with history of recurrent \nnon-healing lower extremity ulcers. Demonstrated evidence of \nosteomyelitis of the L ___ metatarsal on foot XRAY, had been on \nlevofloxacin as an outpatient, which was stopped upon admission \nfor continued antibiotic therapy and surgical planning per \npodiatry, and then went to the OR (___) where ___ metatarsal \nhead was resected, left open and packed, and ultimately a vac \nwas placed. Prelim tissue cultures grew MSRA, planned for 6 week \ncourse of Vancomycin with HD, expected end date ___. Final \ncultures and pathology on the bone fragment pending at \ndischarge. Should have outpatient ID followup. Wound vac \ntransitioned to wet-to-dry on discharge, plan for ___ to replace \nvac at home on ___, continue pending podiatry f/u ___. \n\n#Hyperkalemia: EKG's continue to have no changes, and remains \nasymptomatic throughout his stay. Electrolytes managed at \ndialysis. Low K diet.\n\nCHRONIC ISSUES: \n==================\n#ESRD on ___ dialysis schedule\n\n#T2DM (c/b neuropathy and ESRD): Takes lantus 60 AM and 40 ___ \nwith HISS at home. Put on lower long acting regimen here given \nNPO for procedure and reduced PO intake, continued on 40 AM and \n20 ___ of lantus on discharge and instructed to check FSG TID.\n\n#Anemia\n#Thrombocytopenia: Appears at or above baseline for platelets \nand Hgb. Pt is status post nine months of CHOP chemotherapy, and \nlikely has some degree of bone marrow suppression which fits his \nmacrocytosis. Iron studies c/w AIC.\n\n#HTN: Well controlled with Irbesartan, transitioned to \nLisinopril ___ house as irbesartan nonformulary.\n\n#HFpEF: Volume managed at dialysis. Continued on home \nmetoprolol.\n\n#DLBCL: S/p CHOP chemo. Not on active chemo during this \nadmission (last round of chemo one month prior to admission)\n\n#CAD: Continue home atorvastatin, metoprolol\n\n#Hyperparathyroidism: Patient states he is no longer on \ncinacalcet, would confirm\n\n#GERD: Continued home pantoprazole\n\n#AFib: Not on anticoagulation ___ setting of history of GIB. \nRates well controlled with Metoprolol as above.\n\n#Gout: Dose reduced allopurinol for renal dosing.\n\n====================\nTransitional Issues\n====================\n[ ] Wound vac: ___ has been coordinated to come to Mr. ___ \nhome to manage his wound vac, will place ___, letter \nprovided with ___ will have vac until podiatry followup \n___\n[ ] Final wound cultures pending at discharge, please f/u\n[ ] Pathology on the bone fragment pending at discharge, please \nf/u\n[ ] Monitor insulin dosing carefully, reduced to 40 AM, 20 ___ \nlantus and blood sugar was well controlled \n[ ] Discharged with Home Physical Therapy.\n[ ] Vanc will be dosed by level at outpatient HD, confirmed\n[ ] Allopurinol dosing reduced to QOD\n[ ] Patient states he took Calcium carbonate 1000 mg TID with \nmeals, would clarify at followup\n\nCODE: Full Code (confirmed)\nEMERGENCY CONTACT HCP: ___ (sister/HCP) ___\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Succinate XL 50 mg PO DAILY \n2. Levofloxacin 250 mg PO Q48H \n3. irbesartan 300 mg oral DAILY \n4. Loratadine 10 mg PO DAILY \n5. Pantoprazole 40 mg PO Q24H \n6. Atorvastatin 80 mg PO QPM \n7. Glargine 60 Units Breakfast\nGlargine 40 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n8. sevelamer CARBONATE 1600 mg PO TID W/MEALS \n9. Calcium Carbonate 1000 mg PO TID W/MEALS \n10. Allopurinol ___ mg PO DAILY \n11. Gabapentin 100 mg PO DAILY:PRN pain \n\n \nDischarge Medications:\n1. ___ MD to order daily dose IV HD PROTOCOL Sliding \nScale \nStart: Today - ___, First Dose: Next Routine Administration \nTime \ncontinue through ___ \nRX *vancomycin 1 gram 1 g IV three times a week during HD Disp \n#*1 Vial Refills:*0 \n2. Allopurinol ___ mg PO EVERY OTHER DAY \n3. Glargine 40 Units Breakfast\nGlargine 20 Units Bedtime\nInsulin SC Sliding Scale using REG Insulin \n4. Atorvastatin 80 mg PO QPM \n5. Calcium Carbonate 1000 mg PO TID W/MEALS \n6. Gabapentin 100 mg PO DAILY:PRN pain \n7. irbesartan 300 mg oral DAILY \n8. Loratadine 10 mg PO DAILY \n9. Metoprolol Succinate XL 50 mg PO DAILY \n10. Pantoprazole 40 mg PO Q24H \n11. sevelamer CARBONATE 1600 mg PO TID W/MEALS \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnosis: Osteomyelitis\n\nSecondary Diagnoses: End Stage Renal Disease, Type 2 Diabetes \n___, Peripheral Neuropathy, Hypertension, Obesity \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr ___,\n\nYou came into the hospital for management of the ulcer on your \nleft pinky toe, which was found to have an infection ___ the bone \n(osteomyelitis). You had surgery to clean out the wound and \nremove the infected part of the bone on your pinky toe. After \nsurgery you remained ___ the hospital and were given antibiotics \nto help fight any lingering infection, while you continued \ndialysis.\n\nSometimes the bone infection can persist ___ your body for a \nweeks without any visible sign of it, therefore even after you \nleave the hospital, you will continue to receive antibiotics \nthrough ___, even if you feel fine. \n\nWhen you leave the hospital:\n- Please see podiatry ___\n- Please have wound vac placed by ___ on ___\n- Call your primary care doctor to schedule an appointment \n- Call infectious disease clinic to schedule an appointment \n- Monitor your blood sugar 3 times per day. You were given a \nlower dose of insulin than you normally have\n- If you feel feverish or weak, or notice a significant negative \nchange ___ the appearance of your wound, such as more fluid, a \nbad color, or a bad smell it will be important to call your \npodiatrist. \n- You can only place weight on the heel of your left foot. \n\nThank you for coming to ___, and we wish you a speedy \nrecovery. \nYour ___ Team\n\n \nFollowup Instructions:\n___\n" ]

[ "E1169", "M869", "I132", "E1122", "E1142", "D696", "E11621", "E11319", "N186", "I5032", "L97526", "B9562", "Z992", "Z794", "Z6834", "E1165", "Z8572", "D649", "D7589", "I2510", "K219", "I4891", "M109", "E785", "E669", "G4733", "E875" ]

[ "E1169: Type 2 diabetes mellitus with other specified complication", "M869: Osteomyelitis, unspecified", "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "E1142: Type 2 diabetes mellitus with diabetic polyneuropathy", "D696: Thrombocytopenia, unspecified", "E11621: Type 2 diabetes mellitus with foot ulcer", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "N186: End stage renal disease", "I5032: Chronic diastolic (congestive) heart failure", "L97526: Non-pressure chronic ulcer of other part of left foot with bone involvement without evidence of necrosis", "B9562: Methicillin resistant Staphylococcus aureus infection as the cause of diseases classified elsewhere", "Z992: Dependence on renal dialysis", "Z794: Long term (current) use of insulin", "Z6834: Body mass index [BMI] 34.0-34.9, adult", "E1165: Type 2 diabetes mellitus with hyperglycemia", "Z8572: Personal history of non-Hodgkin lymphomas", "D649: Anemia, unspecified", "D7589: Other specified diseases of blood and blood-forming organs", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "K219: Gastro-esophageal reflux disease without esophagitis", "I4891: Unspecified atrial fibrillation", "M109: Gout, unspecified", "E785: Hyperlipidemia, unspecified", "E669: Obesity, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E875: Hyperkalemia" ]

[ "E1122", "D696", "I5032", "Z794", "E1165", "D649", "I2510", "K219", "I4891", "M109", "E785", "E669", "G4733" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nlatex\n \nAttending: ___.\n \nChief Complaint:\ninfected foot\n \nMajor Surgical or Invasive Procedure:\n1. Right foot partial ___ ray amputation with wound vacuum \napplication\n2. Right lower extremity angiogram.\n\n \nHistory of Present Illness:\nHISTORY OF PRESENT ILLNESS:\n===========================\nMr. ___ is a ___ with h/o T1DM c/b neuropathy, HTN,\nESRD on HD MWF, Afib not on AC, HFrEF, h/o DLBCL s/p treatment\n___, h/o h/o recurrent foot ulcers and cellulitis requiring\nsurgical debridement who presents from ___ clinic with R\nfoot ulcer.\n\nPer history obtained in the ED, pt sent in from ___ clinic\nfor worsening cellulitis in the setting of 10 days of p.o.\nantibiotics (doxycycline). Patient had a cut on the bottom of \nhis\nright foot 3 weeks ago which was cleaned and bandaged by his\ndaughter initially. He cut became worse and he was reevaluated \nby\nhis podiatrist and started on p.o. antibiotics. He is on day 10\nof his antibiotics today and was seen for a follow-up \nappointment\nby his podiatrist. His podiatrist debrided his foot and\nrecommended admission for IV antibiotics and further surgical\nmanagement. They also requested vascular surgery evaluation\nsecondary to weak RLE pulses.\n\nOn interview, the patient says he feels quite well. He has no\ncomplaints. He thinks his foot is getting better. His abdomen is\na little distended. He says a few days before coming in, he felt\n\"like the time I had blood poisoning\" but he us much improved\nnow. \n\nIn the ED, initial vitals were:\n- T 98.3 HR 85 BP 139/78 RR 18 O2 94% RA\n\nExam was notable for:\n- R ___ metatarsal ulceration with overlying eschar and\nsurrounding dark discoloration, no gross purulence, b/l ___ \nedema,\nerythema, non-palpable AT/DP or peroneal, + dopplers, cap refil\ntime <3s\n- photo from clinic of foot in OMR\n\n \nPast Medical History:\n- Diastolic Heart Failure \n- ESRD on HD (MWF) \n- Type II Diabetes complicated by Diabetic Rentinopathy and \nPeripheral Neuropathy \n- Hypertension \n- Obesity \n- OSA not on CPAP \n- CAD \n- Atrial Fibrillation \n- GI Bleed ___ Multiple Duodenal Ulcers in ___ \n- Hyperlipidemia \n- Erectile Dysfunction \n- Colonic Adenoma \n- Hyperparathyroidism \n- Coagulopathy\n \nSocial History:\n___\nFamily History:\nFather with diabetes and hypertension died at age ___ due to \nMI. Mother with diabetes ___ is in her ___. Maternal \ngrandfather possibly died of lymphoma age ___. \n \nPhysical Exam:\n24 HR Data (last updated ___ @ 721)\n Temp: 97.6 (Tm 98.3), BP: 108/61 (103-144/60-70), HR: 74\n(66-83), RR: 20 (___), O2 sat: 96% (93-97), O2 delivery: ra \n\nGENERAL: Alert and interactive. In no acute distress.\nHEENT: PERRL, EOMI. Sclera anicteric and without injection. \nCARDIAC: RRR, no m/r/g\nLUNGS: CTAB, No increased work of breathing.\nBACK: No CVA tenderness.\nABDOMEN: Soft, nontender, obese, mild distension, normoactive\nbowel sounds, no organomegaly \nEXTREMITIES: Podiatry dressing intact with no strikethrough,\nactive drainage, erythema extending up to the pre-tibial area\nwith mild warmth and no tenderness, 2+ pitting edema to the knee\non the R side\nSKIN: Warm, well perfused. Cap refill <3s. \nNEUROLOGIC: AOx3. CN2-12 grossly WNL. \n \nPertinent Results:\nADMISSION LABS:\n================\n___ 11:45AM BLOOD WBC-8.2 RBC-3.49* Hgb-11.2* Hct-35.7* \nMCV-102* MCH-32.1* MCHC-31.4* RDW-16.6* RDWSD-62.4* Plt ___\n___ 02:04PM BLOOD ___ PTT-35.7 ___\n___ 11:45AM BLOOD Glucose-353* UreaN-81* Creat-9.6*# \nNa-130* K-6.4* Cl-84* HCO3-24 AnGap-22*\n___ 11:45AM BLOOD Albumin-3.4*\n___ 11:45AM BLOOD CRP-122.3*\n___ 06:47AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG\n___ 06:47AM BLOOD HCV Ab-NEG\n\nIMAGING:\n==========\n FOOT AP/LAT\nIMPRESSION: \n \nPostsurgical changes at the level of the left fifth metatarsal \nand proximal \nfifth phalanx as described above. \n \nLOWER EXT U/S\nIMPRESSION: \nNo evidence of deep venous thrombosis in the right lower \nextremity veins. \n\nART EXTREMITIES \nIMPRESSION: \nSevere right, mild left tibial arterial insufficiency. \n\nMICRO:\n=======\nPATHOLOGIC DIAGNOSIS:\n1. ___ metatarsal, right, excision:\n- Acute osteomyelitis.\n2. Proximal margin, right ___ metatarsal, excision:\n- Bone with marrow fibrosis and reactive changes; acute \nosteomyelitis is not identified.\n\nDISCHARGE LABS:\n=================\n\n___ 06:05AM BLOOD WBC-6.4 RBC-3.41* Hgb-10.7* Hct-34.8* \nMCV-102* MCH-31.4 MCHC-30.7* RDW-16.2* RDWSD-61.7* Plt ___\n___ 06:05AM BLOOD ___ PTT-43.7* ___\n___ 06:05AM BLOOD Glucose-172* UreaN-46* Creat-6.0*# \nNa-132* K-4.6 Cl-90* HCO3-26 AnGap-16\n___ 06:05AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.___RIEF HOSPITAL COURSE:\n===================\nMr. ___ is a ___ with a history of insulin dependent \ndiabetes ___ complicated by neuropathy, hypertension, \nend-stage renal disease on hemodialysis (___), paroxysmal \natrial fibrillation, heart failure with reduced ejection \nfracture, history of diffuse large B cell lymphoma s/p treatment \nin ___, history of recurrent foot ulcers and cellulitis \nrequiring surgical debridement who presented from ___ \nclinic with a R foot ulcer on the ___ metatarsal to the ED on \n___. He was initially seen for worsening cellulitis in \nsetting of 10 days of PO doxycycline. On day of admission, he \nwas on day 10 of his antibiotics and seen for f/u by podiatrist \nwho debrided the foot and recommended admission for IV \nantibiotics, further surgical management, and vascular surgery \neval of work RLE pulses. In the ED, given 1000 mg vanc and 2g \ncefepime. Given low suspicion of bacteremia, these antibiotics \nwere discontinued on the floor for evaluation of wound culture \nafter pending debridement by podiatry. He was initially \nevaluated by vascular surgery for chronic limb ischemia in the \nsetting of peripheral artery disease. A right lower extremity \nangiogram showed evidence of stenosis in the anterior and \nposterior tibial arteries, requiring angioplasty and stent \nplacement respectively (on ___. He was subsequently placed \non clopidogrel to complete a 30 day regimen. Podiatry then \nperformed tissue debridement and exploration which necessitated \na right foot partial ___ ray amputation and application of wound \nvac on ___, and sent specimens to pathology which returned \nwith negative margins for active osteomyelitis. \n\nDuring the management of his right foot wound, he also had \nhyponatremia and hyperkalemia on admission that resolved with \nresumption of his regular hemodialysis sessions. His IDDM \ninsulin regimen was also optimized accordingly during his \nhospitalization, now on 30 units of glargine at bedtime, 5 units \nof Humalog at Breakfast and Dinner, and 7 units of Humalog at \nLunch. For his AFib, he was started on 2.5 mg PO BID of apixaban \nafter discussing anticoagulation options with his cardiologist, \nDr. ___. The patient also had a mildly elevated INR without \nany clear etiology; mixing studies were sent but uninterpretable \nper hematology, with recommendation for outpatient follow up \nwith no immediate concern for bleeding risk.\n\nACUTE/ACTIVE ISSUES:\n====================\n# R foot wound (ischemic ulcer vs. infectious ulcer)\nDebrided in ___ clinic, admitted for worsening foot wound.\nCRP was elevated to 122.3, concerning for osteomyelitis. \nPodiatry then performed tissue debridement and exploration which \nnecessitated a right foot partial ___ ray amputation and \napplication of wound vac on ___, and sent specimens to \npathology which returned with negative margins for active \nosteomyelitis. Wound culture obtained during the surgery grew \nMSSA. He was discharged to complete a 7 day course of Augmentin \n(final day of antibiotics: ___. Multi-podus off-loading \nboot for heel wound was recommended by vascular surgery. To get \nwound vac again at rehab.\n\n# Chronic limb ischemia\n# Peripheral artery disease\nSeen by vascular surgery for likely chronic limb ischemia. ___\n(+) with doppler b/l. A right lower extremity angiogram showed \nevidence of stenosis in the anterior and posterior tibial \narteries, requiring angioplasty and stent placement respectively \n(on ___. He was subsequently placed on clopidogrel to \ncomplete a 30 day regimen (D1 ___, final day ___. He \nwas continued on his home gabapentin and received Tylenol as \nneeded for pain control.\n\n#H/o pAFib not on AC\nPer PCP, he was never started on AC after being diagnosed ___ \nyears ago in setting of GI bleeding. His Cardiologist Dr. \n___ was reached by email who agreed to start on AC. He was \nstarted on 2.5 mg PO BID apixaban.\n\n#Insulin dependent diabetes ___\n#Hyperglycemia\nHe received standing insulin (Glargine and Humalog) as well as a \nsliding scale. He should be evaluated by Nutrition and receive \ndiabetic diet education.\n\nCHRONIC/STABLE ISSUES:\n======================\n#Coagulopathy\nHis INR was noted to be elevated to ~1.5 during this admission, \neven while not on anticoagulation. Trialed on 3 days of vitamin \nK challenge with only minimal improvement. It is possible that \nthis is due to a factor inhibitor, and further evaluation can be \nperformed in the outpatient setting.\n\n# ESRD ___ DM/HTN: \nOn HD ___ via LUE AVF since ___, which was continued during \nthis admission. His home sevelamer and calcium carbonate were \ncontinued.\n\n#Hyperkalemia\nOn admission serum K 6.5 and he was given calcium gluconate x1. \nECG did not have T wave abnormalities. He received HD ___ \nwhile inpatient.\n\n# Hyponatremia (hypervolemic)\nLikely in the setting of volume overload from missing dialysis,\nadditionally in the setting of acute infection and \nhyperglycemia. He wsa noted to have normal mental status. Acute \nintervention was not required.\n\n#HTN\nHe was continued on his home metoprolol. His home irbesartan was \nnon-formulary, so he received valsartan instead.\n\n#HFrEF: EF 35%. He was not decompensated during this admission. \nHe received volume control with dialysis. He was continued on \nhis home metoprolol succinate. His home irbesartan was \nnon-formulary, so he received valsartan instead.\n\n#Gout\ncontinued home allopurinol ___ every other day\n\nTRANSITIONAL ISSUES\n=================\n[] He was discharged with a 7 day course of Augmentin, which \nwill be completed on ___\n[] He was started on clopidogrel to complete a 30 day regimen \n(D1 ___, final day ___\n[] A wound vac should be placed to his right foot wound while at \nrehab on either ___ or ___.\nWound Vacuum Specifications:\n 1. Wound measurements: ~ 5 x 4 cm\n 2. Sponge Size and Color: Small black\n 3. Frequency of Change: Every 3 days\n 4. Pressure: 125 mmHg continuous\n 5. Outer dressing: ABD to protect skin from tubing, ACE wrap\n 6. WB status: NWB to the RLE while vac in tact \n[] Please place his right leg in a multi-podus off-loading boot \nfor heel wound\n[] He should be evaluated by Nutrition and receive diabetic diet \neducation.\n[] Hemodialysis ___ should be continued as an outpatient.\n[] He should receive outpatient workup for his elevated PTT, \nwhich was noted during this admission.\n\n# CODE: Full\n# CONTACT: \n Proxy name: ___ \n Relationship: Sister \n Phone: ___ (home), ___ (cell)\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. irbesartan 300 mg oral DAILY \n3. Gabapentin 300 mg PO TID:PRN pain \n4. Pantoprazole 40 mg PO Q24H \n5. Allopurinol ___ mg PO EVERY OTHER DAY \n6. Loratadine 10 mg PO DAILY:PRN allergies \n7. Metoprolol Succinate XL 50 mg PO DAILY \n8. Glargine 20 Units Breakfast\nGlargine 20 Units Lunch\nGlargine 20 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin\n9. sevelamer CARBONATE 1600 mg PO TID W/MEALS \n10. Calcium Carbonate 500 mg PO QIDACHS \n\n \nDischarge Medications:\n1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days \n\n2. Apixaban 2.5 mg PO BID \n3. Clopidogrel 75 mg PO DAILY \n4. Miconazole Powder 2% 1 Appl TP BID \n5. Glargine 30 Units Bedtime\nHumalog 5 Units Breakfast\nHumalog 7 Units Lunch\nHumalog 5 Units Dinner\nInsulin SC Sliding Scale using HUM Insulin \n6. Loratadine 5 mg PO DAILY:PRN allergies \n7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n8. Allopurinol ___ mg PO EVERY OTHER DAY \n9. Calcium Carbonate 500 mg PO QIDACHS \n10. Gabapentin 300 mg PO TID:PRN pain \n11. irbesartan 300 mg oral DAILY \n12. Metoprolol Succinate XL 50 mg PO DAILY \n13. Pantoprazole 40 mg PO Q24H \n14. sevelamer CARBONATE 1600 mg PO TID W/MEALS \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPrimary Diagnoses:\nRight foot osteomyelitis\nRight foot diabetic ulcer\nPeripheral artery disease\nChronic limb ischemia\nCoagulopathy of uncertain discharge\nHyperkalemia\nHyponatremia\n\nSecondary Diagnoses:\nParoxysmal Atrial Fibrillation, non-valvular\nInsulin dependent diabetes ___\nHypertension\nHeart failure with reduced ejection fraction\nGout\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 ___,\n\nIt was a privilege taking care of you at ___ \n___. \n\nWHY WAS I ADMITTED TO THE HOSPITAL?\n===================================\n-You were admitted here for treatment an infection in and poor \nblood supply to the ___ digit of your right foot.\n\nWHAT HAPPENED WHILE I WAS IN THE HOSPITAL?\n==========================================\n- Your non-healing wound on your right fifth toe was found to \nhave signs of infection and tissue death, so your podiatry team \namputated the toe. To help with the healing process, you will \nbe on a wound vacuum while at rehab and will be taking seven \ndays of Augmentin, an antibiotic, to prevent further infection. \n\n- You were evaluated for poor blood circulation in your right \nleg with an angiogram, which required placement of a stent to \nincrease blood circulation in your lower leg arteries. You were \nstarted on a blood thinner known as Plavix (clopidogrel) on ___, which you will need to continue daily (75 mg dose) for 30 \ndays until ___. \n\n- You were also evaluated for your atrial fibrillation which was \npreviously diagnosed ___ years ago. You were not on medication \nto prevent the formation of blood clots on admission. After \ndiscussing the most appropriate medication regimen with your \ncardiologist, Dr. ___ agreed to start you on a blood \nthinner known as apixaban, at a dose of 2.5 mg twice a day. \n\n- We adjusted your insulin regimen given your high blood sugars \non your previous home regimen. You were most recently on 30 \nunits of glargine at bedtime, 5 units of Humalog at Breakfast \nand Dinner, and 7 units of Humalog at Lunch. We recommend \ncontinuing to optimize your regimen with your care team at rehab \nand in the outpatient setting, and also ensuring that you eat \nconsistent, portion controlled meals during the day.\n\n- Lastly, lab tests showed that you had an elevated INR, which \nmeasures how much time it takes for a patient's blood to clot. \nWe ordered a blood mixing study to determine if there were \npotential deficiencies in certain clotting factors in your \nblood; however, the study was unable to be completed. There were \nno immediate concerns for your elevated INR. This can be further \ndiscussed with your outpatient provider and possibly evaluated \nwith a hematologist in the future.\n\nWHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?\n============================================ \n- Please continue to take all your medications and follow up \nwith your doctors at your ___ appointments. \n\n-Weigh yourself every morning, and call MD if weight goes up \nmore than 3 lbs.\n\nWe wish you all the best!\n\nSincerely, \nYour ___ Care Team \n\n \nFollowup Instructions:\n___\n" ]

[ "E1052", "N186", "I70261", "I5022", "E871", "M86171", "I132", "L03115", "D688", "L97518", "E872", "E1069", "Z8572", "E875", "E10621", "I480", "B9561", "G4733", "E1065", "Z992", "E1022", "E8770", "M109", "E1042", "I2510", "E669", "Z6837", "E785", "E213", "D649", "J302" ]

[ "E1052: Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene", "N186: End stage renal disease", "I70261: Atherosclerosis of native arteries of extremities with gangrene, right leg", "I5022: Chronic systolic (congestive) heart failure", "E871: Hypo-osmolality and hyponatremia", "M86171: Other acute osteomyelitis, right ankle and foot", "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "L03115: Cellulitis of right lower limb", "D688: Other specified coagulation defects", "L97518: Non-pressure chronic ulcer of other part of right foot with other specified severity", "E872: Acidosis", "E1069: Type 1 diabetes mellitus with other specified complication", "Z8572: Personal history of non-Hodgkin lymphomas", "E875: Hyperkalemia", "E10621: Type 1 diabetes mellitus with foot ulcer", "I480: Paroxysmal atrial fibrillation", "B9561: Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere", "G4733: Obstructive sleep apnea (adult) (pediatric)", "E1065: Type 1 diabetes mellitus with hyperglycemia", "Z992: Dependence on renal dialysis", "E1022: Type 1 diabetes mellitus with diabetic chronic kidney disease", "E8770: Fluid overload, unspecified", "M109: Gout, unspecified", "E1042: Type 1 diabetes mellitus with diabetic polyneuropathy", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E669: Obesity, unspecified", "Z6837: Body mass index [BMI] 37.0-37.9, adult", "E785: Hyperlipidemia, unspecified", "E213: Hyperparathyroidism, unspecified", "D649: Anemia, unspecified", "J302: Other seasonal allergic rhinitis" ]

[ "E871", "E872", "I480", "G4733", "M109", "I2510", "E669", "E785", "D649" ]

[]

[ " \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:\nEpistaxis, leg redness\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ male with past medical history end-stage renal \ndisease on a ___ dialysis who presents from \nthe dialysis center with epistaxis and 1 day of redness, pain \nand purulent wound to the left lower extremity. He was admitted \nto ___ for 10 days, discharged yesterday for lower \nGI bleeding. During that admission, he had EGD, colonoscopy \nwhich demonstrated duodenal ulcers and polyps. He states that he \nwas transfused 5 units while at ___. He felt well \nupon waking today. He went to his scheduled dialysis, which he \nstates he completed without difficulties. Approximately 1 hour \nprior to the end of dialysis he started to have epistaxis \nprimarily of the right nare. He is not anticoagulated. Pressure \nwas applied and he was transferred to ___ ED for eval. during \ndialysis, he was also noted to have left lower leg erythema that \nhe states has been new over the last day. The leg has 2 wounds \nthat have been dressed by nurses while in ___, and \nper patient there was no concern for infection during that time.\n\nToday while at dialysis he started to have epistaxis. Staff at \ndial___ also noted that his left leg seem to be red, and he \nfelt that this was new today. He has had no fevers, no chest \npain, no difficulty breathing. He reports light brown stools \nwithout blood since his discharge from ___. \n\ntachy on arrival. afib on ekg. patient does not know of any \nhistory of AFib. Unclear trigger, possibly infection however \ninfection has reported short course so far. No anticoagulation. \nGiven small amount of hydration as he had 1.5 L removed at \ndialysis today, however did not want to hydrate him too much as \nhe was dyspneic with O2 sats 92% on room air. Dyspnea improved \non nasal cannula. Given 5 IV metoprolol. Treating cellulitis.\n\nIn the ED, initial vitals were: 99.3 131/71 101 18 92%RA\n- Exam notable for: \nnares: dried blood throughout. no visible source of bleeding, no \nactive bleeding\nent: scant dried blood to posterior orpharynx. no clots. \nLLE: circumferential erythema, with 2cm wound to medial tibial \nsurface, fibrinous discharge apparent. \n\n- Labs notable for: \n\n8.1>8.5/25.0<154 with 85%N\n\n___\n---------<203\n3.7/31/3.8\n\n___ 15.0/1.4 with normal PTT\n\n- Imaging was notable for: \nCXR PA/LAT\nAP upright and lateral views of the chest provided. Lung volumes \nare low and there is bronchovascular crowding in the lower \nlungs. Tiny pleural effusions are suspected. No convincing signs \nof pneumonia or overt edema. Difficult to exclude mild \ncongestion. Cardiomediastinal silhouette is stable. No large \neffusion or pneumothorax. Bony structures are intact. \n\n- Patient was given: ceftriaxone 1g IV, vancomycin 1000mg, \n500cc NS, metoprolol tartrate 5mg IV x1\n- Vitals prior to transfer: 98.6 115/50 84 18 99%NC\n\nUpon arrival to the floor, patient reported feeling much better \nwithout continued bleeding.\n\nREVIEW OF SYSTEMS: \n(+) Per HPI \n(-) 10 point ROS reviewed and negative unless stated above in \nHPI \n \n\n \nPast Medical History:\n-heart failure w/preserved EF\n -ESRD\n-DM2\n-htn\n-obesity\n-OSA on CPAP \n-Seasonal allergy. \n-History of pneumonia in ___ leading to ESRD in setting of \nlong-standing DM2\n-CAD\n-diffuse large B cell lymphoma\n \nSocial History:\n___\nFamily History:\nHe denies any family history of kidney disease. His father with \ndiabetes ___ and hypertension died at age ___ due to heart \nattack. His mother with diabetes ___ is in her ___'s. \n\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM\n=======================\nVital Signs: 98.7 102/61 117 20 94%2L\nGeneral: Alert, oriented, no acute distress \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. \nNeck: Supple. JVP not elevated. no LAD \nCV: Irregular, tachycardia. Normal S1+S2, no murmurs, rubs, \ngallops. \nLungs: Clear to auscultation bilaterally, decreased at bases \nAbdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \nGU: No foley \nExt: L leg with tender warm erythematous region outlined, as \nwell as open wound on medial aspect of shin with granulation \ntissue\nNeuro: CNII-XII intact, ___ strength upper/lower extremities, \ngrossly normal sensation, 2+ reflexes bilaterally, gait \ndeferred. \n\nDISCHARGE PHYSICAL EXAM\n=======================\nVital Signs: 97.3 114/67 85 20 93% RA \nGeneral: Alert, oriented, no acute distress \nHEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL. \nNeck: Supple. JVP not elevated. no LAD \nCV: Irregular, tachycardia. Normal S1+S2, no murmurs, rubs, \ngallops. \nLungs: Mild bibasilar crackles\nAbdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \nGU: No foley \nExt: L leg with non-tender cool erythematous region outlined, as \nwell as open wound on medial aspect of shin with granulation \ntissue, about 85% improving from admission. Significant \nbilateral lower extremity edema.\nNeuro: CNII-XII intact, ___ strength upper/lower extremities, \ngrossly normal sensation, 2+ reflexes bilaterally, gait \ndeferred. Effusive affect, incongruent with situation.\n \nPertinent Results:\nADMISSION LABS\n==============\n___ 06:55PM BLOOD WBC-8.1 RBC-2.63* Hgb-8.5* Hct-25.0*# \nMCV-95# MCH-32.3* MCHC-34.0 RDW-18.1* RDWSD-62.4* Plt ___\n___ 06:55PM BLOOD ___ PTT-34.3 ___\n___ 06:55PM BLOOD Glucose-203* UreaN-22* Creat-3.8*# Na-138 \nK-3.7 Cl-94* HCO3-31 AnGap-17\n___ 09:36AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.8\n___ 01:35AM BLOOD UricAcd-3.6\n\nPERTINENT STUDIES/IMAGING/MICRO\n===============================\nCXR ___\nFINDINGS: \nAP upright and lateral views of the chest provided. Lung \nvolumes are low and there is bronchovascular crowding in the \nlower lungs. Tiny pleural effusions are suspected. No \nconvincing signs of pneumonia or overt edema. Difficult to \nexclude mild congestion. Cardiomediastinal silhouette is \nstable. No large effusion or pneumothorax. Bony structures are \nintact. \n \nIMPRESSION: \nAs above. \n\n___ 6:55 pm BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n\n___ 7:52 pm BLOOD CULTURE 2 OF 2. \n\n Blood Culture, Routine (Pending): \n\nDISCHARGE LABS\n==============\n___ 07:45AM BLOOD WBC-5.7 RBC-2.43* Hgb-7.7* Hct-22.9* \nMCV-94 MCH-31.7 MCHC-33.6 RDW-17.3* RDWSD-59.1* Plt ___\n___ 07:45AM BLOOD ___ PTT-35.7 ___\n___ 07:45AM BLOOD Glucose-170* UreaN-54* Creat-7.2*# Na-135 \nK-4.1 Cl-95* HCO3-25 AnGap-19\n___ 07:45AM BLOOD Calcium-8.1* Phos-4.0 Mg-1.8\n \nBrief Hospital Course:\nMr. ___ is a ___ man with ESRD on HD, diffuse \nlarge B-cell lymphoma on R CHOP, diastolic heart failure and \nhistory of GI bleed recently discharged from ___ \nafter GIB requiring multiple units pRBC with multiple duodenal \nulcers who presents after being found to have cellulitis and \nepistaxis at hemodialysis center on ___. Epistaxis resolved on \nday of admission with pressure and nasal sprays without any \nfurther problems. He was initially treated with IV \nvancomycin/cefepime for cellulitis and was transitioned to \naugmentin 500mg Q24H for a total of 10 days to end ___. His \ncellulitis was significantly improved prior to discharge but \nstill resolving. He had dialysis with ultrafiltration to remove \nexcess fluid and was discharged at a weight of 121kg. He \ncontinued to be in recently diagnosed atrial fibrillation \nthroughout this admission and was treated with rate control but \nwas not started on anticoagulation due to his recent bleeding \nevents. As he was clinically stable with improving cellulitis \nand no further bleeding episodes, he was discharged with plan to \nfollow up with his PCP and oncologist.\n\n#Cellulitis: Likely due to venous stasis ulcers and component of \nprobable tinea pedis. Initially treated with IV vanc/cefepime \n___ then transitioned to oral augmentin 500mg Q24H for total \n10 day course to end ___. Greatly improved with about 85% \nreduction in erythema prior to discharge, and was stable after \nswitching to PO antibiotics.\n\n#Acute on chronic diastolic heart failure: Patient with hypoxia \nand tachypnea which improved after dialysis and ultrafiltration. \nLikely had not been dialyzed to true dry weight on admission. He \nwas dialyzed to a weight of 120kg prior to discharge without O2 \nrequirements. He will get further ultrafiltration today ___ at \ndialysis.\nHis previous dry weight was thought to be ~122 kg but unclear \nhow accurate this is. His weight on discharge from ___ was \n117 kg. \n\n#Coagulopathy: Unclear etiology. Potentially due to nutritional \ndeficiency after recent hospitalization. He was given 5mg IV vit \nKx1 and a total of 15mg PO vitamin K prior to discharge. His INR \nwas 1.5 prior to discharge and should continue to be monitored. \nPotential etiologies also include progression of his DLBCL vs. \npotential liver disease. Will likely need further outpatient \nworkup and recheck of INR.\n\n#Epistaxis: Had significant epistaxis at hemodialysis on ___ \nwithout clear precipitating factor. Resolved with afrin, \npressure without further problems. \n\n#Atrial fibrillation: Newly diagnosed at hospitalization at \n___ for GIB. Not on anticoagulation given recent bleeding \nepisodes. He was continued on metoprolol succinate 50mg XL \nduring his hospitalization with good rate control. He continued \nto be in atrial fibrillation throughout his hospitalization. He \nwill need discussion regarding risks and benefits of \nanticoagulation as an outpatient and potential discussion of \ncardioversion if he cannot be anticoagulated. \n\n#Anemia\n#GIB: No further black stools during admission, though had large \nduodenal ulcers at ___ and recent GIB there. He is s/p 1u \nPRBC on admission without need for further transfusion. He was \ncontinued on PPI throughout and had a pending capsule study at \n___. \n\n# ESRD on HD: He was continued on ___ hemodialysis (and ___ \nevery other week). Home diuretics were discontinued as patient \nwas not making significant amounts of urine. He was continued on \nhome sevelamer and calcitriol.\n\n# CAD\n# Troponin elevation: Likely demand in the setting of volume \noverload, atrial fibrillation and anemia. Negative CTA at \n___. Abnormal perfusion stress in ___, supposed to see \ncardiology as an outpatient. Likely has underlying CAD. Troponin \npeaked at .23 during this admission. No ischemic changes on EKG. \n \n\n# Diabetes: Patient was started on lower dose of Lantus of 20U \nBID from home regimen given reports of poor PO intake and \nconcern for hypoglycemia prior to admission. He was discharged \non regimen of lantus 20 U BID, with instructions to check his \nblood sugars regularly and titrate his insulin accordingly. He \nexpressed comfort and understanding of this plan.\n \n# Diffuse large B-cell lymphoma: Patient reports he was due for \nanother cycle during admission which was deferred in the setting \nof acute illness. LDH and uric acid wnl and no c/f TLS. His \noutpatient oncologist plans to resume R-CHOP soon after this \ndischarge. \n \n# Hypertension: Patients home meds were restarted after \nstabilization of bleeding and infection.\n\n# CODE: full (confirmed) \n# CONTACT: sister, ___ ___, or \n___\n\nTRANSITIONAL ISSUES\n=================== \n[ ] Please continue to monitor INR, was elevated to 1.5 during \nadmission, got vitamin K prior to discharge. Consider work up \nfor etiology of coagulopathy if no response to vitamin K.\n[ ] Please recheck CBC at next appointment to ensure anemia is \nimproving/stable\n[ ] Patient with newly diagnosed atrial fibrillation and high \nCHADsVASC score; anticoagulation not started due to recent \nbleeds, please discuss with patient and consider rhythm control \nstrategy if anticoagulation contraindicated.\n[ ] Antibiotic course: Augmentin 500mg PO Q24H last day ___ for \ntotal of 10 day course. Please reexamine leg before giving him \nanother round of R-CHOP to ensure it still looks on track to \nresolve.\n[ ] Discharge weight 120kg\n[ ] Obtain records from ___ for capsule study results\n[ ] Furosemide discontinued as patient making minimal urine and \nthought to be ineffective\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Metoprolol Succinate XL 50 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. irbesartan 300 mg oral DAILY \n4. Allopurinol ___ mg PO EVERY OTHER DAY \n5. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n6. Cinacalcet 60 mg PO 5X/WEEK (___) \n7. sevelamer CARBONATE 2400 mg PO TID W/MEALS \n8. Glargine 20 Units Breakfast\nGlargine 20 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n9. Omeprazole 40 mg PO DAILY \n10. Furosemide 80 mg PO BID \n11. Calcium Carbonate 1250 mg PO TID W/MEALS with each meal \n\n \nDischarge Medications:\n1. Amoxicillin-Clavulanic Acid ___ mg PO Q24H \nTake through ___. \nRX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by \nmouth Daily Disp #*5 Tablet Refills:*0 \n2. Glargine 20 Units Breakfast\nGlargine 20 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n4. Allopurinol ___ mg PO EVERY OTHER DAY \n5. Atorvastatin 80 mg PO QPM \n6. Calcium Carbonate 1250 mg PO TID W/MEALS with each meal \n7. Cinacalcet 60 mg PO 5X/WEEK (___) \n8. irbesartan 300 mg oral DAILY \n9. Metoprolol Succinate XL 50 mg PO DAILY \n10. Omeprazole 40 mg PO DAILY \n11. sevelamer CARBONATE 2400 mg PO TID W/MEALS \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS\n=================\nCellulitis\nAcute on chronic diastolic heart failure\nEpistaxis\n\nSECONDARY DIAGNOSIS\n===================\nObstructive sleep apnea\nAtrial fibrillation\nDiabetes ___ type 2\nEnd-stage renal disease on hemodialysis\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane).\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou came to the hospital because you were experiencing profuse \nbleeding from your nose as well as swelling and redness of one \nof your legs. Your bleeding stopped with pressure and some nasal \nsprays. \n\nYou were found to have an infection of your leg called \ncellulitis. You received IV antibiotics for this and were \nswitched to pill antibiotics which you will need to continue for \nthe next few days. \n\nYou were also intermittently needing some oxygen to help with \nyour breathing. This was probably due to accumulation of fluid \nand you had extra fluid taken off at dialysis.\n\nYour coagulation numbers (INR) were slightly high during your \nhospital stay and you should make sure to follow up with your \nprimary care doctor and oncologist about this.\n\nPlease continue to follow up with your doctors and take your \nmedications as prescribed.\n\nIt was a pleasure taking care of you,\nYour ___ Care Team\n \n ___ MD ___\n \nCompleted by: ___\n" ]

[ "L03116", "I5033", "C8332", "N186", "D689", "E1122", "K269", "I83228", "L97829", "I132", "R040", "G4733", "I2510", "E669", "Z6835", "Z992", "Z794", "I4891", "D122", "D123", "B353", "R0902" ]

[ "L03116: Cellulitis of left lower limb", "I5033: Acute on chronic diastolic (congestive) heart failure", "C8332: Diffuse large B-cell lymphoma, intrathoracic lymph nodes", "N186: End stage renal disease", "D689: Coagulation defect, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "K269: Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation", "I83228: Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation", "L97829: Non-pressure chronic ulcer of other part of left lower leg with unspecified severity", "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "R040: Epistaxis", "G4733: Obstructive sleep apnea (adult) (pediatric)", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "E669: Obesity, unspecified", "Z6835: Body mass index [BMI] 35.0-35.9, adult", "Z992: Dependence on renal dialysis", "Z794: Long term (current) use of insulin", "I4891: Unspecified atrial fibrillation", "D122: Benign neoplasm of ascending colon", "D123: Benign neoplasm of transverse colon", "B353: Tinea pedis", "R0902: Hypoxemia" ]

[ "E1122", "G4733", "I2510", "E669", "Z794", "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\n \nMajor Surgical or Invasive Procedure:\nHemodialysis - ___\n \nHistory of Present Illness:\nMr. ___ is a ___ male with history of DLBCL on\nR-CHOP, ESRD on HD (MWF), diastolic heart failure, and newly\ndiagnosed atrial fibrillation (on rate control, not on\nanticoagulation ___ recent GI bleed) who presents with dyspnea \non\nexertion, anemia, and weakness.\n\nThe patient presented to ___ clinic morning of admission \nfor\n___ cycle R-CHOP. He has been doing poorly with more weakness \nand\nfeeling drained since ___ after HD. He uses a walker at\nbaseline but was unable to get up a single step to his second\nfloor bedroom due to severe weakness in his arms and legs. He\ncalled the police who came to his ___ and carried him up the\nstairs to his bedroom. He spent the weekend on the second floor.\nOn ___ he had his ___ and ___ visit who noted him to be very\nweak while using the walker and called a chair car to bring him\nto dialysis. However, this arrived too late and he missed his HD\nappointment that day. He instead went for dialysis on ___ \nand\n___ which were uneventful and he completed both sessions.\nHe has ordered a hospital bed for the first floor but it has not\narrived yet. He also notes dyspnea on exertion. He continues to\nfeel progressively weak and unable to walk more than a few steps\nwith the walker. He notes mild cough that he feels is from post\nnasal drip and allergies. He notes he has lower extremity edema\nwhich is improved after his ___ started using compression\nstockings. He believes he is close to his dry weight which he\nthinks is about 121kg. He makes a very small amount of urine \neach\nday.\n\nOn arrival to the ED, initial vitals were 97.1 86 151/71 18 96%\n2L. Labs were notable for WBC 9.9, H/H 6.9/21.9, Plt 196, INR\n1.6, Na 130, K 6.7 (hemolyzed) -> 4.7 , BUN/Cr 33/5.0, glucose\n249, Trop 0.34, and BNP >70k. CXR showed pulmonary vascular\ncongestion and no focal consolidation. Patient was given calcium\ncarbonate 500mg PO and sevelamer 1600mg PO. ___ Oncology (Dr.\n___ was consulted who recommended no diuresis, no\ntransfusion, TTE, and admission to OMED. Atrius Cardiology was\nconsulted and unsure if saw patient/left recommendations. Prior\nto transfer vitals were 98.2 87 130/73 18 96% 2L.\n\nOn arrival to the floor, patient reports weakness and \ngeneralized\nfatigue. He notes occasional numbness in his fingers and toes. \nHe\ndenies fevers/chills, night sweats, headache, vision changes,\ndizziness/lightheadedness, hemoptysis, chest pain, palpitations,\nabdominal pain, nausea/vomiting, diarrhea, hematemesis,\nhematochezia/melena, dysuria, hematuria, urinary/fecal\nincontinence, and new rashes.\n\n \nPast Medical History:\n-heart failure w/preserved EF\n-ESRD\n-DM2\n-htn\n-obesity\n-OSA on CPAP \n-Seasonal allergy. \n-History of pneumonia in ___ leading to ESRD in setting of \nlong-standing DM2\n-CAD\n-diffuse large B cell lymphoma\n\nPAST ONCOLOGIC HISTORY:\n- ___ by Dr ___ management of his newly\ndiagnosed B cell diffuse large cell lymphoma, dx'd by a core\nbiopsy 5 d ago of a large pelvic mass. He noted RLE swelling in\nearly ___. LENIs were negative for clot but did show an\nenlarged groin node. The picture was felt to be from a prior\ncellulitis of his foot and he was followed. His swelling\ncontinued and repeat LENIs in early ___ showed suggestion of \nan\nobstruction higher up and he underwent a CT of his abdomen and\npelvis that showed a large pelvic mass with splenomegaly and\nmediastinal and portacaval adenopathy and lytic lesions in the\nright pubic symphysis and inferior pubic ramus. A subsequent \nPET\nscan delineated those areas as well as moderate disease in his\nchest. He underwent a core bx in ___ last week which showed B \ncell\ndiffuse large cell lymphoma, germinal center origin (better\nprognosis) with a high proliferative index of 80-90%.\nCytogenetics showed bcl 6 rearrangement but no worrisome\nmutations. Interestingly, his LDH is normal. He continues to \nhave\nRLE edema but denies any abdominal pain or pelvic pain. His wt \nis\nstable. He denies any fevers, night sweats or pruritis. He has\nmultiple medical problems with DM since adolescence and has been\non dialysis for the past ___ years. He denies any cardiac disease\nbut did have mild dysfunction on a cardiac PET test a year ago.\nHe is complaining of left elbow pain, having fallen at dialysis\nseveral days ago, striking his left elbow and leg. Xrays at the\n___ were negative. Sent home without a sling or any advice. Exam\nshowed obesity, 3 fb splenomegaly, pain, swelling left elbow and\n2+ RLE edema Labs: Hct 32, LDH- 171, protein elec-normal. Hep\nserologies normal. \nA: Stage IIIA large cell lymphoma. High intermediate risk given\nage, performance status and multiple sites of disease with CR\nestimated at 56%, ___ year OS of 37%. Recommended Rit/CHOP chemo.\n- ___: Started chemo with Rit/CHOP. Split dose Rituxan with \n50\nmg/m2 given on day 1. The rest to be given day 6. Under mistaken\nimpression that he was to take his prednisone indefinitely so\nstayed on it until subsequent GI bleed.\n- ___/: Rituxan given.\n- ___: Hosp FH for acute GI bleed. Upper endoscopy showed\nduodenal ulcers. Missed chemo ___ due to miscommunication.\n- ___: Hosp ___ for ___ cellulitis LLE and epistaxis. Also\nhad paroxysmal atrial fib. \n- ___: Cycle 2 Rit/CHOP given. Neulasta given on day 2.\nTreatment delayed 2 wks due to gi bleed and LLE cellulitis.\n- ___: CT showed near resolution of soft tissue masses in \nright iliopsoas and obturator internus muscles, persistence of \nsplenomegaly and bone lytic lesions \n- ___: Resumed chemo with rituxin and bendamustine\n- ___: Received day 2 of rituxin and bendamustine\n\n \nSocial History:\n___\nFamily History:\nHe denies any family history of kidney disease. His father with \ndiabetes ___ and hypertension died at age ___ due to heart \nattack. His mother with diabetes ___ is in her ___. \n\n \nPhysical Exam:\nADMISSION EXAM:\nVS: Temp 98.7, BP 119/74, HR 100, RR 20, O2 sat 96% 3L.\nWeight: 122 kg\nGENERAL: Pleasant man, in no distress, lying in bed comfortably.\nSpeaking in full sentences.\nHEENT: Anicteric, PERLL, OP clear.\nCARDIAC: Irregularly irregular rhythm, normal s1/s2, no m/r/g.\nLUNG: Appears in no respiratory distress, bibasilar inspiratory\ncrackles. JVP elevated to the ear.\nABD: Obese, soft, non-tender, non-distended, normal bowel \nsounds.\nEXT: Warm, well perfused, 2+ bilateral lower extremity pitting\nedema to the hips. Bilateral venous\nNEURO: A&Ox3, good attention and linear thought, CN II-XII\nintact. Strength full throughout. Sensation to light touch\nintact. Able to state ___ backwards.\nSKIN: Bilateral chronic venous stasis changes. Scattered\nexcoriations on bilateral lower extremities.\nEXTREM: LUE AVF.\n\nDISCHARGE EXAM:\nVITALS: 97.6PO 145 / 74 88 18 97 Ra\nGENERAL: Pleasant man, in no distress, lying in bed comfortably.\nSpeaking in full sentences.\nEYES: Anicteric, PERLLA.\nCARDIAC: JVP at mid neck with HOB at 45 degrees, irregularly \nirregular rhythm, no r/m/g\nLUNGS: Crackles at lung bases\nABD: soft, NT/ND no HSM.\nEXT: trace ___ edema, compression stockings in place\nNEURO: A&Ox3, good attention and linear thought, no focal \ndeficits.\nSKIN: Bilateral chronic venous stasis changes. Scattered \nexcoriations on bilateral lower extremities.\nEXTREM: LUE AVF, +thrill +bruit\nPSYCH - pleasant\n\n \nPertinent Results:\nADMISSION RESULTS:\n___ 01:26PM BLOOD WBC-9.9# RBC-2.23* Hgb-6.9* Hct-21.9* \nMCV-98 MCH-30.9 MCHC-31.5* RDW-22.3* RDWSD-74.6* Plt ___\n___ 01:26PM BLOOD ___ PTT-35.4 ___\n___ 01:26PM BLOOD Glucose-249* UreaN-33* Creat-5.0*# \nNa-130* K-6.7* Cl-88* HCO3-27 AnGap-22*\n___ 03:00PM BLOOD ALT-42* AST-14 LD(LDH)-243 AlkPhos-95 \nTotBili-0.7\n___ 03:00PM BLOOD calTIBC-243* Ferritn-2230* TRF-187*\n\nRELEVANT IMAGING:\n___ TTE:\nConclusions \nThe left atrium is mildly dilated. The right atrium is \nmoderately dilated. No atrial septal defect is seen by 2D or \ncolor Doppler. There is moderate symmetric left ventricular \nhypertrophy. The left ventricular cavity size is normal. There \nis moderate global left ventricular hypokinesis (LVEF = 30 %). \nThe right ventricular cavity is mildly dilated with mild global \nfree wall hypokinesis. The aortic arch is mildly dilated. The \naortic valve leaflets are moderately thickened. The mitral valve \nleaflets are mildly thickened. There is no mitral valve \nprolapse. The tricuspid valve leaflets are mildly thickened. \nThere is moderate pulmonary artery systolic hypertension. There \nis no pericardial effusion. \n\nIMPRESSION: Moderate global left ventricular hypokinesis. Mildly \ndilated right ventricle with mild free wall hypokinesis. Mildly \ndilated aortic arch. Moderate pulmonary hypertension. \n\n___ R leg US with Doppler:\nIMPRESSION: \nNo evidence of deep venous thrombosis in the right lower \nextremity veins. \n\n___ CT Torso with contrast:\n1. Near resolution of soft tissue masses within the right \niliopsoas and \nobturator internus muscles seen on the prior CT of the \nabdomen/pelvis from ___, in keeping with known diffuse \nlarge B-cell lymphoma. Persistent mild asymmetric enlargement \nof the right obturator internus muscle and soft tissue \nencasement of the right external iliac vessels. \n2. Unchanged splenomegaly. \n3. Unchanged lytic lesions within the right inferior pubic ramus \nand \nparasymphyseal region. \n4. Small amount of scattered ascites within the abdomen and \npelvis, new from prior. \n5. Persistent mediastinal lymphadenopathy, improved compared to \nPET-CT from ___. \n6. Geographic areas air trapping in the lungs, suggestive of \nsmall airways \ndisease. \n7. Several scattered calcified granulomas in both lungs, as well \nas other tiny pulmonary nodules measuring 3 mm or less, which \nare not definitely calcified. Attention on follow-up is \nrecommended. \n8. Unchanged sclerosis and a moderate compression deformity of \nthe T3 \nvertebral body. \n\n \nBrief Hospital Course:\nMr. ___ is a ___ with history of DLBCL on R-CHOP, ESRD on HD \n(MWF), diastolic heart failure, and atrial fibrillation (not on \nanticoagulation ___ GI bleed with duodenal ulcers) admitted with \nweakness and dyspnea, found to have newly depressed EF to 30%. \n\n#Acute on chronic systolic HF: TTE on admission with newly \ndepressed EF to 30% with global hypokinesis, concerning for \ndoxorubicin-induced cardiomyopathy (although tachy-mediated \ncardiomyopathy also possible given new AF). Cardiology \nconsulted, recommended continuing home meds irbesartan and \nmetoprolol. Volume was managed with HD. He received adjusted \nchemotherapy due to concern for toxicity.\nDischarge weight: 117 kg\n\n# DLBCL: Stage IIIA large cell lymphoma, presented s/p C2 of \nR-CHOP. High-intermediate risk given age, performance status and \nmultiple sites of disease with CR estimated at 56%, ___ year OS of \n37%. Unusually, pt's LDH was wnl, raising possibility of \nindolent lymphoma (e.g. in spleen, bone) transforming to \nhigh-grade lymphoma with masses in R iliopsoas and obturator \ninternus. The patient received 2 days of rituxan/bendamustine on \n___ and ___. He received two doses of neupogen on ___ and ___ \nprior to discharge, with plan for Onc f/u on ___ to receive \nneulasta.\n\n# ESRD on HD (MWF): Continue home sevelamer, calcitriol, and \ncalcium carbonate. Patient received ultrafiltration for \nmanagement of acute CHF, and continued with his regularly \nscheduled MWF dialysis. \n\n# Anemia of chronic disease with contribution of marrow \nsuppression from chemo: Stable throughout admission.\n\n# Atrial fibrillation: Continued home metoprolol for rate \ncontrol. Not on anticoagulation due to past GIB.\n\n# CAD: Continued on home metop and atorva. \n\n# IDDM: Continued on lantus 20U BID at home + HISS.\n\n# HTN: Continued on home irbesartan, metop\n\n# Hx GOUT: Continued on home allopurinol\n\nTRANSITIONAL ISSUES:\n====================\n- Please arrange transportation for patient to ___ \non ___ for Neulasta at 12:00 ___. He should then go to his \ndialysis sessiona\n- Follow up is recommended for several scattered calcified \ngranulomas in both lungs, as well as other tiny pulmonary \nnodules measuring 3 mm or less, which are not definitely \ncalcified found on CT A/P\n- Consider insulin adjustment on days where patient receives \ndexamethasone\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n2. Allopurinol ___ mg PO EVERY OTHER DAY \n3. Atorvastatin 80 mg PO QPM \n4. Calcium Carbonate 1250 mg PO TID W/MEALS with each meal \n5. Cinacalcet 60 mg PO 5X/WEEK (___) \n6. Metoprolol Succinate XL 50 mg PO DAILY \n7. sevelamer CARBONATE 2400 mg PO TID W/MEALS \n8. irbesartan 300 mg oral DAILY \n9. Pantoprazole 40 mg PO Q24H \n10. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n11. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n12. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/insomnia \n13. PredniSONE 50 mg PO BID AS DIRECTED WITH CHEMOTHERAPY \n14. Loratadine 10 mg PO DAILY:PRN allergies \n15. Glargine 20 Units Breakfast\nGlargine 15 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n\n \nDischarge Medications:\n1. Benzonatate 100 mg PO TID \n2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild \n3. Allopurinol ___ mg PO EVERY OTHER DAY \n4. Atorvastatin 80 mg PO QPM \n5. Calcium Carbonate 1250 mg PO TID W/MEALS with each meal \n6. Cinacalcet 60 mg PO 5X/WEEK (___) \n7. Glargine 20 Units Breakfast\nGlargine 15 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n8. irbesartan 300 mg oral DAILY \n9. Loratadine 10 mg PO DAILY:PRN allergies \n10. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/insomnia \n11. Metoprolol Succinate XL 50 mg PO DAILY \n12. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting \n13. Pantoprazole 40 mg PO Q24H \n14. PredniSONE 50 mg PO BID AS DIRECTED WITH CHEMOTHERAPY \n15. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting \n16. sevelamer CARBONATE 2400 mg PO TID W/MEALS \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\n-Acute on chronic systolic heart failure\n\nSECONDARY DIAGNOSES:\n-ESRD\n-Diffuse Large B Cell Lymphoma\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\nYou were recently admitted to the hospital after experiencing \nshortness of breath and weakness. While you were here, you were \ndiagnosed with worsening heart failure, likely due to one of the \nchemotherapy medications. \n\nThe heart failure was treated with medication as well as by \nremoving fluid from your body through hemodialysis. You were \nalso started on a new chemotherapy regimen for your lymphoma \nthat is now complete.\n\nIt has been a pleasure taking care of you. \n\nSincerely, \nYour ___ care team\n \nFollowup Instructions:\n___\n" ]

[ "I132", "I5033", "N186", "C8338", "D689", "E1122", "I427", "D62", "E11319", "E669", "E213", "Z6839", "E785", "G4733", "I2510", "I480", "I878", "J8410", "D6481", "M109", "R918", "R0902", "T451X5A", "Z992", "Z794", "Z833", "Y92009" ]

[ "I132: Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease", "I5033: Acute on chronic diastolic (congestive) heart failure", "N186: End stage renal disease", "C8338: Diffuse large B-cell lymphoma, lymph nodes of multiple sites", "D689: Coagulation defect, unspecified", "E1122: Type 2 diabetes mellitus with diabetic chronic kidney disease", "I427: Cardiomyopathy due to drug and external agent", "D62: Acute posthemorrhagic anemia", "E11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema", "E669: Obesity, unspecified", "E213: Hyperparathyroidism, unspecified", "Z6839: Body mass index [BMI] 39.0-39.9, adult", "E785: Hyperlipidemia, unspecified", "G4733: Obstructive sleep apnea (adult) (pediatric)", "I2510: Atherosclerotic heart disease of native coronary artery without angina pectoris", "I480: Paroxysmal atrial fibrillation", "I878: Other specified disorders of veins", "J8410: Pulmonary fibrosis, unspecified", "D6481: Anemia due to antineoplastic chemotherapy", "M109: Gout, unspecified", "R918: Other nonspecific abnormal finding of lung field", "R0902: Hypoxemia", "T451X5A: Adverse effect of antineoplastic and immunosuppressive drugs, initial encounter", "Z992: Dependence on renal dialysis", "Z794: Long term (current) use of insulin", "Z833: Family history of diabetes mellitus", "Y92009: Unspecified place in unspecified non-institutional (private) residence as the place of occurrence of the external cause" ]

[ "E1122", "D62", "E669", "E785", "G4733", "I2510", "I480", "M109", "Z794" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nmorbid obesity\n \nMajor Surgical or Invasive Procedure:\n___: laparoscopic sleeve gastrectomy\n\n \nHistory of Present Illness:\n___ is a ___ female referred for the evaluation\nof gastric restrictive surgery in the treatment and management \nof\nmorbid obesity by her primary care provider ___. \n___ ___ in\n___. ___ was seen and evaluated in our ___ clinic on ___ and ___.\n___ presented initially to begin the evaluation process in our\nProgram ___ and on ___ however she did not move\nforward secondary to undergo an left nephrectomy for renal\ncarcinoma on ___.\n\n___ has class III morbid obesity with weight of 258.5 pounds \nas\nof ___ with her initial screen weight of 261.9 pounds at\nheight of 64.5 inches and BMI of 43.7. On her presentation\n___ she weighed 282.2 pounds and on ___ she weighed\n273.6 pounds. Her previous weight loss efforts have included\nWeight Watchers, medical management, prescription weight loss\nmedication phentermine and self-directed diets. \n\nShe denied history of eating disorders -no\nanorexia, bulimia, diuretic or laxative abuse and she denied\nbinge eating with purging. She does have depression/anxiety and\nhas been followed by psychiatry at ___, has not been\nhospitalized for mental health issues and she is on psychotropic\nmedications (sertraline and clonazepam).\n \nPast Medical History:\nPCOS, anemia, appendectomy ___ years old,\nlaparoscopic urethral suspension in ___, one C-section.\n\n \nSocial History:\n___\nFamily History:\nNephrectomy in her uncle who recently had kidney cancer in \n___.\n\n \nPhysical Exam:\nExam Upon Discharge:\n\nFocused Physical Exam:\n24 HR Data (last updated ___ @ 542)\n Temp: 98.5 (Tm 98.7), BP: 137/78 (129-148/78-85), HR: 68\n(62-70), RR: 18 (___), O2 sat: 100% (98-100), O2 delivery: RA\nGen: Appears well, AAOx3\nCV: RRR\nResp: Normal effort, no distress\nAbdomen: Soft, nondistended, nontender, no rebound or guarding\nWound: all 5 dressings C/D\nExt: Warm, well perfused, no edema\n \nPertinent Results:\nN/A\n \nBrief Hospital Course:\n___ is a ___ morbid obesity who underwent a \nlaparoscopic sleeve gastrectomy on ___. There were no \nadverse events in the operating room; please see the operative \nnote for details. Pt was extubated, taken to the PACU until \nstable, then transferred to the ward for observation. \nNeuro: The patient was alert and oriented throughout \nhospitalization; pain was managed with a preoperative TAP block \nand postoperative ketorolac, gabapentin and acetaminophen; \nopioid medication was used only for severe breakthrough pain \nprn.\nCV: The patient remained stable from a cardiovascular \nstandpoint; vital signs were routinely monitored. \nPulmonary: The patient remained stable from a pulmonary \nstandpoint; vital signs were routinely monitored. Good pulmonary \ntoilet, early ambulation and incentive spirometry were \nencouraged throughout hospitalization. \nGI/GU/FEN: The patient was initially kept NPO. Afterwards, the \npatient was started on a stage 1 bariatric diet, which the \npatient tolerated well. Subsequently, the patient was advanced \nto stage 2, which the patient was tolerating on day of \ndischarge. \nID: The patient's fever curves were closely watched for signs of \ninfection, of which there were none. \nProphylaxis: The patient received subcutaneous heparin and ___ \ndyne boots were used during this stay and was encouraged to get \nup and ambulate as early as possible. \nAt the time of discharge, the patient was doing well, afebrile \nand hemodynamically stable. The patient was tolerating a \nbariatric stage 2 diet, ambulating, voiding without assistance, \nand pain was well controlled. The patient received discharge \nteaching and follow-up instructions with understanding \nverbalized and agreement with the discharge plan. \n \n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever \n2. ClonazePAM 0.5 mg PO ASDIR \n3. Bifera Rx (iron ps-iron hem poly-FA-B12) ___ \nmg-mg-mg-mcg oral ASDIR \n4. Omeprazole 20 mg PO BID heartburn \n5. Sertraline 100 mg PO DAILY \n6. tetrahydrozoline-zinc 0.05-0.25 % ophthalmic (eye) ASDIR \n\n \nDischarge Medications:\n1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild/Fever \nRX *acetaminophen 650 mg/20.3 mL 20.3 ml by mouth q6hr Disp #*1 \nBottle Refills:*0 \n2. Bifera Rx (iron ps-iron hem poly-FA-B12) ___ \nmg-mg-mg-mcg oral ASDIR \n3. ClonazePAM 0.5 mg PO ASDIR \n4. Omeprazole 20 mg PO BID heartburn \nOpen capsule, sprinkle contents onto applesauce, swallow whole. \nPlease take twice daily. \n5. Sertraline 100 mg PO DAILY \n6. tetrahydrozoline-zinc 0.05-0.25 % ophthalmic (eye) ASDIR \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nmorbid obesity\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___, You have undergone a laparoscopic sleeve \ngastrectomy, recovered in the hospital and are now preparing for \ndischarge to home with the following instructions:\n\nPlease call your surgeon or return to the Emergency Department \nif you develop a fever greater than ___ F, shaking chills, chest \npain, difficulty breathing, pain with breathing, cough, a rapid \nheartbeat, dizziness, severe abdominal pain, pain unrelieved by \nyour pain medication, a change in the nature or severity of your \npain, severe nausea, vomiting, abdominal bloating, severe \ndiarrhea, inability to eat or drink, foul smelling or colorful \ndrainage from your incisions, redness, swelling from your \nincisions, or any other symptoms which are concerning to you. \nDiet: Stay on Stage II diet until your follow up appointment; \nthis stage was previously called stage III and consists of \nprotein shakes, sugar free smooth pudding/ yogurt, etc; please \nrefer to your work book for detailed instructions. Do not self- \nadvance your diet and avoid drinking with a straw or chewing \ngum. To avoid dehydration, remember to sip small amounts of \nfluid frequently throughout the day to reach a goal of \napproximately ___ mL per day. Please note the following signs \nof dehydration: dry mouth, rapid heartbeat, feeling dizzy or \nfaint, dark colored urine, infrequent urination. \nMedication Instructions: \nPlease refer to the medication list provided with your discharge \npaperwork for detailed instruction regarding your home and newly \nprescribed medications. \nSome of the new medications you will be taking include: \n1. Pain medication: You will receive a prescription for liquid \nacetaminophen (Tylenol), do not exceed 3000 mg per 24 hour \nperiod. \n2. Antacids: You will be taking famotidine tablets, 20 mg twice \ndaily, for one month. This medicine reduces stomach acid \nproduction. Please crush. \n3. You must not use NSAIDS (non-steroidal anti-inflammatory \ndrugs) unless approved by your Weight Loss Surgery team. \nExamples include, but are not limited to Aleve, Arthrotec, \naspirin, Bufferin, diclofenac, Ecotrin, etodolac, ibuprofen, \nIndocin, indomethacin, Feldene, ketorolac, meclofenamate, \nmeloxicam, Midol, Motrin, nambumetone, Naprosyn, Naproxen, \nNuprin, oxaprozin, Piroxicam, Relafen, Toradol and Voltaren. \nThese agents may cause bleeding and ulcers in your digestive \nsystem. If you are unclear whether a medication is considered an \nNSAID, please ask call your nurse or ask your pharmacist. \n4. Vitamins/ minerals: You may resume a chewable multivitamin, \nhowever, please discuss when to resume additional vitamin and \nmineral supplements with your bariatric dietitian. \nActivity: \nYou should continue walking frequently throughout the day right \nafter surgery; you may climb stairs. \nYou may resume moderate exercise at your discretion, but avoid \nperforming abdominal exercises or lifting items greater than10 \nto 15 pounds for six weeks. \nWound Care: \nYou may remove any remaining gauze from over your incisions. You \nwill have thin paper strips (Steri-Strips) over your incision; \nplease, remove any remaining Steri-Strips seven to 10 days after \nsurgery. \nYou may shower 48 hours following your surgery; avoid scrubbing \nyour incisions and gently pat them dry. Avoid tub baths or \nswimming until cleared by your surgeon. You may wear your \nabdominal binder as needed for comfort. \nIf there is clear drainage from your incisions, cover with \nclean, dry gauze. \nPlease call the doctor if you have increased pain, swelling, \nredness, cloudy, bloody or foul smelling drainage from the \nincision sites. \nAvoid direct sun exposure to the incision area for up to 24 \nmonths. \nDo not use any ointments on the incision unless you were told \notherwise. \n\n \nFollowup Instructions:\n___\n" ]

[ "E6601", "K219", "E282", "K449", "Z6841", "Z85528", "F419", "D649" ]

[ "E6601: Morbid (severe) obesity due to excess calories", "K219: Gastro-esophageal reflux disease without esophagitis", "E282: Polycystic ovarian syndrome", "K449: Diaphragmatic hernia without obstruction or gangrene", "Z6841: Body mass index [BMI]40.0-44.9, adult", "Z85528: Personal history of other malignant neoplasm of kidney", "F419: Anxiety disorder, unspecified", "D649: Anemia, unspecified" ]

[ "K219", "F419", "D649" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: SURGERY\n \nAllergies: \nlisinopril / Topamax\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\n___: Laparoscopic Cholecystectomy\n\n \nHistory of Present Illness:\nMr. ___ is a ___ male with a PMHX of obesity, HTN, \nHLD, BPH who presented for jaundice found to have \ncholedocholithiasis. Patient was having 9 days of diarrhea and \npresented to PCP office and was found to be jaundiced. He\npresented to ___, where labs were notable for AST 142, \nALT 343, T. bili 7.___/P revealed multiple stones in \nthe CBD. Given no ERCP coverage over the weekend, he was \ntransferred to ___. He denies abdominal pain, chest pain, \ndifficulty breathing, fever. No history of abdominal surgeries. \nNot on anticoagulation.\n\nIn the ED, initial VS were 98.5 119 151/94 16 98% RA. Labs \nnotable for CBC with WBC of 4.2, H/H of 12.5/40.2, Plt 244. Labs \nwith HCO3 of 19, otherwise normal BMP. LFTS with ALT 281, AST \n144, Alk Phos 361, T. bili 6.7, D bili 4.5, Lipase 112. Labs \nwith IV zosyn, IV LR, and IV vancomycin. \n\nPatient was taken to ERCP where they performed a sphincterotomy \nand a plastic stent was placed. He was noted to have lots of \nstones in the CBD as well as cystic duct. ERCP recommended NPO, \nIVF, cipro x5 days, ACS c/s for CCY, and will need repeat ERCP \nin 4 weeks. \n\nUpon arrival to the floor, he reports that he was having pale \nloose BM, about twice a day for the past 9 days. He denies ever \nhaving abdominal pain or fever. He denies nausea, vomiting, but \nstates less PO intake in the past week. No melena/hematochezia, \ndysuria, chest pain, dyspnea, headache, blurry vision. After \nERCP, he continues to deny abdominal pain.\n\nIn regards to his HTN, he reports being on atenolol for over ___ \nyears and notes always having a slow heart rate In regards to \nrecent R hip replacement, he reports pain is manageable and he \nambulates with a cane, but slowly In regards to his obesity, he \nreports he was started on metformin to help lose weight. Denies \na hx of diabetes although tells me he was previously on \ntrulicity as well. \n \nPast Medical History:\nHigh Cholesterol, CAD, HTN, Heart disease\n \nSocial History:\n___\nFamily History:\nnon contributory\n \nPhysical Exam:\nVITALS: 97.9 174 / 87 53 18 98 RA \nGENERAL: obese male, laying in bed in NAD\nEYES: Icteric sclera. PERRL. Constricted pupils, but reactive to\nlight.\nENT: Ears and nose unremarkable. MMM\nCV: RRR. S1, S2. No mrg\nRESP: Unlabored breathing. CTA b/l \nGI: +BS. Soft, NTND. Negative ___ sign\nGU: foley not present\nMSK: WWP. Trace edema. \nSKIN: No rashes or ulcerations noted\nNEURO: Alert, oriented, face symmetric. Speech fluent, moves all\nlimbs.\nPSYCH: flat affect\n\ndischarge physical exam:\nPhysical Exam:\n\nGen: [x] NAD, [x] AAOx3\nCV: [x] RRR, [] murmur\nResp: [x] breaths unlabored, [] CTAB, [] wheezing, [] rales\nAbdomen: [x] soft, [] distended, [x] appropriately tender, []\nrebound/guarding\nWound: [x] incisions clean, dry, intact\nExt: [x] warm, [] tender, [] edema\n\n \nPertinent Results:\n___ 03:43AM BLOOD WBC-7.5 RBC-4.05* Hgb-11.9* Hct-38.5* \nMCV-95 MCH-29.4 MCHC-30.9* RDW-15.4 RDWSD-53.7* Plt ___\n___ 03:00AM BLOOD WBC-4.1 RBC-3.92* Hgb-11.5* Hct-36.3* \nMCV-93 MCH-29.3 MCHC-31.7* RDW-15.4 RDWSD-52.6* Plt ___\n___ 05:45AM BLOOD WBC-4.2 RBC-4.03* Hgb-11.9* Hct-37.6* \nMCV-93 MCH-29.5 MCHC-31.6* RDW-15.4 RDWSD-53.1* Plt ___\n___ 08:05PM BLOOD WBC-4.2 RBC-4.25* Hgb-12.5* Hct-40.2 \nMCV-95 MCH-29.4 MCHC-31.1* RDW-15.6* RDWSD-54.2* Plt ___\n___ 08:05PM BLOOD Neuts-66.1 ___ Monos-9.7 Eos-3.1 \nBaso-0.7 Im ___ AbsNeut-2.79 AbsLymp-0.84* AbsMono-0.41 \nAbsEos-0.13 AbsBaso-0.03\n___ 03:43AM BLOOD Plt ___\n___ 03:00AM BLOOD Plt ___\n___ 03:43AM BLOOD Glucose-104* UreaN-11 Creat-0.8 Na-141 \nK-4.3 Cl-106 HCO3-21* AnGap-14\n___ 03:00AM BLOOD Glucose-74 UreaN-11 Creat-0.7 Na-141 \nK-3.6 Cl-106 HCO3-21* AnGap-14\n___ 05:45AM BLOOD Glucose-82 UreaN-11 Creat-0.7 Na-142 \nK-3.8 Cl-108 HCO3-20* AnGap-14\n___ 05:17PM BLOOD ALT-304* AST-176* AlkPhos-312* \nTotBili-5.8*\n___ 03:43AM BLOOD ALT-313* AST-194* AlkPhos-302* \nTotBili-6.9*\n___ 04:00PM BLOOD ALT-296* AST-154* AlkPhos-334* \nTotBili-7.4*\n___ 03:00AM BLOOD ALT-259* AST-127* AlkPhos-302* \nTotBili-6.5*\n___ 05:45AM BLOOD ALT-268* AST-129* AlkPhos-328* \nTotBili-6.6*\n___ 08:05PM BLOOD ALT-281* AST-144* AlkPhos-361* \nTotBili-6.7* DirBili-4.5* IndBili-2.2\n___ 03:43AM BLOOD Calcium-9.0 Phos-4.5\n___ 03:00AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.6\n___ 05:45AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.6\n___ 08:05PM BLOOD Albumin-3.6 Calcium-9.1 Phos-3.7 Mg-1.8\n___ 02:59PM BLOOD %HbA1c-4.6 eAG-85\n\nERCP with sphincterotomy and placement of stent for CBD stones. \nCholethiasis noted\n \nBrief Hospital Course:\nThe patient was admitted to the General Surgical Service on ___ \nfrom an OSH for ERCP and cholecyctectomy. The patient underwent \nERCP and stenting followed by laparoscopic cholecystectomy, \nwhich went well without complication (reader referred to the \nOperative Note for details). After a brief, uneventful stay in \nthe PACU, the patient arrived on the floor on IV fluids. The \npatient was hemodynamically stable.\n\nPain was well controlled. Diet was progressively advanced as \ntolerated to a regular diet with good tolerability. The patient \nvoided without problem. During this hospitalization, the patient \nambulated early and frequently, was adherent with respiratory \ntoilet and incentive spirometry, and actively participated in \nthe plan of care. The patient received subcutaneous heparin and \nvenodyne boots were used during this stay.\n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating a regular \ndiet, ambulating, voiding without assistance, and pain was well \ncontrolled. The patient was discharged home without services. \nThe patient received discharge teaching and follow-up \ninstructions with understanding verbalized and agreement with \nthe discharge plan.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Terazosin 10 mg PO QHS \n2. Lovastatin 20 mg oral DAILY \n3. Finasteride 5 mg PO DAILY \n4. Atenolol 25 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q8H \nplease limit to 3000mg in 24 hour period. \n2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - \nModerate \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\nmay cause drowsiness \nRX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp \n#*3 Tablet Refills:*0 \n3. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third \nLine \nmay discontinue when bowel pattern normalizes. \n4. Senna 8.6 mg PO BID:PRN Constipation - First Line \nmay discontinue when bowel pattern normalizes. \n5. Atenolol 25 mg PO DAILY \n6. Finasteride 5 mg PO DAILY \n7. Lovastatin 20 mg oral DAILY \n8. Terazosin 10 mg PO QHS \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nCholedocholithiasis\nCholecystitis\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 with acute cholecystitis. You \nwere taken to the operating room and had your gallbladder \nremoved laparoscopically. You tolerated the procedure well and \nare now being discharged home to continue your recovery with the \nfollowing instructions.\n \nPlease follow up in the Acute Care Surgery clinic at the \nappointment listed below.\n \nACTIVITY:\no Do not drive until you have stopped taking pain medicine and \nfeel you could respond in an emergency.\no You may climb stairs. \no You may go outside, but avoid traveling long distances until \nyou see your surgeon at your next visit.\no Don't lift more than ___ lbs for 4 weeks. (This is about \nthe weight of a briefcase or a bag of groceries.) This applies \nto lifting children, but they may sit on your lap.\no You may start some light exercise when you feel comfortable.\no You will need to stay out of bathtubs or swimming pools for a \ntime while your incision is healing. Ask your doctor when you \ncan resume tub baths or swimming.\n \nHOW YOU MAY FEEL: \no You may feel weak or \"washed out\" for a couple of weeks. You \nmight want to nap often. Simple tasks may exhaust you.\no You may have a sore throat because of a tube that was in your \nthroat during surgery.\no You might have trouble concentrating or difficulty sleeping. \nYou might feel somewhat depressed.\no You could have a poor appetite for a while. Food may seem \nunappealing.\no All of these feelings and reactions are normal and should go \naway in a short time. If they do not, tell your surgeon.\n \nYOUR INCISION:\no Tomorrow you may shower and remove the gauzes over your \nincisions. Under these dressing you have small plastic bandages \ncalled steri-strips. Do not remove steri-strips for 2 weeks. \n(These are the thin paper strips that might be on your \nincision.) But if they fall off before that that's okay).\no Your incisions may be slightly red around the stitches. This \nis normal.\no You may gently wash away dried material around your incision.\no Avoid direct sun exposure to the incision area.\no Do not use any ointments on the incision unless you were told \notherwise.\no You may see a small amount of clear or light red fluid \nstaining your dressing or clothes. If the staining is severe, \nplease call your surgeon.\no You may shower. As noted above, ask your doctor when you may \nresume tub baths or swimming.\n \nYOUR BOWELS:\no Constipation is a common side effect of narcotic pain \nmedications. If needed, you may take a stool softener (such as \nColace, one capsule) or gentle laxative (such as milk of \nmagnesia, 1 tbs) twice a day. You can get both of these \nmedicines without a prescription.\no If you go 48 hours without a bowel movement, or have pain \nmoving the bowels, call your surgeon. \n \nPAIN MANAGEMENT:\no It is normal to feel some discomfort/pain following abdominal \nsurgery. This pain is often described as \"soreness\". \no Your pain should get better day by day. If you find the pain \nis getting worse instead of better, please contact your surgeon.\no You will receive a prescription for pain medicine to take by \nmouth. It is important to take this medicine as directed. o Do \nnot take it more frequently than prescribed. Do not take more \nmedicine at one time than prescribed.\no Your pain medicine will work better if you take it before your \npain gets too severe.\no Talk with your surgeon about how long you will need to take \nprescription pain medicine. Please don't take any other pain \nmedicine, including non-prescription pain medicine, unless your \nsurgeon has said its okay.\no If you are experiencing no pain, it is okay to skip a dose of \npain medicine.\no Remember to use your \"cough pillow\" for splinting when you \ncough or when you are doing your deep breathing exercises.\nIf you experience any of the following, please contact your \nsurgeon:\n- sharp pain or any severe pain that lasts several hours\n- pain that is getting worse over time\n- pain accompanied by fever of more than 101\n- a drastic change in nature or quality of your pain\n \nMEDICATIONS:\nTake all the medicines you were on before the operation just as \nyou did before, unless you have been told differently.\nIf you have any questions about what medicine to take or not to \ntake, please call your surgeon.\n \nFollowup Instructions:\n___\n" ]

[ "K8064", "I10", "E669", "Z6839", "E785", "N401", "R338", "Z96641", "R000", "Z96653", "E162", "Z23" ]

[ "K8064: Calculus of gallbladder and bile duct with chronic cholecystitis without obstruction", "I10: Essential (primary) hypertension", "E669: Obesity, unspecified", "Z6839: Body mass index [BMI] 39.0-39.9, adult", "E785: Hyperlipidemia, unspecified", "N401: Benign prostatic hyperplasia with lower urinary tract symptoms", "R338: Other retention of urine", "Z96641: Presence of right artificial hip joint", "R000: Tachycardia, unspecified", "Z96653: Presence of artificial knee joint, bilateral", "E162: Hypoglycemia, unspecified", "Z23: Encounter for immunization" ]

[ "I10", "E669", "E785" ]

[]

[ " \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:\nback pain\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMs ___ is a ___ YOF with PMH of HTN, HLD, IDDM (a1c 7.8), CKD, \nh/o RCC (sp R partial nephrectomy in ___, h/o pseudotumor \ncerebri, GERD, glaucoma, asthma, hypothyroidism, h/o laminectomy \n(L4-S1), who p/w worsening LBP radiating down R leg into foot. \nPt states the pain came on suddenly 3 days ago, without clear \ninciting event including lifting, cough or trauma, prompting her \npresentation to ___ where MRI showed L5-S1 disc bulge without \nany spinal canal or neuroforaminal narrowing. CT showed no \nhardware loosening. These results were discussed with Dr ___ \n___ spine service who recommended no surgery, however patient \nwith uncontrolled pain and difficulty uptitrating pain meds due \nto somnolence, therefore she was transferred for pain service \nand spine eval. While at ___ she was treated with gabapentin, \nsteroids, flexeril and PRN oxycodone and dilaudid. She denies \nchills, saddle anesthesia, incontinence fever. \n\nCurrently, pt states that pain is ___, can get as high as \n___. Pain meds help for a short period of time but then pain \nreturns. Pt states that she also had some numbness of the R \nleg, but none currently. Has not been able to walk since \npresentation ___ pain, weakness. No BM in 5 days.\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. Denies chest pain \nor tightness, palpitations. Denies nausea, vomiting, diarrhea, \nconstipation or abdominal pain. No recent change in. No dysuria. \n All other systems negative.\n\n \nPast Medical History:\nHTN\nHLD\nIDDM (a1c 7.8)\nCKD, h/o RCC (sp R partial nephrectomy in ___\nh/o pseudotumor cerebri\nGERD\nasthma, well controlled\nL carotid stenosis\n hypothyroidism\nh/o laminectomy x2 (L4-S1)\nh/o cholelithiasis\nh/o atypical CP\nR knee replacement\n \nSocial History:\n___\nFamily History:\n(per chart, confirmed with pt):\nFather with lung ca\nMother with kidney and breast ca\nsister with malt lymphoma, AML\nSister ___ +\n\n \nPhysical Exam:\nADMISSION EXAM\nVitals: 98.5 138/90 63 18 97 RA\nConstitutional: Alert, oriented, no acute distress\nHEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL\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 in RUQ, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding\nGU: No foley\nExt: Warm, well perfused, no CCE, RLE TTP\nNeuro: aaox3 CNII-XII grossly intact, ___ strength in ___ pain\nSkin: no rashes or lesions\n\nDISCHARGE EXAM\nGEN: No acute distress, comfortable appearing\nHEENT: NCAT, anicteric sclera\nCV: Normal S1, S2, no murmurs\nRESP: Good air entry, no rales or wheezes\nABD: Normal bowel sounds, soft, non-tender, non-distended, no \nrebound/guarding; \nEXTR: No edema. Intact pulses.\nDERM: No rash.\nNEURO: Face symmetric, speech fluent, 4+/5 right lower extremity \nflexion; strength otherwise intact; sensation to light touch \nintact\nPSYCH: Calm, cooperative \n \nPertinent Results:\nIMAGING / STUDIES:\nMRI lumbar spine ___\n 1. The patient is status post L4 through S1 left \nhemilaminectomy with\n fusion with bilateral L4-L5 pedicle screws and rods and \nL4-L5\n intervertebral spacer. No significant enhancing \ngranulation tissue\n encroaches on the spinal canal or neural foramina.\n 2. At L5-S1, a disc bulge with annular fissure does not \nsignificantly\n narrow the spinal canal or neural foramina however, the \ndisc may\n mildly flatten the under surfaces of the exiting nerve \nroots, more prominently on the right. Clinical correlation is \nrecommended.\n 3. Additional findings as described above.\n \nCT Lumbar spine ___\n 1. Spinal fusion hardware streak artifact limits \nexamination.\n 2. Postsurgical changes related to prior L4-5 posterior \nfusion and L4\n through S1 hemilaminectomies as described.\n 3. Within limits of study, no definite evidence of spinal \nhardware\n fusion fracture or loosening.\n 4. Stable grade 1 L4-5 anterolisthesis as described.\n 5. No definite evidence of fracture.\n 6. Limited imaging of the abdomen suggest postsurgical \nchanges\n related to right heminephrectomy.\n 7. Atherosclerotic changes of the abdominal aorta.\n\nNUCLEAR PHARMACOLOGIC STRESS TEST:\nSUMMARY FROM THE EXERCISE LAB:\n For pharmacologic stress dipyridamole was infused intravenously \nfor approximately 4 minutes at a dose of 0.142 \nmilligram/kilogram/min. 1 to 2 minutes after the cessation of \ninfusion, the stress dose of the radiotracer was injected.\n\n COMPARISON: None\n\n TECHNIQUE: ISOTOPE DATA: (___) 32.1 mCi Tc-99m Sestamibi \nStress; DRUG DATA: (Non-NM admin) Dipyridamole.\n\n Following intravenous infusion of the pharmacologic agent, the \nstress dose of sestamibi was administered intravenously. Stress \nimages were obtained approximately 30 minutes following tracer \ninjection.\n Imaging protocol: Gated SPECT.\n This study was interpreted using the 17-segment myocardial \nperfusion model.\n\n FINDINGS:Left ventricular cavity size is normal\n Rest and stress perfusion images reveal uniform tracer uptake \nthroughout the left ventricular myocardium.\n\n Gated images reveal normal wall motion.\n The calculated left ventricular ejection fraction is 67%\n\n IMPRESSION: Normal myocardial perfusion study with an estimated \nleft ventricular ejection fraction of 67%.\n\nEKG: normal sinus rhythm, no acute ST/TW changes\n\nLABS:\n___ 05:59AM BLOOD WBC-10.2* RBC-4.36 Hgb-12.7 Hct-39.5 \nMCV-91 MCH-29.1 MCHC-32.2 RDW-13.2 RDWSD-43.6 Plt ___\n___ 05:59AM BLOOD UreaN-24* Creat-1.1 Na-137 K-4.1 Cl-100 \nHCO3-27 AnGap-14\n___ 05:59AM BLOOD Calcium-9.1 Phos-4.4 Mg-1.8\n___ 11:45PM BLOOD cTropnT-<0.01\n___ 05:10PM BLOOD cTropnT-<0.01\n___ 08:50AM BLOOD cTropnT-<0.01\n___ 03:25AM BLOOD cTropnT-<0.___ yo f who presents for pain control and surgical eval for \nherniated disk.\n\n# Back pain due to herniated disc with lumbar radiculopathy: \nPatient presented with acute on chronic back pain secondary to \nL5-S1 herniated disk, no spinal canal or neuroforaminal \nnarrowing. No red flag signs, spinal hardware remains in place, \nnl ESR and imaging without evidence fo infection are reassuring. \n Case discussed with spine surgery while pt was at ___ and \n___ surgery recommended at this time, however she was transferred \nhere for formal spine eval and pain eval for possible spinal \ninjections given that she has been unable to tolerate increase \nin narcotics due to somnolence. \n- Pain surgery consulted and recommended outpatient appointment \nfor injections, scheduled as listed below\n- Spine surgery consulted and recommended non-surgical \nmanagement\n- Physical therapy consultated and recommended short term rehab \ndue to significant limitation to her functional status due to \npain\n- Started the following pain regimen:\n- Gabapentin 300mg/300mg/600mg, could increase PRN\n- Tizanidine 2mg TID\n- Oxycodone 10mg Q4H as needed for breakthrough pain\n- Aggressive bowel regimen\n- Patient was given prednisone at ___, but given that pain \nrelatively well controlled and no clear benefit of steroids was \ndiscontinued upon arrival here\n\n# Chest pain / hypertensive urgency: Patient had vague chest \npain at ___ with normal trops and EKG. While at ___, she \nhad two episodes of recurrent chest pain, once in the setting of \nhypertension to the 170s, and another time in the setting of \nnormotension. EKG without ischemic ST changes, and serial \ntroponins have been cycled 3 times and have been negative. Last \ncatheterization by Dr. ___ in ___ with minimal coronary \ndisease, but she does have significant risk factors and \ncrescendo chest pain over the past month. Cardiology was \nconsulted and recommended inpatient nuclear stress test, which \nrevealed normal perfusion and normal function\nShe was started on aspirin and continued on statin. \n- Amlodipine was discontinued and furosemide was decreased given \nconcern for dehydration and overly aggressive treatment of \nhypertension\n\n# Constipation: Treated with aggressive bowel regimen with good \neffect - patient had a large bowel movement the day prior to \ndischarge\n\n# Leukocytosis: likely due to recent steroids, no signs/symptoms \nof infection, resolved without\n\n# ___ on CKD: creatinine up to 1.2 from 1.0 at OSH; unclear ___, \nhowever not significantly elevated, improved with IV fluids\n\nCHRONIC / STABLE ISSUES\n# DM: poorly controlled: cont home glargine, ISS\n# HLD: cont statin\n# Depression: cont paroxetine\n# Insomnia: cont zolpidem\n# Hypothyroidism: cont home synthroid\n# GERD: cont home omeprazole\n\nPatient is medically stable for discharge\n> 30 minutes spent on discharge activities, including \ncoordination of appropriate post-discharge follow-up and \npreparation of paperwork for discharge to short term rehab\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. LORazepam 0.5 mg PO BID:PRN anxiety \n2. Glargine 44 Units Dinner\n3. Victoza 2-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL) \nsubcutaneous QHS \n4. MetFORMIN (Glucophage) 1000 mg PO BID \n5. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob \n6. Levothyroxine Sodium 137 mcg PO DAILY \n7. PARoxetine 40 mg PO DAILY \n8. Benzonatate 100 mg PO TID:PRN cough \n9. Atorvastatin 40 mg PO QPM \n10. Amlodipine 5 mg PO DAILY \n11. Zolpidem Tartrate 5 mg PO QHS \n12. Furosemide 40 mg PO EVERY OTHER DAY \n13. Omeprazole 40 mg PO BID \n14. Clobetasol Propionate 0.05% Cream 1 Appl TP BID \n15. Multivitamins 1 TAB PO DAILY \n16. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg \ncalcium- 200 unit oral DAILY \n\n \nDischarge Medications:\n1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob \n2. Atorvastatin 40 mg PO QPM \n3. Furosemide 20 mg PO EVERY OTHER DAY \n4. Glargine 44 Units Dinner\n5. Levothyroxine Sodium 137 mcg PO DAILY \n6. LORazepam 0.5 mg PO BID:PRN anxiety \n7. Omeprazole 40 mg PO BID \n8. PARoxetine 40 mg PO DAILY \n9. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia \n10. Acetaminophen 1000 mg PO Q8H \n11. Docusate Sodium 100 mg PO BID \n12. Gabapentin 300 mg PO BID \nRX *gabapentin 300 mg ___ capsule(s) by mouth three times a day \nDisp #*120 Capsule Refills:*0\n13. Gabapentin 600 mg PO QHS \n14. Lidocaine 5% Patch 1 PTCH TD QPM \n15. Milk of Magnesia 30 mL PO Q12H:PRN constipation \nDo not co-administer with levothyroxine or gabapentin \n16. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*30 Tablet Refills:*0\n17. Polyethylene Glycol 17 g PO DAILY \n18. Senna 8.6 mg PO BID \n19. Tizanidine 2 mg PO TID \nRX *tizanidine 2 mg 1 capsule(s) by mouth three times a day Disp \n#*21 Capsule Refills:*0\n20. Benzonatate 100 mg PO TID:PRN cough \n21. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg \ncalcium- 200 unit oral DAILY \n22. Clobetasol Propionate 0.05% Cream 1 Appl TP BID \n23. MetFORMIN (Glucophage) 1000 mg PO BID \n24. Multivitamins 1 TAB PO DAILY \n25. Victoza 2-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL) \nsubcutaneous QHS \n26. Aspirin 81 mg PO DAILY \n\n \nDischarge Disposition:\nExtended Care\n \nFacility:\n___\n \nDischarge Diagnosis:\nDisc herniation\nBack pain with lumbar radiculopathy\nGait instability\nChest 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:\nYou were hospitalized for back pain, which is due to a herniated \ndisc. You were evaluated by the pain service and spine surgery \nwho recommended a medication regimen and an outpatient \nevaluation for injections, but no surgery.\n\nYou were also evaluated for chest pain with a stress test, which \nrevealed normal perfusion throughout your heart.\n\nPlease take medications as prescribed and follow up as \nrecommended.\n \nFollowup Instructions:\n___\n" ]

[ "H409", "M5116", "G8929", "R0789", "I129", "K5900", "D72829", "N179", "R2689", "N189", "E1165", "E785", "R600", "F329", "G4700", "E039", "K219", "J45909", "Z794", "Z85528", "Z87891" ]

[ "H409: Unspecified glaucoma", "M5116: Intervertebral disc disorders with radiculopathy, lumbar region", "G8929: Other chronic pain", "R0789: Other chest pain", "I129: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease", "K5900: Constipation, unspecified", "D72829: Elevated white blood cell count, unspecified", "N179: Acute kidney failure, unspecified", "R2689: Other abnormalities of gait and mobility", "N189: Chronic kidney disease, unspecified", "E1165: Type 2 diabetes mellitus with hyperglycemia", "E785: Hyperlipidemia, unspecified", "R600: Localized edema", "F329: Major depressive disorder, single episode, unspecified", "G4700: Insomnia, unspecified", "E039: Hypothyroidism, unspecified", "K219: Gastro-esophageal reflux disease without esophagitis", "J45909: Unspecified asthma, uncomplicated", "Z794: Long term (current) use of insulin", "Z85528: Personal history of other malignant neoplasm of kidney", "Z87891: Personal history of nicotine dependence" ]

[ "G8929", "I129", "K5900", "N179", "N189", "E1165", "E785", "F329", "G4700", "E039", "K219", "J45909", "Z794", "Z87891" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: MEDICINE\n \nAllergies: \nlatex / bananas, apples, pears\n \nAttending: ___.\n \nChief Complaint:\nNausea/vomiting\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ with hx DM1 and seasonal allergies presenting with nausea \nand vomiting x3 days. Vomiting started ___ evening. \nPatient symptoms may have been due to eating ground ___ from \n___. Denies sick contacts. He reports almost hourly \nn/v since that time. He has had limited PO intake since then \ndue to the ongoing n/v. Did try to drink some ___. Denies \nbloody emesis. Due to being unable to take POs, he self dc'd \nhis long-acting insulin. Patient reports taking 4U novolog \nyesterday due to elevated FSBS and 6U when ambulance picked him \nup today when FSBS was 336. Denies fevers, cough, shortness of \nbreath, URI symptoms, diarrhea, dysuria.\n \nIn the ED, initial vitals: T99.7 HR85 BP110/50 RR18 SaO2100% \nRA\n--initial labs: WBC 18.4, Hgb/Hct 14.7 / 44.3, Plt 276, Na/K \n131/4.9, BUN/Cr 34/1.2, VBG: 7.24 | 31 | 43, lactate 3.2, u/a \nwith ketones.\n--CXR without acute cardiopulmonary process\n--ECG NSR, early repolarization\n--patient was given: 4L NS, 4 mg Zofran, and started on insulin \ngtt @ 4U per hour\n \nOn arrival to the MICU, T98.8, HR 94, BP 112/45, RR 22, SaO2 \n100% RA. Patient reported feeling thirsty and hungry, but \notherwise was without complaints.\n\n \nPast Medical History:\n-DM1\n-seasonal allergies\n-h/o eosinophilic esophagitis\n \nSocial History:\n___\nFamily History:\n-Mother with DMI, MGM Type 2; \"stomach issues\" on father's side \nof family, MGF with CAD\n \nPhysical Exam:\nADMISSION PHYSICAL EXAM:\n==========================\nVitals: T98.8, HR 94, BP 112/45, RR 22, SaO2 100% RA \nGENERAL: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, dry MM, oropharynx clear \nNECK: supple, JVP not elevated, no LAD \nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, 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 excoriations \nNEURO: Moving all extremities, speech fluent\n\nDISCHARGE PHYSICAL EXAM:\n===============================\nGENERAL: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP not elevated, no LAD \nLUNGS: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, \ngallops \nABD: soft, 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 excoriations \nNEURO: Moving all extremities, speech fluent\n \n \nPertinent Results:\nLABS:\n=======================\n\n___ 09:00PM BLOOD WBC-18.4* RBC-4.93 Hgb-14.7 Hct-44.3 \nMCV-90 MCH-29.8 MCHC-33.2 RDW-12.0 RDWSD-39.5 Plt ___\n___ 12:05AM BLOOD WBC-15.0* RBC-4.19* Hgb-12.5* Hct-37.5* \nMCV-90 MCH-29.8 MCHC-33.3 RDW-12.1 RDWSD-39.5 Plt ___\n___ 05:15AM BLOOD WBC-12.7* RBC-3.85* Hgb-11.5* Hct-34.0* \nMCV-88 MCH-29.9 MCHC-33.8 RDW-12.2 RDWSD-39.3 Plt ___\n___ 09:00PM BLOOD Glucose-425* UreaN-34* Creat-1.2 Na-131* \nK-4.9 Cl-95* HCO3-12* AnGap-29*\n___ 12:05AM BLOOD Glucose-234* UreaN-29* Creat-1.0 Na-133 \nK-6.8* Cl-104 HCO3-15* AnGap-21*\n___ 02:10AM BLOOD Glucose-168* UreaN-25* Creat-0.9 Na-136 \nK-4.2 Cl-108 HCO3-18* AnGap-14\n___ 05:15AM BLOOD Glucose-190* UreaN-22* Creat-0.9 Na-136 \nK-3.8 Cl-107 HCO3-21* AnGap-12\n___ 12:54PM BLOOD Glucose-278* UreaN-17 Creat-0.9 Na-133 \nK-3.8 Cl-104 HCO3-21* AnGap-12\n___ 05:56PM BLOOD Glucose-234* UreaN-16 Creat-0.8 Na-136 \nK-3.1* Cl-103 HCO3-23 AnGap-13\n___ 12:05AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.2\n___ 05:56PM BLOOD Calcium-8.8 Phos-1.8* Mg-1.8\n___ 02:55AM BLOOD %HbA1c-6.6* eAG-143*\n___ 09:10PM BLOOD ___ pO2-43* pCO2-31* pH-7.24* \ncalTCO2-14* Base XS--12\n___ 12:22AM BLOOD ___ pO2-30* pCO2-32* pH-7.28* \ncalTCO2-16* Base XS--11\n___ 02:19AM BLOOD ___ pO2-72* pCO2-33* pH-7.37 \ncalTCO2-20* Base XS--4\n___ 05:34AM BLOOD ___ pO2-69* pCO2-37 pH-7.36 \ncalTCO2-22 Base XS--3\n___ 09:10PM BLOOD Lactate-3.2* K-4.8\n___ 12:22AM BLOOD Lactate-2.4* K-4.5\n___ 02:19AM BLOOD Lactate-1.2 K-4.1\n___ 05:34AM BLOOD Lactate-1.1 K-3.6\n___ 10:30PM URINE Color-Straw Appear-Clear Sp ___\n___ 10:30PM URINE Blood-NEG Nitrite-NEG Protein-TR \nGlucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG\n___ 10:30PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE \nEpi-<1\n\nMICRO:\n==============\nBLOOD CULTURES FROM ___ NEGATIVE AS OF DISCHARGE DATE\n\nIMAGING:\n================\nCXR ___:\nFINDINGS: \nPA and lateral views the chest provided demonstrate no focal \nconsolidation, large effusion or pneumothorax. \nCardiomediastinal silhouette is normal. Bony structures are \nintact. No free air below the right hemidiaphragm.\nIMPRESSION:\nNo acute intrathoracic process. \n\n \nBrief Hospital Course:\n___ with h/o Type 1 Diabetes admitted with nausea/vomiting x3 \ndays found to have DKA.\n\n# DKA: likely secondary to stopping long-acting insulin after \ndeveloping gastroenteritis. Patient reported limited PO intake \nx3 days and was severely dehydrated on exam. Initial labs showed \nanion-gap metabolic acidosis, hyperglycemia, and ketones in \nurine. Patient was given IV fluids and started on insulin drip \nand his electrolytes were closely monitored. Anion gap closed \nand patient's nausea/vomiting resolved. Patient was \nsubsequently started on his home lantus and was tolerating meals \non day of discharge. Patient's A1c was 6.6%. He was seen by \n___ team who felt patient was safe to be discharged \non home regimen of lantus/novolog and was given information and \nencouraged to follow up with ___ for continued management of \nhis diabetes while he lives in ___ (from ___, living in \n___ as student).\n\n# Gastritis: likely viral gastritis after eating out on \n___. No diarrhea, and lack of sick contacts, thus \nnorovirus is less likely. N/v resolved with treatment of his \nDKA as above (IVF + insulin gtt).\n\n# Leukocytosis: likely stress response in setting of DKA. CXR \nand U/A negative. Improved with treatment of his DKA as noted \nabove.\n\nTRANSITIONAL ISSUES\n=================================\n[] blood cultures pending at the time of discharge\n[] patient does not have a primary care doctor in the ___ \narea. \n[] patient given contact info to establish care at ___ for \ncontinued management of his Type 1 Diabetes\n \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Lantus (insulin glargine) 32 units subcutaneous DAILY \n2. Novolog 6 Units Breakfast\nNovolog 8 Units Lunch\nNovolog 8 Units Dinner\nNovolog 4 Units Bedtime\n3. Glucagon 1 mg SUBCUT ONCE hypoglycemia \n\n \nDischarge Medications:\n1. Glucagon 1 mg SUBCUT ONCE hypoglycemia Duration: 1 Dose \nRX *glucagon (human recombinant) [Glucagon Emergency Kit \n(human)] 1 mg 1 mg IM once Disp #*1 Kit Refills:*1\n2. Novolog 6 Units Breakfast\nNovolog 8 Units Lunch\nNovolog 8 Units Dinner\nNovolog 4 Units Bedtime\n3. Lantus (insulin glargine) 32 units subcutaneous DAILY \n4. Ketone Urine Test (acetone (urine) test) 1 strip \nmiscellaneous ONCE:PRN hyperglycemia \nRX *acetone (urine) test as needed for hyperglycemia Disp #*30 \nStrip Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary diagnosis: diabetic ketoacidosis\nSecondary diagnosis: gastroenteritis \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. You were admitted with \ndiabetic ketoacidosis (DKA) which means that your blood sugar \nwas elevated and you had ketones in your body. You were \nmonitored in the intensive care unit and you received insulin \nand fluids. Your labs improved and you were started on novolog. \nYou were seen by the diabetes doctors and ___. It is \nvery important that you continue to monitor your blood sugars \nand drink plenty of fluids. Please return to the hospital if \nyour blood sugars remain elevated or if you are unable to eat or \ndrink anything.\n\nPlease continue taking lantus 32 units every morning and novolog \n6 u with breakfast; 8 u with lunch; 8u with dinner; ___ with \nsupper (28u\ntotal scheduled).\n\nYour ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "E1010", "Z9641", "Z794", "Z720" ]

[ "E1010: Type 1 diabetes mellitus with ketoacidosis without coma", "Z9641: Presence of insulin pump (external) (internal)", "Z794: Long term (current) use of insulin", "Z720: Tobacco use" ]

[ "Z794" ]

[]

[ " \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:\nN/V, abdominal pain\n \nMajor Surgical or Invasive Procedure:\nEUS\nERCP\nEGD\n \nHistory of Present Illness:\nThis is a ___ woman with history of duodenal ulcer, hiatal\nhernia, and retinal vasculitis leading to legal blindness, who\npresents with three days of abdominal pain and bilious vomiting. \n\n \nShe reports that she has been suffering from abdominal pain for\nmonths now, however that pain is mild to moderate and usually\nimproved with PPI. She has been evaluated in the outpatient\nsetting and found to have gastric ulcerations and a hiatal\nhernia, she is being evaluated for surgical correction of the\nhernia to treat her symptoms. More recently, on ___ she\nstarted having severe pain which is worse in intensity and more\npersistent than her subacute-chronic abdominal pain. The pain\nstarted ___ and is described as severe, very intense and\ncrampy in nature. The pain has been associated with severe \nnausea\nand vomiting and the pain is worse with food intake, in fact she\nhasn't eaten in several days as a result. She has not had a BM\nfor ___ days. Due to her vision loss, she is not able to say\nwhether there was any blood in emesis or stools or melena. She\nhas not have any fevers or chills. \n \nIn the ED, initial vitals were: ___ pain 97.4 77 152/112 18 \n96%\nRA. Exam was notable for active vomiting, with bilious emesis in\nbag, significant abdominal tenderness across upper quadrants, no\nlower quandrant tenderness, rectal- Guaiac negative, formed \nstool\nin the rectal vault, no frank blood. Labs revealed leukocytosis\nbut otherwise were unremarkable. CT A/P was performed which\nrevealed dilatated biliary ducts and possible impacted stone. \nShe\nreeived IV Morphine, Zofran, 1L IVFs, NGT was placed for\ndecompression and 400cc of dark bilious fluid however patient\nindicates to this provider that decompression did not improve \nher\nsymptoms. She was then admitted to medicine. \n \nOn the floor, she reports her pain and nausea are in good\ncontrol. When asked what helped the most she responds \"morphine\"\nand denies that NGT with decompression alleviated her symptoms.\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. Denies chest pain\nor tightness, palpitations. No dysuria. Denies arthralgias or\nmyalgias. Otherwise ROS is negative.\n\n \nPast Medical History:\n- HTN\n- Hiatal Hernia\n- Duodenal Ulcer\n- Retinal Vasculitis leading to blindness\n- Depression\n \nSocial History:\n___\nFamily History:\nMultiple family members with gallstones, both parents recently \nhad CCY\nParents in assisted living with Alzheimers/dementia\nFather with MI age ___, CAD\nFamily history of DM, stomach cancer\n\n \nPhysical Exam:\nAdmission PHYSICAL EXAM: \nVitals: 97.4 82 145/92 18 96% RA\nPain Scale: ___\nGeneral: Patient appears uncomfortable, she moves little in bed\ncareful to not move her abdomen specifically. Otherwise, \nhowever,\nshe is alert, oriented and not in extremis. She is legally blind\nand does not make eye contact\nHEENT: Legally blind, dry mucous membranes, pink nasal mucosa\nNeck: supple, JVP low, no LAD appreciated\nLungs: Clear to auscultation bilaterally, moving air well and\nsymmetrically, no wheezes, rales or rhonchi appreciated \nCV: Regular rate and rhythm, S1 and S2 clear and of good \nquality,\nno murmurs, rubs or gallops appreciated\nAbdomen: Tender to palpation over epigastrium but otherwise \nsoft,\nnon-distended, no rebound or guarding, normoactive bowel sounds\nthroughout, no peritoneal signs\nExt: Warm, well perfused, full distal pulses, no clubbing,\ncyanosis or edema \nNeuro: CN2-12 grossly in tact, motor and sensory function \ngrossly\nintact in bilateral UE and ___, symmetric\n\nDischarge physical exam:\n\n \nPertinent Results:\nAdmission Labs:\n\n___ 04:45PM BLOOD WBC-11.7* RBC-5.02 Hgb-16.5* Hct-47.9* \nMCV-95 MCH-32.9* MCHC-34.4 RDW-13.8 RDWSD-48.1* Plt ___\n___ 04:45PM BLOOD Neuts-66.0 ___ Monos-6.7 Eos-1.9 \nBaso-0.5 Im ___ AbsNeut-7.70* AbsLymp-2.85 AbsMono-0.78 \nAbsEos-0.22 AbsBaso-0.06\n___ 04:45PM BLOOD Plt ___\n___ 04:45PM BLOOD Glucose-112* UreaN-15 Creat-0.9 Na-143 \nK-4.1 Cl-97 HCO3-24 AnGap-22*\n___ 04:45PM BLOOD ALT-26 AST-19 AlkPhos-100 TotBili-0.9\n___ 04:45PM BLOOD Lipase-31\n___ 04:45PM BLOOD Albumin-4.4\n___ 04:56PM BLOOD Lactate-2.5*\n___ 08:57PM BLOOD Lactate-1.6\n\nDischarge Labs:\n\nImaging:\nKUB ___- Large hiatal hernia, with tip of NG tube likely \nterminating within the stomach. No definite signs of bowel \nobstruction, paucity of bowel gas limits evaluation however. \n\nCT abd/pelvis ___. Increased intrahepatic and extrahepatic \nbiliary ductal dilation extending to the distal most portion of \nthe common bile duct with a possible obstructing stone or \nlesion. Recommend further evaluation with ERCP. \n2. Probably subacute or chronic L1 burst fracture with 5 mm \nosseous \nretropulsion into the spinal canal. \n\nMRCP:\nIMPRESSION:\n1. Mild central intrahepatic and extrahepatic biliary ductal \ndilatation, with the common bile duct measuring up to 11 mm in \ndiameter. Transient opening of the common bile duct into the \nampulla is demonstrated. Findings are most compatible with \nsphincter of Oddi dysfunction.\n\nEUS:\nlarge hiatal hernia, question of subacute volvulus, not able to \ndo EUS; recommend surgical consultation and then reconsult for \nEUS +/- ERCP after surgical completion\n\nKUB:\nNonspecific nonobstructive bowel gas pattern.\n \nBrief Hospital Course:\n___ woman with history of duodenal ulcer, hiatal hernia, and \nretinal vasculitis leading to legal blindness, who presents with \nthree days of abdominal pain and bilious vomiting. \n \n# Nausea with vomiting\n# r/o choledocholithiasis\n# sphincter of oddi dysfunction\n# hiatal hernia\nPatient has abdominal pain worse with PO intake, colicky in \nnature located over epigastrium and RUQ, with associated nausea \nand vomiting as well as CT findings demonstrating dilated \nintrahepatic and extrahepatic bile ducts and possible impacted \nbile stone in the proximal common bile duct all consistent with \ncholedocholithiasis and obstruction as etiology to symptoms. \nHowever LFTs did not support this, MRCP without obstruction \n(just sphincter of oddi dysfunction). EUS non-diagnostic as \nunable to bypass hiatal hernia; EUS was also concerning for \nsubacute volvulus. Failed NGT removal and PO challenge. Was \nevaluated by surgery and GI. She was gradually able to \nintroduce PO intake, without any vomiting or abdominal pain. \nThe bulk of her symptoms thought related to her hiatal hernia. \nShe is safe for discharge today, now that she has tolerated PO \nintake, and has not vomited. To complete workup before surgery, \nshe will need esophageal manometry, to conclusively rule in/or \nout, any dysmotility issues. \n \n# Duodenal Ulcer: had some red emesis at times, but this has \nfully resolved., continued PPI. Hgb stable. \n \n# Retinal Vasculitis: held MTX/pred while NPO and gave IV \nsteroids in the interim. Transitioned back to PO once able to \ntake. \n \n# Depression: held lexapro/trazodone/buprion while NPO\n\nPatient seen and discharged on ___. This note was entered \nlate on ___.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Escitalopram Oxalate 40 mg PO DAILY \n2. FoLIC Acid 1 mg PO DAILY \n3. PredniSONE 4 mg PO DAILY \n4. BuPROPion XL (Once Daily) 450 mg PO DAILY \n5. Methotrexate 15 mg PO 1X/WEEK (TH) \n6. TraZODone ___ mg PO QHS:PRN insomnia \n7. Omeprazole 20 mg PO DAILY \n8. InFLIXimab x mg IV Q6WEEKS \n9. Alendronate Sodium 70 mg PO QMON \n10. Metoprolol Tartrate 25 mg PO DAILY \n\n \nDischarge Medications:\n1. InFLIXimab determined by physician ___ -- IV Q6WEEKS \n\n2. Alendronate Sodium 70 mg PO QMON \n3. BuPROPion XL (Once Daily) 450 mg PO DAILY \n4. Escitalopram Oxalate 40 mg PO DAILY \n5. FoLIC Acid 1 mg PO DAILY \n6. Methotrexate 15 mg PO 1X/WEEK (TH) \n7. Metoprolol Tartrate 25 mg PO DAILY \n8. Omeprazole 20 mg PO DAILY \n9. PredniSONE 4 mg PO DAILY \n10. TraZODone ___ mg PO QHS:PRN insomnia \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nsymptomatic hiatal hernia\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\n\n \nDischarge Instructions:\nDear ___ were admitted with nausea and worsening abdominal pain. ___ \nwere found to have a large hiatal hernia. The surgical team \nevaluated ___ and felt that your symptoms were related to this \nhernia. No operations done during this hospitalization. ___ \nhave outpatient follow up scheduled. \n\nBest of luck in your recovery.\nYour ___ care team\n \nFollowup Instructions:\n___\n" ]

[ "K449", "I10", "H548", "K269", "H35069", "F329", "K209" ]

[ "K449: Diaphragmatic hernia without obstruction or gangrene", "I10: Essential (primary) hypertension", "H548: Legal blindness, as defined in USA", "K269: Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation", "H35069: Retinal vasculitis, unspecified eye", "F329: Major depressive disorder, single episode, unspecified", "K209: Esophagitis, unspecified" ]

[ "I10", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nDizziness, unsteady gait\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year-old right-handed woman with a history of\nocular vasculitis with visual impairment, hypertension, and\ndepression who presented with tremor, and \"mental fog\" since 4PM\non the day of presentation. Patient said she noted the onset of \na\nvague dizzy sensation described as non-vertiginous but \nassociated\nwith new gait instability. She stated that she was having\ndifficulty walking down her spiral staircase and did trip on her\nway down to\nmeet with EMTs.\n\nShe noted that she has had difficulty with ambulating on and off\nfor a number of weeks, but she denied frank weakness or sensory\nchanges. She denies any other falls, head strike, LOC. She \nnoted\nshe is partially blind in her L eye from her known vasculitis. \n\nIn the ED, initial VS were: 98.6 ___ 20 98% RA\n\nHer gait was found to be severely unstable so Code Stroke was\ncalled. NIHSS was 2 which is her baseline due to visual\nimpairment. CTA and CTP were negative, so in addition to low\nNIHSS, tPA was not given.\n\nUpon evaluation by neurology in the ED, her exam was notable \nfor:\nTachycardia, coarse waxing-and-waning tremor of the upper\nextremities (and also teeth chattering on re-examination)\npositive Romberg, though there was no proprioceptive deficit nor\nnystagmus (when tracking to the best of her ability, but this \nmay\nbe less sensitive in her case). She does not complain of any\nsubjective vertigo. Strength is intact throughout. Coordination\nis intact in the extremities, and there is no truncal ataxia. \n\nLabs showed:\nLactate 3.2, concentrated urine (SpGrav >1.050), and few \nbacteria\nin her urine. Her WBC is 9.4 but this may be abnormally high in\nher case as she is immunosuppressed on infliximab, methotrexate,\nand chronic prednisone. Negative serum/urine tox.\n\nImaging showed:\nCXR: \n1. No acute cardiopulmonary abnormality.\n2. Large hiatal hernia.\n\nNCHCT:\nNon-contrast CT Head: No acute intracranial hemorrhage or\nevidence of large territorial infarction. Confluent\nperiventricular, subcortical, and deep white matter \nhypodensities\nare nonspecific, but may represent sequela of chronic\nmicrovascular ischemic disease.\n\nCTA Head and Neck:\nBovine aortic arch anatomy is noted. There is no evidence\nof aneurysmal dilatation or high-grade stenosis of the main\nvessels of the head or neck.\n\nCTP:\nNo evidence of perfusional abnormalities to explain patient's \nthe\ninstability.\n\nPatient received: No medications\n\n \nPast Medical History:\nRetinal vasculitis\nHypertension\nDepression \nDiverticulitis\n \nSocial History:\n___\nFamily History:\nParents in assisted living with Alzheimers/dementia\nFather with MI age ___, CAD\nFamily history of DM, stomach cancer\n\n \nPhysical Exam:\nPHYSICAL EXAM ON ADMISSION:\n===========================\nVS: 98.3 PO 165 / 99 79 18 95 Ra \nGENERAL: NAD \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,\nMMM; L sided hemineglect r/t blindness\nNECK: supple, no LAD, no JVD \nHEART: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly \nEXTREMITIES: no cyanosis, clubbing, or edema; back without\nspinous process ttp or paraspinal ttp\nPULSES: 2+ DP pulses bilaterally \nNEURO: A&Ox3, CN ___ intact, ___ motor strength in all muscle\ngroups, sensation to light touch intact throughout\nSKIN: warm and well perfused, no excoriations or lesions, no\nrashes \n\nPHYSICAL EXAM ON DISCHARGE:\n===========================\nVS: Afebrile 127 / 87 96 18 96 RA \nGENERAL: NAD \nHEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,\nMMM; L sided hemineglect r/t blindness\nNECK: supple, no LAD, no JVD \nHEART: RRR, S1/S2, no murmurs, gallops, or rubs \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles \nABDOMEN: nondistended, nontender in all quadrants, no\nrebound/guarding, no hepatosplenomegaly \nEXTREMITIES: no cyanosis, clubbing, or edema\\\nPULSES: 2+ DP pulses bilaterally \nNEURO: A&Ox3, CN ___ intact, ___ motor strength in all muscle\ngroups, sensation to light touch intact throughout, tremor noted\nin both hands \nSKIN: warm and well perfused, no excoriations or lesions, no\nrashes \n\n \nPertinent Results:\nLABS ON ADMISSION:\n==================\n___ 07:10PM BLOOD WBC-9.4 RBC-4.38 Hgb-14.3 Hct-42.7 MCV-98 \nMCH-32.6* MCHC-33.5 RDW-13.4 RDWSD-47.5* Plt ___\n___ 07:10PM BLOOD Neuts-55.7 ___ Monos-9.3 Eos-2.0 \nBaso-0.5 Im ___ AbsNeut-5.20 AbsLymp-3.00 AbsMono-0.87* \nAbsEos-0.19 AbsBaso-0.05\n___ 07:10PM BLOOD Glucose-96 UreaN-13 Creat-0.9 Na-137 \nK-4.6 Cl-105 HCO3-23 AnGap-9\n___ 07:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 07:20PM BLOOD Glucose-91 Lactate-3.2* Na-140 K-4.5 \nCl-103 calHCO3-22\n\nLABS ON DISCHARGE:\n==================\n___ 04:45AM BLOOD WBC-6.4 RBC-4.28 Hgb-14.0 Hct-42.2 \nMCV-99* MCH-32.7* MCHC-33.2 RDW-13.8 RDWSD-49.2* Plt ___\n___ 04:45AM BLOOD Glucose-89 UreaN-9 Creat-0.9 Na-142 K-4.6 \nCl-103 HCO3-25 AnGap-14\n\nMICRO:\n======\n___ 7:10 pm BLOOD CULTURE\n\n Blood Culture, Routine (Pending): \n\n___ 9:14 pm URINE\n\n **FINAL REPORT ___\n\n URINE CULTURE (Final ___: \n STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000 \nCFU/mL.\n\nIMAGING:\n========\n___ CTA HEAD AND NECK:\n1. No large acute infarct or area of ischemia on CT perfusion \nimages. \n2. Mild intracranial atherosclerosis, without stenosis or \nocclusion. \n3. Mild extracranial atherosclerosis, without stenosis by NASCET \ncriteria. \n4. Probable chronic small vessel disease. \n\n___ CHEST X-RAY:\n1. No acute cardiopulmonary abnormality. \n2. Large hiatal hernia. \n \nBrief Hospital Course:\n___ year-old right-handed woman with a history of ocular \nvasculitis with visual impairment, hypertension, and depression, \nwho presented with tremor, a \"metal fog\", and unsteady gait. \n\nACUTE ISSUES:\n=============\n#Tremor:\n#Unsteady gait: Patient presented with acute hands shakiness. In \nthe ED her gait was found to be severely unstable so Code Stroke \nwas called. CTA and CTP were negative, so stroke was ruled out. \nHer exam was significant for tachycardia and coarse \nwaxing-and-waning tremor of the upper extremities. Her symptoms \nresolved within a few hours. It is unclear why she had the \ntremor, it could have been related to anxiety or dehydration (as \nsuggested by orthostatic hypotension and tachycardia). She was \nencouraged to increase her PO intake.\n\nCHRONIC ISSUES:\n===============\n#Depression: Continued on home bupropion after clarifying dose \nwith pharmacy.\n\n#Retinal vasculitis: Continued on infliximab 350mg IV Q6Weeks \n(since ___, prednisone 5mg daily, methotrexate 15mg weekly.\n\n***TRANSITIONAL ISSUES:***\n- Monitor symptoms of tremor\n- Consider medication toxicity causing the tremor, and ensure \npatient is taking all medications as prescribed\n- Repeat orthostatic vital signs, and ensure patient is well \nhydrated\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Omeprazole 20 mg PO DAILY \n2. BuPROPion XL (Once Daily) 450 mg PO DAILY \n3. InFLIXimab 100 mg IV Q8WEEKS \n4. Alendronate Sodium 70 mg PO QMON \n5. FoLIC Acid 1 mg PO DAILY \n6. PredniSONE 5 mg PO DAILY \n7. Methotrexate 15 mg PO 1X/WEEK (TH) \n8. TraZODone ___ mg PO QHS:PRN insomnia \n9. Escitalopram Oxalate 40 mg PO DAILY \n\n \nDischarge Medications:\n1. Alendronate Sodium 70 mg PO QMON \n2. BuPROPion XL (Once Daily) 450 mg PO DAILY \n3. Escitalopram Oxalate 40 mg PO DAILY \n4. FoLIC Acid 1 mg PO DAILY \n5. InFLIXimab 100 mg IV Q8WEEKS \n6. Methotrexate 15 mg PO 1X/WEEK (TH) \n7. Omeprazole 20 mg PO DAILY \n8. PredniSONE 5 mg PO DAILY \n9. TraZODone ___ mg PO QHS:PRN insomnia \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSIS:\nTremor\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear ___,\n\n___ was a pleasure taking care of you at ___ ___ \n___. You came to the hospital because you developed \nsudden shakiness in your arms and unsteady gait. In the \nEmergency Department, you were evaluated by the neurology team \nand you underwent multiple brain imaging. You were not found to \nhave a stroke. Your symptoms improved within hours. Your \nshakiness could be related to anxiety or dehydration.\n\nWhat should you do after your hospital discharge?\n- You should make sure to drink a lot of fluids to stay hydrated\n- Follow-up with your doctors as ___\n\nWe wish you all the best in health.\n\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "R251", "R42", "R2681", "I10", "H548", "K449", "F329", "H35063", "Z833", "Z8249" ]

[ "R251: Tremor, unspecified", "R42: Dizziness and giddiness", "R2681: Unsteadiness on feet", "I10: Essential (primary) hypertension", "H548: Legal blindness, as defined in USA", "K449: Diaphragmatic hernia without obstruction or gangrene", "F329: Major depressive disorder, single episode, unspecified", "H35063: Retinal vasculitis, bilateral", "Z833: Family history of diabetes mellitus", "Z8249: Family history of ischemic heart disease and other diseases of the circulatory system" ]

[ "I10", "F329" ]

[]

[ " \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 \n___ Complaint:\npain in her left thigh and left lateral chest wall\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\nMs. ___ is a ___ with a past medical history significant\nfor blindness who presents to the hospital with a chief \ncomplaint\nof pain in her left thigh and left lateral chest wall. She\nreports that yesterday at 630pmm she experienced a mechanical\nfall. She says that she fell down some stairs (she believes it\nwas four steps) because they were slippery. She denies any head\nstrike and remembers everything in detail. She reports that she\nlanded on her left side after the fall and then she subsequently\ngot up and went home. However, she started experiencing pain in\nher left thigh and left lateral chest wall and for this reason\nshe presented to the hospital (Via ambulance) for further\nmanagement. \n\nROS:\n(+) per HPI\n(-) Denies fevers chills, night sweats, unexplained weight\nloss, fatigue/malaise/lethargy, changes in appetite, trouble \nwith\nsleep, pruritis, jaundice, rashes, bleeding, easy bruising,\nheadache, dizziness, vertigo, syncope, weakness, paresthesias,\nnausea, vomiting, hematemesis, bloating, cramping, melena, \nBRBPR,\ndysphagia, chest pain, shortness of breath, cough, edema, \nurinary\nfrequency, urgency\n\n \nPast Medical History:\nRetinal vasculitis\nHypertension\nDepression \nDiverticulitis\n \nSocial History:\n___\nFamily History:\nParents in assisted living with Alzheimers/dementia\nFather with MI age ___, CAD\nFamily history of DM, stomach cancer\n\n \nPhysical Exam:\nAdmission physical exam\n===================\nVitals:\n___, BP 125/77, HR 89, RR 15, 98% RA\nGEN: A&O, NAD\nHEENT: No scleral icterus, mucus membranes moist\nCV: RRR\nPULM: Clear to auscultation b/l, mild tenderness to palpation on\nleft lateral chest wall\nABD: Soft, nondistended, nontender, no rebound or guarding,no\npalpable masses\nExt: No ___ edema, ___ warm and well perfused. Pulse exam: ___\nbilaterally palpable. \nScratches present throughout her entire extremities \nLeft posterior thigh with ecchymosis and a palpable hematoma\nNeuro: Cranial nerves ___ intact (patient has blindness at\nbaseline)\nStrength: ___ throughout upper and lower extremities\nSensation: Intact throughout upper and lower extremities\nPelvis: Stable\nSpine: No tenderness to palpation\n\nDischarge physical exam\n==================\nGen: [x] NAD, [x] AAOx3\nCV: [x] RRR, [] murmur\nResp: [x] breaths unlabored, [x] CTAB, [] wheezing, [] rales\nAbdomen: [x] soft, [] distended, [] tender, [] rebound/guarding\nExt: [x] warm, [x] tender L thigh, [] edema, L posterior thigh\nwith ecchymosis and a palpable hematoma now covered by dressing.\nTenderness on palpation on left chest wall. \n\n \nPertinent Results:\nadmission labs\n===========\n\n___ 04:05AM BLOOD WBC-9.0 RBC-3.87* Hgb-12.6 Hct-37.2 \nMCV-96 MCH-32.6* MCHC-33.9 RDW-13.8 RDWSD-47.5* Plt ___\n___ 04:05AM BLOOD Neuts-75.2* Lymphs-17.9* Monos-5.0 \nEos-1.1 Baso-0.4 Im ___ AbsNeut-6.79* AbsLymp-1.62 \nAbsMono-0.45 AbsEos-0.10 AbsBaso-0.04\n___ 04:05AM BLOOD Glucose-182* UreaN-17 Creat-1.0 Na-136 \nK-4.8 Cl-102 HCO3-19* AnGap-15\n\nImaging\n======\nleft femur x-ray ___\nNo acute fracture or dislocation.\n\nNC chest CT ___\n1. Mild ecchymosis along the left lateral upper chest. No \nevidence of acute\nfractures.\n2. Chronic left-sided rib fractures and chronic mild L1 \ncompression deformity.\n3. Markedly dilated common bile duct, measuring up to 16 mm, \nincreased\ncompared to MRCP from ___. Correlation with LFTs is \nrecommended,\nand repeat MRCP on an outpatient basis could be considered.\n4. Severe coronary calcification.\n\nCXR ___\nNo acute cardiopulmonary process. Multiple chronic left-sided \nrib fractures\nare better evaluated on same-day chest CT.\n\nU/S LLE ___\n8.0 x 1.8 x 3.7 cm complex fluid collection likely represents a \nhematoma. \nHowever, given recent trauma and its location near the greater \ntrochanter and\nalong the deep subcutaneous fat, Morel ___ lesion cannot be \nexcluded. \nClinical and/or ultrasound follow-up to resolution is \nrecommended.\n\nMRI THIGH LEFT ___\n1. Favored 5.3 x 3.3 x 9.3 cm subcutaneous hematoma in the \nposterolateral\nproximal left thigh, not fitting criteria for Morel ___ \nlesion. \nRecommend follow-up to resolution. If the lesion enlarges or \npersists after 3\nmonths, recommend repeat ultrasound or MRI imaging.\n \n2. Sequela of prior soft tissue injury seen in the proximal \nleft\nthigh/gluteal region.\n\nDISCHARGE LABS\n==============\n\n___ 05:25AM BLOOD WBC-6.6 RBC-3.16* Hgb-10.3* Hct-31.5* \nMCV-100* MCH-32.6* MCHC-32.7 RDW-13.5 RDWSD-48.9* Plt ___\n \nBrief Hospital Course:\nP - Patient summary statement for admission\n___ with blindness who presents s/p fall now with a left thigh\nhematoma could not exclude Morel ___ lesion. \n\nA - Acute medical/surgical issues addressed\nShe underwent an ultrasound of left thigh which showed 8.0 x 1.8 \nx 3.7 cm complex fluid collection likely represents a hematoma \nand Morel ___ lesion couldn't be excluded. She underwent an \nMRI of left thigh which showed hematoma. She was given \nmedication for pain control and she was monitored during the \nhospitalization. \n\nC - Chronic issues pertinent to admission (ex. HTN, held \nLisinopril for ___\nShe was continued on her home medication for depression and \nhypertension during hospitalization. \n\nT - Transitional Issues (ex. follow up Cr and restart \nLisinopril)\n[]Please repeat imaging as follow up for left thigh hematoma\n[]Please encourage incentive spirometer use for chronic \nleft-side rib fractures\n[]Please repeat LFTs and MRCP as follow up for dilated common \nbile duct as outpatient\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 ___\n \nMedications on Admission:\nMedications - Prescription\nALENDRONATE [FOSAMAX] - Dosage uncertain - (Prescribed by Other\nProvider)\nBUPROPION HCL [WELLBUTRIN SR] - Wellbutrin SR 150 mg tablet, 12\nhr sustained-release. 1 tablet(s) by mouth once a day - \n(Prescribed by Other Provider)\nESCITALOPRAM OXALATE [LEXAPRO] - Lexapro 20 mg tablet. 1\ntablet(s) by mouth - (Prescribed by Other Provider)\nMETHOTREXATE SODIUM [TREXALL] - Trexall 15 mg tablet. tablet(s)\nby mouth weekly - (Prescribed by Other Provider)\nMETOPROLOL SUCCINATE - Dosage uncertain - (Prescribed by Other\nProvider)\nPREDNISONE - Dosage uncertain - (Prescribed by Other Provider)\nRYMADIL - Dosage uncertain - (Prescribed by Other Provider)\n \nDischarge Medications:\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever \nRX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6) \nhours Disp #*24 Tablet Refills:*0 \n2. Docusate Sodium 100 mg PO BID \nRX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice \na day Disp #*6 Capsule Refills:*0 \n3. Lidocaine 5% Patch 1 PTCH TD QAM \nRX *lidocaine 5 % Please apply to left side chest wall once a \nday Disp #*3 Patch Refills:*0 \n4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - \nModerate \nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nDisp #*15 Tablet Refills:*0 \n5. Polyethylene Glycol 17 g PO DAILY \nRX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 1 dose by \nmouth once a day Disp #*3 Packet Refills:*0 \n6. Senna 8.6 mg PO BID:PRN Constipation - First Line \nPlease hold for loose stools \nRX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 tablet(s) by \nmouth twice a day Disp #*6 Tablet Refills:*0 \n7. BuPROPion (Sustained Release) 150 mg PO QAM \n8. Escitalopram Oxalate 20 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nLeft thigh hematoma\nChronic left rib 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 Ms. ___,\n\nYou came to the hospital because you had a fall and you had a \nhematoma on your left thigh. We obtained an MRI of your left leg \nwhich showed \n1. Favored 5.3 x 3.3 x 9.3 cm subcutaneous hematoma in the \nposterolateral \nproximal left thigh, not fitting criteria for Morel ___ \nlesion. \nRecommend follow-up to resolution. If the lesion enlarges or \npersists after 3 \nmonths, recommend repeat ultrasound or MRI imaging. \n2. Sequela of prior soft tissue injury seen in the proximal \nleft \nthigh/gluteal region. \nYou also underwent a CT chest which showed:\n1. Mild ecchymosis along the left lateral upper chest. No \nevidence of acute \nfractures. \n2. Chronic left-sided rib fractures and chronic mild L1 \ncompression deformity. \n3. Markedly dilated common bile duct, measuring up to 16 mm, \nincreased \ncompared to MRCP from ___. Correlation with LFTs is \nrecommended, \nand repeat MRCP on an outpatient basis could be considered. \n4. Severe coronary calcification. \nYou were monitored and given medication for pain control. Now \nyou are ready to be discharged home. \n\n* You have chronic rib fractures which can cause severe pain and \nsubsequently cause you to take shallow breaths because of the \npain. * You should take your pain medication as directed to stay \nahead of the pain otherwise you won't be able to take deep \nbreaths. If the pain medication is too sedating take half the \ndose and notify your physician. * Pneumonia is a complication of \nrib fractures. In order to decrease your risk you must use your \nincentive spirometer 4 times every hour while awake. This will \nhelp expand the small airways in your lungs and assist in \ncoughing up secretions that pool in the lungs. * You will be \nmore comfortable if you use a cough pillow to hold against your \nchest and guard your rib cage while coughing and deep breathing. \n* Symptomatic relief with ice packs or heating pads for short \nperiods may ease the pain. * Narcotic pain medication can cause \nconstipation therefore you should take a stool softener twice \ndaily and increase your fluid and fiber intake if possible. * Do \nNOT smoke * If your doctor allows, non-steroidal \n___ drugs are very effective in controlling pain ( \nie, Ibuprofen, Motrin, Advil, Aleve, Naprosyn) but they have \ntheir own set of side effects so make sure your doctor approves. \n* Return to the Emergency Room right away for any acute \nshortness of breath, increased pain or crackling sensation \naround your ribs (crepitus). Lap CCY: Please follow up in the \nAcute Care Surgery clinic at the appointment listed below. \n\nACTIVITY: -Do not drive until you have stopped taking pain \nmedicine and feel you could respond in an emergency. -You may \nclimb stairs. -You may go outside, but avoid traveling long \ndistances until you see your surgeon at your next visit. -Don't \nlift more than ___ lbs for 4 weeks. (This is about the weight \nof a briefcase or a bag of groceries.) This applies to lifting \nchildren, but they may sit on your lap. -You may start some \nlight exercise when you feel comfortable. -You will need to stay \nout of bathtubs or swimming pools for a time while your incision \nis healing. Ask your doctor when you can resume tub baths or \nswimming. HOW YOU MAY FEEL: -You may feel weak or \"washed out\" \nfor a couple of weeks. You might want to nap often. Simple tasks \nmay exhaust you. -You may have a sore throat because of a tube \nthat was in your throat during surgery. -You might have trouble \nconcentrating or difficulty sleeping. You might feel somewhat \ndepressed. -You could have a poor appetite for a while. Food may \nseem unappealing. -All of these feelings and reactions are \nnormal and should go away in a short time. If they do not, tell \nyour surgeon. \n\nPlease call your doctor or nurse practitioner or return to the \nEmergency Department for any of the following:\n\n*You experience new chest pain, pressure, squeezing or \ntightness.\n\n*New or worsening cough, shortness of breath, or wheeze.\n\n*If you are vomiting and cannot keep down fluids or your \nmedications.\n\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\n*You see blood or dark/black material when you vomit or have a \nbowel movement.\n\n*You experience burning when you urinate, have blood in your \nurine, or experience a discharge.\n\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\n*You have shaking chills, or fever greater than 101.5 degrees \nFahrenheit or 38 degrees Celsius.\n\n*Any change in your symptoms, or any new symptoms that concern \nyou.\n\nPlease resume all regular home medications, unless specifically \nadvised not to take a particular medication. Also, please take \nany new medications as prescribed.\n\nPlease get plenty of rest, continue to ambulate several times \nper day, and drink adequate amounts of fluids. Avoid lifting \nweights greater than ___ lbs until you follow-up with your \nsurgeon.\n\nAvoid driving or operating heavy machinery while taking pain \nmedications\n\n \nFollowup Instructions:\n___\n" ]

[ "S7012XA", "N179", "M8448XA", "W010XXA", "W109XXA", "H35069", "I10", "F329", "H548" ]

[ "S7012XA: Contusion of left thigh, initial encounter", "N179: Acute kidney failure, unspecified", "M8448XA: Pathological fracture, other site, initial encounter for fracture", "W010XXA: Fall on same level from slipping, tripping and stumbling without subsequent striking against object, initial encounter", "W109XXA: Fall (on) (from) unspecified stairs and steps, initial encounter", "H35069: Retinal vasculitis, unspecified eye", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "H548: Legal blindness, as defined in USA" ]

[ "N179", "I10", "F329" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: SURGERY\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain, N/V \n \nMajor Surgical or Invasive Procedure:\nEsophageal Manometry ___\nLaparoscopic paraesophageal hernia repair with Nissen \nFundoplication ___ ___\n\n \n___ of Present Illness:\nPatient is a ___ with history of duodenal ulcer, hiatal\nhernia, depression, and retinal vasculitis leading to legal\nblindness (on prednisone, MTX, infliximab) who presents with\nacute on chronic abdominal pain and nausea/vomiting. \n\nOf note, patient was admitted to ___ ___ after \npresenting\nwith abdominal pain and bilious vomiting. Her abdominal pain \nhad\nbeen ongoing for months, responsive to PPI, though acutely \nbecame\nsevere and crampy. It was associated with severe nausea and\nvomiting, worse with food intake. CT A/P showed dilated\nintrahepatic and extrahepatic bile ducts and possible impacted\nbile stone in the proximal common bile duct, concern for\ncholedocholithiasis (though LFTs were wnl). ERCP team was\nconsulted, abx were deferred as patient did not appear\nsystemically sick. ERCP was non-diagnostic ___, MRCP showed\nlikely sphincter of Oddi dysfunction with mild central\nintrahepatic and extrahepatic biliary ductal dilatation. EGD\nperformed ___ had shown hiatal hernia and esophagitis. Her\nsymptoms were ultimately thought to be related to her hiatal\nhernia, surgery was consulted (large paraesophageal hernia type\n3), no acute surgical intervention. Once patient's were under\nbetter control with supportive measures, decision was made to\ndischarge her home with outpatient surgical follow-up.\n\nAfter discharge, patient states that she has been unable to\ntolerate POs consistently. Multiple episodes of recurrent\nbilious emesis starting ___ evening with severe nausea. \nUnclear if there is any blood given patient's legal blindness. \nNo fevers/chills. She also continues to have crampy abdominal\npain ___ in severity, waxing and waning, worse with food\nintake. Her last BM earlier this AM was quite loose, again\nunsure if bloody. Given her worsening symptoms, patient decided\nto represent to the ___ ED. \n\nIn the ED, initial VS were: 97 80 133/98 20 99% RA \n\nExam notable for: TTP in epigastric region. No guarding or\nrebound. \n\nECG: NSR (87bpm), normal intervals, normal intervals, difficult\nto interpret baseline, no ischemic changes. \n\nLabs showed:\nCBC 12.9>15.3/44.2<376\nBMP ___ (AG 27) \nALT 62\nAST 25\nALP 95\nTbili 1.0\nAlbumin 4.4\nLipase 22 \nLactate 2.0 \n\nConsults: NONE \n\nPatient received:\n___ 20:15 IVF NS \n___ 20:39 IV Morphine Sulfate 2 mg \n___ 21:04 IV Potassium Chloride (40 mEq ordered) \n___ 21:04 IV LORazepam 1 mg \n___ 22:31 IV Morphine Sulfate 2 mg \n___ 22:31 IV LORazepam .5 mg\n \nTransfer VS were: \n99.0 96 162/103 18 99% RA \n\nOn arrival to the floor, patient recounts the history as above. \nShe is visibly uncomfortable, intermittently having small \nvolumes\nof bilious emesis. Abdominal pain is intermittently severe,\nparoxysms ___ and crampy, predominantly epigastric. One\nepisode of loose stools AM ___. No palpitations. No\nlightheadedness/dizziness. No fevers/chills. \n \n\n \nPast Medical History:\nRetinal vasculitis\nHypertension\nDepression \nDiverticulitis\n \nSocial History:\n___\nFamily History:\nParents in assisted living with Alzheimers/dementia\nFather with MI age ___, CAD\nFamily history of DM, stomach cancer\n\n \nPhysical Exam:\nADMISSION EXAM\n==========================\nVS: 98.3 ___ 95 \nGENERAL: Uncomfortable appearing.\nHEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, dry MMM. \n\nNECK: No appreciable JVP.\nHEART: RRR, S1/S2, no murmurs, gallops, or rubs. \nLUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably\nwithout use of accessory muscles. \nABDOMEN: +BS, nondistended, mild diffuse tenderness, guarding\nwith palpation over epigastrum, no rebounding, no\nhepatosplenomegaly. \nEXTREMITIES: No cyanosis, clubbing, or edema. \nPULSES: 2+ radial pulses bilaterally. \nNEURO: A&Ox3, moving all 4 extremities with purpose. \nSKIN: Warm and well perfused, no excoriations or lesions, no\nrashes. \n\nDISCHARGE EXAM\n==========================\n\n \nPertinent Results:\n___ 05:40AM BLOOD WBC-11.3* RBC-3.23* Hgb-10.4* Hct-32.3* \nMCV-100* MCH-32.2* MCHC-32.2 RDW-14.6 RDWSD-53.4* Plt ___\n___ 05:20AM BLOOD WBC-12.6* RBC-3.72* Hgb-12.1 Hct-36.6 \nMCV-98 MCH-32.5* MCHC-33.1 RDW-14.5 RDWSD-52.2* Plt ___\n___ 05:40AM BLOOD Glucose-135* UreaN-10 Creat-0.6 Na-140 \nK-4.3 Cl-104 HCO3-25 AnGap-11\n \nBrief Hospital Course:\nMs. ___ is a ___ female with history of \nlarge hiatal hernia, paraesophageal hernia, recently healed \nduodenal ulcer, gastritis, esophagitis, and biliary dilation who \npresented with abdominal pain, nausea, and vomiting. \n \nACUTE ISSUES: \n=================================\n# Nausea/vomiting\n# Epigastric pain\n# Hiatal hernia: \nPatient had been recently hospitalized with similar symptoms \nlikely due to hiatal hernia. She was discharged on liquid diet \nand outpatient surgical follow-up but did not tolerate liquids \nat home. She was readmitted with abdominal pain, nausea, and \nvomiting. She was made NPO and NGT was placed for decompression \ngiven concern for obstruction. KUB did not show obstruction and \nCMV was negative. Patient had ketonuria on admission suggesting \nmalnutrition. GI and General Surgery were consulted. She had \nmanometry which showed mild esophageal dysmotility. \n\nThe patient was then transferred to the ___ Surgical \nService for further management of her hiatal hernia. Ms. ___ \nreceived a laparoscopic repair of hiatal hernia with Nissen \nfundoplication and ___ gastroplasty on ___ and \ntherefore transferred to the surgical service. Please see the \noperative report for further details. The patient did experience \nslight aspiration of gastric contents intra-operatively. \nPost-operatively the patient was taken to the PACU until stable \nand then transferred to the wards until stable to go home. \n\n___ Course (___)\n#NEURO: The patient was alert and oriented throughout \nhospitalization; pain was initially managed with a PCA and was \nthen transitioned to PO pain meds. Pain was very well \ncontrolled.\n\n#CV: The patient remained stable from a cardiovascular \nstandpoint; vital signs were routinely monitored. \n\n#PULMONARY: The patient remained stable from a pulmonary \nstandpoint; vital signs were routinely monitored. Good pulmonary \ntoilet, early ambulation and incentive spirometry were \nencouraged throughout hospitalization. \n\n#GI/GU/FEN: The patient had a foley placed intra-operatively, \nwhich was removed post-surgery on POD1 with autonomous return of \nvoiding. The patient's diet was then advanced slowly while she \nwas concurrently on TPN for nutritional support. The patient was \ndischarged without TPN. The patient was tolerating a regular \ndiet prior to discharge. \n\n#ID: The patient's fever curves were closely watched for signs \nof infection, of which there were none. \n\n#HEME: Patient received BID SQH for DVT prophylaxis, in addition \nto encouraging early ambulation and Venodyne compression \ndevices. \n--------------------\n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating diet as \nabove per oral, ambulating, voiding without assistance, and pain \nwas well controlled. The patient was discharged home without \nservices. The patient received discharge teaching and follow-up \ninstructions with understanding verbalized and agreement with \nthe discharge plan.\n\n# Malnutrition: Patient had ketonuria on admission suggesting \nmalnutrition due to poor PO intake from hiatal hernia, nausea, \nvomiting, chronic abdominal pain. Patient was NPO in \nanticipation for surgery and nutrition was consulted for TPN \ninitiation. She was started on TPN which was continued until \n___ and was discontinued on discharge.\n\n# Anemia\nLikely dilutional iso of IVF, but possible that pt is bleeding, \ngiven hx of duodenal ulcer and GI irritation. \n-Monitored throughout the patient's hospitalization.\n\n# Transaminitis \nPatient was just recently worked up for choledocholithiasis\nduring recent admission, MRCP showed Sphincter of Oddi\ndysfunction and biliary duct dilation. ALT elevated only mildly\nwithout any signs of obstruction. \n- Continue to trend LFTs\n\nCHRONIC ISSUES: \n===============================\n# Retinal vasculitis:\nPatient is legally blind at baseline and takes prednisone, MTX \nonce weekly, and infliximab. Her outpatient Rheumatologist was \ncontacted and she had recently received Infliximab and did not \nneed dosing while inpatient. Per her Rheumatologist, she did not \nneed to receive PO MTX while remaining NPO for surgery. If she \nwere NPO for a prolonged period of time, he recommended \nequivalent IM dosing of MTX. Her home prednisone was replaced \nwith IV methylprednisolone 4 mg daily. \n\n# Depression\nHeld home wellbutrin, escitalopram iso NPO.\nThese medications were resumed on discharge.\n\n# HTN\nHeld home metoprolol iso NPO.\nThese medications were resumed on discharge.\n\n# L1 burst fracture \nNoted on CT A/P during previous admission. Vitamin D level was \nlow this admission and during previous admission. \n- Noted on CT A/P during her last admission. \nHypovitaminosis D on recent labs. Patient is at increased risk\nof osteoporosis iso chronic steroids.\n- Continue Vitamin D supplementation\n \nTRANSITIONAL ISSUES\n==============================\n- Transitional issue: bisphosphonate (though patient has\nesophagitis), DEXA scan \n\n \nMedications on Admission:\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. BuPROPion XL (Once Daily) 450 mg PO DAILY \n2. Escitalopram Oxalate 40 mg PO DAILY \n3. FoLIC Acid 1 mg PO DAILY \n4. Methotrexate 15 mg PO 1X/WEEK (TH) \n5. Metoprolol Tartrate 25 mg PO DAILY \n6. PredniSONE 4 mg PO DAILY \n7. TraZODone ___ mg PO QHS:PRN insomnia \n8. Omeprazole 20 mg PO DAILY \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Metoprolol Tartrate 25 mg PO/NG DAILY \nStart: Upon Arrival \n3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \n Reason for PRN duplicate override: dcing\nRX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours \nPRN Disp #*20 Tablet Refills:*0 \n4. TraZODone 25 mg PO QHS:PRN insomnia \n5. BuPROPion XL (Once Daily) 450 mg PO DAILY \n6. Escitalopram Oxalate 40 mg PO DAILY \n7. FoLIC Acid 1 mg PO DAILY \n8. Methotrexate 15 mg PO 1X/WEEK (TH) \n9. Omeprazole 20 mg PO DAILY \n10. PredniSONE 4 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nParaesophageal hernia\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 here at ___ \n___. You were admitted to our hospital for \nhiatal hernia. You had a hiatal hernia repair and Nissen \nfundopliation on ___ ___. You tolerated the \nprocedure well and are ambulating, stooling, tolerating a \nregular diet, and your pain is controlled by pain medications by \nmouth. You are now ready to be discharged to home. Please follow \nthe recommendations below to ensure a speedy and uneventful \nrecovery. \n\nACTIVITY:\n- Do not drive until you have stopped taking pain medicine and \nfeel you could respond in an emergency.\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.\n- Heavy exercise may be started after 6 weeks, but use common \nsense and go slowly at first. \n- No heavy lifting (10 pounds or more) until cleared by your \nsurgeon, usually about 6 weeks. \n- You may resume sexual activity unless your doctor has told you \notherwise.\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) or gentle laxative (such as milk \nof magnesia, 1 tbs) twice a day. You can get both of these \nmedicines without a prescription.\n- If you go 48 hours without a bowel movement, or have pain \nmoving the bowels, call your surgeon.\n- After some operations, diarrhea can occur. If you get \ndiarrhea, don't take anti-diarrhea medicines. Drink plenty of \nfluids and see if it goes away. If it does not go away, or is \nsevere and you feel ill, please call your surgeon.\n\nPAIN MANAGEMENT:\n- You are being discharged with a prescription for oxycodone for \npain control. You may take Tylenol as directed, not to exceed \n3500mg in 24 hours. Take regularly for a few days after surgery \nbut you may skip a dose or increase time between doses if you \nare not having pain until you no longer need it. You may take \nthe oxycodone for moderate and severe pain not controlled by the \nTylenol. You may take a stool softener while on narcotics to \nhelp prevent the constipation that they may cause. Slowly wean \noff these medications as tolerated. \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\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\nAdditional: \n- pain that is getting worse over time, or going to your chest \nor back\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 shower with any bandage strips that may be covering \nyour wound. Do not scrub and do not soak or swim, and pat the \nincision dry. If you have steri strips, they will fall off by \nthemselves in ___ weeks. If any are still on in two weeks and \nthe edges are curling up, you may carefully peel them off. *** \nYour staples will be removed by your surgeon at your follow up \nappointment. \n Do not take baths, soak, or swim for 6 weeks after surgery \nunless told otherwise by your surgical team. \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\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\n-- Your ___ Care Team\n\n \nFollowup Instructions:\n___\n" ]

[ "K449", "E43", "G92", "E871", "N179", "E876", "Z6825", "S32011D", "X58XXXD", "I10", "F329", "Z7952", "Z79899", "H35069", "E559", "D649", "D72829", "K224" ]

[ "K449: Diaphragmatic hernia without obstruction or gangrene", "E43: Unspecified severe protein-calorie malnutrition", "G92: Toxic encephalopathy", "E871: Hypo-osmolality and hyponatremia", "N179: Acute kidney failure, unspecified", "E876: Hypokalemia", "Z6825: Body mass index [BMI] 25.0-25.9, adult", "S32011D: Stable burst fracture of first lumbar vertebra, subsequent encounter for fracture with routine healing", "X58XXXD: Exposure to other specified factors, subsequent encounter", "I10: Essential (primary) hypertension", "F329: Major depressive disorder, single episode, unspecified", "Z7952: Long term (current) use of systemic steroids", "Z79899: Other long term (current) drug therapy", "H35069: Retinal vasculitis, unspecified eye", "E559: Vitamin D deficiency, unspecified", "D649: Anemia, unspecified", "D72829: Elevated white blood cell count, unspecified", "K224: Dyskinesia of esophagus" ]

[ "E871", "N179", "I10", "F329", "D649" ]

[]

[ " \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:\nR MCA syndrome s/p tPA\n \nMajor Surgical or Invasive Procedure:\nstatus post tPA\nright carotid stenting and thrombectomy ___\n\n \nHistory of Present Illness:\nMr. ___ is a ___ right handed man with a past medical\nhistory of Eosinophilic Esophagitis and Chronic Hepatitis B who\npresents s/p tPA for sudden onset left hemiplegia and mild\nneglect, with evidence of a hyperdense R MCA at OSH.\n\nHistory is gathered from patient at bedside, but is limited. \n\nIn brief, Mr. ___ was at his baseline state of health this\nmorning when around roughly 8PM he was driving to ___ to \nvisit\na friend. He recalls smelling burning rubber (and thinking that\nhe blew a car tire). The next thing he recalled was being on \nthe\nside of the road following a car accident. EMS arrived, and due\nto concern for a facial droop he was taken to OSH.\n\nThere, there was concern for a stroke. ___ revealed a \npossible\nhyperdense Right MCA. NIHSS was at least 6 (exact details\nunclear), with 1 point for Left facial palsy, 1 for dysarthria, \n___nd 1 for leg and arm drift respectively. \nHe was given IV tPA roughly 2 hours following onset of symptoms\n(roughly 10pm) He was transferred to ___ for endovascular\nconsideration. \n\nHere, NIHSS was 9. CTA reconfirmed occlusion of the right\ninternal carotid artery distal to the bifurcation, with\nre-cannulization exiting the cavernous sinus. He was taken\nurgently for Neurovascular intervention. Groin puncture was at\n00:15 with placement of 1 right ECA stent and 2 Right ICA stents\nwith carotid recanalization. Subsequent underwent stent\nretrieval and suction catheterization. During this procedure he\nreceived integrillin and IV heparin per endovascular team.\n\nRoS unable to be fully gathered. Endorses mild headache.\n \nPast Medical History:\nChronic Hepatitis B\nEosinophilic Esophagitis\nSplenic Artery Aneurysm\n \nSocial History:\n___\nFamily History:\nDenies any family history of neurologic issues including stroke\nor seizure.\n \nPhysical Exam:\nADMISSION EXAMINATION:\n\nVitals: 98.0 73 139/89 16 96% RA \nGeneral: Awake, cooperative, NAD.\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in \noropharynx\nNeck: Supple. No nuchal rigidity\nPulmonary: Lungs CTA bilaterally\nCardiac: RRR, nl. S1S2\nAbdomen: soft, NT/ND.\nExtremities: WWP.\nSkin: no rashes or lesions noted.\n\nNeurologic:\n\n-Mental Status: Alert, oriented to person place and date. Able \nto\nrelate history regarding car crash without difficulty. He is \nnot\naware of his left sided weakness or sensory deficits and\nexcluding a headache reports he otherwise feels well. Attentive\nto examiner and tasks. In the setting of the left hemisensory\nneglect as below, he does acknowledge providers on both sides.\nLanguage is fluent with intact repetition and comprehension.\nNormal prosody. There were no paraphasic errors. Pt was able to\nname both high and low frequency objects. Speech was mildly\ndysarthric but easily understandable. Able to follow both \nmidline\nand appendicular commands. \n\n-Cranial Nerves:\nII, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without\nnystagmus. Normal saccades. Visual fields with likely left\nneglect versus left hemianopsia, but difficult to clarfiy. \nV: Facial sensation intact to light touch, but with intermittent\nleft neglect.\nVII: Clear left UMN pattern facial droop.\nVIII: Hearing intact room voice.\nIX, X: Palate midline.\nXI: Turns head side to side w/o difficulty.\nXII: Tongue protrudes in midline.\n\n-Motor: Normal bulk, tone throughout. Left pronator drift\npresent. No adventitious movements, such as tremor, noted. \nLimited\nstrength assessment. RUE and RLE appear grossly full to\ncontfronational strength testing. LUE was perhaps subtly weak \nat\nleft deltoid and triceps. LLE with mild weakness of IP, perhaps\nhamstring. unfortunately, due to urgency of intervention, full\nexam unable to be performed.\n\n-Sensory: Has left hemibody sensory extinction to DSS. \nInconsistent neglect to left hemisensory light touch. Otherwise\ngrossly intact to light touch and tickle.\n\n-DTRs:\n Bi Tri ___ Pat Ach\nL 2 2 2 3 1\nR 2+ 2 2 3 1\n- Pec jerk present on left, not present on right\n- Plantar response was flexor bilaterally.\n\n-Coordination: No intention tremor. Limited assessment of RAM. \nMild LUE ataxia in proportion to weakness. \n\n-Gait: Unable to assess.\n\n**********\n\nDISCHARGE EXAMINATION:\n\nGeneral: Awake, cooperative, NAD.\nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in \noropharynx\nNeck: Supple. No nuchal rigidity\nPulmonary: Lungs CTA bilaterally\nCardiac: RRR, nl. S1S2\nAbdomen: soft, NT/ND.\nExtremities: WWP.\nSkin: no rashes or lesions noted.\n\nNeurologic:\n\n-Mental Status: Alert, oriented x 3. Able to relate history \nwithout difficulty. Attentive, able to name ___ backward without \ndifficulty. Language is fluent with intact repetition and \ncomprehension. Normal prosody. There were no paraphasic errors. \nPt was able to name both high and low frequency objects. Able \nto read without difficulty. Speech was not dysarthric. Able to \nfollow both midline and appendicular commands. There was no \nevidence of apraxia or neglect.\n\n-Cranial Nerves:\nII, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without \nnystagmus. Normal saccades. VFF to confrontation.\nV: Facial sensation intact to light touch.\nVII: Mild L NLFF and decreased activation of left facial \nmuscles.\nVIII: Hearing intact to finger-rub bilaterally.\nIX, X: Palate elevates symmetrically.\nXI: ___ strength in trapezii and SCM bilaterally.\nXII: Tongue protrudes in midline.\n\n-Motor: Normal bulk, tone throughout. Mild cupping of left hand \nwith eyes closed. No adventitious movements, such as tremor, \nnoted. No asterixis noted.\n Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___\nL 5 ___ ___ 5 5 5 5 5 5 5\nR 5 ___ ___ 5 5 5 5 5 5 5\n\n-Sensory: No deficits to light touch, pinprick, vibratory sense \nthroughout. No extinction to DSS.\n\n-DTRs:\n Bi Tri ___ Pat Ach\nL 2 2 2 2 1\nR 2 2 2 2 1\nPlantar response was flexor bilaterally.\n\n-Coordination: No intention tremor, no dysdiadochokinesia noted. \nNo dysmetria on FNF or HKS bilaterally.\n\n-Gait: deferred.\n\n \nPertinent Results:\nLABS:\n\n___ 11:45PM BLOOD WBC-8.0 RBC-4.72 Hgb-14.4 Hct-42.1 MCV-89 \nMCH-30.5 MCHC-34.2 RDW-12.4 RDWSD-40.7 Plt ___\n___ 11:45PM BLOOD Neuts-67.4 ___ Monos-7.0 Eos-3.6 \nBaso-0.5 Im ___ AbsNeut-5.38 AbsLymp-1.68 AbsMono-0.56 \nAbsEos-0.29 AbsBaso-0.04\n___ 11:45PM BLOOD ___ PTT-29.6 ___\n___ 11:45PM BLOOD Glucose-99 UreaN-15 Creat-0.9 Na-140 \nK-3.8 Cl-102 HCO3-26 AnGap-16\n___ 03:31AM BLOOD Albumin-3.8 Calcium-8.3* Phos-3.2 Mg-2.1 \nCholest-141\n___ 03:31AM BLOOD ALT-20 AST-25\n___ 03:31AM BLOOD %HbA1c-5.3 eAG-105\n___ 03:31AM BLOOD Triglyc-79 HDL-31 CHOL/HD-4.5 LDLcalc-94\n___ 03:32AM URINE Blood-NEG Nitrite-NEG Protein-TR \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG\n\n******************\n\nIMAGING:\n\nCTA head and neck ___:\n1. Complete occlusion R ICA bifurcation to cavernous sinus. \n2. Abrupt right V3 caliber change, reflect dissection.\n\nCerebral angiographay ___: \nIMPRESSION: \nPresumed right internal carotid artery dissection causing \ncarotid occlusion and middle cerebral artery occlusion carotid \nstenting and thrombectomy. TICI3 recanalization. \n\nCT head noncontrast ___:\nIMPRESSION: \nUnchanged mild loss of gray-white matter differentiation in the \nright frontal lobe, without evidence of new hemorrhage. \n\nMRI Brain ___:\n1. Acute infarction involving the right frontal operculum and \ninsular cortices corresponding to the middle cerebral artery. \n2. Numerous punctate infarcts involving the right \ntemporo-occipital cortex. Punctate infarcts involving the right \nanterior limb internal capsule and posterior external capsule. \nNo evidence of hemorrhagic conversion. The parietal infarcts \nmay be in watershed distribution. \n3. Background sequela chronic microangiopathy. \n\nTransthoracic echocardiogram ___:\nIMPRESSION:\nMildly dilated aortic arch. Normal biventricular cavity sizes \nwith preserved regional and global biventricular systolic \nfunction. No definite structural cardiac source of embolism \nidentified.\n\nCLINICAL IMPLICATIONS: \nThe patient has a mildly dilated ascending aorta. Based on ___ \nACCF/AHA Thoracic Aortic Guidelines, a follow-up echocardiogram \nis suggested in ___ years. \n \nBrief Hospital Course:\nThis is a ___ year old man with chronic Hep B, splenic art \naneurysm who presented acutely after new left-sided weakness and \nneglect leading to MVA on ___. On arrival to OSH he was found \nto have NIHSS of 6 and CT showed hyperdense R MCA, was given iv \ntPA at 22:00 and transferred to ___.\n\n# Neuro\nAt ___ was 8 (LUE went to 2 and sensory deficit noted \nin addition to tactile extinction) and CT/CTA showed R \nextracranial carotid occlusion, right vert dissection and distal \nR M1/M2 occlusion. He was taken urgently for endovacular \nintervention around midnight and had 3 stents placed \nextracranially (1 in the ECA, two in series in the ICA), he had \nclot retreival, and carotid was successfully recanalized at \n01:10 (~5h). He was admitted to the neurology ICU for post-tPA \ncare and monitoring. He had an unremarkable course and was \nsubsequently transferred to the floor, where his neurologic \nexamination continued to improve. Suspected etiology R-ICA \ndissection with R-MCA (M-2) occlusion. Echo and telemetry did \nnot suggest alternative cardioembolic source, although he had \nmildly dilated aortic arch on echo without any other associated \nabnormalities for which he needs a follow up study in ___ years \nas recommended by Cardiology guidelines. Evaluation of stroke \nrisk factors revealed A1c of 5.3 and LDL of 94. He was started \nASA 81mg/Plavix 75mg for indefinite secondary stroke prevention. \nSBP goals 120-160 and plan for DriveWise driving clearance as \noutpatient.\n\nTransitional issues:\n[ ] continue aspirin 81mg + Plavix 75mg for secondary stroke \nprevention in setting of carotid stent\n[ ] patient needs a follow up echocardiogram in ___ years (___) \nfor mildly dilated aortic arch without any other signs of \nvalvular or functional impairment\n[ ] recommend interval vascular imaging to evaluate for right \ncarotid artery and stent\n[ ] patient was encouraged to obtain DriveWise evaluation prior \nto resuming driving\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 = 94) - () No \n5. Intensive statin therapy administered? (simvastatin 80mg, \nsimvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, \nrosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) 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? () Yes - (x) No [if LDL >100, \nreason not given: ] \n10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) \nAntiplatelet - aspirin/plavix () Anticoagulation] - () No \n11. Discharged on oral anticoagulation for patients with atrial \nfibrillation/flutter? () Yes - () No - (x) N/A \n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQID:PRN SOB, wheeze \n2. Omeprazole 20 mg PO BID \n3. azelastine 137 mcg (0.1 %) nasal BID \n\n \nDischarge Medications:\n1. azelastine 137 mcg (0.1 %) nasal BID \n2. Omeprazole 20 mg PO BID \n3. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nQID:PRN SOB, wheeze \n4. Clopidogrel 75 mg PO DAILY \nRX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 \nTablet Refills:*3\n5. Aspirin 81 mg PO DAILY \nRX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet \nRefills:*3\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nAcute stroke\nRight internal carotid occlusion\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Mr. ___,\n\nYou were hospitalized due to symptoms of left-sided weakness \nleading to a car accident resulting from an ACUTE ISCHEMIC \nSTROKE, a condition where a blood vessel providing oxygen and \nnutrients to the brain is blocked by a clot. The brain is the \npart of your body that controls and directs all the other parts \nof your body, so damage to the brain from being deprived of its \nblood supply can result in a variety of symptoms. \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 gave you the medication \nfor acute stroke (tPA) and took you for angiographic \nintervention (with placement of right internal carotid artery \nstents and clot retrieval).\n\nWe are changing your medications as follows: \n- ADDING aspirin 81mg daily and Plavix 75mg daily which you \nshould remain on indefinitely.\n\nYOU SHOULD REFRAIN FROM DRIVING until you are evaluated by the \n___ DriveWise Team and are cleared to drive. We do not think \nthere is a serious contraindication for you traveling via plane \n(you asked specifically about an upcoming trip to ___, \nand we think this would be safe).\n\nYour echocardiogram did not show any possible sources of stroke, \nalthough there was one small unusual finding for which you \nshould receive a repeat echocardiogram in ___ years.\n\nPlease take your other medications as prescribed. \nPlease followup with Neurology and your primary care physician \nas listed below. \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\nIt was a pleasure taking care of you during this \nhospitalization.\n\nSincerely, \nYour ___ Neurology Team\n \nFollowup Instructions:\n___\n" ]

[ "I63031", "I7774", "I7771", "B181", "G8194", "R414", "Z9282", "I6601" ]

[ "I63031: Cerebral infarction due to thrombosis of right carotid artery", "I7774: Dissection of vertebral artery", "I7771: Dissection of carotid artery", "B181: Chronic viral hepatitis B without delta-agent", "G8194: Hemiplegia, unspecified affecting left nondominant side", "R414: Neurologic neglect syndrome", "Z9282: Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility", "I6601: Occlusion and stenosis of right middle cerebral artery" ]

[]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nNo Known Allergies / Adverse Drug Reactions\n \nAttending: ___.\n \nChief Complaint:\nAbdominal pain\n \nMajor Surgical or Invasive Procedure:\nUS-guided endoscopic celiac block on ___\n\n \nHistory of Present Illness:\nMs. ___ is a ___ with locally advanced, unresectable \npancreatic adenocarcinoma s/p palliative \nbiliary/gastrointestinal bypass ___, currently on gemzar, \nabraxane (___), recently initiated cyberknife, alcohol \nabuse, atrial fibrillation not on Coumadin, who presents after \nchemotherapy and alcohol ingestion with acute on chronic \nabdominal pain and several days of diarrhea. \n\nShe received cyberknife on ___ and ___, but developed \ndiarrhea and confusion over the weekend. Diarrhea began ___, \nprofuse, watery, and unable to control it (\"ran down my leg \nwithout me even knowing it\"). Pt is a poor historian but states \nthat she took 3 Imodium on ___. Has not had any further \ndiarrhea since. She also admits to feeling confused, \nspecifically in regards to the calendar. Losing track of time - \ndoesn't know what day it is unless she looks at her calendar. \nVery frustrating for her because she never used to have to rely \non a calendar. Also loses track of days (what happened yesterday \nv. 2 days ago, etc). No fevers, chills or sweats. No dizziness \nor lightheadedness. No falls. No chest pain, shortness of \nbreath or difficulty breathing. No palpitations. No rashes, no \nskin changes, no edema, no back pain, no joint pain, no urinary \nsymptoms.\n\nDespite these symptoms, she received C4D1 of gemcitabine and \nAbraxane yesterday (___). After chemo, she drank some vodka. She \nthen presented to ___ with abdominal pain and unsteady \ngait. \n\nPain is epigastric but radiates diffusely. Denies nausea, \nvomiting, fevers. Reports profuse diarrhea with bowel \nincontinence and urinary incontinence. Incontinence has been \npresent for several months. Reports generalized weakness but \ndenies numbness in the arms/legs. \n\nAt ___, EtOH level was 75. NCHCT and CXR were normal. CT \nof the abdomen and pelvis was performed and showed increased \nperipancreatic fluid collections. She was given Zosyn, thiamine, \nand IVF and was transferred to ___.\n\nIn the ED, initial VS were: 98.8 63 109/62 18 99% RA \nLabs were notable for: Bicarb at 20 with gap of 14, lactate 2.5, \notherwise labs at baseline including Chem-7, CBC, coags, LFTs, \nlipase \nConsults called:\nSurgery evaluated the patient: CT scan showed equivocal \nenlargement of chronic peripancreatic fluid collections. No \nacute surgical issue at this time. Recommend: Omed evaluation, \nConsider celiac plexus block per advanced endoscopy \nTreatments received: \n___ 07:01 IV HYDROmorphone (Dilaudid) 1 mg \n___ 08:09 IVF 1000 mL NS 1000 mL \n___ 08:09 PO/NG Levothyroxine Sodium 137 mcg \n\n \nPast Medical History:\nAtrial fibrillation- pt says that the physicians at first \nthought that she had atrial fibrillation but then she was \ndetermined not to have it. \nHypothyroidism\nETOH abuse- sober for ___ months previously 1 pint of vodka \ndaily for ___ years\nShe was diagnosed with cirrhosis at age ___\n \nSocial History:\n___\nFamily History:\nBoth parents have dementia. Her PGM died of rectal cancer. Her \nMGM died of rectal cancer. \n \nPhysical Exam:\nPHYSICAL EXAM:\nVITALS 98.8 63 109/62 18 99% RA \nGENERAL: Pleasant, lying in bed comfortably\nHEENT: \nCARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops\nLUNG: Appears in no respiratory distress, clear to auscultation \nbilaterally, no crackles, wheezes, or rhonchi\nABD: Normal bowel sounds, soft, nontender, nondistended, no \nhepatomegaly, no splenomegaly\nEXT: Warm, well perfused, no lower extremity edema\nPULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses\nNEURO: Alert, oriented, CN II-XII intact, motor and sensory \nfunction grossly intact\nSKIN: No significant rashes\n\nDISCHARGE PHYSICAL EXAM: \nVS: 98.0 108/60 59 18 94%\ngeneral: no in pain or distress. pale. \nHEENT: pupils equal and reactive to light\n___: normal S1 and S2 no murmur rubs or gallops\nAbdomen: mildline scar above the umbilicus, as well as scar at\n9o'clock position from the umbilicus extending to the right\nflank. tender abdomen on light palpation. \nGU: no foley\nNeurological: grossly intact.\n \nPertinent Results:\nLABS:\n=============\n\n___ 09:25AM LACTATE-1.7\n___ 07:56AM ___ PTT-31.2 ___\n___ 07:02AM ___ COMMENTS-GREEN\n___ 07:02AM LACTATE-2.5*\n___ 06:55AM GLUCOSE-119* UREA N-8 CREAT-0.8 SODIUM-143 \nPOTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-20* ANION GAP-18\n___ 06:55AM ALT(SGPT)-17 AST(SGOT)-24 ALK PHOS-113* TOT \nBILI-0.6\n___ 06:55AM LIPASE-6\n___ 06:55AM ALBUMIN-4.1\n___ 06:55AM WBC-4.5 RBC-3.63* HGB-10.5* HCT-33.5* MCV-92 \nMCH-28.9 MCHC-31.3* RDW-17.9* RDWSD-57.1*\n___ 06:55AM NEUTS-82.9* LYMPHS-13.4* MONOS-3.3* EOS-0.0* \nBASOS-0.2 IM ___ AbsNeut-3.72 AbsLymp-0.60* AbsMono-0.15* \nAbsEos-0.00* AbsBaso-0.01\n___ 06:55AM PLT COUNT-496*\n___ 12:01PM UREA N-7 CREAT-0.7 SODIUM-141 POTASSIUM-4.3 \nCHLORIDE-107 TOTAL CO2-24 ANION GAP-14\n___ 12:01PM ALT(SGPT)-12 AST(SGOT)-24 ALK PHOS-107* TOT \nBILI-0.3\n___ 12:01PM CALCIUM-9.2 PHOSPHATE-3.7 MAGNESIUM-2.1\n___ 12:01PM TSH-0.56\n___ 12:01PM WBC-5.3 RBC-3.34* HGB-9.8* HCT-29.8* MCV-89 \nMCH-29.3 MCHC-32.9 RDW-17.6* RDWSD-53.2*\n___ 12:01PM AbsNeut-2.89\n___ 12:01PM PLT COUNT-381\n___ 05:30AM BLOOD WBC-3.8* RBC-3.15* Hgb-9.0* Hct-29.0* \nMCV-92 MCH-28.6 MCHC-31.0* RDW-17.6* RDWSD-58.0* Plt ___\n___ 05:30AM BLOOD WBC-3.8* RBC-3.15* Hgb-9.0* Hct-29.0* \nMCV-92 MCH-28.6 MCHC-31.0* RDW-17.6* RDWSD-58.0* Plt ___\n___ 05:30AM BLOOD Plt ___\n___ 05:30AM BLOOD Glucose-93 UreaN-9 Creat-0.7 Na-143 K-4.1 \nCl-112* HCO3-25 AnGap-10\n___ 05:30AM BLOOD Calcium-8.8 Phos-5.4* Mg-2.0\n\nIMAGING::\n===========\n___ Imaging UNILAT LOWER EXT VEINS: NO DVT\n\nIMAGING from OSH (all from ___\n___ NCHCT: (wet read) no acute intracranial process\n___ CXR PA/L: (my read) Port at R chest, no pleural effusions, \ngrossly clear\n___ CT Abd/pel w/ con: per report, mildly enlarge \n___ fluid collections\n\n \nBrief Hospital Course:\nMs. ___ is a ___ with locally advanced, unresectable \npancreatic adenocarcinoma s/p palliative \nbiliary/gastrointestinal bypass ___, currently on gemzar, \nabraxane (___), recently initiated cyberknife, alcohol \nabuse, atrial fibrillation not on Coumadin, who presents after \nchemotherapy and alcohol ingestion with acute on chronic \nabdominal pain and several days of diarrhea. The patient pain \nwas controlled after US guided celiac plexus block.\n\n# Abdominal pain: acute on chronic pain she has had since \nwhipple in ___. Labs and vitals at baseline. CT \nabdomen/pelvis w/o acute process. Surgical evaluation concluded \nno acute surgical issue. Her exam on presentation was benign. \nMost likely due to ongoing cancer with acute exacerbation due to \nrecent cyber knife.\nThe patient underwent a celiac block via US-guided endoscopy on \n___. Her pain improved significantly. \n\n# Diarrhea: Several episodes after cyberknife over the weekend, \nloose to the point of incontinence. Her diarrhea improved \nwithout significant interventions. while on opiate analgesics, \nthe patient developed contipatoin and was started on stool \nsoftners. \n\n# Confusion: resolved on presentation. Labs checked, ammonia \nnormal (was concerned for hepatic encephalopathy). NCHCT w/o \nacute process. TSH wnl. Currently alert and oriented x 3 without \nfocal neurologic deficit. ___ be side effect from chemo. \n \n# Alcohol abuse: No history of withdrawal/DTs. EtOH 75 at OSH. \nEvidence of macronodular cirrhosis on imaging, but no \nbiochemical evidence of synthetic dysfunction, no history of HE, \nno varices on EGD. We arranged that SW sees her during her \nadmission. \n\n# Pancreatic cancer: On C4 of gemcitabine and Abraxane after \ncompleting CK. \n\n# Atrial fibrillation and flutter: has a CHADSVASC score is 1 \nindicating low risk of cardioenbolic events. We continued her \nmetoprolol for rate control.\n\n# Hypothyroidism: We continued her home levothyroxine.\n\nTRANSITIONAL ISSUES:\n- patient underwent successful US-guided endoscopic celiac \nblock. Would recommend following up the patient pain levels on \nfollow up.\n- the patient reported consumption of alcohol after being sober \nfor 9 months. Would recommend counseling and providing support \nand follow up regarding alcohol addiction.\n- There was concern that the patient may be taking 2 of her 1mg \nhome Ativan pills at a time. She was counseled to only take her \nmedications as prescribed. This may have contributed to her \ndifficulty remembering dates.\n\nName of health care proxy: ___ \nRelationship: Sister \nPhone number: ___ \nCell phone: ___ \nCode: full\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Aspirin 81 mg PO DAILY \n2. FoLIC Acid 1 mg PO DAILY \n3. Levothyroxine Sodium 137 mcg PO DAILY \n4. Lorazepam 0.5 mg PO Q6H:PRN anxiety \n5. Metoprolol Succinate XL 50-100 mg PO DAILY \n6. Multivitamins 1 TAB PO DAILY \n7. Pantoprazole 40 mg PO Q24H \n8. Polyethylene Glycol 17 g PO QHS:PRN constipation \n9. Vitamin B Complex 1 CAP PO DAILY \n10. Gabapentin 300 mg PO QHS \n11. lipase-protease-amylase 20,000-68,000 -109,000 unit oral TID \nW/MEALS \n12. Ibuprofen 400 mg PO Q8H:PRN pain \n13. Buprenorphine 8 mg SL DAILY \n14. Prochlorperazine 10 mg PO Q8H:PRN nausea \n15. Ondansetron 8 mg PO Q8H:PRN nausea \n\n \nDischarge Medications:\n1. Buprenorphine 8 mg SL DAILY \n2. Levothyroxine Sodium 137 mcg PO DAILY \n3. LORazepam 0.5 mg PO Q6H:PRN anxiety \n4. Multivitamins 1 TAB PO DAILY \n5. Ondansetron 8 mg PO Q8H:PRN nausea \n6. Pantoprazole 40 mg PO Q24H \n7. Polyethylene Glycol 17 g PO QHS:PRN constipation \n8. Prochlorperazine 10 mg PO Q8H:PRN nausea \n9. Aspirin 81 mg PO DAILY \n10. FoLIC Acid 1 mg PO DAILY \n11. lipase-protease-amylase 20,000-68,000 -109,000 unit oral TID \nW/MEALS \n12. Vitamin B Complex 1 CAP PO DAILY \n13. Gabapentin 300 mg PO QHS \n14. Ibuprofen 400 mg PO Q8H:PRN pain \n15. Metoprolol Succinate XL 100 mg PO DAILY \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY: \n- abdominal pain\n- Ampullary adenocarcinoma \n- confusion NOS\n- alcohol abuse\n\nSECONDARY DIAGNOSIS:\n- Hypothyroidism\n- atrial fibrilation\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 meeting you and taking care of you. You were \ntransferred from ___ to treat your abdominal pain \ndiarrhea and confusion. Imaging of your belly and blood tests \nexcluded any inflammation of the pancreas. On ___, you \nunderwent a procedure using a camera inserted into your stomach \nand intestine that blocked pain nerves around your pancreas. You \npain improved after the procedure and you did not have \ncomplications. You confusion improved without interventions and \nyour diarrhea resolved. \n\nPlease read the follow up recommendations below and be sure to \nkeep these appointments. \n\nWe wish you the best, \nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "G893", "C259", "I4892", "F1010", "E039", "K5909", "F1920", "I4891", "R4182" ]

[ "G893: Neoplasm related pain (acute) (chronic)", "C259: Malignant neoplasm of pancreas, unspecified", "I4892: Unspecified atrial flutter", "F1010: Alcohol abuse, uncomplicated", "E039: Hypothyroidism, unspecified", "K5909: Other constipation", "F1920: Other psychoactive substance dependence, uncomplicated", "I4891: Unspecified atrial fibrillation", "R4182: Altered mental status, unspecified" ]

[ "E039", "I4891" ]

[]

[ " \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:\nfever and abdominal pain\n \nMajor Surgical or Invasive Procedure:\nNone\n\n \nHistory of Present Illness:\n___ w hx ETOH abuse and presumed cholangitis ___ biliary stone \nvs malignancy, presenting with immediate fever to 103.1 after \ncholangiogram with brush biopsy today. \n\nPatient was recently hospitalized at ___ ___ for \nobstructive jaundice and periumbilical pain, Tbili 27, ALT \n80,AST 100,ALP 300,INR 1.5,PLT 200. CT showed possible mass at \ndistal CBD and PD dilation. Failed ERCP x2 due to ampullary \nmaceration. PTBD performed ___ due to concern for \ncholangitis, biliary drain placed for decompression. MCRP \n___ showed narrowing of distal CBD with ductal dilation.\n\nToday, patient presented for f/u cholangiogram with brush biopsy \ndue to concern for ampullary mass and replacement of \ninternal/external biliary drain. Patient received 1g CTX prior \nto procedure. After cholangiogram, patient spiked to 103.1. BCx \nsent. Started on IV unasyn 3g. Biliary drain openned to external \ndrainage and Demerol, Tylenol given. Patient was directly \nadmitted to Medicine for further management.\n\nPresently, patient is complaining of ___ sharp knife-like pain \nin her abdominal, new since the procedure. Endorses chills and \nrigors after the procedure, also nausea, no vomiting. Denies \nchest pain or SOB. \n\nROS otherwise notable for diarrhea (most recently 2 days ago), \nwhich she believes is ___ antibiotic (completed full course \n___. Resolved with Imodium. Some blood staining on toilet \npaper that she believes is due to hemorrhoids, but no grossly \nbloody stools. \n \nROS: as above. Denies changes in vision or hearing, no changes \nin balance. No cough, no shortness of breath, no dyspnea on \nexertion. No chest pain or palpitations. No dysuria or \nhematuria. \n \nPast Medical History:\nAtrial fibrillation- pt says that the physicians at first \nthought that she had atrial fibrillation but then she was \ndetermined not to have it. \nHypothyroidism\nETOH abuse- sober for ___ months previously 1 pint of vodka \ndaily for ___ years\nShe was diagnosed with cirrhosis at age ___\n \nSocial History:\n___\nFamily History:\nBoth parents have dementia. Her PGM died of rectal cancer. Her \nMGM died of rectal cancer. \n \nPhysical Exam:\nPHYSICAL EXAM ON ADMISSION:\n=============================\nVS: 98.4 114/55 74 20 98RA \nGEN: Alert, lying in bed, no acute distress. Jaundiced\nHEENT: Tacky MM, Icteric sclerae \nNECK: Supple without LAD \nPULM: Generally CTA b/l without wheeze or rhonchi \nCOR: RRR (+)S1/S2 no m/r/g \nABD: Soft, non-distended. Diffusely tender to palpation, most \nsevere in RUQ. Clean dressing with biliary drain in place. \nEXTREM: Warm, well-perfused, 1+ pitting edema in ___\nNEURO: CN II-XII intact, extensor and flexor strength ___ \nbilaterally in UEs and ___ \n\nPHYSICAL EXAM ON DISCHARGE:\n=============================\nVS: Tm 99.0 98.3 105/55 73 18 94RA I/O 1220/2510\nGEN: Alert, lying in bed, no acute distress. Jaundiced\nHEENT: Tacky MM, Icteric sclerae \nNECK: Supple without LAD \nPULM: Generally CTA b/l without wheeze or rhonchi \nCOR: RRR (+)S1/S2 no m/r/g \nABD: Soft, non-distended. Improved tenderness to palpation. \nReduced guarding. Clean dressing.\nEXTREM: Warm, well-perfused, trace edema in ___\nNEURO: CN II-XII grossly intact. Moving all extremities.\n \nPertinent Results:\nLABS ON ADMISSION:\n==========================\n___ 11:20PM BLOOD WBC-13.5*# RBC-3.51* Hgb-11.0* Hct-33.0* \nMCV-94 MCH-31.3 MCHC-33.3 RDW-13.2 RDWSD-45.4 Plt ___\n___ 11:20PM BLOOD Neuts-69.4 ___ Monos-4.1* \nEos-0.5* Baso-0.6 Im ___ AbsNeut-9.40* AbsLymp-3.39 \nAbsMono-0.55 AbsEos-0.07 AbsBaso-0.08\n___ 11:20PM BLOOD ___ PTT-34.6 ___\n___ 11:20PM BLOOD Plt ___\n___ 07:30AM BLOOD Glucose-82 UreaN-6 Creat-0.7 Na-135 \nK-5.9* Cl-104 HCO3-20* AnGap-17\n___ 07:30AM BLOOD estGFR-Using this\n___ 11:20PM BLOOD ALT-13 AST-28 AlkPhos-127* TotBili-5.9*\n___ 11:20PM BLOOD Calcium-8.1* Phos-3.5 Mg-1.8\n\nLABS ON DISCHARGE:\n==========================\n___ 08:57AM BLOOD WBC-9.4 RBC-3.66* Hgb-11.4 Hct-34.8 \nMCV-95 MCH-31.1 MCHC-32.8 RDW-13.2 RDWSD-45.6 Plt ___\n___ 08:57AM BLOOD Plt ___\n___ 08:57AM BLOOD Glucose-141* UreaN-5* Creat-0.6 Na-131* \nK-3.7 Cl-100 HCO3-21* AnGap-14\n___ 07:10AM BLOOD ALT-10 AST-28 AlkPhos-116* TotBili-5.7*\n___ 08:57AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.0\n\nIMAGING:\n==========================\nCT CHEST ___BD & PELVIS WITH CO ___. Patient is status post PTBD stent placement within no \nevidence of stent \nocclusion. There is pneumobilia consistent with recent ERCP, \nstent placement, cholangiogram and catheter exchange. \n2. Small area of peripheral hyperenhancement the right lobe of \nthe liver is consistent with recent catheter placement. No \nfocal hepatic lesions. \n3. Severe pancreatic duct dilatation, unchanged from prior, and \nscattered \npancreatic calcifications, consistent with chronic pancreatitis. \n\n4. Cholelithiasis without evidence of cholecystitis. \n5. Small amount of free fluid in the pelvis of uncertain \netiology. No \nabscess. \n6. Small bilateral pleural effusions, right greater than left, \nand adjacent atelectasis. \n\n \nBrief Hospital Course:\n# Cholangitis: Patient admitted with fever, jaundice, and RUQ \npain, initially met ___ SIRS criteria. Started on IV unasyn, WBC \ndowntrended and fever improved. CT abdomen/pelvis was performed \ngiven abdominal pain, found to be unchanged from prior. Patient \ntransitioned from unasyn to PO augmentin x 7 days (d7= ___ \nfor full treatment of presumed cholangitis. Biliary drain \ncapped. Patient initially on IV dilaudid for pain control, \ntransitioned to PO oxycodone with significant improvement in \nabdominal pain over hospital course. Discharged with no pain \nmedication.\n\n# Adenocarcinoma: brush biopsy returned adenocarcinoma. Oncology \nnotified, and patient will see GI and Oncology as an outpatient \nto discuss further treatment. ___ will call patient to schedule \nan appointment. CT Chest performed for staging purposes while in \nhospital. CT Abd/Pel and MRCP also performed recently. \n\n# Diarrhea: patient had diarrhea while on augmentin prior to \nadmission, resolved day prior to admission with Imodium. \n\nTRANSITIONAL ISSUSES:\n========================\n*Followup scheduled for adenocarcinoma evaluation with GI and \noncology. ___ will call patient with follow-up appointment. \n*7 day augmentin course to be completed ___ \n*If patient develops worsening abdominal pain, fever, or leakage \naround the tube, she should open up the tube to drain into a bag \nand come back to the hospital\n*Sodium should be rechecked at next follow-up appointment to \nensure resolution\n*Discontinued metoprolol given normal blood pressures and heart \nrates off of metoprolol during this admission\n*1+ bilateral pitting lower extremity edema, which patient \nreports is chronically managed with compression stockings at \nhome. Consider adding a diuretic if patient's edema persists or \nworsens.\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. FoLIC Acid 1 mg PO DAILY \n2. Levothyroxine Sodium 137 mcg PO DAILY \n3. Lorazepam 1 mg PO QHS:PRN insomnia \n4. Vitamin B Complex 1 CAP PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. Metoprolol Tartrate 25 mg PO BID \n7. Buprenorphine 8 mg SL DAILY \n\n \nDischarge Medications:\n1. Aspirin 81 mg PO DAILY \n2. Buprenorphine 8 mg SL DAILY \n3. FoLIC Acid 1 mg PO DAILY \n4. Levothyroxine Sodium 137 mcg PO DAILY \n5. Lorazepam 1 mg PO QHS:PRN insomnia \n6. Vitamin B Complex 1 CAP PO DAILY \n7. Amoxicillin-Clavulanic Acid ___ mg PO Q12H \nRX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by \nmouth twice a day Disp #*10 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPrimary:\nCholangitis\nAdenocarcinoma of the biliary duct \n\nSecondary:\nObstructive jaundice\n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nDear Ms. ___,\n\nYou were admitted to the hospital with fever and chills after \nyour outpatient cholangiogram and biopsy. This is most likely \ndue to an infection, and you were started on IV antibiotics, \nwhich were transitioned to antibiotics by mouth that you will \ncomplete on ___. \n\nYour biliary drain was capped prior to discharge. If you \nexperience worsening abdominal pain, fever, or leakage around \nthe tube, you should open up the tube to drain into a bag and \ncome back to the hospital. \n\nThe biopsy that was taken during your cholangiogram showed \nadenocarcinoma, a type of cancer. You have been set up with \nGastrointestinal Oncology to discuss the next steps regarding \nyour diagnosis. You received CT imaging of your chest, abdomen, \nand pelvis while in the hospital, and these will also help guide \ntreatment. \n\nIt was a pleasure being part of your care.\n\nThe ___ Team\n \nFollowup Instructions:\n___\n" ]

[ "K830", "K831", "C240", "E871", "E861" ]

[ "K830: Cholangitis", "K831: Obstruction of bile duct", "C240: Malignant neoplasm of extrahepatic bile duct", "E871: Hypo-osmolality and hyponatremia", "E861: Hypovolemia" ]

[ "E871" ]

[]

[ " \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:\nJaundice/dark urine/abdominal pain\n \nMajor Surgical or Invasive Procedure:\nPTBD\nUnsuccessful ERCP\n\n \nHistory of Present Illness:\n___ yo F w/Hx of ETOH consumption,p/w 3 weeks of obstructive \njaundice. She noticed dark urine 2 weeks ago along with a \ndecrease in her appetite. No clear weight loss. Two days ago she \ndeveloped ankle edema. She noted abdominal distention and \ntightness for 10 days. She went to see her PCP who wanted her to \ngo to the ED but she only presented two days later since she had \nto find a place for her animals to stay and someone to care for \nher elderly parents with dementia. No fevers or chills. Her \nstomach is now slitly \"crampy\" ___ periumbilicum. This pain \njust started during the encounter and has not happened before. \nNo nausea or vomiting. , TbIli 27, ALT 80,AST 100,ALP 300,INR \n1.5,PLT 200.CT scan: Possible mass at distal CBD,PD \ndilation.Failed ERCP today:Abnormal ampulla but not typical \nappearance of ampullary carcinoma. Contrast injected into \nbiliary tree,no drainage, high risk for cholangitis.Massive \ndilation of right system. She was then transferred to ___ for \nERCP. During the ERCP at ___ the ampulla was very edematous \nand macerated with oozing of blood. Careful attempts to \ncannulate with gentle probing using the wire were unsuccessful. \nERCP team recommends PTBD with ___ with placement of wire in the \nduodenum to allow ERCP team to perform ERCP. \n\n.\n\nPAIN SCALE: ___ abdomen \n.\nREVIEW OF SYSTEMS:\nCONSTITUTIONAL: As per HPI\nHEENT: [X] All normal\nRESPIRATORY: [X] All normal\nCARDIAC: [X] All normal\nGI: As per HPI\nGU: [+] HPI- dark urine but denies dysuria\nSKIN: [+] jaundice\nMUSCULOSKELETAL: [X] All normal\nNEURO: [X] All normal\nENDOCRINE: [X] All normal\nHEME/LYMPH: [X] All normal\nPSYCH: [X] All normal\nAll other systems negative except as noted above\n\n \nPast Medical History:\nAtrial fibrillation- pt says that the physicians at first \nthought that she had atrial fibrillation but then she was \ndetermined not to have it. \nHypothyroidism\nETOH abuse- sober for ___ months previously 1 pint of vodka \ndaily for ___ years\nShe was diagnosed with cirrhosis at age ___\n \nSocial History:\n___\nFamily History:\nBoth parents have dementia. Her PGM died of rectal cancer. Her \nMGM died of rectal cancer. \n \nPhysical Exam:\nVitals: T 97.4 P 64 BP 102/66 RR 18 SaO2 100% on RA\nGEN: NAD, comfortable appearing \nHEENT: deeply jaundiced\nNECK: supple\nCV: s1s2 rr no m/r/g - distant heart sounds\nRESP: b/l ae no w/c/r \nABD: Massively distended abdomen, ? abdominal mass with \nsubcutaneous nodule\n+ petechiae\n+ spider angiomata\nNon tender in all four quadrants, soft, + bs\nEXTR: 2+ edema b/l, 2+ DPP pulses b/l \nDERM: diffuse petechiae in b/l upper an lower extremities\nNEURO: face symmetric speech fluent \nPSYCH: calm, cooperative, very pleasant \n\nExam on discharge:Objective: \nVitals: T: 98.5 BP: 109/59 P:64 RR:18 O2 sat 98%RA\nGeneral: tired appearing middle aged woman, NAD. +Jaundice \n+telangectasias\nHEENT: icteric sclera, MMM\nHeart: RRR, no m/r/g\nLungs: CTAB\nAbdomen: soft, mildly distended, non-tender, +BS, no rebound or\nguarding\nExtremities: WWP, 2+ pulses, 2+ edema to knee L>R scar on left \nfoot\n\n \nPertinent Results:\nDirect bili = 21.2\nTotal bili = 26.7\nETOH level = 0\nLipase = 5\nHep A, B, C ab negative\nINR = 1.53\nU tox negative\nUA negative except positive for bilirubin\n.\n\n9.5/34.9\\216\n.\nWBC was 12.8 on admission with 73% PMNs and 1% bands\n.\nALT = 20/AST = 69/\n.\n135|99|9/\n========\\108\n3.7|23|0.47\n.\nAlbumin = 3.0\nLipase = 5\n.\nRUQ US: Mild dilatation of the CBD, hepatic duct and gall \nbladder with visible stone in the CBD.\n.\nECG: NSR at 78 bpm, normal axis and intervals.\n.\n___\nEvidence of prior precut (access) sphincterotomy was noted from \nthe prior ERCP performed at ___. \n•The ampulla appeared severely edematous and macerated with \noozing of blood. \n•Given the presence of an edematous and macerated ampulla with \noozing, great care was taken to minimize further trauma to this \narea. \n•A wire was placed through the sphincterotome and the ampulla \nwas gently probed in order to identify the biliary orifice. \n•However, the bile duct could not be successfully cannulated \ndue to inflammation of the papilla from the previously attempted \nERCP at ___.\n \n\nRecommendations: •Admit to ___ for further management. \n•Obtain MRCP. \n•NPO overnight with aggressive IV hydration with LR at 200 cc/hr \n\n•Continue with antibiotics - Ciprofloxacin 500mg BID x 5 days. \n•Consult ___ for PTBD with placement of wire into the duodenum to \nfacilitate repeat ERCP. \n•Follow for response and complications. If any abdominal pain, \nfever, jaundice, gastrointestinal bleeding please call ERCP \nfellow on call ___\n \n\nCTA PANCREAS:\nIMPRESSION: \n \n1. Massive intrahepatic and extrahepatic biliary dilatation, \nwith a markedly dilated gallbladder, and massively dilated \npancreatic duct and multiple side branches. Findings suggest \nthe presence of an ampullary lesion or stricture, however no \ndefinite mass/enhancement is identified by CT. Therefore, MRCP \nis recommended for further evaluation. \n \n2. Dilated CBD causes mass effect on the adjacent duodenum and \nbranches of the celiac axis. \n \n3. Dense contrast, presumably from the recent ERCP procedures, \nfills the \nmarkedly dilated pancreatic duct, with almost no residual \npancreatic tissue identified. \n \n4. Early origin of the right hepatic artery ff the celiac \ntrunk, however the remainder of the celiac axis is conventional \nin anatomy. \n \n5. Multiple pancreatic ductal stones and gallstones. \n \nRECOMMENDATION(S): MRCP is recommended for further evaluation \nfor suspected ampullary lesion or stricture. \n\nMRCP: ___\nIMPRESSION: \n \n1. Post internal-external biliary drain placement with marked \ndecompression of the intra- and extrahepatic ducts and \ngallbladder since the CT examination from ___. \n2. The distal-most 2.6 cm of the CBD is focally narrowed, \noccurring at the same level as a sharp transition point of the \ndilated pancreatic duct. No associated discrete mass is seen, \nalthough the study is limited by lack of IV contrast. The \nfindings likely represent inflammatory stricture related to the \nrecent ERCP findings, however, continued imaging surveillance is \nrecommended. \n3. Cholelithiasis and persistent gallbladder wall edema. Lack \nof intravenous contrast limits assessment; however, the edema is \nlikely related to recent obstruction seen on the ___ \nstudy. \n4. Severely dilated main and side-branch pancreatic duct \ndilatation is \nconsistent with chronic pancreatitis. \n \n\n \nBrief Hospital Course:\nThe patient is a ___ year old female with h/o alcoholic \ncirrhosis, ?afib who presents with severe jaundice, biliary \nobstruction and abdominal distension.\n\n#JAUNDICE\n#OBSTRUCTIVE CHOLEDOLITHIASIS vs AMPULLARY MASS\n# BILE OBSTRUCTION\nFailed attempt at ERCP at ___. She \ninitially had a leukocytosis and was started on antibiotics \ngiven possible early cholangitis. At ___ unable to be \nsuccessful due maceration at ampulla site and unable to \ncannulate. ___ consulted and underwent successful PTBD with \ncopious bilious drainage. Her LFTs improved. Given CT findings, \nMRCP was ordered to evaluate for ampullary mass. MRCP did not \nshow a clear mass. There was evidence of bile duct stricture \nwhich will need to be biopsied at repeat cholangiogram. She was \non Unasyn which was transitioned to Augmentin to complete a 7 \nday course. Her PTBD was capped on ___. She tolerated \ncapping trial with continued improvement in LFTs. She will be \ndischarged home with her biliary drain capped. She has ___ follow \nup scheduled for ___ for repeat cholangiogram and biopsy of \nstricture with possible dilation. The patient was discharged on \nantibiotics for an additional 5 days.\n\n#Alcohol Cirrhosis:\nCompensated. Provided supportive care\n\n#NARCOTIC ADDICTION/OPIOID DEPENDENCE\n- continued suboxone\n\n#Atrial fibrillation\nPatient reports she does not have afib. She was continued on low \ndose betablocker while hospitalized.\n\nTransitional issues:\n- Needs follow up with ___, GI which has been scheduled\n- Needs biopsy of bile duct stricture at time of repeat \ncholangiogram\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Buprenorphine-Naloxone (2mg-0.5mg) 4 TAB SL DAILY \n2. Ondansetron 4 mg IV Q6H:PRN nausea \n3. Ampicillin-Sulbactam 3 g IV Q6H \n4. Levothyroxine Sodium 137 mcg PO DAILY \n5. Lorazepam 1 mg PO QHS:PRN insomnia \n6. Aspirin 81 mg PO DAILY \n7. Vitamin B Complex 1 CAP PO DAILY \n8. FoLIC Acid 1 mg PO DAILY \n9. Metoprolol Tartrate 25 mg PO BID \n\n \nDischarge Medications:\n1. FoLIC Acid 1 mg PO DAILY \n2. Levothyroxine Sodium 137 mcg PO DAILY \n3. Lorazepam 1 mg PO QHS:PRN insomnia \n4. Vitamin B Complex 1 CAP PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. Metoprolol Tartrate 25 mg PO BID \n7. Buprenorphine-Naloxone (2mg-0.5mg) 4 TAB SL DAILY \n8. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Days \nRX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by \nmouth Q12hrs Disp #*10 Tablet Refills:*0\n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___ \n \nDischarge Diagnosis:\nBile obstruction\nPresumed choledocholithiasis\nAlcoholic cirrhosis\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n \nDischarge Instructions:\nMs. ___,\n\nYou were admitted for evaluation of jaundice and an obstruction \nin your common bile duct. ERCP was unsuccessful, so you \nunderwent Percutaneous drain placement. You will be discharged \nwith the internal drain in place with a cap on. If you develop \nabdominal pain, fever or you have other questions please call \nthe on call ___ fellow at : ___. You need to continue \nantibiotics for an additional 5 days.\nYou have a follow up appointment on ___ with \nthe interventional radiology team here at ___. They will \ncontact you with additional information regarding this \nappointment.\nIt is important that you follow up with your doctors. ___ \nappointments are listed below\n \nFollowup Instructions:\n___\n" ]

[ "K8051", "F1120", "K830", "E46", "K7030", "I4891", "I10", "E039", "F1010", "E785" ]

[ "K8051: Calculus of bile duct without cholangitis or cholecystitis with obstruction", "F1120: Opioid dependence, uncomplicated", "K830: Cholangitis", "E46: Unspecified protein-calorie malnutrition", "K7030: Alcoholic cirrhosis of liver without ascites", "I4891: Unspecified atrial fibrillation", "I10: Essential (primary) hypertension", "E039: Hypothyroidism, unspecified", "F1010: Alcohol abuse, uncomplicated", "E785: Hyperlipidemia, unspecified" ]

[ "I4891", "I10", "E039", "E785" ]

[]

[ " \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:\ntransferred from ___ with concerns for pancreatic \nnecrosis and abscess.\n \nMajor Surgical or Invasive Procedure:\nEndoscopic ultrasound without aspiration (___)\n\n \nHistory of Present Illness:\nMs. ___ is a ___ year old woman with a history of locally \nadvanced pancreatic adenocarcinoma (C1D27 gemcitabine AND \npaclitaxel), previous alcohol abuse, atrial fibrillation (not on \nanticoagulation), and hypothyroidism who was transferred from \n___ with concerns for pancreatic necrosis and abscess.\n\nShe initial presented to her outpatient oncologist for the \nbeginning of her C2D1 chemo. However, her initial finding of \nleukocytosis and thrombocytosis was concerning in addition to \nher abdominal pain. A US of the abdomen by the oncologist showed \npossible thrombosis within the suprarenal IVC. Thus, she was \nreferred to the ED in ___ for further evaluation.\n\nIn the ED at ___ her initial WBC was 17.0 (compared to 8.0 \non ___, also Plt 972.\n\nTotal Bilirubin 0.44 AST 11 ALT 10. lipase:5 amylase:not \nmeasured.\n\nCT ___ excluded IVC thrombosis but showed extensive \nperipancreatic stranding concerning for pancreatitis. \n- A 2.1 cm x 1.5-cm hypodense collection lateral to the fiducial \nseed.\n- inferiorly, bilobed collection is identified measuring 1.8-cm \nx 2.3cm\n- tubular collection inferior to the main portal vein with \nfecalized appearance of the internal contents measures 1.7-cm x \n3.4-cm\n- possible necrosis as well as fluid collection.\n \nPast Medical History:\nAtrial fibrillation- pt says that the physicians at first \nthought that she had atrial fibrillation but then she was \ndetermined not to have it. \nHypothyroidism\nETOH abuse- sober for ___ months previously 1 pint of vodka \ndaily for ___ years\nShe was diagnosed with cirrhosis at age ___\n \nSocial History:\n___\nFamily History:\nBoth parents have dementia. Her PGM died of rectal cancer. Her \nMGM died of rectal cancer. \n \nPhysical Exam:\nadmission physical exam:\n\nADMISSION PHYSICAL EXAM:\nVITALS: 97.7 113/68 59 18 99% on RA\ngeneral: no in pain or distress. pale. \nHEENT: pupils equal and reactive to light\n___: normal S1 and S2 no murmur rubs or gallops\nAbdomen: mildline scar above the umbilicus, as well as scar at \n9o'clock position from the umbilicus extending to the right \nflank. tender abdomen on light palpation. \nGU: no foley\nNeurological: grossly intact.\n\nDISCHARGE PHYSICAL EXAM:\nVITALS: 98.2 102-110/60-63 65-66 ___ 100% on RA\ngeneral: no in pain or distress. pale. \nHEENT: pupils equal and reactive to light\n___: normal S1 and S2 no murmur rubs or gallops\nAbdomen: mildline scar above the umbilicus, as well as scar at\n9o'clock position from the umbilicus extending to the right\nflank. tender abdomen on light palpation. \nGU: no foley\nNeurological: grossly intact.\n \nPertinent Results:\nADMISSION LABS:\n\n___ 09:19PM TYPE-MIX PH-7.38\n___ 09:19PM freeCa-1.10*\n___ 08:50PM GLUCOSE-151* UREA N-9 CREAT-0.5 SODIUM-136 \nPOTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-24 ANION GAP-11\n___ 08:50PM ALT(SGPT)-13 AST(SGOT)-18 LD(___)-142 ALK \nPHOS-132* AMYLASE-14 TOT BILI-0.4\n___ 08:50PM LIPASE-7\n___ 08:50PM ALBUMIN-2.9* CALCIUM-8.8 PHOSPHATE-3.4 \nMAGNESIUM-1.9\n___ 08:50PM WBC-10.6* RBC-3.15* HGB-8.3* HCT-26.9* MCV-85 \nMCH-26.3 MCHC-30.9* RDW-18.6* RDWSD-54.6*\n___ 08:50PM NEUTS-52.5 ___ MONOS-11.2 EOS-2.6 \nBASOS-0.5 IM ___ AbsNeut-5.56 AbsLymp-3.44 AbsMono-1.18* \nAbsEos-0.27 AbsBaso-0.05\n___ 08:50PM PLT SMR-VERY HIGH PLT COUNT-1017*#\n___ 08:50PM ___ PTT-33.2 ___\n___ 08:50PM ___\n___ 03:21PM TYPE-CENTRAL VE PO2-44* PCO2-44 PH-7.38 TOTAL \nCO2-27 BASE XS-0 COMMENTS-GREEN TOP \n___ 03:21PM freeCa-1.10*\n___ 03:05PM GLUCOSE-85 UREA N-10 CREAT-0.5 SODIUM-139 \nPOTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-24 ANION GAP-12\n___ 03:05PM ALT(SGPT)-11 AST(SGOT)-16 LD(___)-135 ALK \nPHOS-135* AMYLASE-11 TOT BILI-0.4\n___ 03:05PM LIPASE-8\n___ 03:05PM ALBUMIN-2.8* CALCIUM-9.0 PHOSPHATE-3.8 \nMAGNESIUM-2.0\n___ 03:05PM WBC-11.4* RBC-3.14* HGB-8.3* HCT-26.9* MCV-86 \nMCH-26.4 MCHC-30.9* RDW-18.6* RDWSD-54.2*\n___ 03:05PM NEUTS-56.9 ___ MONOS-10.8 EOS-2.2 \nBASOS-0.5 NUC RBCS-0.2* IM ___ AbsNeut-6.45*# AbsLymp-3.31 \nAbsMono-1.23* AbsEos-0.25 AbsBaso-0.06\n___ 03:05PM PLT COUNT-608*\n___ 03:05PM ___ PTT-36.8* ___\n___ 03:05PM ___\n___ 12:40PM UREA N-11 CREAT-0.7 SODIUM-135 POTASSIUM-4.6 \nCHLORIDE-98 TOTAL CO2-24 ANION GAP-18\n___ 12:40PM estGFR-Using this\n___ 12:40PM ALT(SGPT)-12 AST(SGOT)-12 ALK PHOS-161* TOT \nBILI-0.6\n___ 12:40PM CALCIUM-9.0 PHOSPHATE-4.1 MAGNESIUM-1.7\n___ 12:40PM WBC-22.7*# RBC-3.45* HGB-9.5* HCT-29.0* \nMCV-84 MCH-27.5 MCHC-32.8 RDW-18.6* RDWSD-52.0*\n___ 12:40PM NEUTS-75* BANDS-0 LYMPHS-17* MONOS-6 EOS-1 \nBASOS-0 ATYPS-1* ___ MYELOS-0 AbsNeut-17.03* AbsLymp-4.09* \nAbsMono-1.36* AbsEos-0.23 AbsBaso-0.00*\n___ 12:40PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-NORMAL \nMACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+\n___ 12:40PM PLT SMR-VERY HIGH PLT COUNT-1115*#\n\nENDOSCOPIC US:\nEUS was performed using a linear echoendoscope at ___ MHz \nfrequency: \n•The following pancreatic parenchymal changes were \nnoted:lobularity, hyperechoic foci,calcifications.\n___ pancreatic collections were noted but were not amenable to \nsafe endoscopic aspiration. \n•A 11.7 ___ lymph node was noted.\n\nDISCARGE LABS:\n\n___ 05:51AM BLOOD WBC-8.9 RBC-3.10* Hgb-8.2* Hct-26.5* \nMCV-86 MCH-26.5 MCHC-30.9* RDW-18.7* RDWSD-54.7* Plt ___\n___ 08:50PM BLOOD Neuts-52.5 ___ Monos-11.2 Eos-2.6 \nBaso-0.5 Im ___ AbsNeut-5.56 AbsLymp-3.44 AbsMono-1.18* \nAbsEos-0.27 AbsBaso-0.05\n___ 05:51AM BLOOD Plt ___\n___ 05:51AM BLOOD Glucose-102* UreaN-6 Creat-0.5 Na-140 \nK-4.4 Cl-108 HCO3-25 AnGap-11\n___ 05:51AM BLOOD Calcium-9.2 Phos-4.9* Mg-2.___ year old woman with a history of locally advanced pancreatic \nadenocarcinoma (C1D27 gemcitabine AND paclitaxel; s/p surgical \nresection performed on ___: open cholecystectomy, \nRoux-en-Y retrocolic hepaticojejunostomy and antecolic \ngastrojejunostomy), previous alcohol abuse, atrial fibrillation \n(not on anticoagulation) who was transferred from ___ \nfor further workup and management of pancreatic fluid \ncollections. \n\n# the patient is s/p Whipple procedure presented with abdominal \npain and leukocytosis (11.4) concerning for infection and did \nnot have evidence of pancreatitis on labs. The patient was \nstarted on IVF which improved her overall condition. She \nunderwent MRCP pm ___ showed small peripancreatic fluid \ncollections, unclear whether these are post-surgical or were \nrelated to acute on chronic pancreatitis, or are abscesses. Her \nleukocytosis suggested an inflammatory process but does not help \ndistinguish any of the above possibilities. The leukocytosis \nalso resolved without any intervention and she was afebrile with \nnormal vitals. the patient was evauated by the pain services who \noptimize her pain medication to dilaudid ___ PO. She underwent \nendoscopic ultrasound but the fluid collections were not \naccessible to drainage. The patient was well appearing, \ntolerating a diet, and without clear evidence of infection. \nGiven that she had improvement without antibiotics, was \nrequesting discharge and had good followup, decision was made to \ndischarge home with close followup and plan for interval \ncross-sectional imaging to assess for changes. She will followup \nwith Hematology/Oncology and Hepatopancreaticobilliary Surgery \nin the next week. \n\n# Locally advanced pancreatic adenocarcinoma on gemcitabine / \npaclitaxel. stable\n\n# Atrial fibrillation and flutter: has a CHADSVASC score is 1 \nindicating low risk of cardioenbolic events. We continued her \nmetoprolol for rate control.\n\n# Hypothyroidism: we continued her home levothyroxine\n\n# Spinal stenosis: not an active issue during this admission.\n\nTRANSITIONAL ISSUES: \n===========================\n# CODE: DNR/DNI\n# CONTACT: ___ ___\n[] She is overdue for cycle 2 of gemcitabine and abraxane, but \nthis is on hold until it is clear whether there is an infection. \n\n[] Recommend followup with Dr. ___ Dr. ___ as an \noutpatient.\n - Per surgical service, Dr. ___ will be away next week but \nwill return to office in two weeks. Recommend followup in two \nweeks following CT. \n[] Ensure repeat CBC (to monitor for leukocytosis and \nthrombocytosis) at next visit. \n[] Ensure repeat CT abd/pelvis within one week. \n[] Ms. ___ was seen by chronic pain service who recommended \ndischarge on PO hydromorphone and gabapentin. Should she feel \nneed to resume buprenorphine recommend resuming this in \nconsultation with outpatient psychiatrist. \n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Levothyroxine Sodium 137 mcg PO DAILY \n2. Pantoprazole 40 mg PO Q24H \n3. Metoprolol Succinate XL 50-100 mg PO DAILY \n4. Aspirin 81 mg PO DAILY \n5. Buprenorphine ___ mg SL DAILY \n6. Ibuprofen 400 mg PO Q8H:PRN pain \n7. Lorazepam 0.5 mg PO Q6H:PRN anxiety \n8. FoLIC Acid 1 mg PO DAILY \n9. Vitamin B Complex 1 CAP PO DAILY \n10. lipase-protease-amylase 20,000-68,000 -109,000 unit oral TID \nW/MEALS \n11. Ondansetron 8 mg PO Q8H:PRN nausea \n12. Multivitamins 1 TAB PO DAILY \n13. Polyethylene Glycol 17 g PO QHS:PRN constipation \n14. Acetaminophen 500 mg PO Q6H:PRN pain \n\n \nDischarge Medications:\n1. Acetaminophen 500 mg PO Q6H:PRN pain \n2. Aspirin 81 mg PO DAILY \n3. FoLIC Acid 1 mg PO DAILY \n4. Levothyroxine Sodium 137 mcg PO DAILY \n5. Lorazepam 0.5 mg PO Q6H:PRN anxiety \nRX *lorazepam [Ativan] 0.5 mg 1 tab by mouth ___ six hours Disp \n#*84 Tablet Refills:*0\n6. Metoprolol Succinate XL 50-100 mg PO DAILY \n7. Multivitamins 1 TAB PO DAILY \n8. Pantoprazole 40 mg PO Q24H \n9. Polyethylene Glycol 17 g PO QHS:PRN constipation \n10. Vitamin B Complex 1 CAP PO DAILY \n11. Gabapentin 300 mg PO QHS \nRX *gabapentin 300 mg 1 capsule(s) by mouth at night Disp #*30 \nCapsule Refills:*0\n12. lipase-protease-amylase 20,000-68,000 -109,000 unit oral TID \nW/MEALS \n13. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain \nRX *hydromorphone 4 mg ___ tablet(s) by mouth every four hours \nDisp #*84 Tablet Refills:*0\n14. Ibuprofen 400 mg PO Q8H:PRN pain \n15. Ondansetron 8 mg PO Q8H:PRN nausea \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nPRIMARY: \n- Pancreatic fluid collections with concern for infection\n\nSECONDARY: \n- abdominal pain\n- Ampullary adenocarcinoma \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 meeting you and taking care of you. You were \nseen at ___ with an elevated white blood cell count and \nimaging concerning for fluid collections in your pancreas. You \nwere transferred to ___ for evaluation by our surgical, \nendoscopic and interventional radiology teams. We obtained an \nMRI of the abdomen to help aide their decision making and they \nfelt that an endoscopic drainage would be best, however this \nprocedure was not successful as it was thought the collections \nwere too deep to be safely drained. We talked to your oncologist \nwho felt that you should have a repeat CT scan in approximately \none week based on your symptoms. As you improved without \nantibiotics and were tolerating food, we felt it was safe for \nyou to go home as long as you return to the emergency department \nwith worsening symptoms. \n\nPlease read the followup recommendations below and be sure to \nkeep these appointments. \n\nWe wish you the best, \n\nYour ___ team\n \nFollowup Instructions:\n___\n" ]

[ "K859", "C259", "K7460", "F1920", "K861", "Z66", "E039", "I4891", "Z87891", "F1010" ]

[ "K859: Acute pancreatitis, unspecified", "C259: Malignant neoplasm of pancreas, unspecified", "K7460: Unspecified cirrhosis of liver", "F1920: Other psychoactive substance dependence, uncomplicated", "K861: Other chronic pancreatitis", "Z66: Do not resuscitate", "E039: Hypothyroidism, unspecified", "I4891: Unspecified atrial fibrillation", "Z87891: Personal history of nicotine dependence", "F1010: Alcohol abuse, uncomplicated" ]

[ "Z66", "E039", "I4891", "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:\nAmpullary adenocarcinoma\nAtrial fibrillation\nmalnutrition\n \nMajor Surgical or Invasive Procedure:\n1. Exploratory laparoscopy.\n2. Exploratory laparotomy.\n3. Bilobar core liver biopsy.\n4. Complete pancreatic mobilization and inspection of\n mesenteric vasculature.\n5. Open cholecystectomy.\n6. Roux-en-Y retrocolic hepaticojejunostomy.\n7. Antecolic gastrojejunostomy.\n8. Placement of gold fiducials.\n\n \nHistory of Present Illness:\nMs. ___ is a ___ woman who recently\ndeveloped periumbilical abdominal pain, worsening anorexia and\nweight loss, totalling 30 pounds. She developed dark urine and\nwas referred to the emergency room, where her total bilirubin \nwas\n27. A CT scan done at that time, which I reviewed personally,\ndemonstrates severe dilation of the gallbladder and extrahepatic\nbile duct, with the main pancreatic duct measuring as much as 3\ncm in diameter. Both ducts terminated in a stricture at the\npancreatic head. An initial attempt at ERCP was unsuccessful. \nShe was subsequently transferred to ___ where distortion and\nedema of the ampulla prevented cannulation. A subsequent\ntranshepatic catheter was placed for biliary drainage.\n\nMs. ___ underwent a CT scan of the abdomen and pelvis, which\nwe reviewed today. The gallbladder has decompressed after\nplacement of her stent. She has severe pancreatic ductal\ndilatation with calcifications of the uncinate process \nconsistent\nwith chronic pancreatitis. The liver appears to have early\nmorphologic changes consistent with cirrhosis. There was no\nascites or variceal transformation. An MRI from ___\ndemonstrates intra and extrahepatic biliary ductal dilatation\nwith 2.6 cm dilation of the extrahepatic bile duct. There are\ngallstones in the gallbladder. A CT scan of the chest\ndemonstrates no evidence of intrathoracic metastasis.\n\nDistal bile duct biopsies demonstrate poorly differentiated\nadenocarcinoma.\n \nPast Medical History:\nAtrial fibrillation- pt says that the physicians at first \nthought that she had atrial fibrillation but then she was \ndetermined not to have it. \nHypothyroidism\nETOH abuse- sober for ___ months previously 1 pint of vodka \ndaily for ___ years\nShe was diagnosed with cirrhosis at age ___\n \nSocial History:\n___\nFamily History:\nBoth parents have dementia. Her PGM died of rectal cancer. Her \nMGM died of rectal cancer. \n \nPhysical Exam:\nOn pre-operative physical exam, Ms. ___ weighs 156 pounds. \nHer blood\npressure is 116/62 with pulse 72. She has resolving scleral and\ncutaneous icterus. She has no alopecia. Her feet face is\nsymmetric. Her pupils are equal. Her oropharynx is clear. She\nhas no cervical or supraclavicular adenopathy and no carotid\nbruits. Her heart has a regular rate and rhythm. Her chest is\nclear to auscultation. She has no costovertebral angle\ntenderness. Her heart has a regular rate and rhythm. She has a\nPTC catheter in the right midclavicular line. Her liver is\npalpable two fingerbreadths below right costal margin. She has\nfew spider angiomas across her chest. She has no caput medusae. \n\nShe has no lower extremity edema and her pedal pulses are \nintact.\n She has no umbilical or inguinal adenopathy.\n\nOn discharge exam:\nTemp. 98.5; P: 84; BP: 106/67; RR: 18: O2:98%RA\nGeneral: alert, orientedX3; in no acute distress\nHEENT: atraumatic, normocephalic, oral mucosa moist\nResp: clear breath sounds bilaterally\nCV: RRR, no murmurs, rubs, or gallops\nAbd: soft, non-distended; appropriate ___ tenderness\nExtr: atraumatic, skin intact\n\n \nPertinent Results:\n___ 04:15PM BLOOD WBC-16.9*# RBC-4.32 Hgb-12.6 Hct-38.0 \nMCV-88 MCH-29.2 MCHC-33.2 RDW-13.1 RDWSD-42.1 Plt ___\n\n___ 06:10AM BLOOD WBC-16.8* RBC-4.02 Hgb-11.8 Hct-36.0 \nMCV-90 MCH-29.4 MCHC-32.8 RDW-13.4 RDWSD-43.7 Plt ___\n\n___ 07:15PM BLOOD WBC-14.3* RBC-3.96 Hgb-11.5 Hct-35.6 \nMCV-90 MCH-29.0 MCHC-32.3 RDW-13.3 RDWSD-43.6 Plt ___\n\n___ 05:39AM BLOOD WBC-13.7* RBC-3.77* Hgb-10.9* Hct-34.9 \nMCV-93 MCH-28.9 MCHC-31.2* RDW-13.4 RDWSD-45.3 Plt ___\n\n___ 05:23AM BLOOD WBC-10.6* RBC-3.58* Hgb-10.3* Hct-32.4* \nMCV-91 MCH-28.8 MCHC-31.8* RDW-13.2 RDWSD-43.5 Plt ___\n\n___ 05:36AM BLOOD WBC-9.5 RBC-3.91 Hgb-11.1* Hct-34.4 \nMCV-88 MCH-28.4 MCHC-32.3 RDW-13.2 RDWSD-41.9 Plt ___\n\n___ 04:15PM BLOOD Glucose-159* UreaN-14 Creat-0.8 Na-140 \nK-3.8 Cl-105 HCO3-20* AnGap-19\n\n___ 06:10AM BLOOD Glucose-175* UreaN-11 Creat-0.7 Na-139 \nK-3.8 Cl-105 HCO3-23 AnGap-15\n\n___ 07:15PM BLOOD Glucose-130* UreaN-11 Creat-0.7 Na-137 \nK-4.0 Cl-108 HCO3-23 AnGap-10\n\n___ 05:39AM BLOOD Glucose-116* UreaN-11 Creat-0.6 Na-137 \nK-4.2 Cl-107 HCO3-23 AnGap-11\n\n___ 05:23AM BLOOD Glucose-131* UreaN-9 Creat-0.7 Na-134 \nK-4.2 Cl-103 HCO3-26 AnGap-9\n\n___ 05:36AM BLOOD Glucose-104* UreaN-5* Creat-0.5 Na-137 \nK-3.2* Cl-103 HCO3-23 AnGap-14\n\n___ 07:55PM BLOOD Na-134 K-3.4 Cl-100\n\n___ 05:25AM BLOOD Glucose-125* UreaN-4* Creat-0.5 Na-134 \nK-4.1 Cl-100 HCO3-28 AnGap-10\n\n___ 05:45AM BLOOD Glucose-109* UreaN-3* Creat-0.6 Na-138 \nK-3.7 Cl-104 HCO3-24 AnGap-14\n\n___ 07:15PM BLOOD ALT-43* AST-78* AlkPhos-77 TotBili-1.1\n\n___ 05:39AM BLOOD ALT-39 AST-54* AlkPhos-89 TotBili-0.7\n\n___ 05:23AM BLOOD ALT-29 AST-23 AlkPhos-78 TotBili-0.7\n\n___ ECG\nAtrial fibrillation with rapid ventricular response. Cannot \nexclude prior \ninferior wall myocardial infarction. Compared to the previous \ntracing the \natrial rhythm is less organized and represents frank atrial \nfibrillation. \n\n___ ECG\nAtrial flutter with 2:1 block. Diffuse ST segment abnormalities. \nCompared to the previous tracing the atrial rhythm is more \norganized and is probably atrial flutter. Ventricular response \nrate remains approximately the same. \n\n___ ECG\nAtrial flutter with variable block. Late R wave progression. Low \nlateral \nprecordial lead voltage. Compared to the previous tracing of \n___ the \nventricular rate is now slower. Lateral precordial voltage less \nmay be related to lead or patient position. On ___, the \npattern was more consistent with atrial fibrillation. Clinical \ncorrelation is suggested. \n\n___ Echo\nIMPRESSION: Normal biventricular cavity sizes with preserved \nregional and global biventricular systolic function. No valvular \npathology or pathologic flow identified.\n \n\n \nBrief Hospital Course:\nThe patient presented to pre-op on ___ for planned \nresection of her pancreatic carcinoma. She had an epidural \ncatheter placed electively for pain control and a Foley catheter \nplaced in the operating room. The patient was taken to the \noperating room for a planned resection but underwent a biliary \nand enteric bypass after intraoperative findings of a blocked \nSMV precluded resection. There were no adverse events in the \noperating room; please see the operative note for details. Pt \nwas extubated, taken to the PACU until stable, then transferred \nto the ward for observation with a JP drain in place as well. \nHer post operative check was unremarkable. Her post-operative \ncourse was complicated by several factors. She developed atrial \nfibrillation with rapid ventricular response that required \nmultidrug therapy to control. She also had a post-operative \nileus that resolved on post-operative day 6. She had a small \nfluid collection in the inferior aspect of her wound that \nrequired removal of several staples and wet-to-dry dressing \nchanges as well. In patient cardiology was consulted for a fib \nwith RVR, prior to discharge the patient was put on Metoprolol \nand Diltiazem once daily formulations. Please see below for a \nsystems based review. \n\nNeuro: The patient was alert and oriented throughout \nhospitalization; pain was initially managed with an epidural \ncatheterr which was removed on ___. She simultaneously \ntransitioned to IV pain control. Once tolerating a diet, pt was \ntransitioned to PO pain control with hydromorphone.\nCV: The developed atrial fibrillation with rapid ventricular \nresponse on post-operative day 1. A cardiology consult was \nobtained at that time. She initially was managed with IV \nmetoprolol but experienced repeated episodes and rapid \nventricular response that was difficult to control, requiring \nscheduled metoprolol and PRN doses of diltiazem. She underwent a \ncardiac echo that did not show any abnormality. She was \ntransitioned to standing oral metoprolol and diltiazem on \ndischarge, and was in normal sinus rhythm. \nPulmonary: The patient remained stable from a pulmonary \nstandpoint; vital signs were routinely monitored. Good pulmonary \ntoilet, early ambulation and incentive spirometry were \nencouraged throughout hospitalization. \nGI/GU/FEN: The patient was initially kept NPO. On ___ the \ndiet was advanced to clear liquids after the patient was noted \nto have had flatus. She was then sequentially advanced to a \nregular diet, which was well tolerated. Patient's intake and \noutput were closely monitored. Her JP drain output was monitored \nand her drain was removed on ___ (POD 10). A drain stitch \nwas left in place. Her PTBD was capped post-operatively, and she \nwas discharged with it in place. Her foley catheter was removed \non ___ after her epidural was removed. She successfully \nvoided. \nID: The patient's fever curves were closely watched for signs of \ninfection, of which there were none. A small amount of drainage \nwas noted from her wound on ___ and 2 staples along the \ninferior aspect of her wound were removed. A small amount of \nserosanguinous fluid was expressed and packing was placed. \nHEME: The patient's blood counts were closely watched for signs \nof bleeding, of which there were none. She was started on \nprophylactic enoxaparin on ___. \nProphylaxis: The patient received ___ dyne boots that were used \nduring this stay and she was encouraged to get up and ambulate \nas early as possible.\nAt the time of discharge, the patient was doing well, afebrile \nand hemodynamically stable. The patient was tolerating a diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan.\n\n \nMedications on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Buprenorphine 8 mg SL DAILY \n2. Levothyroxine Sodium 137 mcg PO DAILY \n3. Lorazepam 1 mg PO QHS:PRN insomnia \n4. Aspirin 81 mg PO DAILY \n5. Ibuprofen 400 mg PO Q8H:PRN pain \n\n \nDischarge Medications:\n1. Levothyroxine Sodium 137 mcg PO DAILY \n2. RX *enoxaparin 40 mg/0.4 mL 40 mg SubQ once a day Disp #*30 \nSyringe Refills:*2\n3. Pantoprazole 40 mg PO Q24H \nRX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30 \nTablet Refills:*2\n4. Diltiazem Extended-Release 120 mg PO DAILY \nHold for Heart rate <60 \nRX *diltiazem HCl 120 mg 1 capsule(s) by mouth once a day Disp \n#*30 Capsule Refills:*2\n5. Metoprolol Succinate XL 100 mg PO DAILY \nHold for HR <60 \nRX *metoprolol succinate 100 mg 1 tablet(s) by mouth once a day \nDisp #*30 Tablet Refills:*2\n6. Aspirin 81 mg PO DAILY \n7. Buprenorphine 8 mg SL DAILY \n8. Ibuprofen 400 mg PO Q8H:PRN pain \n9. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain \nRX *hydromorphone 4 mg ___ tablet(s) by mouth every four (4) \nhours Disp #*30 Tablet Refills:*0\nRX *hydromorphone 4 mg ___ tablet(s) by mouth every four (4) \nhours Disp #*60 Tablet Refills:*0\n10. Lorazepam 0.5 mg PO BID anxiety Duration: 90 Doses \n\n \nDischarge Disposition:\nHome With Service\n \nFacility:\n___\n \nDischarge Diagnosis:\nAmpullary adenocarcinoma \nAtrial fibrillation\nMalnutrition\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 ___ and underwent an exploratory \nlaparotomy, bilobar core liver biopsy, complete pancreatic \nmobilization and inspection of mesenteric vasculature, open \ncholecystectomy, roux-en-Y retrocolic hepaticojejunostomy, \nantecolic gastrojejunostomy, and placement of gold fiducials. In \nother words, your gallbladder was removed and your bile duct and \ngastrointestinal tract were re-routed in order to prevent \nobstruction. You had some cardiac arrhythmias, i.e. abnormal \nheart rhythms (atrial fibrillation), after your surgery and were \nseen by the cardiology service while here. You were started on \nnew medications to help control your heart rate. You are now \nready for discharge. Please follow the instructions below:\n\nPlease schedule a follow up appointment with your cardiologist \nat your earliest convenience. \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\nGeneral 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*If the drain is connected to a collection container, please \nnote color, consistency, and amount of fluid in the drain. Call \nthe doctor, ___, or ___ nurse if the amount \nincreases significantly or changes in character. Be sure to \nempty the drain frequently. Record the output, if instructed to \ndo so.\n*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\n \nFollowup Instructions:\n___\n" ]

[ "C241", "K831", "K551", "E46", "C253", "K766", "I480", "K861", "K913", "K8044", "E039", "F1010", "Y838" ]

[ "C241: Malignant neoplasm of ampulla of Vater", "K831: Obstruction of bile duct", "K551: Chronic vascular disorders of intestine", "E46: Unspecified protein-calorie malnutrition", "C253: Malignant neoplasm of pancreatic duct", "K766: Portal hypertension", "I480: Paroxysmal atrial fibrillation", "K861: Other chronic pancreatitis", "K913: Postprocedural intestinal obstruction", "K8044: Calculus of bile duct with chronic cholecystitis without obstruction", "E039: Hypothyroidism, unspecified", "F1010: Alcohol abuse, uncomplicated", "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" ]

[ "I480", "E039" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: M\n \nService: NEUROSURGERY\n \nAllergies: \nbee venom (honey bee)\n \nAttending: ___.\n \nChief Complaint:\naneurysm rupture\n \nMajor Surgical or Invasive Procedure:\n___ Coiling of R Acomm aneurysm\n___ Diagnostic angiogram\n___ R EVD re-placement \n\n \nHistory of Present Illness:\n___ y/o male with hx of HLD who was transferred from ___ with a ruptured ACA aneurysm, with right frontal\nIPH/SAH and bilateral IVH. Per report from OSH the patient was\nfound down at work by a customer with signs of striking his head\nagainst the wall and vomitus in his mouth. On arrival to OSH ED\non ___, the patient was found bradycardic with a GCS of 6,\nrequiring to be intubated. He was seen by neurosurgery, and a\nemergent right EVD was placed, later that day he was found to\nhave some jerking movements and was given lorazepam IV and\nstarted on Keppra with good effect. On ___ the patient\nexperienced elevated ICPs, up to 32, with decerabate posturing\nand fixed eye deviation. Subsequently, he was started on 3%\nsodium drip with good response. He was also initially \nhypotensive\nrequiring pressors but later that day he became hypertensive,\npressors were d/c and he started on Clevidipine gtt and\nNimodipine for prevention of vasospasms. Early morning on ___\nhe was transferred to ___ via ambulance for embolization ACA\nruptured aneurysm. \n \nPast Medical History:\nHLD, and shoulder surgery ___ years ago w nerve\ncomplications.\n \nSocial History:\n___\nFamily History:\nNo history of aneurysms\n \nPhysical Exam:\non admission:\n___: IV Fisher: IV GCS: 3+T\nO: T: 99.5 BP: 148/58 HR: 60 R: 20 O2Sats:99%\nGen: WD/WN, comfortable, NAD.\nExtrem: Warm and well-perfused. No C/C/E.\n\nNeuro:\nMental status: No sedation, intubated, and not following\ncommands. \nOrientation: ETT\nCranial Nerves:\nI: Not tested\nII: Pupils equally round and reactive to light, 3 to 2 mm\nbilaterally. + corneals and minimal gag, no cough. \nMotor: Normal bulk and tone bilaterally. No abnormal movements,\ntremors. \nTo painful stimulus extends and postures BUE, and triple flexes\nBLE. \nToes downgoing bilaterally\n\nOn discharge \n****************\n \nPertinent Results:\n___ CTA head: Ruptured multilobulated ACA aneurysm measuring \n1.0 x 0.5 x 0.6cm with large right frontal IPH/SAH, bilateral \nSAH, and bilateral\nIVH with 4 mm MLS\n\n___ NCHCT: \n1. Extensive subarachnoid, intraventricular, and right frontal \nintraparenchymal hemorrhage, compatible with the given history \nof anterior \ncerebral aneurysm rupture. \n2. Status post right frontal approach ventriculostomy catheter \nplacement. \n3. Mild associated cerebral edema, most notable within the \nright frontal \nlobe, with crowding of the basal cisterns but no evidence of \nimpending \ndownward herniation. \n4. Findings suggesting early anterior cerebral artery \ndistribution \ninfarction, greater on the right than left. \n \n___ post-coiling NCHCT:\n1. Little change compared to prior study performed earlier on \nthe same date. \n2. Stable subarachnoid, intraparenchymal and intraventricular \nhemorrhage. No new hemorrhage. \n3. Stable ventriculomegaly. \n4. No significant evolution in findings suggestive of ACA \nterritory \ninfarction \n\n___ EEG:\nThis is an abnormal continuous ICU EEG monitoring study because \nof a burst suppression background characterized by ___ second \nbursts of \nfrontally predominant theta/delta activity (with unusual \nhemispheric \nasynchrony) and one to four second suppressions consistent with \na severe \nencephalopathy non-specific with regards to etiology. The \npatient's sedating medications (e.g. pentobarbital and propofol) \ncan also contribute to this pattern. There are no epileptiform \ndischarges or seizures. \n \n___ NCHCT:\n1. More pronounced is diffuse cerebral hemispheric sulcal \neffacement. In this setting, subtle new areas of cortical gray \nmatter hypodensity are concerning for possible diffuse areas of \nevolving cortical infarction due to cerebral \nedema. \n2. Evolving bilateral ACA territory infarcts. \n3. Evolving subarachnoid and intraventricular hemorrhage. No new \ninterval \nhemorrhage. \n4. Patent basal cisterns. \n\n___ CTA head:\n1. Evolving bilateral ACA territorial infarctions, as described \nabove. \n2. Multicompartmental intracranial hemorrhages are similar \ncompared to prior CT from approximately 12 hr ago. \n3. ACA aneurysm coil pack and right frontal ventriculostomy \ncatheter are \nunchanged. \n4. CTA portion of the examination is nondiagnostic secondary to \nsuboptimal \nbolus timing. \n\n___ CT HEAD\n1. Similar position of a right frontal ventriculostomy catheter \nwith slight interval decrease in ventricle size. \n2. Similar appearance of extensive multicompartment intracranial \nhemorrhage and bilateral ACA infarcts. \n\n___ CTA\n1. Similar extensive multi-compartment hemorrhage including \nintraventricular, right lobar and subarachnoid hemorrhage. \n2. Interval evolution of the bilateral ACA vascular territorial \ninfarctions. \n3. Improvement in vasospasm following pharmacological treatment. \n\n\n___ ECHO\nThere is mild global left ventricular hypokinesis (LVEF = 40-45 \n%). There is focal hypokinesis of the apical free wall of the \nright ventricle. 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. No mitral regurgitation is seen. There is a \nsmall pericardial effusion. The effusion is echo dense, \nconsistent with blood, inflammation or other cellular elements. \nThere are no echocardiographic signs of tamponade. \n\n___ CTA\n1. Coiled anterior communicating artery aneurysm causing streak \nartifact \nobscuring adjacent structures. \n2. Grossly patent intracranial vasculature with caliber similar \nto prior study \nfrom ___ and improved in comparison to ___, with no definite evidence of vasospasm. \n3. Evolving bilateral anterior communicating artery territory \ninfarctions \nwithout hemorrhagic conversion. \n4. Within limits of study, no definite filling of anterior \ncommunicating \nartery aneurysm. \n5. Stable subarachnoid, intraventricular, and right frontal \nparenchyma \nhemorrhages \n6. Right frontal approach ventriculostomy catheter with edema \nand hemorrhage along the catheter course. \n7. Interval decreased amount of intraventricular blood products \nwithout \nsignificant ventricular dilatation. \n\n___ LENIS\nNo evidence of deep venous thrombosis in the right or left lower \nextremity veins. \n \n___ MRI brain \n1. Re- demonstrated are large bilateral ACA territory infarcts, \nseen on prior \nCT examinations. In addition, there are scattered cortical and \nsubcortical white matter bihemispheric as well as bilateral \ncerebellar late acute to subacute infarcts, not readily \nvisualize on prior CT examinations. \n2. Multi compartment hemorrhages as described above similar \nappearance to CT examination. \n3. Gradient echo susceptibility artifact from ACA aneurysm coil \npacking is identified. \n \n\n \nBrief Hospital Course:\n___ y/o found down at work, found to have ACA aneurysm rupture \nwith SAH/IPH and IVH. Transferred from ___ with EVD that \nwas changed over ___. 5x12mm acomm aneurysm coiled ___, \nhypertonic saline started. Pt tolerated procedure well.\n\nOn ___, had bronch that was positive for GPCs, started on \nvanc/zosyn in setting of T ___. Started having increased ICPs \nto 28 when clamped, NCHCT showed bilateral ACA infarcts L>R. \nICPs refractory so he was cooled, paralyzed, and pentobarb \nstarted. \n\nAngio obtained ___ for possible vasospasm showed **\n\n___ the patient had episodes of afib with RVR and was \ncardioverted a total of three times and he was started on an \namiodarone drip. An echo was done and showed question of \ntakosubo. The patient's EVD was replaced as it had not been \ndraining overnight. The patient was paralyzed and sedated and \ncooled, with ICP's in the 15 range, later that day the patients \nICPs were in the ___ was started and the patient was on \nvasopressin with SBP in 130s and Milrinone was decreased given \ngood cardiac output. Given the patients serum sodium of 157 the \n3% was decreased from 80 to 70.\n\nOn ___ the patient continued to have ICPs in ___. The patient \nwas placed back on pentobarb and burst suppressed since 8pm per \nEEG while continuing to be cooled to 33 degrees. The 3% was \ndropped to 25 because of elevated Na. A repeat CTA was negative \nfor spasm.\n\nOn ___ the patients exam was stable with NR pupils at 3.5 mm \nbilaterally as he remained on pentobarb and was burst \nsurpressed. \n\nOn ___, the patient remained cooled and on pentobarbital and \nEEG remained completely suppressed. \n\nOn ___, pentobarbital was stopped and the rewarmng process was \nstarted, which the patient tolerated well without increase in \nICP. The patient remained on 4 pressors. CTA was completed \nwhich showed no spasm, hypodensity involving the L \nfrontal, R frontal and R temporal lobe is slightly increased. \nEEG showed flat electrical activity x 4 days.\n\nOn ___, the patient was weaned to a single pressor and \nparameters were changed to meet a CPP goal of >70. Subcutaneous \nheparin was restarted. Drain was raised to 15cm. Lower \nextremity ultrasound was performed which showed no DVT. He was \nbolused a total of 750cc normal saline during the day. \nOvernight, he received a dose of DDAVP for high urine output and \nhypernatremia.\n\nOn ___, he was restarted on propofol for increased ICP's. MRI \nperformed on ___ showed scattered cortical and subcortical \nwhite matter bihemispheric as well as bilateral cerebellar late \nacute to subacute infarcts. Sodium remained elevated at 159. \nFamily meeting was scheduled for 3pm. The patient was made CMO \nand extubated. He expired and was pronounced at 1658.\n\n \nMedications on Admission:\nSimvastatin 40mg Daily\n \nDischarge Medications:\nnone\n \nDischarge Disposition:\nExpired\n \nDischarge Diagnosis:\n___\nIVH\nCerebral edema\nACA aneurysm\nIPH\nCerebral vasospasm\nRespiratory failure\nBilateral ACA infarcts\nIncrease ICP\n\n \nDischarge Condition:\nExpired\n\n \nDischarge Instructions:\nExpired\n \nFollowup Instructions:\n___\n" ]

[ "I6022", "G936", "J9600", "J690", "J811", "I63522", "I63521", "G919", "J15211", "I67848", "I5181", "N179", "E870", "I615", "I9589", "R4020", "G932", "I679", "E785", "Z9889", "R001", "Z938", "I480", "K219", "Z781", "Z66", "Z515" ]

[ "I6022: Nontraumatic subarachnoid hemorrhage from anterior communicating artery", "G936: Cerebral edema", "J9600: Acute respiratory failure, unspecified whether with hypoxia or hypercapnia", "J690: Pneumonitis due to inhalation of food and vomit", "J811: Chronic pulmonary edema", "I63522: Cerebral infarction due to unspecified occlusion or stenosis of left anterior cerebral artery", "I63521: Cerebral infarction due to unspecified occlusion or stenosis of right anterior cerebral artery", "G919: Hydrocephalus, unspecified", "J15211: Pneumonia due to Methicillin susceptible Staphylococcus aureus", "I67848: Other cerebrovascular vasospasm and vasoconstriction", "I5181: Takotsubo syndrome", "N179: Acute kidney failure, unspecified", "E870: Hyperosmolality and hypernatremia", "I615: Nontraumatic intracerebral hemorrhage, intraventricular", "I9589: Other hypotension", "R4020: Unspecified coma", "G932: Benign intracranial hypertension", "I679: Cerebrovascular disease, unspecified", "E785: Hyperlipidemia, unspecified", "Z9889: Other specified postprocedural states", "R001: Bradycardia, unspecified", "Z938: Other artificial opening status", "I480: Paroxysmal atrial fibrillation", "K219: Gastro-esophageal reflux disease without esophagitis", "Z781: Physical restraint status", "Z66: Do not resuscitate", "Z515: Encounter for palliative care" ]

[ "N179", "E785", "I480", "K219", "Z66", "Z515" ]

[]

[ " \nName: ___ Unit No: ___\n \nAdmission Date: ___ Discharge Date: ___\n \nDate of Birth: ___ Sex: F\n \nService: MEDICINE\n \nAllergies: \nSulfa (Sulfonamide Antibiotics)\n \nAttending: ___.\n \nChief Complaint:\nAnemia\n \nMajor Surgical or Invasive Procedure:\nNone\n \nHistory of Present Illness:\nMs ___ is a ___ woman with a history of a JAK2 mutation, \nsevere peripheral vascular disease s/p angioplasty, and a \nduodenal ulcer, who presents from her PCP's office with anemia. \n\nPatient underwent angioplasty revision of right leg with \nvascular surgery on ___, and her Hgb was 12.7 at that \ntime. It is unclear what her H/H was immediately post-procedure. \nSince ___, she had been doing better; she was gaining \nweight, had more color in her face, and spirits were up. She was \nliving at home by herself with home ___, getting INR tested and \nfollowed closely by her PCP. \n\nFor the past 1 week, she has been doing worse. She has not been \neating as much and has lost color in her face. Of note, during \nthis time, her INR dropped, and she was started on Lovenox \ninjections. For the past 3 days, she has had increasing fatigue \nand dyspnea on exertion. She had \"jelly, beige\" stool, so made \nappointment for PCP ___ ___. At that visit, H/H had dropped, so \nshe came back for visit on ___, and was sent to the ED. No \nchest pain, no recent falls. No bruising or bleeding, no \nabdominal pain, nausea or vomiting, and no flank pain. No dark, \ntarry, or black stools, no blood in stools, no diarrhea, no \ndysuria, and no vaginal bleeding. When she went to her PCP, ___ \nwas 6.4, so she was transferred to ___.\n\nOf note, patient was diagnosed with a JAK2 mutation in ___. She has never had a bone marrow biopsy, and has never \nbeen on hydroxyurea. In ___, she had black, tarry stools, \nand underwent EGD, which showed a duodenal ulcer, which was \ntreated. She never had colonoscopy.\n \nIn the ED, initial VS were 97.6 74 169/41 18 100% RA \nExam notable for pale, guaiac negative stool \nLabs showed WBC 23.3 (baseline ___, Hgb 6.3 (baseline 11.9), \nplatelet 1206 (baseline 500s-600s). \nEKG: NSR@78 NANI peaked T waves No ST changes\nReceived 2 units pRBC, with Hgb bump to 8.8. Received Tylenol 1g \nand Oxycodone 2.5 mg\nTransfer VS were 99.0 98 186/52 20 98% RA \n\nDecision was made to admit to medicine for further management. \n\nOn arrival to the floor, patient reports feeling well. No \ncurrent headache, chest pain, shortness of breath, abdominal \npain, flank pain, black stools, or other bleeding. No \ncomplaints.\n\nREVIEW OF SYSTEMS: \nDenies fever, chills, night sweats, headache, vision changes, \nrhinorrhea, congestion, sore throat, cough, chest pain, \nabdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, \nmelena, hematochezia, dysuria, hematuria. \nAll other 10-system review negative in detail. \n+ burning chest pain on ___, resolved \n \nPast Medical History:\nPMH: \n- Positive PPD\n- Osteoporosis\n- Sarcoidosis 135 \n- Colonic polyp\n- Acute-angle glaucoma\n- Bilateral pseudophakia\n- Carpal tunnel syndrome\n- Degenerative arthritis of cervical spine, mild\n- Degenerative arthritis of lumbar spine, mild \n- Trigger finger; R ring\n- Trigger finger; R long\n- Shoulder impingement \n\nPSH: \n- Colonoscopy ___, 2 mm cecal polyp bx'd. adenoma\n- Excision pterygium, w/ graft ___ right eye \n- Colonoscopy ___ ___ no polyps. tic's. \n- Cataract extracaps extract, complex w intraocular lens \n___\nleft \n- Cataract extract - phacoemulsification ___ right\n- Post capsulotomy - laser ___ od \n- Incise finger tendon sheath Right ___ finger \n- Hysterectomy\n- Tonsillectomy\n\n \nSocial History:\n___\nFamily History:\n- Mother with breast cancer, diabetes\n- Father with CAD, prostate cancer\n- Brother: prostate cancer\n- No known family history of heme malignancy or anemia \n \nPhysical Exam:\n=======================\nAdmission Physical Exam\n=======================\nVS - 97.8 196/109 (160/60 after getting home med) 97 18 99% ra\nWt: 47.9kg\nGEN: elderly woman, lying in bed, NAD\nHEENT: EOMI, no scleral icterus, mmm, nl OP\nNECK: supple\nCV: tachycardic, regular rhythm, no m/r/g\nPULM: nl wob on ra, LCAB, no crackles or wheezes\nABD: soft, NT/ND, +bs\nBACK: no bruising, bleeding or tenderness\nEXTREM: R hallux with large superficial eschar with surrounding \nborder of fibronous exudate, other toes intact without pus, \nerythema, or drainage \nPULSES: faint DP pulse bilaterally\nNEURO: Alert, CN II-XII grossly intact, no asymmetry, moving all \n4 extremities\nSKIN: dark skin over R>L lower extremity, no large ecchymosis, \nno petichiae, warm\n=======================\nDischarge Physical Exam\n=======================\nVS - 98 80 137/77 18 95% ra \nGEN: elderly woman, lying in bed, NAD\nHEENT: EOMI, no scleral icterus, mmm, nl OP\nCV: regular rate and rhythm, no m/r/g\nPULM: nl wob on ra, LCAB, no crackles or wheezes\nABD: soft, NT/ND, +bs\nBACK: no bruising, bleeding or tenderness\nEXTREM: R hallux with large superficial eschar with surrounding \nborder of fibronous exudate, other toes intact without pus, \nerythema, or drainage, faint DP pulse bilaterally\nNEURO: Alert, CN II-XII grossly intact, no asymmetry, moving all \n4 extremities\nSKIN: dark skin over R>L lower extremity, no large ecchymosis, \nno petichiae, warm\n \nPertinent Results:\nADMISSION LABS:\n=========================\n___ 06:56PM BLOOD WBC-23.3*# RBC-3.03*# Hgb-6.3*# \nHct-24.3*# MCV-80*# MCH-20.8*# MCHC-25.9* RDW-17.6* RDWSD-48.5* \nPlt ___\n___ 06:56PM BLOOD Neuts-78.2* Lymphs-11.4* Monos-4.7* \nEos-3.4 Baso-0.9 NRBC-0.3* Im ___ AbsNeut-18.25*# \nAbsLymp-2.65 AbsMono-1.09* AbsEos-0.79* AbsBaso-0.22*\n___ 07:17PM BLOOD ___ PTT-51.0* ___\n___ 06:56PM BLOOD Glucose-103* UreaN-28* Creat-0.9 Na-135 \nK-5.4* Cl-103 HCO3-22 AnGap-15\n___ 05:43AM BLOOD ALT-9 AST-22 LD(LDH)-415* AlkPhos-74 \nAmylase-82 TotBili-0.9\n___ 05:43AM BLOOD Albumin-3.6 Calcium-9.4 Phos-4.2 Mg-2.1 \nIron-27*\n___ 05:43AM BLOOD calTIBC-476* Ferritn-8.8* TRF-366*\n\nOTHER PERTINENT LABS:\n=========================\nStrongyloides: pending at time of discharge\n\nIMAGING/STUDIES:\n=========================\nNone\n\nDISCHARGE LABS:\n=========================\n___ 05:50AM BLOOD WBC-20.2* RBC-3.62* Hgb-8.2* Hct-29.7* \nMCV-82 MCH-22.7* MCHC-27.6* RDW-17.9* RDWSD-51.8* Plt ___\n___ 05:50AM BLOOD Plt ___\n___ 05:50AM BLOOD ___ PTT-40.6* ___\n___ 05:50AM BLOOD Glucose-92 UreaN-21* Creat-0.9 Na-139 \nK-5.1 Cl-105 HCO3-23 AnGap-16\n___ 05:50AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.___RIEF SUMMARY STATEMENT:\n==========================\n___ F w/ h/o JAK2 mutation, severe peripheral vascular disease \ns/p angioplasty, and a duodenal ulcer, who presented from her \nPCP's office with anemia (Hgb 6.3 from baseline of 11.9). She \nalso had leukocytosis (23.3 from baseline of ___ and \nthrombocytosis (1206 from baseline of 500s-600s). She received \n2u pRBC, with appropriate Hgb bump to 9.6. No melena and stool \nguaiac was negative, so etiology was thought to be hematologic, \nrather than GI bleed. No evidence of ecchymosis or hematoma on \nexam, and no pain. Heme/Onc was consulted and suspected a bleed \ncausing reactive thrombocytosis and leukocytosis. Before full \nworkup could be completed, patient left AMA on ___ (see OMR \nnote).\n\nACTIVE ISSUES:\n==========================\n# ANEMIA: \nPatient presented with a hemoglobin of 6.3, down from a baseline \nof 11.9. After giving her 2 units of pRBC in the ED, her Hgb \nbumped to 9.6. Etiology remained unclear, but was concerning for \na hematologic process. Given her known JAK2 mutation, and change \nin other cell lines (WBC up to 23.3 from baseline of ___ and \nplatelets up to 1206 from baseline of 500s-600s), her \npresentation was concerning for transformation to essential \nthrombocytosis or other heme malignancy. Her diff showed no \nblasts, which was reassuring that this was not AML. GI bleed was \nconsidered, especially given her history of duodenal ulcer. \nHowever, guiaic was negative and no melena. No GU bleeding and \nno signs of ecchymosis on exam. Hemolysis was considered, and \nlabs showed normal haptoglobin. Heme Onc was consulted suspected \na reactive process caused by bleed. Unfortunately, patient \neloped before full evaluation was conducted.\n\n# LEUKOCYTOSIS:\nOn admission, her WBC was up to 23.2 from a baseline of ___. \nShe had no fevers, UTI symptoms, or dysuria to suggest \ninfection. In the setting of her anemia and known JAK2, this was \nmost likely due to underlying hematologic process. Heme/Onc \nconsulted, as above. Unfortunately, patient eloped before full \nevaluation was conducted.\n\n# THROMBOCYTOSIS: \nOn admission, platelets up to 1206 from baseline of 500s-600s. \nAgain, in the setting of known JAK2 mutation, this was most \nlikely due to underlying hematologic process. However, other \ncauses include a reactive process caused by infection, \nmalignancy, acute loss of blood, or iron deficiency. \nUnfortunately, patient eloped before full evaluation was \nconducted.\n\n# PVD WITH RECENT SURGERY ON RIGHT BIG TOE: \nVascular surgery evaluated the patient, and her toe was stable. \nContinued home Aspirin, Plavix, Warfarin, and Atenolol, as well \nas wound care. On ___, planned to discontinue Warfarin due to \nconcern for GI bleed, but unfortunately, patient eloped before \nfull evaluation was conducted.\n\nCHRONIC ISSUES\n==========================\n# ALLERGIES: Continued home Allegra\n\n# DRY EYES: Continued home Betimol eye drops\n\n# INSOMNIA: Continued home amitriptyline 10 mg tablet\n\n# CHRONIC PAIN: Continued home Acetaminophen with oxycodone \n___ q6 hour prn\n\n# GERD: Continued home omeprazole 40 mg daily\n\nTRANSITIONAL ISSUES:\n==========================\n# Unfortunately, patient eloped before full evaluation was \nconducted. She and her daughters will follow up at ___.\n# HEME/ONC FOLLOW UP: Patient needs outpatient Heme/Onc \nfollow-up within 1 week of hospital discharge. Please check \nrepeat CBC with diff at that visit\n# CODE: DNR/DNI\n# CONTACT: ___, ___. ___ (daughter in \n___ ___\n \n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Allegra-D 24 Hour (fexofenadine-pseudoephedrine) 180-240 mg \noral DAILY \n2. Betimol (timolol) 0.5 % ophthalmic BID \n3. Acetaminophen w/Codeine 1 TAB PO QHS:PRN pain \n4. Acetaminophen 650 mg PO Q4H:PRN pain \n5. Amitriptyline 10 mg PO QHS \n6. Aspirin 81 mg PO DAILY \n7. Atenolol 25 mg PO DAILY \n8. Atorvastatin 80 mg PO QPM \n9. Clopidogrel 75 mg PO DAILY \n10. Omeprazole 40 mg PO DAILY \n11. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN severe \npain \n12. Warfarin 2.5 mg PO DAILY16 \n\n \nDischarge Medications:\n1. Acetaminophen 650 mg PO Q4H:PRN pain \n2. Aspirin 81 mg PO DAILY \n3. Atenolol 25 mg PO DAILY \n4. Atorvastatin 80 mg PO QPM \n5. Clopidogrel 75 mg PO DAILY \n6. Omeprazole 40 mg PO DAILY \n7. OxycoDONE (Immediate Release) 2.5-5 mg PO Q6H:PRN severe \npain \nRX *oxycodone 5 mg ___ tablet(s) by mouth q6 hours prn Disp \n#*30 Tablet Refills:*0\n8. Warfarin 2.5 mg PO DAILY16 \n9. Collagenase Ointment 1 Appl TP DAILY \n10. Enoxaparin Sodium 40 mg SC Q24H \nStart: Today - ___, First Dose: Next Routine Administration \nTime \n11. Acetaminophen w/Codeine 1 TAB PO QHS:PRN pain \n12. Allegra-D 24 Hour (fexofenadine-pseudoephedrine) 180-240 mg \noral DAILY \n13. Amitriptyline 10 mg PO QHS \n14. Betimol (timolol) 0.5 % ophthalmic BID \n\n \nDischarge Disposition:\nHome\n \nDischarge Diagnosis:\nPRIMARY DIAGNOSES\n- Anemia\n- Thrombocytosis\n- Leukocytosis\n\nSECONDARY DIAGNOSES\n- Peripheral vascular disease\n- Chronic pain \n\n \nDischarge Condition:\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.\n\n \nDischarge Instructions:\nWHY WAS I ADMITTED TO THE HOSPITAL\n- You had shortness of breath and fatigue\n- This was caused by low blood counts\n\nWHAT HAPPENED IN THE HOSPITAL\n- You got 2 blood transfusions for low blood counts\n- You were seen by our Hematology/Oncology doctors\n\nWHAT ___ I NEED TO ___ WHEN I LEAVE THE HOSPITAL\n- Take all of your medicines as prescribed\n- Go to all of your follow-up appointments\n- Weigh yourself every morning, call MD if weight goes up more \nthan 3 lbs.\n- If you have any blood in your stool, worsening fatigue, or \nshortness of breath, please see you doctor immediately\n \nFollowup Instructions:\n___\n" ]

[ "D62", "I739", "D751", "M810", "D72829", "D473", "G4700", "G8929", "K219", "Z86718", "Z7901", "Z7902" ]

[ "D62: Acute posthemorrhagic anemia", "I739: Peripheral vascular disease, unspecified", "D751: Secondary polycythemia", "M810: Age-related osteoporosis without current pathological fracture", "D72829: Elevated white blood cell count, unspecified", "D473: Essential (hemorrhagic) thrombocythemia", "G4700: Insomnia, unspecified", "G8929: Other chronic pain", "K219: Gastro-esophageal reflux disease without esophagitis", "Z86718: Personal history of other venous thrombosis and embolism", "Z7901: Long term (current) use of anticoagulants", "Z7902: Long term (current) use of antithrombotics/antiplatelets" ]

[ "D62", "G4700", "G8929", "K219", "Z86718", "Z7901", "Z7902" ]

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